CSF, rhinorrhea, clear nasal drips, endoscopy, endoscopic nasal procedure, diagnosis, management, sunil, baniya, aetilogy, definition, presentation to hospital, physical examination, differential diagnosis, laboratory values, imaging, techniques, follow up complications, outcome, prognosis, nose, blood, devastating, Dandy, surgical repair, CSF leak, frontal, craniotomy, approach, Wigand, endoscope, skull, skull base, defect, success, rate, preferred, local, locally aggressive, defective, anterior, anterior neuropore, neuropore, acquired, traumatic, iatrogenic, embryologic, fonticulus, foramen, cecum, tumors, idiopathic, spontaneous, conservative management, inclination, CSF pressure, cistern, basal, sneezing, nose blowing, heavy lifting, straining, stool softner, subarachnoid, lumbar drain, antibiotics, diuretics, acetazolamide, surgical, neurosurgical repair, extracranial, intracranial, approach, frontal, craniotomy, middle, posterior, free, pedicled, periosteal flap, dural flap, muscle plugs, falx cerebri, fascia, graft, flaps fibrin glue, osteoplastic flap, lamina papyracea, transnasal, external, ethmoid, ethmoidectomy, transethmoidal, sphenoidectomy, sphenoidotomy, transseptal, transantral, caldwell luc procedure, endoscopic, decongestion, visualization, epinephrine, cocaine,specific, design, access, efficient,transfrontal, transsellar, transcribriform, transplanum, transpterygoid, transclival, non absorbable, packing, debridement, recurrence, encephalocele, raised ICP, electrolyte, ventriculoperitoneal shunt, complications, meningitis, bacterial meningitis, aseptic meningitis, anosmia, months, years, references, dhingra, shrivastav,

1. CSF RHINORRHEA
Intern Dr Sunil Baniya
Shree Birendra Hospital
ENT Department
1

2. CASE
The patient presented with clear nasal drips
after an endoscopic nasal procedure. What is
the diagnosis and subsequent management?
2

3. CONTENTS
 Definition
 Etiology
 Presentation to Hospital
 Physical Examinations
 Differential Diagnoses
 Laboratory Values
 Imaging Techniques
 Management
 Follow Up
 Complications
 Outcome & Prognosis
3

4. DEFINITION
 Leakage of CSF into the nose
 Clear fluid or fluid mixed with blood
 Rare but potentially devastating condition
 History:
 Dandy(1926): first surgical repair of CSF leak via frontal
craniotomy approach
 Wigand (1981): use of endoscope for the first time to
assist with repair of skull base defect
[ 90-95% success rate with decreased associated morbidity – thus preferred] 4

5. 5

6. ETIOLOGY
A. Congenital:
 Defective anterior neuropore closure
 Embryologic defect-patent fonticulus frontalis or
foramen cecum
B. Acquired:
1. Traumatic (9O%)
2. Iatrogenic
3. Idiopathic/ Spontaneous
4. Certain tumors
6

7. Traumatic CSF Rhinorrhea:
 90% of CSF rhinorrhea
 Anterior > middle > posterior cranial fossa
 can be:
 Immediate (< 48 hours) - Motor Vehicle Accidents (MVA)
 Delayed (in 3 months) - proposed different theories
Intact dural layer slowly herniated through bony defect
Finally tearing & CSF leak
Another Theory:
Bony defect & dural tear +nt from the time of original injury
Leakage once masking hematoma resolves
7

8. Iatrogenic CSF Rhinorrhea:
 Any surgical manipulation near skull base
i. Neurosurgical:
 most commonly craniotomy & trans-sphenoidal pitutary resections
ii. Otolaryngological:
 FESS (lateral lamella of cribriform plate, fovea ethmoidalis, posterior
aspects of frontal recess)
 Septoplasty
 Present as:
 Simple cracks in bony architecture
 Large (>1 cm) defects
 Presents in within 1st week of insult 8

9. Idiopathic/ Spontaneous CSF Rhinorrhea:
 Without antecedent cause
 Site: anterior cranial fossa mostly
 subjected to wide variations of CSF pressure due to normal arterial
and respiratory fluctuations
 Cause: secondary to raised ICP
 Idiopathic Intracranial Hypertension (IIH)
 Obstructive Sleep Apnea (OSA)
 Stressors: Valsalva like manoeuvers during nose blowing or straining
 Other causes: Focal atrophy, persistent embryonic olfactory lumen,
rupture of arachnoid projections accompanying olfactory nerves
9

10. Congenital Tumors:
1. Locally aggressive: Inverted papilloma
2. Malignant neoplasms: eg. Glioma
Erode bone of anterior cranial fossa
Inflammation and potential violation of dura
10

11. PRESENTATION TO HOSPITAL
 Clear watery unilateral/ bilateral nasal discharge
 Anosmia- in some traumatic cases
 Congenital:
Furstenberg sign:
Meningoencephaloceles in child as intranasal/ extranasal mass
Transilluminates and expands with crying (high index of suspicion with
midline mass) No biopsy till complete imaging
 CSF otorhinorrhea: in some traumatic/ iatrogenic cases
 Idiopathic/ Spontaneous: headache 11

