Management of CSF RhinorrheaSPENCER C. PAYNE, MDASSOCIATE PROFESSOR

DIRECTOR OF RHINOLOGY & SINUS SURGERY

DEPARTMENT OF OTOLARYNGOLOGY – HEAD & NECK SURGERY

AND DIVISION OF ALLERGY & CLINICAL IMMUNOLOGY

UNIVERSITY OF VIRGINIA

Disclosures

u Consulting: Cook Medicalu Clinical Research (Industry Sponsored)

u Cumberland Pharmaceuticals

u Astra-Zeneca

CSF Leak Etiology

u Traumau Neoplasmu Congenitalu Spontaneous

CSF Physiology

u Produced in Choroid Plexusu Lateral, third and fourth ventricles

u 0.35 mL/min

u 90-150 mL total volume

u Normal Pressure: 5 – 15 cmH2Ou Multiple factors for variation

u Time, Age, Activity, Sleep

Case

u 47 year old femaleu 3 month history of

unilateral right nasal drainage; clear, watery

u Seems to be bad for several days then improves for a week or so

u PMH: obesity, HTN, pre-diabetic

u Meds: Metoprolol 50 BID

Not all clear rhinorrhea is a Leak!

Nellis and Payne. Otolaryngol Head Neck Surg. 2014;150:157-159.

Case – Workup?

u Labsu Halo Signu Glucoseu Beta-2 / Tauu Beta Trace

u Imagingu Radionuclide cisternographyu CT Cisternographyu High Res CT Scanu MR Cisternography

Oakley GM et al. Int Forum Allergy Rhinol. 2016;6:8–16.

Diagnostic Algorithm

Oakley GM et al. Int Forum Allergy Rhinol. 2016;6:8–16.

Imaging

Additional WorkupMODIFYING FACTORS

OSA and Spontaneous CSF Leak

u 70 Patients (59 female)

u Average BMI of 35.64

u 30% of patients with OSA

Fleischman et al. Laryngoscope. 2014 Nov; 124(11): 2645–2650.

Transverse Sinus Stenosis

u Idiopathic Intracranial Hypertension demographics similar to CSF leak

u Up to 90% of IIH patients have transverse sinus stenosis u Cause?

u Effect?

u Several series indicate improvement / resolution of symptoms after treatment (stenting)

Kanagalingam, S. & Subramanian, P.S. Curr Treat Options Neurol (2018) 20: 24.

“Non-Surgical” Management

u Grade D, Level 5 Evidence:u Case Reports:

uRansom and colleagues: Leak resolution after VP shunt revision

u Three case reports note resolution of CSF Leak after bariatric surgery

Wang et al. Otolaryngol Clin N Am 2011;44:845–856.

Non-Surgical Management

Non-Surgical Managementu Retrospective Studyu 16 patients u Average duration of leak 4.8

months prior to presentationu Acetazolamide 250 mg BID

and u HOB Elevation

u Stool Softeners

u Activity restriction

u 5/16 resolved without surgeryu Average 470 day follow-up

Summary

u Primary diagnostic tool: u Beta-2 (Tau) transferrinu But beta-trace may surpass in future

u Primary imaging modalities: u High Resolution CT Scan (< 1mm axials)u MR Cisternography can help

u Primary Management: Surgical Repairu Non-surgical treatments may be an option

Thank you!