1. C.S.F RHINORRHEA Lt Col Mian Amer Majeed Classified ENT Specialist MH Rawalpindi

2. INTRODUCTION It is the failed containment of the cerebrospinal fluid in the subarachnoid compartment. It is the failed containment of the cerebrospinal fluid in the subarachnoid compartment. It indicates a communication with the subarachnoid space & therefore an opening of the arachnoid, the dura and the bone to permit exit of the CSF through the nose. It indicates a communication with the subarachnoid space & therefore an opening of the arachnoid, the dura and the bone to permit exit of the CSF through the nose.

3. Cont…. The actual loss of CSF is of no particular consequence however the persistent dural fistula represents a persistent hazard for a potentially fatal purulent meningitis leading to death if unrecognized. The actual loss of CSF is of no particular consequence however the persistent dural fistula represents a persistent hazard for a potentially fatal purulent meningitis leading to death if unrecognized. Persistent CSF rhinorrhea is therefore an absolute indication for a surgical repair of the leak. Persistent CSF rhinorrhea is therefore an absolute indication for a surgical repair of the leak.

4. ORIGIN Origin may be from any cranial fossa i.e Anterior, Anterior, Middle, or Middle, or Posterior Posterior

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

6. CAUSES OF CSF RHINORRHEA TRAUMATIC TRAUMATIC Accidental Accidental Acute Acute Delayed Delayed Iatrogenic Iatrogenic Acute Acute Delayed Delayed

7. Cont…. NON TRAUMATIC NON TRAUMATIC High pressure High pressure Tumours (direct/ indirect effect ) Tumours (direct/ indirect effect ) Hydrocephalus Hydrocephalus Normal pressure Normal pressure Congenital anomalies Congenital anomalies Focal atrophy of olfactory/sellar area Focal atrophy of olfactory/sellar area Osteomyelitic erosion Osteomyelitic erosion Idiopathic Idiopathic

8. CAUSES….Traumatic 80 %....secondary to head trauma with associated skull base #. 80 %....secondary to head trauma with associated skull base #. 16%....operations on nose, paranasal sinuses, skull base. 16%....operations on nose, paranasal sinuses, skull base. Mostly occur through anterior cranial fossa. As the bone of the anterior skull is thin & densly adherent to the dura so dural tears also occur. Mostly occur through anterior cranial fossa. As the bone of the anterior skull is thin & densly adherent to the dura so dural tears also occur.

9. Cont…. Sites commonly involved in the anterior cranial fossa are Sites commonly involved in the anterior cranial fossa are Cribriform plate (commonest ) Cribriform plate (commonest ) Fovea ethmoidalis Fovea ethmoidalis Posterior wall of frontal sinus Posterior wall of frontal sinus

10. Cont…. Middle cranial fossa fractures are less likely to cause CSF leakage into the nose however common routes are Middle cranial fossa fractures are less likely to cause CSF leakage into the nose however common routes are Via the sphenoid sinus Via the sphenoid sinus Eustachian tube Eustachian tube

11. Cont…. CSF rhinorrhea may occur from the posterior fossa in fractures of CSF rhinorrhea may occur from the posterior fossa in fractures of Clivus Clivus Petrous temporal bone Petrous temporal bone

12. Cont…. Post traumatic CSF rhinorrhea is immediate in most of the cases Post traumatic CSF rhinorrhea is immediate in most of the cases When delayed, it appears within 3 months in 95% cases, probably due to When delayed, it appears within 3 months in 95% cases, probably due to initial inflammation & edema initial inflammation & edema resorption of bone/soft tissue resorption of bone/soft tissue disrupted blood supply disrupted blood supply weakening of pia arachnoid seal weakening of pia arachnoid seal

13. NONTRAUMATIC CAUSES Uncommon Uncommon Mostly in adults Mostly in adults 4 th decade 4 th decade ♂ : ♀ ratio is 1:2 ♂ : ♀ ratio is 1:2 May occur after an episode of coughing, sneezing or straining. May occur after an episode of coughing, sneezing or straining.

14. High pressure leaks Arise from the cribriform area in 75 % of cases Arise from the cribriform area in 75 % of cases They act as a safety valve to decrease the raised ICP They act as a safety valve to decrease the raised ICP 84% are associated with slow growing intra cranial tumours (Pituitary neoplasms are the commonest) 84% are associated with slow growing intra cranial tumours (Pituitary neoplasms are the commonest) 16 % are related to hydrocephalus 16 % are related to hydrocephalus

15. Normal pressure leaks Mostly are from the cribriform area and the sella turcica but may be from the middle fossa. Mostly are from the cribriform area and the sella turcica but may be from the middle fossa. 90 % are due to potential congenital pathways 90 % are due to potential congenital pathways 10 % are due to direct erosion of skull base due to infections/ tumours like Osteomas of the fronto ethmoidal region, Nasopharyngeal angiofibromas, Nasopharyngeal CA, Osteomylitic erosion 10 % are due to direct erosion of skull base due to infections/ tumours like Osteomas of the fronto ethmoidal region, Nasopharyngeal angiofibromas, Nasopharyngeal CA, Osteomylitic erosion

