CSF rhinorrhea

CSF rhinorrhea
Leakage of CSF in to the nose
Clear /
mixed with blood (in a/c head injuries)

Etiology
Trauma (commonest)
Accidental
Surgical ( FESS, nasal polypectomy, trans sphenoidal
hypophysectomy,skull base surgery)

Neoplasms (benign/malignant) invading skull base

Inflammations (mucocele of sinuses ,sinu nasal polyposis,
fungal infections of sinusitis & osteomyelitis erode the bone &
dura)
Congenital (meningocele,meningoencephalocele & glioma with
skull
base defect)
Idiopathic

Site of leakage
1. anterior cranial fossa
a) Cribriform plate
b) Roof of ethmoid
c) Frontal sinus

2. Middle cranial fossa

1. injuries to sphenoid sinus
2. In # of temporal bone CSF ME ET nose (CSF
otorhinorhea)

Diagnosis
h/o clear watery discharge on bending head/ straining
sudden gush cant be sniffed back
Reservoir sign :
When rising in morning csf collected in sinuses on bending
head

 After a head trauma

Double target sign when collected on a piece of filter paper
with central blood & peripheral llighter halo

 Nasal endoscopy localize site of CSF leak

Otoscopic /microscopic examination of ear } CSF
otorrhinorhea

Laboratory tests
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

Localisation of site
High resolution CT scan
Coronal & axial cuts at 1-2 mm } bony defects
Axial } frontal & sphenoid sinus

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

Treatment
Conservative
Bed rest
Elevating the head
Stool softeners
Avoidance of node blowing, sneezing & straining
Prophylatic abx } meningitis
Acetazolamide } formn of CSF

Surgical repair
Neurosurgical intra cranial approach
Extra dural approach
External ethmoidectomy } cribriform plate
Trans septal sphenoidal approach } sphenoid
Osteoplastic flap } frontal

 Trans nasal endoscopic approach

With endoscope
Site of leak
1.
2.
3.
4.
5.

Cribriform plate
Lateral lamina close to anterior ethmoid a
Roof of ethmoid
Frontal sinus leak
Sphenoid sinus

Preparation of graft site

Underlay placement of graft extra durally (mucosa for small defect.. Septal cartilage
if>2cm)
Surgical & gelfoam strengthen
Lumbar drain if CSF pressure is high
abx

 Intrathecal fluorescein study

Pre operatively }to dx site

Intra operatively for repair
Invasive
0.25-0.5 ml of 5% fluorescein mixed with patients own CSF is injected & pt lies in
10 head down position for some time dye ca be detected intranasally with the
help of endoscope.appears bright yellow but when seen with blue filter }
flurescent green
Localise the lesion

CT cisternogram
Localise the lesion
Intrathecal injection of iohexol & CT
Where B2 transferrin cant be done