C.S.F C.S.F RHINORRHEARHINORRHEA

Lt Col Mian Amer MajeedLt Col Mian Amer Majeed

Classified ENT SpecialistClassified ENT Specialist

MH RawalpindiMH Rawalpindi

INTRODUCTIONINTRODUCTION

It is the failed containment of It is the failed containment of the cerebrospinal fluid in the the cerebrospinal fluid in the subarachnoid compartment.subarachnoid compartment.

It indicates a communication with It indicates a communication with the subarachnoid space & therefore the subarachnoid space & therefore an opening of the arachnoid, the an opening of the arachnoid, the dura and the bone to permit exit of dura and the bone to permit exit of the CSF through the nose.the CSF through the nose.

Cont….Cont….

The actual loss of CSF is of no particular The actual loss of CSF is of no particular consequence however the persistent consequence however the persistent dural fistula represents a persistent dural fistula represents a persistent hazard for a potentially fatal purulent hazard for a potentially fatal purulent meningitis leading to death if meningitis leading to death if unrecognized.unrecognized.

Persistent CSF rhinorrhea is therefore Persistent CSF rhinorrhea is therefore an absolute indication for a surgical an absolute indication for a surgical repair of the leak.repair of the leak.

ORIGINORIGIN

Origin may be Origin may be from any cranial from any cranial fossa i.e fossa i.e

Anterior, Anterior, Middle, orMiddle, or PosteriorPosterior

CSF PRESSURECSF PRESSURE

Normal CSF Normal CSF pressure is 40 mm pressure is 40 mm in infants & 140 in infants & 140 mm in adults.mm in adults.

CAUSES OF CSF CAUSES OF CSF RHINORRHEARHINORRHEA

TRAUMATICTRAUMATIC

AccidentalAccidental

AcuteAcute

DelayedDelayed

IatrogenicIatrogenic

AcuteAcute

DelayedDelayed

Cont….Cont…. NON TRAUMATICNON TRAUMATIC High pressureHigh pressure Tumours (direct/ indirect effect )Tumours (direct/ indirect effect ) HydrocephalusHydrocephalus Normal pressureNormal pressure Congenital anomaliesCongenital anomalies Focal atrophy of olfactory/sellar Focal atrophy of olfactory/sellar

areaarea Osteomyelitic erosionOsteomyelitic erosion IdiopathicIdiopathic

CAUSES….TraumaticCAUSES….Traumatic

80 %....secondary to head trauma 80 %....secondary to head trauma with associated skull base #.with associated skull base #.

16%....operations on nose , 16%....operations on nose , paranasal sinuses, skull base.paranasal sinuses, skull base.

Mostly occur through anterior Mostly occur through anterior cranial fossa. As the bone of the cranial fossa. As the bone of the anterior skull is thin & densly anterior skull is thin & densly adherent to the dura so dural tears adherent to the dura so dural tears also occur.also occur.

Cont….Cont….

Sites commonly involved in the Sites commonly involved in the anterior cranial fossa areanterior cranial fossa are

Cribriform plate Cribriform plate (commonest )(commonest )

Fovea ethmoidalisFovea ethmoidalis

Posterior wall of frontal Posterior wall of frontal sinussinus

Cont….Cont….

Middle cranial fossaMiddle cranial fossa fractures are fractures are less likely to cause CSF leakage into less likely to cause CSF leakage into the nose however common routes the nose however common routes areare

Via the sphenoid sinusVia the sphenoid sinus

Eustachian tubeEustachian tube

Cont….Cont….

CSF rhinorrhea may occur from the CSF rhinorrhea may occur from the posterior fossaposterior fossa in fractures of in fractures of

ClivusClivus

Petrous temporal bonePetrous temporal bone

Cont….Cont….