12. PHYSICAL EXAMINATIONS
o Multimodality approach:
o Reservoir sign:
headache relieved due to CSF drainage externally intermittently
from one of the accumulated paranasal sinuses with the change in
head position
 Queckenstedt Stooky test:
On endoscopy, CSF drainage is elicited by patient having perform
Valsalva manoeuver or by compressing both jugular veins
 Double ring/ Halo sign:
CSF detected from mixed blood when placed on filter paper with clinically
detectable ring
Rhinologic: Endoscopy Otologic Head and neck Neurologic evaluation
12

13. 13

14. DIFFERENTIAL DIAGNOSES
 Allergic Rhinitis
 Vasomotor Rhinitis
Differences between CSF Rhinorrhea & Nasal secretions:
Features CSF Rhinorrhea Nasal secretions
History Trauma/ Surgery/ Tumor Sneezing, stuffinesss
Flow Drops/ stream, not sniffed back Continuous, sniffed back
Character Clear, watery Slimy
Taste Sweet Salty
Sugar +nt >30 mg/dl <10 mg/dl
Beta2
transferrin
Always present Always absent
14

15. LABORATORY VALUES
 Rapid but highly
unreliable
 Not for screening or
confirmation
 False +ve: d/t
reducing substance
in nasolacrimal
secretions
 False –ve: acute
meningitis
 92% sensitive, 100%
specific
 PG-D synthase
 Production: Arachnoid
cells, oligodendrocytes
& choroid plexus
 Altered by:renal
failure, multiple
sclerosis, cerebral
infarction, CNS tumors
Glucose Content Beta-trace protein Beta-2 transferrin
 Highly sensitive & specific
 Rapid, Non-invasive
 Currently single best lab
test to identify +nce of
CSF in sinonasal fluid
 Produced by
neuraminidase activity
 Present in CSF +
Perilymph + Aqueous
humor
15

16. IMAGING TECHNIQUES
1. CT-Scan:
o HRCT
 imaging of choice
 Axial plane with <1 mm thickness & reformatted into coronal and
sagittal plane
 Congenital defects- best diagnosed with 3-D reconstruction
o CT-cisternography: intrathecal contrast to identify leak easily
2. MRI: less diagnostic
3. Nuclear Medicine Studies (Serial scanning/ Scintiphotography):
using DTPA, Radioactive Iodine-131
16

17. 17

18. MANAGEMENT
Conservative Management:
1. 15-30˚ bed inclination: decrease CSF pressure @ basal
cisterns
2. Avoid: sneezing, coughing, nose blowing & heavy lifting
3. Stool softner: to decrease straining
4. Subarachnoid lumbar drain: 5-10 ml/hr, intermittent, in small
defects
5. Antibiotics: prophylactic
6. Diuretics (Acetazolamide): in spontaneous type
18

19. Surgical Management:
o Neurosurgical intracranial approach:
o Frontal craniotomy
o Middle/Posterior craniotomy
o Repair techniques:
 Free or pedicled periosteal or dural flaps
 Muscle plugs
 Mobilized portions of falx cerebri
 Fascia graft
 Flaps + fibrin glue 19

20. 20

21.  Extracranial approach:
• Leakage from sphenoidal sinus
• Osteoplastic flap for defects >2 cm above floor & lateral
to lamina papyracea
Transnasal approach:
 External ethmoidectomy
 Transethmoidal sphenoidectomy
 Transseptal sphenoidotomy
 Transantral approach- Caldwell- Luc procedure 21

22.  Endoscopic technique:
 Most widely used
 General concepts:
 Decongestion to maximize visualization (1:1000 epinephrine or
4% cocaine solution)
 Specific endoscopic approach:
 Designed to gain access to the area of interest in most efficient
fashion
 Approaches:
Transfrontal
Transcribriform
Transplanum
Transsellar
Transclival
Transpterygoid
22

23. FOLLOW UP
 Non absorbable packing: removed on day 7-10 of operation
 Regular endoscopic examination & minimal debridement of
surgical site to r/o recurrence of encephalocele/ CSF leak
 Close f/u in raised ICP
 Acetazolamide use:
 Close electrolyte monitoring
 Ventriculoperitoneal shunt if intolerable S/Es
23

24. COMPLICATIONS
1. Meningitis: most feared & severe
i. Bacterial:
 S. pneumoniae, H. influenzae
 In first 3 weeks with trauma (10%) & non-trauma(40%)
ii. Aseptic:
 Meningeal irritation due to manipulation during surgical repair
2. Anosmia
OUTCOME & PROGNOSIS:
Recurrence type Average time from repair
Most leak 2 years
Spontaneous leak 7 months
Traumatic leak 4 months (50% in 2 weeks) 24

25. REFERENCES
1. Image-Based Case Studies in ENT and Head &
Neck Surgery by Rahmat Omar & Prepageran
Narayanan
2. Diseases of Ear, Nose & Throat by PL Dhingra &
Shruti Dhingra 6th Edition
3. An illustrated text book Ear, Nose & Throat and
Head & Neck Surgery by Rakesh Prasad
Shrivastav 2nd Edition
25

26. THANK YOU
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