Csf Rhinorrhea - Overview

Dr G. Malleswara Rao - Professor & Head of Department
Department of Neurosurgery, Mamata Superspecialty Hospital Khammam

1. CSF RHINORRHOEA Dr g Malleswara Rao M.S. Mch PROF & Head Dept. of Neurosurgery Mamata Medical College Khammam

2. CSF leak are the results of osseous defects at the skull base coupled with dura and arachnoid injury due to pressure gradient system .

3. Physiology CSF forms a jacket of fluid round the brain and spinal cord acting as a buffer against sudden jerks. Secreted by choroid plexus in the lateral,third & fourth ventricle & absorbed into dural venous sinuses by arachnoid villi . Villi have one-way valve mechanism allowing CSF of the subarachnoid space to be absorbed in to the blood . Total volume of CSF varies 90 to 150 ml.

4. Csf - Physiology It is secreted at the rate of about 20ml/ hr (350-500mL/day ). Thus total CSF is replaced three to five times every day. CSF pressure rise on coughing, sneezing, nose blowing straining on stools or lifting heavy weight. These activities should be avoided in cases of CSF leak or after its repair.

5. Anatomy

6. Sites of Leakage 1. CSF from Anterior cranial fossa reaches the nose via a) Cribriform plate b) Roof of ethmoid c) Frontal sinus 2 . CSF from Middle cranial fossa  1. injuries to sphenoid sinus 2 . In fracture of temporal bone CSF  Middle Ear  Eustachian Tube  nose ( CSF otorhinorhea )

7. Etiology – CSF Rhinorrhoea Trauma (commonest) Accidental Surgical ( Trans-sphenoidal hypophysectomy,skull base surgery) Neoplasms (benign/malignant) invading skull base Inflammations ( mucocele of sinuses , sinunasal polyposis, fungal infections of sinuses & osteomyelitis erode the bone & dura) Congenital ( meningocele,meningoencephalocele & gliomas with skull base defect ) Idiopathic

8. CSF vs Nasal Discharge

9. Clinically H/o clear watery discharge on bending head/ straining ,sudden gush can’t be sniffed back Headache nausea Signs of facial injury Anosmia Vertigo Meningism Seizures Fever

10. Clinical testing Reservoir sign : When rising in morning CSF collected in sinuses on bending head Double target sign when collected on a piece of filter paper with central blood & peripheral lighter halo Handkerchief test Valsalva manuover

11. Double target sign when collected on a piece of filter paper with central blood & peripheral lighter halo – also “ halo sign ”

12. Handkerchief Test Discharge from the nose is blown into a handkerchief and is allowed to dry. If the discharge is CSF the handherchief will not stiffen, if the discharge is secretions from the nose the handkerchief stiffens due to the presence of mucin in the nasal secretions.

13. investigations 1. Biochemical 2. Digital X-ray 3. CT Scan 4. MRI Scan 5. Cisternal fluorescin staining test 6. Radionucleotide scan

14. Biochemical 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

15. Roentgen Father of X-Ray

16. Sir Godfrey Newbold Hounsfield Father of CT Scan

17. Localisation OF Site of Leak High resolution CT scan Coronal & axial cuts at 1-2 mm } bony defects Axial frontal & sphenoid sinus

18. 3D CT Reconstruction

19. Localization contd.  Coronal CT cisternogram showing CSF draining from the subarachnoid space through the roof of the right ethmoid sinus(arrow ) into the nose .

20. Localization MRI T2 weighted image Site of leak Active CSF leak is needed Non invasive

21. Localization contd. Intrathecal fluorescein study it can be done preoperative  invasive procedure 0.25-0.5 Ml of 5% fluorescein diluted with 10mL of CSF is injected. patient lies in 10 degree head down position. D ye can be detected intranasally with the help of endoscope Dye appears bright yellow but when seen with blue filter it appear fluorescent green. Helps localize the lesion The most sensitivve test to detect CSF leak is intrathecal radionucleotide test.

22. Nasal Endoscopy

23. Radionucleotide sca n

24. Management E arly case of post traumatic Case of CSF rhinorrhea can be managed by : Conservative measures Bed rest Elevating the head of bed Stool softeners Avoidance of nose blowing, sneezing & straining Prophylactic antibiotics can be used to prevent meningitis Acetazolamide ↓ formation of CSF Mannitol as per ICP

25. Surgical treatment – history of Galen in 2 nd century AD mentioned about csf Miller in 1826 described csf circulation Dandy pioneered intracranial repairs in 1926. Extracranial repair by dohlam in 1948 Waiganand described endoscopic repair in 1981

26. Indication for Surgery Recurrent attacks of meningitis with continuing leak despite conservative management †Patients with enlarging pneumocephalus ( > 2 cc persistent intracranial air - significant) despite conservative treatment † Acute traumatic or post-operative leaks that recur or persist after 10-13 days of conservative management including Lumbar CSF drainage Proven intermittent or delayed leaks † High pressure leaks with hydrocephalus

27. Surgical Management

28. Trans Nasal Endoscopic Approach  Trans nasal endoscopic approach  With endoscope  Site of leak 1. Cribriform plate 2. Lateral lamina close to anterior ethmoid artery 3. Roof of ETHMOID 4. Frontal sinus leak 5. Sphenoid sinus

29. Endoscopic Repair

30. Summary

31. “The feasibily of an operation is not an indication for its performance!!”

32. Thank You