complications causes ent images meningitis diagnosis Reservoir sign : Double target sign differece between nasal secretion B2 transferrin Localisation treatment CT MRI conservative surgical

1. CSF rhinorrhea

2. CSF rhinorrhea
• Leakage of CSF in to the nose
• Clear /
• mixed with blood (in a/c head injuries)

3. Etiology
• Trauma (commonest)
• Accidental
• Surgical ( FESS, nasal polypectomy, trans sphenoidal hypophysectomy,skull
base surgery)
• Neoplasms (benign/malignant) invading skull base
• Inflammations (mucocele of sinuses ,sinu nasal polyposis, fungal
infections of sinusitis & osteomyelitis erode the bone &
dura)
• Congenital (meningocele,meningoencephalocele & glioma with skull
base defect)
• Idiopathic

4. Site of leakage
1. anterior cranial fossa
a) Cribriform plate
b) Roof of ethmoid
c) Frontal sinus
2. Middle cranial fossa 
1. injuries to sphenoid sinus
2. In # of temporal bone CSF ME ET nose (CSF otorhinorhea)

5. Diagnosis
• h/o clear watery discharge on bending head/ straining
• sudden gush can’t be sniffed back
• Reservoir sign :
• When rising in morning csf collected in sinuses on bending head

6. • After a head trauma
• Double target sign when collected on a piece of filter paper with central
blood & peripheral llighter halo

7. • Nasal endoscopy  localize site of CSF leak
• Otoscopic /microscopic examination of ear } CSF otorrhinorhea

9. Laboratory tests
• B2 transferrin
• Sensitive & specific
• Only few drops of csf is needed
• Perilymph & aqueous also contains it but not in nasal discharge
• Beta trace protein
• Specific for CSF
• Glucose testing
• > 30 mg/dl in csf
• <10 mg/dl in nasal discharge

10. Localisation of site
• High resolution CT scan
• Coronal & axial cuts at 1-2 mm } bony defects
• Axial } frontal & sphenoid sinus
• MRI
• T2 weighted image Site of leak
• Active CSF leak is needed
• Non invasive

11. Treatment
• Conservative
• Bed rest
• Elevating the head
• Stool softeners
• Avoidance of node blowing, sneezing & straining
• Prophylatic abx } meningitis
• Acetazolamide } ↓ formn of CSF

12. Surgical repair
• Neurosurgical intra cranial approach
• Extra dural approach
• External ethmoidectomy } cribriform plate
• Trans septal sphenoidal approach } sphenoid
• Osteoplastic flap } frontal

13. • Trans nasal endoscopic approach
• With endoscope
• Site of leak
1. Cribriform plate
2. Lateral lamina close to anterior ethmoid a
3. Roof of ethmoid
4. Frontal sinus leak
5. Sphenoid sinus
• Preparation of graft site
• Underlay placement of graft extra durally (mucosa for small defect….. Septal cartilage
if>2cm)
• Surgical & gelfoam strengthen
• Lumbar drain if CSF pressure is high
• abx

14. • Intrathecal fluorescein study
• Pre operatively }to dx site
• Intra operatively for repair
• Invasive
• 0.25-0.5 ml of 5% fluorescein mixed with patients own CSF is injected & pt lies in 10 ’
head down position for some time dye ca be detected intranasally with the help of
endoscope……….appears bright yellow but when seen with blue filter } flurescent
green
• Localise the lesion
• CT cisternogram
• Localise the lesion
• Intrathecal injection of iohexol & CT
• Where B2 transferrin can’t be done