The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. 2016 Jan. 6 (1):8-16. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is a fistula between the dura and the skull base and discharge of CSF from the nose. Laryngoscope. Cranial CSF leaks occur in the head and are associated with CSF rhinorrhea, in which the cerebrospinal fluid escapes through the nasal passages (runny nose). Coryza, ie the common cold. Sometimes it can even leak out through the ears where it is then known as CSF otorrhea. [Medline]. CSF consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). What is the treatment for a cerebrospinal fluid (CSF) leak? From the first intracranial repair in the 1900s to the use of endoscopes and image-guidance systems, the management of cerebrospinal fluid (CSF) rhinorrhea has greatly evolved. The primary site of CSF production is the choroid plexus, which is responsible for 50-80% of its daily production. Another advantage is the ability to more accurately position underlay or overlay grafts. J Neurosurg. If an iatrogenic leak is detected intraoperatively, it should be repaired at the time of the original surgery. Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic SocietyDisclosure: Nothing to disclose. Cerebrospinal fluid (CSF) vs Nasal discharge – Differences Watery discharge from the nose can occur in cases of CSF rhinorrhoea and allergic rhinitis (also in other causes of increased mucus secretion in nose). CT scans may demonstrate skull base defects resulting from accidental or iatrogenic trauma, an underlying anatomic or developmental abnormality, or an erosive lesion such as a neoplasm. meningitis) can be serious and should not be taken lightly. 1990 Dec. 53(12):1072-5. Rebound congestion can occur when topical decongestant drugs are stopped. Kevin C Welch, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology and Skull Base Surgery, Northwestern University, The Feinberg School of Medicine Perennial rhinitis: this is rhinitis which occurs all year round and is usually due to allergy. Cappabianca P, Cavallo LM, Esposito F, et al. In most cases, the patient will have been discharged when the leak presents itself. Dandy is credited with the first surgical repair of a CSF leak via a frontal craniotomy approach in 1926. [Medline]. Since then, endoscopic repair has become the preferred method of addressing CSF rhinorrhea, given the high success rate of 90-95% and the decreased morbidity associated with this approach. During this appointment, you may be asked to perform a Smell Identification Test to determine if there is olfactory (smell) dysfunction. Handbook of Otolaryngology – Head and Neck Surgery. A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is a fistula between the dura and the skull base and discharge of CSF from the nose. 1997 Jun;11(3):189-90. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Ultimately, a defect is formed. We gave pneumococcal vaccine and discharged her home on prophylactic amoxicillin until she could have definitive surgical management. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. If you are having the symptoms listed above, you should seek an evaluation by an otolaryngologist. Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. CSF otorrhea). [Medline]. Outcomes of endoscopic repair of cerebrospinal fluid rhinorrhea without lumbar drains. (Defect measured approximately 7mm.). 2017 Feb. 78 (1):18-23. Nadieska Caballero, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic SocietyDisclosure: Nothing to disclose. Int Forum Allergy Rhinol. Certain neurosurgical procedures such as craniotomy and transsphenoidal pituitary resections are most commonly associated with an increased risk of CSF rhinorrhea. The association between intracranial hypertension and spontaneous cerebrospinal fluid (CSF) rhinorrhoea is being increasingly recognized among patients with OSA 1-4. Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea. J Neurol Neurosurg Psychiatry. In contrast to traumatic leaks, only 50% of patients with iatrogenic CSF leaks present within the first week after the insult. Abstract:CSR Rhinorrhea or Cerebrospinal fluid Rhinorrhea is a rare but potentially dangerous condition of leakage of brain fluid through a breach in dura matter via cribriform plate (a sieve-like plate at the base of skull).The fluid leaks in one of the sinuses and ultimately discharges in the nasal cavity either anteriorly or posteriorly. Another Na+/K+ ATPase lining the ventricular side of the epithelium extrudes Na+ into the ventricle, with water following across this ionic gradient. The opposite is true for nontraumatic leaks, as only one third stop spontaneously. A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is a fistula between the dura and the skull base and discharge of CSF from the nose. [Medline]. Marchiano E, Carniol ET, Guzman DE, Raikundalia MD, Baredes S, Eloy JA. Rhinorrhea (runny nose) that is clear and watery may be the first sign of cerebrospinal fluid rhinorrhea.1 Other signs and symptoms may include: 1. