PowerPoint Presentation
Dr. ADITYA GHOSH ROYM.S. E.N.T. PGT 2N.R.S.M.C.H .
CSF RHINORRHOEA
INTRODUCTIONCSF RHINORRHOEA REFERS TO A FISTULA BETWEEN THE
SUBARACHNOID SPACE AND NASOPHARYNX.DESCRIBED FIRST BY GALEN IN
200B.C.DANDY WAS THE FIRST PERSON TO CLOSE A CSF LEAK USING FRONTAL
CRANIOTOMY APPROACH IN 1926.IN 1964 VRABEC AND HALLBERG DESCRIBED
ENDONASAL APPROACH TO REPAIR A CSF LEAK IN CRIBRIFOM AREA.
Causes of CSF
RhinorrheaCONGENITALIDIOPATHICSURGICALINTRANASALENDOSCOPIC SINUS
SURGERYTRANSCRANIALTRAUMAINFLAMMATORYNEOPLASM
High pressure leaks (always associated with concommitant
hydrocephalus)
Encountered in the cribriform area. This is due to the fagility
and unique anatomy in this area
The leak during these conditions functions as a safety valve
alleviating the increased intracranial pressure.
These high pressure leaks are associated with slow growing
tumors and 1/4 of them have hydrocephalus.
Closure of these leaks may worsen the condition of the patient
if the causative lesion is left untreated.
Normal pressure leaks .Normal pressure leaks may result from
congenital defects such as ,preformedpathways ,fistulas,
meningoceles,meningo encephaloceles .
Ostetis or osteomyelities of skull base bone may cause CSF
rhinorrhoea infrequently.
Lateral lamellae of cribriform plate
Persistence of the lateral craniopharyngeal canal(sternbergs
canal)
SPONTANEOUS CSF RHINORRHOEA
True spontaneous leaks are really rare. There is almost always
some antecedent traumatic event.
NUSS postulated the various causes of spontaneous CSF
rhinorrhoea. He named them as "4 P's".
1. Increased intracranial pressure 2. Brain pulsations which
continuously occur along the skull base 3. Degree of pneumatisation
of the paranasal sinuses 4. Arachnoid pits / villi exist normally
along the skull base. Continued transmission of pulsation, erodes
the bone until the arachnoid communicates with a pneumatised space
with the potential to develop fistula.
Elevated ICP is a primary characteristic of benign intracranial
hypertension (BIH),
Benign intracranial hypertension, also known as idiopathic
intracranial hypertension and pseudotumor cerebri, is a syndrome of
increased ICP in the absence of specific causes such as
intracranial masses, hydrocephalus, and dural sinus thrombosis.
Clinical manifestations of BIH include headache, pulsatile
tinnitus, papilledema, and visual disturbances including abducens
nerve palsy.
In fact, the demographics of the population with spontaneous CSF
leak are quite similar to those of the average population of
patients with BIH
EMPTY SELLA Normally, the pituitary gland fills the entire sella
turcica
arachnoid and CSF herniate through the sellar diaphragm, this
CSF- filled sac may partially or completely compress the pituitary
gland.
When this compression occurs, an empty sella results.
The clinical manifestations and demographic profile of patients
with empty sella syndrome (ESS) are highly similar to those for
patients with BIH and patients with nontraumatic CSF leaks.
The clinical presentation of ESS includes headache, memory
losses, cerebellar ataxia, papilledema, and visual field
defects.
Differential diagnosisCSF ottorhoea
Sinonasal irrigation
Rhinitis
DIAGNOSIS
BEDSIDE TESTS FOR DETECTING CSF RHINORRHOEA
QUECKENSTEDTs TEST pressure on b/l jugular veins increases
rhinorrhea.
RESERVOIR SIGN This test is ideally performed immediately on
rising from the bed. The patient is asked to place the chin over
their chest. The patient must stay in that position for one full
minute. Clear fluid dripping from the nose is CSF.
HALO / DOUBLE RING SIGN If rhinorrhea associated with blood.
Clear ring surrounds blood.
Handkerchief test: Discharge from the nose is blown into a
handkerchief and is allowed to dry. If the discharge is CSF the
handkerchief will not stiffen, if the discharge is secretions from
the nose the handkerchief stiffens due to the presence of mucin in
the nasal secretions.
LABORATORY TEST
Glucose oxidase test Glucose oxidase strips show colour change
on detection of glucose.(high false negative so abandoned)
2 transferrin in the nasal secretions. In CSF Beta 2 transferrin
is present, and it is absent in normal nasal secretions. (100%
Sensitivity and 95% specificity)
Trace Protein 100% sensitive and specific
Intrathecal radionucleotide test Most Specific
Tests that help to localise the CSF leak:
MR Cysternography
CT Cysternography (Contraindicated in active meningitis or High
ICP)
Intra thecal administration of non ionic contrast with high
resolution CT scan. Intra thecal administration of low quantities
of Fluorescein can also be used.