16. Diagnostic Aims Is the fluid CSF? Is the fluid CSF? Cause of leakage Cause of leakage Site of leakage Site of leakage

17. Presence of CSF leak History History In cases of trauma any persistant rhinorrhea should be considered CSF until proved otherwise. Patient with recurrent pneumococcal meningitis Bending the head forward will increase the rate of flow Headache Salty taste Anosmia Associated Symptoms

18. Cont… Examination Examination May be unremarkable except for the rhinorrhea. May be unremarkable except for the rhinorrhea. Positional change or jugular compression can increase the flow Positional change or jugular compression can increase the flow Reservoir sign: After being supine for sometime the patient is brought in an upright position, with the neck flexed. A sudden rush of clear fluid is indicative of CSF fistulae.

19. Cont…. Hankerchief Test: Fluid in rhinitis contains mucous which stifins while CSF doesnot. Hankerchief Test: Fluid in rhinitis contains mucous which stifins while CSF doesnot. Halo Sign: When CSF rhinorrhea is blood stained it dries out with a central blood stain surrounded by a clear ring. Halo Sign: When CSF rhinorrhea is blood stained it dries out with a central blood stain surrounded by a clear ring. Nasal endoscopy with or without intrathecal floresein for leak presence or localization Nasal endoscopy with or without intrathecal floresein for leak presence or localization

20. Cont….. Biochemistry/ Immunochemistry Biochemistry/ Immunochemistry Estimation of glucose, proteins and electrolytes can be done. A concentration of 30mg/dl or 1.6mmol/l of glucose is considered confirmatory of CSF, however active meningitis can lower the CSF glucose level. Estimation of glucose, proteins and electrolytes can be done. A concentration of 30mg/dl or 1.6mmol/l of glucose is considered confirmatory of CSF, however active meningitis can lower the CSF glucose level. β-2 Transferrin is pathognomonic of CSF β-2 Transferrin is pathognomonic of CSF

21. Demonstrate the Cause Over ½ the cases of nontraumatic rhinorrhea are high pressure leaks, majority related to intracranial tumours. Over ½ the cases of nontraumatic rhinorrhea are high pressure leaks, majority related to intracranial tumours. CT scans and MRI have their diagnostic role CT scans and MRI have their diagnostic role

22. Localization of the leak Radiology plays the key role to see the anatomical site, size, side of the fistula Radiology plays the key role to see the anatomical site, size, side of the fistula Bone defects, air fluid levels and erosions can be seen. Bone defects, air fluid levels and erosions can be seen. Plain X rays… Pneumocephalus/ air fluid levels Plain X rays… Pneumocephalus/ air fluid levels CT scan in axial/ coronal views… Skull Base #s, CSF fistulae CT scan in axial/ coronal views… Skull Base #s, CSF fistulae MRI… is not used as it is unable to show bone windows MRI… is not used as it is unable to show bone windows

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

27. Cont… Intrathecal dyes Intrathecal dyes Intrathecal floreciene with nasal endoscopes are used for anterior fossa leaks Intrathecal floreciene with nasal endoscopes are used for anterior fossa leaks

28. Management Management consists of cooperation between Management consists of cooperation between Neurosurgeon Neurosurgeon Neuroradiologist Neuroradiologist Otolaryngologist Otolaryngologist depending upon severity, etiology, extent of injury & anatomical site of leak. depending upon severity, etiology, extent of injury & anatomical site of leak.

29. Cont…. Treatment can be divided into Treatment can be divided into Medical & Medical & Surgical SurgicalMEDICAL In the acute CSF leak an initial trial of conservative treatment should be considered as majority of acute traumatic leaks heal spontaneously. In the acute CSF leak an initial trial of conservative treatment should be considered as majority of acute traumatic leaks heal spontaneously.

30. Cont…. Bed rest in head up position Bed rest in head up position Avoiding coughing, sneezing, nose blowing & straining. Avoiding coughing, sneezing, nose blowing & straining. Drugs to decrease spinal fluid production like acetazolamide and frusemide. Drugs to decrease spinal fluid production like acetazolamide and frusemide. Repeated removal of CSF via lumbar taps or an indwelling lumbar subarachnoid drain. Repeated removal of CSF via lumbar taps or an indwelling lumbar subarachnoid drain. Antibiotics Antibiotics

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

32. Surgical management Intracranial approach Intracranial approach Extra cranial approach Extra cranial approach Endoscopic repair Endoscopic repair

33. CSF rhinorrhea? Confirm presence of leak History Traumatic/Atraumatic examination Nasal endoscopy Glucose/ β2 transferrin conservative failure localization Surgical closure successful

34. Thank you