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Circulation of CSF is maintained by the hydrostatic differences between its rate of production and its rate of absorption. If you have the symptoms listed above, you should not delay an evaluation since CSF rhinorrhea can lead to serious complications. Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. 1993 Apr. If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). 1-7. [2] 5. Lopatin AS, Kapitanov DN, Potapov AA. Depending on your situation, your doctor may also choose to perform an endoscopy. This involves using a tiny fiberoptic scope to visualize any abnormalities to the superior nasal cavity and cribriform plate. Others require surgery to repair underlying defects. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. The aim of this study was to assess the surgical outcomes of endoscopic transnasal cerebrospinal fluid … Laryngoscope. Albu S, Florian IS, Bolboaca SD. Chest. Neurol India. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. James Stankiewicz, MD is a member of the following medical societies: American College of SurgeonsDisclosure: Nothing to disclose. The sella turcica and sphenoid sinus are involved in 15% of the cases as well. Most of the patients (95%) with a delayed CSF leak present within 3 months after the injury. After intrathecal fluorescein is administered, an exposed frontal recess encephalocele is seen. Other stresses include Valsalva-like maneuvers during nose blowing or straining. [Medline]. CSF rhinorrhea is a condition where cerebrospinal fluid (CSF) leaks through the nose. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Cerebrospinal fluid leak and meningitis associated with nasal continuous positive airway pressure therapy, Drainage increases while leaning forward with head down, Β-2 transferrin assay (laboratory test on nasal drainage) to confirm that the substance is in fact CSF, Radioactive pledget scanning is an imaging test that can be rather time-consuming and involves inserting medical cotton in your nose and ears followed by a lumbar puncture, Intrathecal fluorescein can be used to both identify CSF leaks and to surgically repair them. Drainage of CSF in some cases may often be elicited on endoscopy by having the patient perform a Valsalva maneuver or by compressing both jugular veins (Queckenstedt-Stookey test). A large defect is noted, and the meningocele has been resected. In patients with nonsurgical trauma, waiting a period of 5-7 days to allow conservative measures (bed rest, stool softeners, and lumbar drainage) to assist with secondary closure of the traumatic defect is reasonable. An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%). Laryngoscope Investig Otolaryngol. James Stankiewicz, MD Professor, Chair, Program Director, Department of Otolaryngology-Head and Neck Surgery, Loyola University Chicago School of Medicine This test may be done before any treatment in order to determine the baseline function. 2002 Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. A study by Lieberman et al found evidence of a significant incidence of multiple simultaneous skull base defects in cases of spontaneous CSF rhinorrhea, reporting the existence of such defects in eight out of 44 patients (18.2%) in the study. These cases often lead to a misdiagnosis of allergic and vasomotor rhinitis. 1. Spontaneous CSF rhinorrhea usually manifests in adulthood, coinciding with a developmental rise in CSF pressure with maturity. Obstructive sleep apnea (OSA) has also been linked to elevated ICP. These are usually drugs like ephedrine or xylometazoline drops but can include abuse of cocaine. Paradoxical rhinorrhea occurs when midline structures that act as separating barriers (eg, crista galli, vomer) are dislocated. Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. Most spontaneous, or primary, causes of CSF rhinorrhea are now thought actually to be secondary to elevations in intracranial pressure (ICP) that might be seen in patients with idiopathic intracranial hypertension (IIH). Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: a review of 31 cases. Thankfully, since the implementation of seat belt laws, the incidence of CSF rhinorrhea caused by trauma has also declined. [7], A literature review by Lobo et al indicated that in addition to increased ICP, risk factors for spontaneous CSF leaks include obesity, female gender, and obstructive sleep apnea. Carbonic anhydrase catalyzes the formation of bicarbonate inside the epithelial cell. Endoscopic endonasal CSF rhinorrhea repair in children: Systematic review with meta-analysis. Ray BS, Bergland RM. A small cribriform plate encephalocele is observed only after removing the middle turbinate. From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. 