05 04 06 Cerebrospinal Fluid Rhinorrhea

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CEREBROSPINAL

FLUID RHINORRHEA Nino Zaya, MD

May 4, 2006



Objectives

Understand the classification system for variouscauses of CSF rhinorrhea.

Understand the pathophysiology and diagnosis

of CSF rhinorrhea. Review diagnostic testing techniques (chemical

markers and CSF tracers) as well as localization

studies. Review both medical and surgical strategies in

treatment of CSF rhinorrhea.



Case EA

EA is a 55 y.o. female referred to Dr. Garcia with Sx suggesting ETD. She also c/o unilateral rhinorrhea occurring on the leftside. No previous history of head and neck surgery, or trauma.She has had intermittent headaches present. The unilateral

rhinorrhea has been present for 3 years with no improvement with allergy medications. Other history non-contributory.

Physical exam: Well-nourished female NAD, 160 pounds, 5’2”

Ears: weber-left ear, minimal effusion on left ear. R ear nl.

Nose: Anterior rhinoscopy negative. Prone, head-down position with valsalva lead to significant left-sided rhinorrhea. Fluid wascollected for analysis. Remainder of patient’s exam was negative.



Definition

Cerebrospinal fluid (CSF) rhinorrhea resultsfrom a direct communication between the CSF-containing subarachnoid space and the

mucosalized space of the paranasal sinuses.



Historical Perspective

First reported in the 17th century.

Dandy in 20th century, reported first successfulrepair utilizing a bifrontal craniotomy forplacement of a fascia lata graft.

Extracranial approaches introduced mid-20thcentury.

Endoscopic approaches were introduced andpopularized in the 1980s and early 1990s.



Classification of CSF Rhinorrhea

Based on established pathophysiology of CSFrhinorrhea

This has important clinical implications for the

selection of treatment strategies and patient counseling about prognosis.

Initial schemes-traumatic leaks and nontraumatic leaks.

Accidental Trauma-80% of all CSF rhinorrhea Non-traumatic-4% of all CSF rhinorrhea.

Procedure related-16% of all CSF rhinorrhea.



Continued….

Traumatic A. Accidental

1. Immediate2. Delayed

B. Surgical

1. Complication of neurosurgical proceduresa. Transsphenoidal hypophysectomy b. Frontal craniotomy c. Other skull base procedures

2. Complication of rhinologic procedures

a. Sinus surgery b. Septoplasty c. Other combined skull base procedures



Continued….

Nontraumatic A. Elevated intracranial pressure

1. Intracranial neoplasm2. Hydrocephalus

a. Noncommunicating

b. Obstructive3. Benign intracranial hypertensionB. Normal intracranial pressure

1. Congenital anomaly 2. Skull base neoplasm

a. Nasopharyngeal carcinoma

b. Sinonasal malignancy 3. Skull base erosive process

a. Sinus mucocele and Osteomyelitis4. Idiopathic



Pathophysiology

CSF produced by choroid plexus (20 mL/hour).

CSF circulates from ventricles through foraminaLuschka and Magendie to subarachnoid space.

Total CSF volume is 140 mL=20 mL (ventricles)+ 50 mL (intracranial subarachnoid space) + 70mL (paraspinal subarachnoid space).

CSF pressure ranges 40 mm H2O (infants) - 140mm H2O (adults).



Continued….

CSF pressure maintained by relative balance betweenCSF secretion (choroid plexus) and CSF resorption(arachnoid villi).

CSF resorption rate plays major role in determining CSF pressure.

CSF rhinorrhea requires disruption of barriers thatnormally separate the contents of the subarachnoid

space from the nose and paranasal sinuses Pressure gradient is also required to produce flow of

CSF.



Continued….

Conditions with elevated ICP and associatedCSF rhinorrhea.

1. Nontraumatic CSF rhinorrhea

2. Benign Intracranial Hypertension (BIH)

3. Empty Sella Syndrome (ESS)



Continued….

Abnormalities bony architecture of skull baseand CSF rhinorrhea.

1. Lateral lamellar of the cribriform plate (LLCP)



Continued….



Continued….



Continued….

Meningocele or meningoencephalocele may occur in association with CSF rhinorrhea.

Obtain imaging studies prior to blind biopsies.



Continued….



Continued….



