csf rhinorrhoea
TRANSCRIPT
CSF RHINORRHOEA
Dr. Parth RajdevMMIMSR Mullana (Ambala)
CSF BASICS Cerebrospinal fluid (CSF) is a clear,
colorless body fluid found in the brain and spine. It is produced in the choroid plexuses of the ventricles of the brain.
•It acts as a cushion or buffer for the brain's cortex, providing basic mechanical and immunological protection to the brain inside the skull.
CSF BASICS : CIRCULATIONProduced by Choroid plexus in lateral
ventricle and fourth ventricles
Through foramen of Monro
third ventricle Through aqueduct of Sylvius
fourth ventricle Through foramina of
Luschka Subarachnoid space over brain and spinal
cord
Reabsorbed into venous sinus blood via arachnoid granulations
CSF BASICS Total volume of CSF varies from 90 to
150 m.l. It is secreted at the rate of about 20ml/h
(300-350 ml/day) Therefore total CSF is replaced 3-5
times a day. Normal CSF pressure at lumbar
puncture is 50-150 mm H2O It rises on coughing, sneezing, nose
blowing, straining on stools or lifting heavy weight.
CSF RHINORRHOEA
•Leakage of CSF into nose.
•It may be clear fluid or mixed with blood.
Aetiology Trauma : Most common cause. It can be
either accidental or surgical.
SURGICAL TRAUMA includes:- Endoscopic sinus surgery. Trans-sphenoidal hypophysectomy Nasal polypectomy. Skull base surgery.
INFLAMMATIONS : Mucoceles of sinuses. Sinunasal polyposis. Erode bone and Fungal infections of sinuses. dura. Osteomyelitis.
NEOPLASMS: Both benign and malignant, invading the skull base.
CONGENITAL LESIONS: Meningocoele Meningoencephalocoele Gliomas.
IDIOPATHIC CAUSES
•SITES OF LEAKAGE
Anterior crainial fossa:i. Cribriform plate.ii. Root of ethmoidal cells.iii. Frontal sinus
Middle cranial fossa :Injuries to sphenoid sinus
Fracture Temporal bone:• CSF reaches middle ear and then escapes
through the eustachian tube into the nose (CSF otorinorrhoea)
DIAGNOSIS•History of clear watery discharge from
nose on bending the head or straining.•It may be seen on rising in the morning
when the patient bends his head (reservoir sign – fluid which had collected in the sinuses, particularly sphenoid, empties into the nose)
•It should be differentiated from nasal discharge of allergic or vasomotor rhinitis.
•Nasal discharge, stiffens the handkerchief because of its mucus content.
•Double target sign : CSF rhinorrhoea after head trauma is mixed with blood shows this sign when collected on a piece of filter paper i.e. central red spot and peripheral lighter halo.
DIAGNOSTIC NASAL ENDOSCOPY
Nasal endoscopy can help to localize CSF leak in some cases.
LABORATORY TESTSoBeta-2 transferrin : a protein seen in CSF
and not in nasal dischrge, it’s presence is specific and sensitive test.• Requires only a few drops of CSF.• Perilymph and aqueous are the only other
fluids which contain this protein.
oBeta trace protein : also specific for CSF , secreted my meninges and choroid plexus.
LOCALIZATION OF SITE1. HIGH RESOLUTION CT SCAN: Coronal
and axial cuts to see bony defects.
2. CT Cisternogram :It requires intrathecal injection of iohexol
and CT scan to localize site of leakage.
3. MRI : T2 weighted image in depicting site of leak. It requires that CSF leak is active at the time of scan.
• Indicated also if encephalocele or intracranial pathology is suspected.
4. INTRATHECAL FLUORESCEIN STUDYIt is an invasive procedure, use of
intrathecal radioactive substances has been abandoned.
0.25-0.5ml of 5% fl. Dye injected. Patient lies in 10◦ head down position for sometime.
Dye appears green when seen with a blue filter.
TREATMENTEarly cases of post-traumatic CSF leak
can be managed by conservative measures such as bed rest, elevation of the head of the bed, stool softners, and avoidance of nose blowing, sneezing and straining.
Prophylactic antibiotics can be used to prevent meningitis.
These measures can be combined with lumbar drainage.
Surgical Repair
A. Neurosurgical intracranial approach.
B. Extradural approaches : • External ethhmoidectomy for cribriform
plate and ethmoid area.• Trans-septal approach for sphenoid.• Osteoplastic flap approach for frontal
sinus leak.
C. Transnasal endoscopic approach : Most of the leaks from anterior cranial fossa
and sphenoid sinus can be managed endoscopically
Principles of repair:• Defining the site of leak.• Preparation of graft site.• Underlay grafting of fascia extradurally
followed by placement of mucosa.• If bony defect>2cm, it is repaired with
cartilage.• Placement of surgical and gelfoam further
strengthens area.
TYPES OF GRAFTS It depends on the size and location of the
defect, If the defect is large it can be fixed with
bone or cartilage graft taken usually from nasal turbinates.
If the defect is small, it can be repaired with fascia lata grafts, temporalis fascia.
Fibrin glue, surgicel, gelfoam is used to stabilize the graft
•High antibiotic smeared nasal packing.•Sometimes fat from thigh or abdomen is used
to plug the defect in place of fascia graft.
•Lumbar puncture if CSF pressure is high.•Antibiotics•(prophylacticaly)