Cases of csf rhinorrhea are managed according to their cause. A biopsy should never be obtained unless a complete imaging workup has been conducted. Salty or metallic taste in the mouth1 3. Chiapparini L, Ciceri E, Nappini S, Castellani MR, Mea E, Bussone G, Leone M, Savoiardo M. Headache and intracranial hypotension: neuroradiological findings. The resulting communication with the central nervous system (CNS) can result in a multitude of infectious complicati… In contrast to unilateral rhinorrhea, bilateral rhinorrhea gives no clue of the laterality of the defect. Laryngoscope. Ann Emerg Med.
Mirza S, Thaper A, McClelland L, Jones NS. However, most of the time physical examination is unrevealing, especially in patients with intermittent CSF rhinorrhea. Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years. In cases of iatrogenic injury during intracranial surgery, the obvious treatment is repair of the affected site which may require multiple procedures to fix 16).
Clin. CSF rhinorrhoea refers to the drainage of cerebrospinal fluid through the nose. Defects in the closure of the anterior neuropore can result in the herniation of central nervous tissue through anterior cranial fossa. The most common cause of leaking cerebrospinal fluid is a structural compromise secondary to craniofacial trauma, making up 80% of CSF rhinorrhea.
This is attributed to a technical error and is unlikely to represent a true recurrence. 2016 Oct;77(5):404-11. Diagn Interv Imaging. Submit a request for further information, a quotation or indicative cost. However, the proportion of small defects (< 1 cm²) was greater among the outpatients, and the operative technique differed significantly between the two groups 22). Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. Beta-2 transferrin is currently single best laboratory test for identifying the presence of CSF in sinonasal fluid.
Baugnon KL, Hudgins PA. Skull base fractures and their complications. The surgical failure rate is higher among those with elevated intracranial pressure 19). All Rights Reserved. If negative, there is a low likelihood of a leak 10). Depending on the size of the leak, patients may note a continual salty taste and a sense of drainage in the throat or watery drainage from the nose. In many cases the problem goes away on its own after a few days of rest. In those with spontaneous leaks, presentation frequently includes a pressure-like headache that may be positional in nature as well as pulsatile tinnitus 8). As most CSF leaks are secondary to either accidental trauma or iatrogenic causes, the history of a patient presenting with rhinorrhea or otorrhea should raise suspicion for CSF leak; thus one should obtain a recent history of trauma or a surgical procedure. Beta-trace protein also known as prostaglandin D synthase, this protein is synthesized primarily in arachnoid cells, oligodendrocytes, and the choroids plexus within the central nervous system (CNS). Rhinorrhea (runny nose) that is clear and watery may be the first sign of cerebrospinal fluid rhinorrhea.1 Other signs and symptoms may include: 1. Unilateral, clear, watery, salty discharge increase by straining, coughing or leaning forwards and it does not stiffen the handkerchief (no mucous). The most commonly asked questions, answered. The fluid arising from the nose can be tested for a particular protein, thus proving the origin for the fluid to be from the cerebro-spinal fluid. Management of unexpected cerebrospinal fluid leak during endoscopic sinus surgery. It can also be missed when accompanied by blood from the nose (epistaxis). Thus, trauma can easily disrupt both osseous structures and dura. Spontaneous CSF Leaks. A leak in this system, therefore, can be detrimental to brain blood supply and function and can increase the risk of direct trauma to brain parenchyma due to loss of fluid cushion.
Beta-trace protein is also present in the human testes, heart, and serum. In cases of chronic CSF leak or intracranial hypotension, MRI of the brain may show intracranial pachymeningeal thickening and enhancement with contrast, subdural fluid collections, and downward displacement of the brain. Repair the defect by: Graft: fat, muscle, or fascia or Flap (septal flap). Headache 2. google_ad_client: "ca-pub-9759235379140764", }); Huff T, Tadi P, Varacallo M. Neuroanatomy, Cerebrospinal Fluid. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470578. It is altered by the presence of renal failure, multiple sclerosis, cerebral infarction, and certain CNS tumors. Bending over and increased activity can make these symptoms worse. However, the presence of a ring sign is not exclusive to CSF and can lead to false-positive results 9). Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks.