Differential Diagnosis

CSF otorrhea presents as CSF rhinorrhea

Sinonasal saline irrigations

Seasonal & perennial allergic rhinitis Vasomotor rhinitis



History

Unilateral watery nasal discharge (laterality)

Salty taste.

Positional variation.

History trauma or surgery. Weight loss.

Presence of inflammatory paranasal sinus disease.

Headache.

History of single or multiple episodes bacterialmeningitis.



Physical Examination

Position testing.

Halo sign.

Glistening moist nasal mucosa on side of CSF leak.

Clear fluid stream.

Papilledema.

Abducens nerve palsy.

Traumatic CSF rhinorrhea and physical stigmata of recent or distant maxillofacial trauma.



Continued…..



Diagnostic Testing

2 types of testing:

1. Identification substance serves as marker CSF.

2. Agent administration that documents

communication (intradural and extradural space).



Continued….

Chemical markers1. Glucose

2. Beta-2 transferrin

CSF Tracers1. Visible dyes (Intrathecal fluorescin)

2. Radionuclide markers (Radioactive iodine (I131) serumalbumen (RISA), technetium (99mTc)-labeled serumalbumen and diethylenetriamterinepentaacetic acid(DTPA), and Indium (In111)-labeled DTPA)

3. Radiopaque dyes (metrizamide)



Continued….



Continued….



Continued….



Localization Studies

Limitations1. Radionuclide cisternography

Poor spatial resolution.

2. MR cisternography Long scan acquisition times required that produce thick image slices

that cannot identify small skull base defects.

3. CT cisternography (Metrizamide) Difficult to reliably interpret, even with slices of 1 mm.

4. All above studies assume presence active CSF flow (intermittent or very small leaks may not be identified)

Nasal endoscopy after intrathecal fluorescin infusion



Continued….



Continued….



Continued….



Management

Multidisciplinary approach:

1. Otolaryngologist

2. Neurosurgeon

3. Neuroradiologist

4. Infectious disease specialist



Continued….

CONSERVATIVE TREATMENT OF

CSF RHINORRHEA

1. Subarachnoid drainage through a lumbar catheter

2. Strict bed rest

3. Head elevation

4. Stool softeners

5. Patient advised to avoid coughing, sneezing, noseblowing, and straining



Continued….

Transcranial Techniques

1. After craniotomy, defect site identified, and tissuegraft placed to close the defect.

2. Materials used: Fascia lata grafts, muscle plugs, andpedicled galeal flaps may be used.

3. A tissue sealant, such as fibrin glue, may be used to

hold the grafts into position.



Continued….

4. Access to the cribriform plate region and roof of the ethmoid requires a frontal craniotomy.

5. Extended craniotomy and skull base techniques

with even greater brain compression provideaccess to the sphenoid sinus defects.

6. Potential morbidities include brain compression,hematoma, seizures, and anosmia.

7. High failure rates (25%) despite direct access.



Continued….

Extracranial Techniques1. Endoscopic repair of CSF rhinorrhea provides

adequate visualization of defect.

2. Intrathecal fluorescin facilitates defect identification.3. Prepare defect site for grafting.

4. Bipolar cautery or KTP laser used to fulgurate any coincidental meningoencephalocele.

5. Mucosa within 5 mm of the margins of the skullbase defect must be removed to facilitate mucosalgrafting.



Continued….

6. Graft material: Temporalis fascia, fascia lata, muscle plugs,

pedicled middle turbinate flaps (mucosa alone or

mucosa and bone), autogenous fat, free cartilagegrafts (from the nasal septum or the cartilaginousauricle), and free bone grafts (from the nasalseptum or calvarium).

Acellular dermal allograft. Higher failure with with pedicled intranasal grafts

versus free grafts.



Continued….

Underlay technique

Larger defects require layered reconstruction lessrisk of delayed recurrence andmeningoencephalocele formation.



Continued….

Never place mucosal grafts intracranially (intracranial mucocele after repair can occur).

Surgical sealant (fibrin glue) may be used to helphold the grafts in place.

Absorbable nasal packing is placed adjacent tothe grafts, and nonabsorbable packing used to

support absorbable packing.



Continued….



Continued….



Continued….

Pure endoscopic approaches provide excellentaccess to the ethmoid roof, cribriform plate, andmost of the sphenoid sinus.

