C.S.F C.S.F RHINORRHEARHINORRHEA

INTRODUCTIONINTRODUCTION

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

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

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

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

ORIGINORIGIN

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

Anterior, Anterior, Middle, orMiddle, or PosteriorPosterior

CSF PRESSURECSF PRESSURE

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

CAUSES OF CSF RHINORRHEACAUSES OF CSF RHINORRHEA

TRAUMATICTRAUMATIC

AccidentalAccidental

AcuteAcute

DelayedDelayed

IatrogenicIatrogenic

AcuteAcute

DelayedDelayed

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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 areaFocal atrophy of olfactory/sellar area Osteomyelitic erosionOsteomyelitic erosion IdiopathicIdiopathic

CAUSES….TraumaticCAUSES….Traumatic

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

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

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

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

Cribriform plate (commonest )Cribriform plate (commonest )

Fovea ethmoidalisFovea ethmoidalis

Posterior wall of frontal sinusPosterior wall of frontal sinus

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

Via the sphenoid sinusVia the sphenoid sinus

Eustachian tubeEustachian tube

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CSF rhinorrhea may occur from the CSF rhinorrhea may occur from the posterior posterior fossafossa in fractures of in fractures of

ClivusClivus

Petrous temporal bonePetrous temporal bone

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

When delayed, it appears within 3 months in When delayed, it appears within 3 months in 95% cases, probably due to95% 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 CAUSESNONTRAUMATIC CAUSES

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

sneezing or straining.sneezing or straining.

High pressure leaksHigh pressure leaks

Arise from the cribriform area in 75 % of casesArise from the cribriform area in 75 % of cases They act as a safety valve to decrease the raised They act as a safety valve to decrease the raised

ICPICP 84% are associated with slow growing intra 84% are associated with slow growing intra

cranial tumours (Pituitary neoplasms are the cranial tumours (Pituitary neoplasms are the commonest)commonest)

16 % are related to hydrocephalus16 % are related to hydrocephalus

Normal pressure leaksNormal pressure leaks

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

90 % are due to potential congenital pathways90 % are due to potential congenital pathways 10 % are due to direct erosion of skull base due 10 % are due to direct erosion of skull base due

to infections/ tumours like Osteomas of the to infections/ tumours like Osteomas of the fronto ethmoidal region, Nasopharyngeal fronto ethmoidal region, Nasopharyngeal angiofibromas, Nasopharyngeal CA, angiofibromas, Nasopharyngeal CA, Osteomylitic erosionOsteomylitic 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 should be In cases of trauma any persistant rhinorrhea should be

considered CSF until proved otherwise.considered CSF until proved otherwise.Patient with recurrent pneumococcal meningitisPatient with recurrent pneumococcal meningitisBending the head forward will increase the rate of flowBending the head forward will increase the rate of flowHeadache Headache Salty tasteSalty tasteAnosmiaAnosmiaAssociated SymptomsAssociated Symptoms

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ExaminationExamination May be unremarkable except for the May be unremarkable except for the

rhinorrhea.rhinorrhea. Positional change or jugular compression Positional change or jugular compression

can increase the flowcan increase the flowReservoir signReservoir sign: After being supine for sometime : After being supine for sometime

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

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

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

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

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Biochemistry/ ImmunochemistryBiochemistry/ Immunochemistry

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

ββ-2 Transferrin-2 Transferrin is pathognomonic of CSF is pathognomonic of CSF

Demonstrate the CauseDemonstrate the Cause

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

CT scans and MRI have their diagnostic roleCT scans and MRI have their diagnostic 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 erosions can be Bone defects, air fluid levels and erosions can be seen.seen.

Plain X rays… Pneumocephalus/ air fluid levelsPlain X rays… Pneumocephalus/ air fluid levels CT scan in axial/ coronal views… Skull Base #s, CT scan in axial/ coronal views… Skull Base #s,

CSF fistulaeCSF fistulae MRI… is not used as it is unable to show bone MRI… is not used as it is unable to show bone

windowswindows

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Isotope studiesIsotope studies

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

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Intrathecal dyesIntrathecal dyes

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

ManagementManagement

Management consists of cooperation betweenManagement consists of cooperation between

NeurosurgeonNeurosurgeon

NeuroradiologistNeuroradiologist

OtolaryngologistOtolaryngologist

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

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Treatment can be divided intoTreatment can be divided into

Medical &Medical &

SurgicalSurgical

MEDICALMEDICAL

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

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

straining.straining. Drugs to decrease spinal fluid production like Drugs to decrease spinal fluid production like

acetazolamide and frusemide.acetazolamide and frusemide. Repeated removal of CSF via lumbar taps or an Repeated removal of CSF via lumbar taps or an

indwelling lumbar subarachnoid drain.indwelling lumbar subarachnoid drain. AntibioticsAntibiotics

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