The enzymatic breakdown or destruction of the bony architecture results in inflammation and potential violation of the dura. 2016 Nov. 6 (11):1126-30. They are, thus, more commonly associated with CSF leak compared to injuries to other locations due to the generally more extensive force of trauma, such as involvement in a motor vehicle accident. These leaks were typically approached via a frontal craniotomy. However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. Rarely, injury and disruption to the orbit can result in CSF occulorrhea 4). Headache: due to increase or decrease ICT. Measures of CSF components such as glucose have been used in the past, but are neither sensitive nor specific; beta-2 transferrin, however, has been shown to have a high positive predictive value. Meco C, Oberascher G, Arrer E, Moser G, Albegger K. Beta-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula.
Depending on the rate of production and absorption (which varies person to person), the supply of CSF can be replaced about every 7.5 hours. Optic nerve deficits suggest a lesion in the region of tuberculum sellae, sphenoid sinus, or posterior ethmoid cells. This condition is frequently associated with obesity and female sex; In some studies, 60-70% of subjects presenting with spontaneous leak were female and BMI was overweight or obese; in two studies the mean BMI was approximately 35 7). Not all centers are capable of testing fluid for beta2-transferrin; therefore, sending the laboratory specimen out for processing may delay diagnosis. Eur Arch Otorhinolaryngol. Banks CA, Palmer JN, Chiu AG, O’Malley BW, Woodworth BA, Kennedy DW. The remaining cases may need further endoscopic revision with less than 10% of cases requiring open surgical revision 17).
It has been estimated that there is approximately 125 mL to 150 mL of CSF in the body at any given time 1). However, it is often missed if it does not immediately follow an injury as patients mistaken it for nasal mucus (runny nose). Various authors have concluded that most recurrent leaks manifest within 2 years after the repair. 2017 Sep. 127 (9):2011-6. Sometimes, associated symptoms can assist in localizing the leak. Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. It should be kept in mind, however, that beta-2 transferrin test does not provide information regarding the site or laterality of the defect. B-ENT. Platt MP, Parnes SM. 2014 Aug;24(3):439-65, vii-viii. Spontaneous leaks recur in an average of 7 months, while traumatic leaks recur in an average of 4 months. They will respond directly with further information. North Am. Rarely, the leaked fluid may be observed through the nose. Specimens should not be frozen. The resulting communication with the central nervous system (CNS) can result in a multitude of infectious complications that impart significant morbidity and potentially disastrous long-term deficits for the patient. Nasal endoscopic examination may reveal the site of leakage and any other associated meningo-/encephalocele.
Indeed this condition may be the presenting symptom for CSF rhinorrhoea. A CSF rhinorrhea can occur whenever there is open communication between the subarachnoid space and other spaces via meningeal disruption.
In one study, pituitary tumor resection made up nearly half of cases where tumor removal led to confirmed CSF rhinorrhea 6). Overall prognosis of CSF leak is very favorable, with one study citing 90% first attempt success rate of endoscopic repair of CSF rhinorrhea, and another study citing an overall success rate of 98% across traumatic, iatrogenic, and congenital causes 20). In: StatPearls [Internet]. Therefore, beta-2 transferrin is located only within the CSF, perilymph, and aqueous humor. Half of the traumatic leaks recur within 2 weeks postoperatively. Sci. VP shunts can be effective but have relatively high complication rates 15). 2003 Nov;129(5):508-17.
On occasion, the patient has a history of headache relieved by drainage of CSF. This test has been used to diagnose CSF rhinorrhea in multiple studies, with a sensitivity of 92% and specificity of 100%.
Meningoencephaloceles usually present in childhood as an intranasal/extranasal mass that transilluminates and expands with crying (Furstenberg sign). Medicine to Date| Simplified review of diseases by specialized doctors. Patients with recurrent meningitis, especially pneumococcal meningitis, should be evaluated for a defect that exposes the intracranial space to the upper airway, regardless of the presence or absence of CSF rhinorrhea. For example, anosmia (present in 60% of individuals with post-traumatic rhinorrhea), indicates an injury in the olfactory area and anterior fossa, especially when it is unilateral. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Drainage of CSF in some cases may often be elicited on endoscopy by having the patient perform a Valsalva maneuver or by compressing both jugular veins (Queckenstedt-Stookey test).