14
CT CISTERNOGRAPHY
TREATMENT
CONSERVATIVESTRICT BED RESTHEAD END ELEVATIONAVOID
STRAINLAXATIVESORAL DIURETICPROPHYLACTIC
ANTIBIOTICSSURGICALENDONASAL ENDOSCOPIC REPAIR OF CSF LEAK USING
VARIOUS GRAFT MATERIAL BY VARIOUS ENDOSCOPIC
TECHNIQUESTREATMENT
INDICATIONS OF SURGICAL INTERVENTION
Traumatic or post-operative leaks that recur or persists even
after 2 weeks of conservative management.Delayed or intermittent
leaks.High pressure leaks that act as safety valve for
hydrocephalus.Leaks associate with erosion, destruction, disruption
or combination of these at skull base and para nasal sinuses.Leaks
associated with congenital anomalies.Recurrent attacks of
meningitis.
VARIOUS SURGICAL APROACHES TO TREAT CSF RHINORRHOEASURGICAL
MANAGEMENT OF CSF
RHINORRHOEAINTRACRANIALEXTRACRANIALINTRADURALEXTRADURALENDOSCOPICOPENINTRADURAL
-EXTRADURAL
DEFECT LOCALISATION
CSF LEAK SEEN THROUGH ENDOSCOPE PEROPERATIVELY
FRESHEN MARGINS OF DEFECT
FASCIA LATA GRAFT BEING HARVESTED FROM THIGH
FAT BEING PUT TO SEAL DEFECT
GRAFT BEING PLACED TO SEAL DEFECT
SURGICEL & TISSUE GLUE BEING APPLIED
SURGICEL & TISSUE GLUE BEING APPLIED
OVERLAYUNDERLAYBATH PLUG(2)MULTIPLEBLANKETENDOSCOPIC APPROACH :
VARIOUS TECHNIQUES(1)
Overlay techniqueDone when Dura is adherent to the defect and
cannot be elevated.
Graft is placed over the defect after making the edges raw.
FASCIA LATA BEING PUT IN OVERLAY TECHNIQUE
UNDERLAY TECHNIQUE
Graft in form of fascia or cartilage is put between the
intracranial structure and defect
Rough epithelial surface faces the cranial surface while the
smooth endothelial surface faces nasal cavity.
BATH PLUG TECHNIQUE
FAT INSERTED INTO THE DEFECT(BATH PLUG TECHNIQUE)
BATH PLUG TECHNIQUE
MULTIPLE TECHNIQUEThis comprises of several layers of graft
materials used in cases of huge defects.
MULTIPLE LAYERS OF VARIOUS GRAFT MATERIALS BEING PLACED IN A
CASE OF LARGE DEFECT FOR BETTER STRENGTH
Transcranial approachDandy first successful repair
Bifrontal craniotomy and fascia lata graft
Access to cribriform plate region and roof of ethmoid
Exposure brain retracted - defect identified - repair by tissue
material
Extracranial approachDohlman used the naso orbital incision
Dissection through sinus cavities access to skull base defect
identified repair done
DisadvantagesFacial scarFacial numbnessOrbital injury
Trans nasal approachHirsch
Repair of sphenoidal sinus csf leak by this technique
USE OF LUMBAR DRAINAVERAGE DURATION OF KEEPING DRAINIV
ANTIBIOTICSORAL DIURETICSSTOOL SOFTENERSHEAD END ELEVATEDAVOID
STRAINING IN ANY FORMPOST OP MANAGEMENT
CSF rhinorrhea can nowadays be more accurately localized and
diagnosed with the help of modern radiological techniques. The
repair of CSF rhinorrhea has changed from open craniotomy to
minimally invasive techniques i.e. endonasal endoscopic techniques.
Endoscopic technique is practiced by many ENT surgeons and gaining
popularity due to overall success.The presence of CSF rhinorrhea
entails a significant risk to patients life (3). The clinical
confirmation should be performed by nasal inspection and
determination of CSF markers like beta 2 transferrin which has high
sensitivity and specificity (4).
DISCUSSION
CSF RHINORRHOEA-POTENTIALLY LIFE THREATENING OWING TO RISK OF
MENINGITIS MC SITE CRIBRIFORM PLATE OF ETHMOID DIAGNOSIS BY A
VARIETY OF CLINICAL & RADIOLOGICAL TECHNIQUES, THOUGH MR
CISTERNOGRAPHY WITH HEAVILY T2W AND 3D CISS SEQUENCES BEING THE
MODALITY OF CHOICE CONSERVATIVE AND SURGICAL MANAGEMENT DEPENDING
ON THE CAUSE, SITE AND DURATION OF CSF LEAK VARIETY OF
INTRACRANIAL/ EXTRACRANIAL , OPEN/ ENDOSCOPIC APPROACHES AVAILABLE
FUTURE TREND IS TOWARDS MINIMALLY INVASIVE ENDOSCOPIC
APPROACHESCONCLUSION
STEP BY STEP CSF RHINORRHOEA(ENDOSCOPIC NASAL REPAIR) BY NISHIT
J SHAH
WORMALD-ENDOSCOPIC SINUS SURGERY 2ND ED
CLOSURE OF CEREBROSPINAL FLUID LEAKS PREVENTS ASCENDING
BACTERIAL MENINGITIS-BERNAL-SPREKELSEN, ALOBID I, MULLOL J.
SPONTANEOUS CSF LEAK: DEFINITIVE REPAIR AND MANAGEMENT-WOODWORTH
BA, PRINCE A, COHEN NA.
REFERENCES