793582-overview Penetrating and closed-head trauma are responsible for 90% of all cases of CSF leaks. Traumatic causes include both blunt and penetrating facial injuries. Joseph M Scianna, MD   Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Scianna is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society, Srinivas Mukkamala, MD  Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center. CT scans may demonstrate skull base defects resulting from accidental or iatrogenic trauma, an underlying anatomic or developmental abnormality, or an erosive lesion such as a neoplasm. A thorough history is the first step toward accurate diagnosis. A defect in the skull base is measured with a sterile ruler. These are infrequently associated with CSF rhinorrhea. 2000 Jul. [Medline]. Nasal polyps are usually the result of chronic allergy or inflammat… According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. In the absence of prior trauma, we diagnosed spontaneous CSF rhinorrhoea. CSF rhinorrhea or liquorrhoea commonly occurs following head trauma (fronto-basal skull fractures), as a result of intracranial surgery, or destruction lesions. [8]. If you log out, you will be required to enter your username and password the next time you visit. The typical history of a cerebropsinal fluid (CSF) leak is that of clear, watery discharge, usually unilateral. Disruption of the barriers between the sinonasal cavity and the anterior and middle cranial fossae is the underlying factor leading to the discharge of CSF into the nasal cavity. A high index of suspicion should be maintained with all pediatric intranasal masses, particularly those occurring at the midline. A basal layer Na+/K+ ATPase is responsible for actively transporting Na+ into epithelial cells, after which water follows across this gradient. [Medline]. CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. Head trauma, surgery, or even birth defects can make a hole in the membranes that hold this fluid. The resulting fluid is termed cerebrospinal fluid. Am J Rhinol Allergy. Other proposed mechanisms for nontraumatic CSF leaks include focal atrophy, rupture of arachnoid projections that accompany the fibers of the olfactory nerve, and persistence of an embryonic olfactory lumen. Lemonnier LA, Tessema B, Kuperan AB, et al. Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. 93(6):E14-9. The dura of the anterior cranial base is subject to wide variations in CSF pressure because of several factors, including normal arterial and respiratory fluctuations. 4:CD004884. Rhinorrhea (runny nose) that is clear and watery may be the first sign of cerebrospinal fluid rhinorrhea. Other signs and symptoms may include: It's important to realize that these symptoms also occur in many other, more common conditions and should be evaluated by an otolaryngologist (ear, nose, throat specialist or ENT) if they are not easily explained or do not clear up on their own in a week or so. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Drainage increases while leaning forward with head down 4. Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck SocietyDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;Cliexa, eMedevents, Neosoma, MI10
Received income in an amount equal to or greater than $250 from: , Cliexa;;Neosoma
Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Neosoma, eMedevents, MI10. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. Common sites of injury secondary to endoscopic sinus surgery include the lateral lamella of the cribriform plate and the posterior ethmoid roof near the anterior and medial sphenoid wall. Cerebrospinal fluid (CSF) rhinorrhea, the leakage of spinal fluid through the nose, was first described in the secondcentury ADby Galen who postulated that CSF was periodically released into the nose by way of the pituitary and ethmoid regions. Neurosurgery. If you had surgery, you should go to the surgeon that performed your procedure. Hay fever: this is usually seasonal and predictable each year. J Neurosurg. It is important to differentiate between them so that appropriate treatment can be given. New York City, NY:Thieme Medical Publishers, Inc. Kuzniar TJ, Gruber B, Mutlu GM. [Medline]. [Full Text]. The osteoplastic flap provides the surgeon with a view of the entire posterior table of the frontal sinus and is especially useful for defects more than 2 cm above the floor and lateral to the lamina papyracea. CSF otorrhoea). The embryologic defect is typically a patent fonticulus frontalis or foramen cecum. 2. 8(4):433-7. Intracranial repair was frequently used (and is still used in select cases) for the routine repair of anterior cranial fossa CSF leaks. Marshall AH, Jones NS, Robertson IJ. Other sites of production include the ependymal surface layer (up to 30%) and capillary ultrafiltration (up to 20%). We describe one case of CSF Ear Nose Throat J. 2015 Mar-Apr. for: Medscape. Multiple studies demonstrate a 90-95% success rate with closure of skull base defects using the endoscopic approach. 30 (6):424-9. