CEREBROSPINAL

FLUID
RHINORRHEA
Nino Zaya, MD
May 4, 2006

Objectives

Understand the classification system for

various causes 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 left side. 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,
52
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 was collected for analysis. Remainder of
patients exam was negative.

Definition

Cerebrospinal fluid (CSF) rhinorrhea

results from 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
successful repair utilizing a bifrontal
craniotomy for placement of a fascia lata
graft.
Extracranial approaches introduced mid20th century.
Endoscopic approaches were introduced
and popularized in the 1980s and early
1990s.

Classification of CSF
Rhinorrhea

Based on established pathophysiology of CSF

rhinorrhea
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.

A.

B.

Traumatic
Accidental
1. Immediate
2. Delayed
Surgical
1. Complication of neurosurgical procedures
a. 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 neoplasm
2. Hydrocephalus
a. Noncommunicating
b. Obstructive
3. Benign intracranial hypertension
B. 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 Osteomyelitis
4. Idiopathic

Pathophysiology

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

CSF circulates from ventricles through
foramina Luschka and Magendie to
subarachnoid space.
Total CSF volume is 140 mL=20 mL
(ventricles) + 50 mL (intracranial
subarachnoid space) + 70 mL (paraspinal
subarachnoid space).
CSF pressure ranges 40 mm H2O (infants) 140 mm H2O (adults).

Continued.

CSF pressure maintained by relative

balance between CSF secretion (choroid
plexus) and CSF resorption (arachnoid villi).
CSF resorption rate plays major role in
determining CSF pressure.
CSF rhinorrhea requires disruption of
barriers that normally 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

associated CSF rhinorrhea.
1.
2.

3.

Nontraumatic CSF rhinorrhea

Benign Intracranial Hypertension
(BIH)
Empty Sella Syndrome (ESS)

Continued.

Abnormalities bony architecture of

skull base and 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
bacterial meningitis.

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.

2.

Identification substance serves as

marker CSF.
Agent administration that documents
communication (intradural and
extradural space).

Continued.

Chemical markers
1.
2.

Glucose
Beta-2 transferrin

CSF Tracers
1.
2.

3.

Visible dyes (Intrathecal fluorescin)

Radionuclide markers (Radioactive iodine
(I131) serum albumen (RISA), technetium
(99mTc)-labeled serum albumen and
diethylenetriamterinepentaacetic acid (DTPA),
and Indium (In111)-labeled DTPA)
Radiopaque dyes (metrizamide)

Continued.

Continued.

Continued.

Localization Studies

Limitations
1.

Radionuclide cisternography

2.

MR cisternography

3.

Long scan acquisition times required that produce thick

image slices that cannot identify small skull base defects.

CT cisternography (Metrizamide)

4.

Poor spatial resolution.

Difficult to reliably interpret, even with slices of 1 mm.

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.
2.
3.
4.

Otolaryngologist
Neurosurgeon
Neuroradiologist
Infectious disease specialist

Continued.

CONSERVATIVE TREATMENT
OF CSF RHINORRHEA
1.

2.
3.
4.
5.

Subarachnoid drainage through a

lumbar catheter
Strict bed rest
Head elevation
Stool softeners
Patient advised to avoid coughing,
sneezing, nose blowing, and straining

Continued.

Transcranial Techniques
1.

2.

3.

After craniotomy, defect site identified,

and tissue graft placed to close the
defect.
Materials used: Fascia lata grafts,
muscle plugs, and pedicled galeal flaps
may be used.
A tissue sealant, such as fibrin glue,
may be used to hold the grafts into
position.

Continued.
4.

5.

6.

7.

Access to the cribriform plate region and roof

of the ethmoid requires a frontal craniotomy.
Extended craniotomy and skull base
techniques with even greater brain
compression provide access to the sphenoid
sinus defects.
Potential morbidities include brain
compression, hematoma, seizures, and
anosmia.
High failure rates (25%) despite direct
access.

Continued.

Extracranial Techniques
1.
2.
3.
4.
5.