Lateral sphenoid leaks may require an extendedapproach, which incorporates endoscopicdissection of the medial pterygomaxillary space.

Osteoplastic flap or a simple trephine might berequired for repair of defects through theposterior table of the frontal sinus.



Continued….

Postoperative care includes strict bedrest for several days andantistaphylococcal antibiotics.

Observation in ICU for first 24 hours.

Continue lumbar drain for 4 to 5 days.

Nasal packing removed after several days. Operative site may be checked through serial nasal endoscopy.

Patients advised to avoid strenuous activity, sneezing, coughing for 6 weeks after repair.

Primary cases successful repair: 85%-90% Secondary endoscopic repair also has high likelihood of success.



Continued….

Endoscopic techniques offer several advantages.

Excellent visualization afforded by nasalendoscopy facilitates identification of the defectand graft placement.

Endoscopic repair is also well tolerated,especially compared with intracranial techniques.

Report outcomes are excellent for both primary and secondary endoscopic repairs.



Management Strategy

Indications

1. Failed conservative management

2. Intraoperative recognition of a leak (during sinus

surgery, skull base surgery, and craniotomy)

3. Large defects/leaks (especially in association withpneumocephalus)

4. Idiopathic leaks (spontaneous leaks)5. Open traumatic head wounds with CSF leakage



Continued….

Traumatic (Nonsurgical) Etiology

1. Conservative measures (reduces ICP and promotesspontaneous closure).

2. Persistent rhinorrhea-explore and repair.

3. Extracranial endoscopic techniques and opentranscranial procedures (massive head injury

requiring urgent operative exploration) might be warranted.



Continued….

Intraoperative Injury with Immediate

Recognition

1. CSF leaks noted intraoperatively should be

repaired immediately during FESS.2. Intracranial and skull base procedures include

deliberate violations of the dura; provide a

watertight seal at the end of the procedure.



Continued….

Operative Injury with Delayed Recognition

1. Conservative therapy for a few days warrantedsince some leaks will close.

2. Can pursue operative intervention for massiveleaks early.

3. Significant delay between time of surgery and CSF

leak diagnosis-conservative measures lesssuccessful, and early surgical intervention warranted.



Continued….

Nontraumatic Leaks

1. Usually require surgical repair.

2. Can attempt conservative measures.

3. Treat underlying etiology along with CSFrhinorrhea (neoplasm, hydrocephalus, etc.).

4. Always consider unrecognized elevation of ICP

(ESS or BIH) in cases of spontaneous CSF leaks.5. Operative repair in ESS and BIH usually necessary.



Case EA Revisited…..

Patient EA’s fluid analysis-positive Beta-2transferrin.

CT-Scan showed fluid/soft tissue in left

sphenoid sinus.

CSF tracer study utilizing intrathecal omnipaquealong with CT scanning-positive in left sphenoid

sinus for CSF leak.



Case Continued….



Case Continued….

Patient taken to operating room and underwent leftsphenoidotomy with closure of CSF leak.

Small pinpoint defect in left sphenoid sinus had beenidentified.

Fascia lata and lateral rectus muscle were utilized forclosure along with fibrin glue.

Patient had intraop lumbar drain placed for

decompression by Neurosurgery Post-operatively-CSF leak resolved and area where leak

located healed.



Conclusions

Categorize leaks Beta-transferrin assay and several CSF tracer studies available,

but have limitations. High-resolution CT provides detailed information about the

bony skull base anatomy MR assesses soft tissue issues, including unrecognized tumors

and coincidental meningoencephaloceles. Many CSF leaks respond to conservative management

(observation plus measures to minimize ICP).

Traumatic CSF rhinorrhea tends to resolve with conservativemeasures alone. Nontraumatic CSF rhinorrhea require operative repair. Extracranial techniques are first line for CSF rhinorrhea.



Bibliography

Halo signhttp://connection.lww.com/Products/timbyessentials/Ch41.asp

Cummings Otolaryngology: Head and Neck Surgery. Chapter 55. CSF Rhinorrhea

Fluorescin CSF Leak

http://www.geocities.com/shouser144/csf.html

http://connection.lww.com/Products/timbyessentials/Ch41.asp




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05 04 06 Cerebrospinal Fluid Rhinorrhea