Csf rhinorrhea

this lecture about CSF rhinorrhea prepared by Dr. Ali Ghannam Alrshidi from Saudi arabia .

1. Dr. Ali Alrashidi ENT Resident-KSH- SA CSF RHINORRHOEA

2. In this lecture will discus the following : Basics information about CSF . Difintion of CSF rhinorrhea . causes of CSF rhinorrhea . most common sites of leaks . Symptoms and signs of CSF rhinorrhea . Physical Examination for patients with CSF rhinorrhea. How to diagnose patient with CSF rhinorrhea. Management patient with CSF rhinorrhea.

3. CSF BASICS Cerebrospinal fluid (CSF) is a clear , colorless body fluid found in the brain an d spine . It is produced in the choroid plexuses of the ventricles of the brain . It acts as a cushion or buffer for the brain's cortex , providing basic mechanical and immunological protection to the brain .

4. CSF BASICS Total volume of CSF varies from 90 to 150 m.l . It is secreted at the rate about 20m1/h (500 ml/day) There fore total CSF is replaced 3-5 times a day. Normal CSF pressure at lumbar puncture is 50-150 mm H2O It rises on coughing, sneezing, nose blowing, straining or lifting heavy weight.

5. CSF flow

6. CSF RHINORRHOEA •Is result of bony defect at skull base with disruption of arachnoid, dura mater and sinonasal mucosa with a resultant pressure gradient that leads to active CSF leak from the nose.

7. Causes of CSF rhinorrhoea 1 . Acquired: Traumatic ( 95% ) Accidental Head Trauma ( 80% ). Iatrogenic Surgical Trauma ( 15% ) e.g : FESS and Endoscopic neurosurgical Surgeries Non-Traumatic (5% ): Normal ICP. High ICP. 2 . Congenital. Meningocoele , Meningoencephalocoele

8. COMMON SITES OF LEAKAGE : ❑ Anterior crainial fossa Cribriform plate Root of ethmoidal cells Frontal sinus ❑ Middle cranial fossa : Injuries to sphenoid sinus ❑ Fracture Temporal bone : CSF reaches middle ear and then escapes through the eustachian tube into the nose (CSF otorinorrhoea )

9. Symptoms and signs : o Unilateral clear, watery discharge on bending or straining which can't be sniffed back. o Postnasal drip increased in supine position. o Salty taste in patient mouth. o Headache resolves when CSF leak occurs. o History of Sinonasal or neurosurgical procedure. o History of Head trauma. o History of Meningitis. o History of intracranial or skull base tumors •

10. Physical Exam: Manoeuvres to elicit a CSF leak (↑ICP): 1. Chine over the chest for 1 minute with straining ( Reservoir sign /Teapot sign ). 2. Compression of both jugular veins. Nasal endoscope : Unremarkable in most cases. Glistening moist nasal mucosa may be identified on the side of the CSF leak. Signs of High ICP: Papilledema. CN-6 palsy.

11. Clinically Ring (Halo) sign: Mixing CSF with blood and placing it onto a piece of filter paper will give a Ring sign . Central blood with clear ring of CSF.

12. LABORATORY TESTS

13. Imaging : 1. High Resolution CT Scan: Initial imaging study of choice. Should have 1mm cuts with axial, sagittal and coronal views. Sensitivity and specificity > 90%.

14. Treatment of CSF rhinorrhoea:

15. conservative management: The goal of conservative management is to reduce the CSF leak flow by decompressing the intracranial pressure, in this way, healing at the defect site may seal the leak without surgical intervention. o 70% of traumatic CSF leak will spontaneously resolve with conservative measures.

16. Conservative management Consist of: 1. Bed Rest (5-7 days): Head of bed elevated 30 degrees. Maintain normal BP. 2. Avoid (6-8 weeks): Sneezing (Anti-histamine). Coughing (Anti- tussives ). Vomiting (Anti-emetics). Straining (Stool softeners). Nose blowing. Heavy lifting (> 10lbs = 4.5kg). 3. Antibiotics: Controversial. Used to prevent intracranial infection (meningitis). 4. Diuretics: Indicated in patients with high ICP (benign intracranial hypertension). Acetazolamide (Diamox) is used to decrease ICP. 5. Lumbar Drain (5-7 days): Indicated if CSF leak fails to responds after 5-7 days of conservative management. Function to lower ICP and reduce flow through defect.

17. Surgical management : Indications: 1. Failed conservative management. 2. Intra-op recognition of CSF leak . 3. Large defects/leaks: Especially in association with pneumocephalus. 4. Idiopathic (spontaneous) leaks. 5. Open traumatic head wounds with CSF leakage .

18. Surgical management : A - Endoscopic Transnasal Approach: Success rates more than 90%. B- Open Transcranial Approach : it’s either extracranial or intracranial . Indications: 1. Comminuted skull fractures with displaced fragments requiring reduction. 2. Extensive skull base fractures. 3. Fractures associated with intracranial hemorrhages or contusions that require craniotomy for treatment.

19. Types of graft technical : 1- underlay 2- Overlay 3- Multilayers The graft to be : fat tissue. facia . Mucosa . Bone . Cartilages.

20. Questions ?

21. Thank you