CSF RHINORRHEA

Definition:

Cerebrospinal fluid (CSF) rhinorrhea results from direct communication between the CSF-
containing subarachnoid space and the mucosalized space of the paranasal sinuses (the
defect involves the dura, bone and the mucosa)

DDX:

1. seasonal allergic rhinitis

2. perennial non-allergic rhinitis
3. vasomotor rhinitis

Few drops: because it is low pressure leak

Halo Sign= Double Ring sign= target sign:

 Used in traumatic bloody CSF leak

 You put secretions on a tissue (‫محرمة‬.)
 If there is CSF mixed with blood, the CSF will move
by capillary action away from the center
 Center=blood
 Halo= CSF leak

False positive:

1. Tear
2. saliva
 traumatic CSF leak
Head trauma cases 2% will have CSF leak make 90% of CSF
leak cases

so only a minority of pt with head trauma will develop CSF leak

but the majority of patients with CSF leak are due to trauma

6% of pt with basilar skull # will have CSF leak

CSF LEAK
90% TRAUMATIC OTHER CAUSES

20% MENINGITIS Will Be

Their Intial Symptom
 Classification of CSF leak:

90% 10%

The most common cause of accident CSF leak is closed head trauma (80%)

FESS:

 Most of CSF leak are detected intra-operatively

 Rt side > lt side
 Most common site is the lateral lamina of the cribriform plate (ant ethmoid)
 More commonly occurs in the hands of non-experienced surgeon
 Occurs during:
1. ethmoidectomy
2. frontal sinus osteoplastic obliteration
3. sphenoidotomy
The most common site of CSF
leak is from

lateral lamina=medial fovea

ethmoidalis

 Most CSF rhinorrhea results from trauma.

 Approximately 80% of all CSF rhinorrhea occurs in the setting of accidental trauma
 Most common cause of traumatic CSF leak is closed head trauma
 Although CSF rhinorrhea is noted in only 2% to 3% of cases of serious head trauma.
 % of CSF leaks from non-traumatic causes: 3-4%.

 80% of CSF leaks are cranionasal

 Cranio-aural CSF leaks are more likely to spontaneously close than
cranionasal CSF leaks.

Note:
There is association between non-traumatic CSF leak (Spontenous CSF leak) and:
1. Being obese middle aged female
2. Empty sella syndrome
3. Higher risk of recurrence and new leaks
Diagnosis:
The diagnosis of CSF rhinorrhea is typically a two-step process:

1. confirmation of a CSF leak

2. Locate the position of the skull base defect or defects, through which the CSF
is draining.

1. Confirm the CSF leak via:

 Chemical Markers of CSF:

a) b-transferrin:( The Glod standard of Diagnosis)

 Found in CSF, Perilymph, Vitrous

 Highly sensitive (100%) & specific (95%) pathognomonic
 Can be done with small amount
 Not affected with blood transfusion
 Work by electrogradient diffusion
 False positive :
i. Liver Dx
ii. Glycogen storage dx
iii. Rectal Ca
iv. Neuropsychatric Dx

b) Glucose content:

 Using glucose oxidase test strips

 Nasal secretions less than 10 mg/dl (1/3 of blood glucose)
 CSF fluid 30 mg/dl
 This is suggestive test
 False positive results in case of
1. Blood
2. Mucus
3. Tear
 False negative:
1. Concurrent meningitis (because it lowers CSF glucose level)

 CSF Tracer:

 Document the presence of communication between the intradural space &

extradural space

 All of these tests require lumbar puncture for the introduction of a tracer agent into
the subarachnoid space
 considered positive if the agent is visualized within the nose and paranasal sinuses

 Types:
 1. Visible dye (Intra-thecal fluorescin):

 Dilution recommandations:
 0.1 mL of 10% fluorescin (the IV preparation, not the
ophthalmic preparation) in 10 mL of the patient's own CSF;
 Infused slowly over 30 minutes.

 Procedure:
 A lumbar puncture is performed for the introduction of
fluorescin into the intrathecal space
 while the patient is kept in the head down position
 Nasal endoscopy is performed to identify fluorescin within the
nose and sinuses.
 Because the fluorescin has a characteristic green color, it is
quite easy to identify even in minute quantities.
 Specific blue light filters are used as well, but typically they
are not necessary.

 Complications: grand mal seizures (most of these complications seem

to be dose related).

2.Radio- radionuclide marker:

 monitoring the distribution of tracer with a scintillation camera

3.radio-obique (metrizamide):

 used in CT cisternography (detects 80% of CSF leak cases)

2. Localization of skull base defect:

A. CT scan that is :
a. high resolution
b. thin section
c. coronal cuts CT scan
d. with bone window
e. middle + anterior skull base

areas to assess:

1. coronal view:
a) cribriform plate
b) lateral lamina

2. axial View:
 a) post table of the frontal sinus
b) post+ lateral wall of sphenoid
c) clavius

Plus

B. MRI T2 with fat suppression of the middle& anterior skull base

 MRI does not need contrast injection , it depends on the intrinsic signal
characteristic of CSF leak
 Benefits of MRI:
1. differentiation of post obstructive secretions from herniated intracranial
contents
2. CSF can be distinguished from brain parenchyma in the
meningoencephalocele sac on T2-weighted coronal images.
3. Detecting Associated intracranial abnormalities, such as:
a) aberrant vessels
b) adjacent areas of encephalomalacia.
c) Empty sella syndrome (indicates long standing increase
intracranial pressure)
d) intracranial masses

CT and MR are complementary; that is, CT provides detail about the bony anatomy,
including bony skull base dehiscences , whereas MR provides detail about soft tissues,

3. However, if this fails to localize the defect, a CT cisternogram is advised. In this

procedure, CT scan is combined with injection of a contrast material into
intrathecal space via cisterna magna
Management:

Lumbar Drain:

 CSF cell counts, protein, glucose, and cultures should be sent daily.

 An hourly rate of 5 to 10 mL is desirable.

 Complications of lumbar drain:

1. Headache
2. Pneumocephalus
3. Ascending meningitis
4. Cellulitis at the site of injection
Intra Nasal Mucoperichondrial Flap

Never insert mucosal layer

intracranial: to avoid Mucocele

Postoperative care includes:

 Strict bed rest for several days

 Patients should be advised to avoid strenuous activity, sneezing, coughing for 6
weeks.
 Nasal packing is removed several days after surgery
 Anti-staphylococcal antibiotics (for prophylaxis against complications from the nasal
packing).
 If a lumbar drain had been placed intra-operatively, CSF drainage, which
decompresses the pressure on the repair site, should be continued for 4 to 5 days
 Lumber drain should be considered in case of increase intracranial pressure.
 The patient should be informed about the signs and symptoms of meningitis.

Prognosis:

 Most traumatic CSF leak caused by closed head injury resolves with conservative
management
 Most non-traumatic CSF leak require operative repair
 Endoscopic repair of CSF leak has emerged as the preferred method for surgical
closure of the skull base defects when operative closure is indicated
 Only pedicled mucosal falps can be reliably used to reconstruct the site of CSF leak
 Successful repair may be anticipated in more than 85% - 90% of primary cases;
secondary endoscopic repair is also associated with a high likelihood of success.
 Failure rate via cranial approach is high 25 %
‫‪Risk of meningitis:‬‬

‫‪ The risk increases with increase in the duration‬‬

‫‪ Prophylactic antibiotic is controversial.‬‬

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