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Management of CSF RhinorrheaSPENCER C. PAYNE, MDASSOCIATE PROFESSOR
DIRECTOR OF RHINOLOGY & SINUS SURGERY
DEPARTMENT OF OTOLARYNGOLOGY – HEAD & NECK SURGERY
AND DIVISION OF ALLERGY & CLINICAL IMMUNOLOGY
UNIVERSITY OF VIRGINIA
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Disclosures
u Consulting: Cook Medicalu Clinical Research (Industry Sponsored)
u Cumberland Pharmaceuticals
u Astra-Zeneca
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CSF Leak Etiology
u Traumau Neoplasmu Congenitalu Spontaneous
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CSF Physiology
u Produced in Choroid Plexusu Lateral, third and fourth ventricles
u 0.35 mL/min
u 90-150 mL total volume
u Normal Pressure: 5 – 15 cmH2Ou Multiple factors for variation
u Time, Age, Activity, Sleep
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Case
u 47 year old femaleu 3 month history of
unilateral right nasal drainage; clear, watery
u Seems to be bad for several days then improves for a week or so
u PMH: obesity, HTN, pre-diabetic
u Meds: Metoprolol 50 BID
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Not all clear rhinorrhea is a Leak!
Nellis and Payne. Otolaryngol Head Neck Surg. 2014;150:157-159.
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Case – Workup?
u Labsu Halo Signu Glucoseu Beta-2 / Tauu Beta Trace
u Imagingu Radionuclide cisternographyu CT Cisternographyu High Res CT Scanu MR Cisternography
Oakley GM et al. Int Forum Allergy Rhinol. 2016;6:8–16.
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Diagnostic Algorithm
Oakley GM et al. Int Forum Allergy Rhinol. 2016;6:8–16.
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Imaging
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Additional WorkupMODIFYING FACTORS
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OSA and Spontaneous CSF Leak
u 70 Patients (59 female)
u Average BMI of 35.64
u 30% of patients with OSA
Fleischman et al. Laryngoscope. 2014 Nov; 124(11): 2645–2650.
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Transverse Sinus Stenosis
u Idiopathic Intracranial Hypertension demographics similar to CSF leak
u Up to 90% of IIH patients have transverse sinus stenosis u Cause?
u Effect?
u Several series indicate improvement / resolution of symptoms after treatment (stenting)
Kanagalingam, S. & Subramanian, P.S. Curr Treat Options Neurol (2018) 20: 24.
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“Non-Surgical” Management
u Grade D, Level 5 Evidence:u Case Reports:
uRansom and colleagues: Leak resolution after VP shunt revision
u Three case reports note resolution of CSF Leak after bariatric surgery
Wang et al. Otolaryngol Clin N Am 2011;44:845–856.
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Non-Surgical Management
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Non-Surgical Managementu Retrospective Studyu 16 patients u Average duration of leak 4.8
months prior to presentationu Acetazolamide 250 mg BID
and u HOB Elevation
u Stool Softeners
u Activity restriction
u 5/16 resolved without surgeryu Average 470 day follow-up
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Summary
u Primary diagnostic tool: u Beta-2 (Tau) transferrinu But beta-trace may surpass in future
u Primary imaging modalities: u High Resolution CT Scan (< 1mm axials)u MR Cisternography can help
u Primary Management: Surgical Repairu Non-surgical treatments may be an option
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Thank you!