Csfrhinorrhea 141110170914 Conversion Gate02

8/16/2019 Csfrhinorrhea 141110170914 Conversion Gate02

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CSF rhinorrhea



CSF rhinorrhea

•Leakage of CSF in to the nose

• Clear /

• mixed with blood (in a/c head injuries)



Etiology

•

Trauma (commonest)• Accidental

• Surgical ( FESS nasal !oly!ectomy trans s!henoidalhy!o!hysectomyskull base surgery)

• Neoplasms (benign/malignant) in"ading skull base

• Infammations (mucocele of sinuses sinu nasal !oly!

fungal infections of sinusitis # osteomyelitis erode the dura)

• Congenital (meningocelemeningoence!halocele # gliskull base defect)

• Idiopathic



Site of leakage

$% anterior cranial fossaa) Cribriform !late

b) &oof of ethmoid

c) Frontal sinus

'% iddle cranial fossa

$% injuries to s!henoid sinus

'% n * of tem!oral bone CSFE E+ nose (CSFotorhinorhea)



,iagnosis

•

h/o clear watery discharge on bending head/ str• sudden gush can-t be sni.ed back

• Reservoir sign • 0hen rising in morning csf collected in sinuses on be

head



•

1fter a head trauma• Double target sign when collected on a !iece of 2lt

with central blood # !eri!heral llighter halo



•

3asal endosco!y

locali4e site of CSF leak• 5tosco!ic /microsco!ic examination of ear 6 CSF

otorrhinorhea



Laboratory tests

•

7' transferrin• Sensiti"e # s!eci2c

• 5nly few dro!s of csf is needed

• 8erilym!h # a9ueous also contains it but not in nasal d

• 7eta trace !rotein

• S!eci2c for CSF• :lucose testing

• ; <= mg/dl in csf

• >$= mg/dl in nasal discharge



Localisation of site

•

High resolution CT scan• Coronal # axial cuts at $?' mm 6 bony defects

• 1xial 6 frontal # s!henoid sinus

• MRI• +' weighted image Site of leak

• 1cti"e CSF leak is needed• 3on in"asi"e



+reatment

•

Conservative• 7ed rest

• Ele"ating the head

• Stool softeners

•

1"oidance of node blowing snee4ing # straining• 8ro!hylatic abx 6 meningitis

• 1ceta4olamide 6 @ formn of CSF



Surgical re!air

•

3eurosurgical intra cranial a!!roach• Extra dural a!!roach

• External ethmoidectomy 6 cribriform !late

• +rans se!tal s!henoidal a!!roach 6 s!henoid

• 5steo!lastic Aa! 6 frontal



•

+rans nasal endosco!ic a!!roach• 0ith endosco!e

• Site of leak

$% Cribriform !late

'% Lateral lamina close to anterior ethmoid a

<% &oof of ethmoid

B% Frontal sinus leak

% S!henoid sinus

• 8re!aration of graft site

• Dnderlay !lacement of graft extra durally (mucosa for small defect%% Se!if;'cm)

• Surgical # gelfoam strengthen

• Lumbar drain if CSF !ressure is high

• abx



• Intrathecal fuorescein stud• 8re o!erati"ely 6to dx site

• ntra o!erati"ely for re!air

• n"asi"e

• =%'?=% ml of Auorescein mixed with !atients own CSF is injected$= - head down !osition for some time dye ca be detected intranasallyhel! of endosco!e%a!!ears bright yellow but when seen with blu

Aurescent green• Localise the lesion

• CT cisternogram• Localise the lesion

• ntrathecal injection of iohexol # C+

• 0here 7' transferrin can-t be done

Csfrhinorrhea 141110170914 Conversion Gate02

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