Post traumatic CSF rhinorrhea is Post traumatic CSF rhinorrhea is immediateimmediate in most of the cases in most of the cases

When delayed, it appears within 3 When delayed, it appears within 3 months in 95% cases, probably due tomonths in 95% cases, probably due to

initial inflammation & edemainitial inflammation & edema

resorption of bone/soft tissueresorption of bone/soft tissue

disrupted blood supplydisrupted blood supply

weakening of pia arachnoid sealweakening of pia arachnoid seal

NONTRAUMATIC NONTRAUMATIC CAUSESCAUSES

UncommonUncommon Mostly in adultsMostly in adults 44thth decade decade ♂ ♂ : ♀ ratio is 1:2: ♀ ratio is 1:2 May occur after an episode of May occur after an episode of

coughing, sneezing or straining.coughing, sneezing or straining.

High pressure leaksHigh pressure leaks

Arise from the cribriform area in 75 % Arise from the cribriform area in 75 % of casesof cases

They act as a safety valve to decrease They act as a safety valve to decrease the raised ICPthe raised ICP

84% are associated with slow growing 84% are associated with slow growing intra cranial tumours (Pituitary intra cranial tumours (Pituitary neoplasms are the commonest)neoplasms are the commonest)

16 % are related to hydrocephalus16 % are related to hydrocephalus

Normal pressure leaksNormal pressure leaks

Mostly are from the cribriform area and Mostly are from the cribriform area and the sella turcica but may be from the the sella turcica but may be from the middle fossa.middle fossa.

90 % are due to potential congenital 90 % are due to potential congenital pathwayspathways

10 % are due to direct erosion of skull 10 % are due to direct erosion of skull base due to infections/ tumours like base due to infections/ tumours like Osteomas of the fronto ethmoidal region, Osteomas of the fronto ethmoidal region, Nasopharyngeal angiofibromas, Nasopharyngeal angiofibromas, Nasopharyngeal CA, Osteomylitic erosionNasopharyngeal CA, Osteomylitic erosion

Diagnostic AimsDiagnostic Aims

Is the fluid CSF?Is the fluid CSF?

Cause of leakageCause of leakage

Site of leakageSite of leakage

Presence of CSF leakPresence of CSF leak HistoryHistory In cases of trauma any persistant rhinorrhea In cases of trauma any persistant rhinorrhea

should be considered CSF until proved should be considered CSF until proved otherwise.otherwise.

Patient with recurrent pneumococcal meningitisPatient with recurrent pneumococcal meningitisBending the head forward will increase the rate Bending the head forward will increase the rate

of flowof flowHeadache Headache Salty tasteSalty tasteAnosmiaAnosmiaAssociated SymptomsAssociated Symptoms

Cont…Cont…

ExaminationExamination May be unremarkable except for May be unremarkable except for

the rhinorrhea.the rhinorrhea. Positional change or jugular Positional change or jugular

compression can increase the flowcompression can increase the flowReservoir signReservoir sign: After being supine for : After being supine for

sometime the patient is brought in an sometime the patient is brought in an upright position, with the neck flexed. upright position, with the neck flexed. A sudden rush of clear fluid is A sudden rush of clear fluid is indicative of CSF fistulae.indicative of CSF fistulae.

Cont….Cont….

Hankerchief TestHankerchief Test: Fluid in rhinitis : Fluid in rhinitis contains mucous which stifins while contains mucous which stifins while CSF doesnot.CSF doesnot.

Halo SignHalo Sign: When CSF rhinorrhea is : When CSF rhinorrhea is blood stained it dries out with a central blood stained it dries out with a central blood stain surrounded by a clear ring.blood stain surrounded by a clear ring.

Nasal endoscopyNasal endoscopy with or without with or without intrathecal floresein for leak presence intrathecal floresein for leak presence or localizationor localization

Cont…..Cont…..

