頭蓋底部多発瘻孔に起因する髄液鼻漏に対して修復術を行った1例

Repair of Spontaneous Cerebrospinal Fluid Leakage due to Multiple Defects in the Skull Base:A Case Report

Ⅰ．はじめに

　外傷や腫瘍，医療行為などに関連しない特発性髄液鼻漏は，頻度こそ高くはないものの，時に漏出部位が複数箇所にわたることが報告されている^10,17)．外科治療では経鼻内視鏡的に修復術を行うことが比較的多いが，漏出部位の同定が困難な場合や他部位から再度漏出する可能性もあり，再発することも少なくない¹⁰⁾．今回，頭蓋底部に複数の瘻孔を有した特発性髄液鼻漏に対して2度の手術を行った症例を報告する．

　Spontaneous cerebrospinal fluid（CSF）rhinorrhea may have multiple leakage sites, and occasionally, may become difficult to manage.

　A 46-year-old man was admitted to our hospital presenting with bacterial meningitis that occurred after CSF rhinorrhea. The CSF leak had stopped following conservative medical treatment;however, it recurred immediately. The leakage was assumed to be in the left lateral recess of the sphenoid sinus based on the location of fluid accumulation on the CT and MR images and the nasal endoscopic findings. First, we performed an endoscopic endonasal repair of the CSF leakage sites. There were multiple defects in the roof of the sphenoid sinus, including the left lateral sphenoid recess. These bone defects were repaired with abdominal fat;however, this did not stop the CSF leak. Therefore, he underwent a craniotomy and nasal endoscopy, which were performed simultaneously using a galeal flap. The galeal flap was inserted from the middle of the skull base to the sphenoid sinus to cover the bone defects, and the position was adjusted under the guidance of nasal endoscopy. Moreover, intraoperatively, another meningocele with CSF leak was discovered in the cribriform plate and was repaired using abdominal fat. The CSF leak stopped after the second surgery.

　It is important to be mindful of possible multiple leakage sites when treating cases of idiopathic CSF leakage;moreover, the determination of the leakage sites can be difficult. A repair surgery using a galeal flap is preferable in cases of multiple CSF leakage sites, such as in this case, because it allows for all defects to be covered and repaired simultaneously.