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. Most cases are best managed conservatively for the first 14 days during which the majority resolve spontaneously. The abnormal space that allows CSF to leak can be caused by: The exact incidence of CSF rhinorrhea is unknown but some studies have suggested that the rate of CSF rhinorrhea complications from sinus surgery is rare, only 0.5%. Otolaryngology procedures, including FESS and septoplasty, can lead to a skull base defect and CSF rhinorrhea. Journal Article, You are being redirected to Rarely, the leak can originate in the middle or posterior cranial fossa and can reach the nasal cavity by way of the middle ear and eustachian tube. On occasion, the patient has a history of headache relieved by drainage of CSF. Zhang C, Ding X, Lu Y, Hu L, Hu G Acta Otorhinolaryngol Ital 2017 Aug;37(4):303-307. doi: 10.14639/0392-100X-1086. Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. 110(7):1166-72. 'spontaneous' cerebrospinal fluid rhinorrhoea itself wouldappearto beinexact, bearingnorelationship to either the pathogenesis or natural history ofthe disease. Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. [Medline]. Other common locations include the posterior fovea ethmoidalis and the posterior aspect of the frontal recess. In the study, about 72% of patients with spontaneous CSF leaks were female, and about 45% had obstructive sleep apnea. CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. [Medline]. CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. [Medline]. Compared with external techniques, endoscopic techniques have several advantages, including better field visualization with enhanced illumination and magnified, as well as angled, visualization. Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. In patients undergoing endoscopic sinus surgery, the site of injury is most frequently the lateral lamella of the cribriform plate, where the bone of the anterior skull base is thinnest. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Some cases may be treated with a combination of bed rest and medication. However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. The risk of central nervous system infection in these conditions is severe and can be life threatening. CSF rhinorrhoea refers to a symptom of cerebrospinal fluid (CSF) leakage extracranially into the paranasal sinuses, thence into the nasal cavity, and exiting via the anterior nares. It can occur whenever there is an osseous or dural defect of the skull base (cf. Cerebrospinal fluid rhinorrhea is not infrequent, and patients may have to be returned to the operating room to repack and close a leak. CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. Otolaryngology and Facial Plastic Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Academy of Facial Plastic and Reconstructive Surgery. While cerebrospinal fluid rhinorrhea is a rare condition, the complications (e.g. PMID: 9231004 [PubMed - indexed for MEDLINE] Publication Types: Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. 2014 Jun. Such a communication creates the potentially grave risk of intracranial infection; therefore, the condition must be diagnosed accurately and the communication sealed off. Lack of smell (anosmia)1 5. CSF rhinorrhoea: the place of endoscopic sinus surgery. However, if you have not had nasal sinus surgery, you should obtain any CT scans or other radiographic images of your sinuses that you may have had in the past and take them to an ENT specialist for evaluation. Conservative management consists of a 7-10 day trial of bed rest with the head of the bed elevated approximately 15-30°. Arch Otolaryngol Head Neck Surg. Elmorsy SM, Khafagy YW. Traumatic CSF rhinorrhoea MC cause of CSF leak is head trauma, particularly, basilar skull fracture CSF leaks occur in approximately 3% of all head injuries & 12-30% o basilar skull #, depending upon the accelerative forces Typically begin within 48 hours, and 95% will manifest within 3 months of injury The majority of patients with a CSF leak due to accidental trauma (eg, motor vehicle accident) present immediately. In 1981, Wigand reported on the use of the endoscope to assist with the repair of a skull base defect. [Medline]. Lee TJ, Huang CC, Chuang CC, et al. Defects in the posterior table of the frontal sinus may be approached externally via a coronal incision and osteoplastic flap. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. 322713-overview Walsh M, Curran AJ. CSF Rhinorrhea: Management and Practice covers the current concepts in the etiology, diagnosis, and treatment of the condition, as well as long-term management of patients following successful treatment. At this point, the dura herniates through the defect (meningocele). [Medline]. The management of posttraumatic cerebrospinal fluid (CSF) rhinorrhoea remains a clinical challenge. Unless medical or surgical contraindications exist, surgical repair is recommended in all patients with spontaneous or iatrogenic cerebropsinal fluid (CSF) rhinorrhea in order to prevent ascending meningitis. [Medline]. This article discusses current concepts in the etiology, diagnosis, and treatment of CSF rhinorrhea, as well as long-term management of patients following successful treatment.
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