Biochemistry/ ImmunochemistryBiochemistry/ Immunochemistry

Estimation of glucose, proteins Estimation of glucose, proteins and electrolytes can be done. A and electrolytes can be done. A concentration of 30mg/dl or 1.6mmol/l concentration of 30mg/dl or 1.6mmol/l of glucose is considered confirmatory of glucose is considered confirmatory of CSF, however active meningitis can of CSF, however active meningitis can lower the CSF glucose level.lower the CSF glucose level.

ββ-2 Transferrin-2 Transferrin is pathognomonic of is pathognomonic of CSFCSF

Demonstrate the CauseDemonstrate the Cause

Over ½ the cases of nontraumatic Over ½ the cases of nontraumatic rhinorrhea are high pressure leaks, rhinorrhea are high pressure leaks, majority related to intracranial majority related to intracranial tumours.tumours.

CT scans and MRI have their CT scans and MRI have their diagnostic rolediagnostic role

Localization of the leakLocalization of the leak

Radiology Radiology plays the key role to see the plays the key role to see the anatomical site, size, side of the fistulaanatomical site, size, side of the fistula

Bone defects, air fluid levels and Bone defects, air fluid levels and erosions can be seen.erosions can be seen.

Plain X rays… Pneumocephalus/ air Plain X rays… Pneumocephalus/ air fluid levelsfluid levels

CT scan in axial/ coronal views… Skull CT scan in axial/ coronal views… Skull Base #s, CSF fistulaeBase #s, CSF fistulae

MRI… is not used as it is unable to MRI… is not used as it is unable to show bone windowsshow bone windows

Cont…Cont…

Isotope studiesIsotope studies

In case of inactive, intermittent, In case of inactive, intermittent, small or doubtful leak, CT scan with small or doubtful leak, CT scan with contrast will not reveal the leak. In contrast will not reveal the leak. In such cases radio nuclied such cases radio nuclied cisternography is more effective. cisternography is more effective. Indium III- DPTA is generally used.Indium III- DPTA is generally used.

Cont…Cont…

Intrathecal dyesIntrathecal dyes

Intrathecal floreciene with nasal Intrathecal floreciene with nasal endoscopes are used for anterior endoscopes are used for anterior fossa leaksfossa leaks

ManagementManagement

Management consists of cooperation Management consists of cooperation betweenbetween

NeurosurgeonNeurosurgeon

NeuroradiologistNeuroradiologist

OtolaryngologistOtolaryngologist

depending upon severity, etiology, depending upon severity, etiology, extent of injury & anatomical site of extent of injury & anatomical site of leak.leak.

Cont….Cont….

Treatment can be divided intoTreatment can be divided into

Medical &Medical &

SurgicalSurgical

MEDICALMEDICAL

In the acute CSF leak an initial trial In the acute CSF leak an initial trial of conservative treatment should be of conservative treatment should be considered as majority of acute considered as majority of acute traumatic leaks heal spontaneously.traumatic leaks heal spontaneously.

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Bed rest in head up positionBed rest in head up position Avoiding coughing, sneezing, nose Avoiding coughing, sneezing, nose

blowing & straining.blowing & straining. Drugs to decrease spinal fluid production Drugs to decrease spinal fluid production

like acetazolamide and frusemide.like acetazolamide and frusemide. Repeated removal of CSF via lumbar Repeated removal of CSF via lumbar

taps or an indwelling lumbar taps or an indwelling lumbar subarachnoid drain.subarachnoid drain.

AntibioticsAntibiotics

Cont….Cont….

If conservative treatment fails after If conservative treatment fails after 10 to 14 days or if the leak recurs 10 to 14 days or if the leak recurs then surgical treatment is indicated.then surgical treatment is indicated.

Surgical managementSurgical management

Intracranial approachIntracranial approach Extra cranial approachExtra cranial approach Endoscopic repairEndoscopic repair

CSF rhinorrhea?CSF rhinorrhea?

Confirm presence of leak

History examination Glucose/ β2 transferrin

Nasal endoscopyTraumatic/Atraumatic

conservative

failure successful

localization

Surgical closure

Thank youThank you