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CSF Rhinorrhea

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,

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CSF Rhinorrhea

  1. 1. CSF RHINORRHEA Intern Dr Sunil Baniya Shree Birendra Hospital ENT Department 1
  2. 2. CASE The patient presented with clear nasal drips after an endoscopic nasal procedure. What is the diagnosis and subsequent management? 2
  3. 3. CONTENTS  Definition  Etiology  Presentation to Hospital  Physical Examinations  Differential Diagnoses  Laboratory Values  Imaging Techniques  Management  Follow Up  Complications  Outcome & Prognosis 3
  4. 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
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  6. 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. 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. 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. 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. 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. 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. 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
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  14. 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. 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. 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. 17
  18. 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. 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. 20
  21. 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. 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. 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. 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. 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. 26. THANK YOU 26
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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,

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