Endoscopic repair of CSF rhinorrhea provides

adequate visualization of defect.
Intrathecal fluorescin facilitates defect
identification.
Prepare defect site for grafting.
Bipolar cautery or KTP laser used to fulgurate
any coincidental meningoencephalocele.
Mucosa within 5 mm of the margins of the
skull base defect must be removed to
facilitate mucosal grafting.

Continued.
6.

Graft material:

Temporalis fascia, fascia lata, muscle

plugs, pedicled middle turbinate flaps
(mucosa alone or mucosa and bone),
autogenous fat, free cartilage grafts (from
the nasal septum or the cartilaginous
auricle), and free bone grafts (from the
nasal septum or calvarium).
Acellular dermal allograft.
Higher failure with with pedicled
intranasal grafts versus free grafts.

Continued.

Underlay technique
Larger defects require layered
reconstruction less risk of delayed
recurrence and
meningoencephalocele formation.

Continued.

Never place mucosal grafts

intracranially (intracranial mucocele
after repair can occur).
Surgical sealant (fibrin glue) may be
used to help hold the grafts in place.
Absorbable nasal packing is placed
adjacent to the grafts, and
nonabsorbable packing used to
support absorbable packing.

Continued.

Continued.

Continued.

Pure endoscopic approaches provide

excellent access to the ethmoid roof,
cribriform plate, and most of the sphenoid
sinus.
Lateral sphenoid leaks may require an
extended approach, which incorporates
endoscopic dissection of the medial
pterygomaxillary space.
Osteoplastic flap or a simple trephine might
be required for repair of defects through
the posterior table of the frontal sinus.

Continued.

Postoperative care includes strict bedrest for

several days and antistaphylococcal 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 nasal
endoscopy facilitates identification of the
defect and 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.
2.

3.

4.
5.

Failed conservative management

Intraoperative recognition of a leak
(during sinus surgery, skull base surgery,
and craniotomy)
Large defects/leaks (especially in
association with pneumocephalus)
Idiopathic leaks (spontaneous leaks)
Open traumatic head wounds with CSF
leakage

Continued.

Traumatic (Nonsurgical) Etiology

1.

2.
3.

Conservative measures (reduces ICP and

promotes spontaneous closure).
Persistent rhinorrhea-explore and repair.
Extracranial endoscopic techniques and
open transcranial procedures (massive
head injury requiring urgent operative
exploration) might be warranted.

Continued.

Intraoperative Injury with

Immediate Recognition
1.

2.

CSF leaks noted intraoperatively

should be repaired immediately during
FESS.
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.

2.

3.

Conservative therapy for a few days

warranted since some leaks will close.
Can pursue operative intervention for
massive leaks early.
Significant delay between time of surgery
and CSF leak diagnosis-conservative
measures less successful, and early
surgical intervention warranted.

Continued.

Nontraumatic Leaks
1.
2.
3.

4.

5.

Usually require surgical repair.

Can attempt conservative measures.
Treat underlying etiology along with CSF
rhinorrhea (neoplasm, hydrocephalus, etc.).
Always consider unrecognized elevation of
ICP (ESS or BIH) in cases of spontaneous
CSF leaks.
Operative repair in ESS and BIH usually
necessary.

Case EA Revisited..

Patient EAs fluid analysis-positive

Beta-2 transferrin.
CT-Scan showed fluid/soft tissue in
left sphenoid sinus.
CSF tracer study utilizing
intrathecal omnipaque along with CT
scanning-positive in left sphenoid
sinus for CSF leak.

Case Continued.

Case Continued.

Patient taken to operating room and

underwent left sphenoidotomy with closure
of CSF leak.
Small pinpoint defect in left sphenoid sinus
had been identified.
Fascia lata and lateral rectus muscle were
utilized for closure 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
conservative measures alone.
Nontraumatic CSF rhinorrhea require operative repair.
Extracranial techniques are first line for CSF
rhinorrhea.

Bibliography

Halo sign
http://connection.lww.com/Products/
timbyessentials/Ch41.asp
Cummings Otolaryngology: Head
and Neck Surgery. Chapter 55. CSF
Rhinorrhea
Fluorescin CSF Leak
http://www.geocities.com/shouser14
4/csf.html