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Cerebrospinal Fluid (CSF) Rhinorrhea causes, symptoms, treatment, complications

Definition: CSF Rhinorrhea (liquorrhoea) is leakage of cerebrospinal fluid from the nose and it occurs when there is a fistula between the dura and the skull base.

Etiology:
  • Congenital: defect in anterior skull base, with or without meningocele.
  • Traumatic (90%): - Accidental: fracture base.
  • Surgical e.g. Endoscopic Sinus Surgery (ESS).
  • Inflammatory: Osteomyelitis, syphilis.
  • Neoplastic: e.g. nasal carcinoma.
    CSF-rhinorrhea
  • Idiopathic: due to increased intracranial tension.

Pathology: 
Origin may be:
  1. Roof of nose (cribriform plate) 
  2. Roof of ethmoids
  3. Sphenoid sinus 
  4. Middle ear cleft (CSF ottorhinorrhea)

Symptoms of CSF Rhinorrhea:

  • Unilateral, clear, watery, salty discharge increase by straining, coughing or leaning forwards  and it does not stiffen the handkerchief (no mucous).
  • Headache: due to increase or decrease ICT.

Signs:

  • Usually there are no sings on examination.
  • Rarely, the leaked fluid may be observed through the nose. This may be increased by asking the patient to lean forwards in the seated position and pressing on the ipsilateral side of the neck thus occluding the IJV and raising the intracranial pressure.
  • Halo sign: an important marker for CSF rhinorrhea. It’s a clear ring which surrounds a central bloody spot after bloody nasal discharge is dropped upon a handkerchief or paper towel. It does not stiffen the handkerchief. This test may be done immediately after trauma in case of suspicion. It’s to be noted that either tears or saliva is likely to give a false positive halo sign.
  • Nasal endoscopic examination may reveal the site of leakage and any other associated meningo-/encephalocele.

Investigations for confirmation of diagnosis:

Chemical markers:

  • Glucose oxidase test strips.
  • B2 transferrin.
  • Beta-trace protein.
    CT-CSF-rhinorrhea

Localization studies:

  • CT nose, PNS and skull base.
  • CT cisternography: CT as above together with intrathecal injection of a radio-opaque material (omnipaque).
  • MRI of the nose, PNS and skull base: usually gives good idea about site of CSF leakage as CSF appears hyperintense in T2-wighted images.

Treatment of CSF Rhinorrhea:

a. Conservative:

  • Bed rest in head up position.
  • Avoid nose blowing and straining.
  • Avoid intra nasal medications.
  • Prophylactic antibiotics.
  • Sometimes repeated lumber puncture or even lumbar drain.

b. Surgical: 

  • If failed medical treatment for 3 weeks or complications.
  • Repair the defect by: Graft: fat, muscle, or fascia or Flap (septal flap).
Done via: Transcranial (external) or transnasal (endoscopic) approaches.

Complications of CSF Rhinorrhea:

  •  Meningitis 
  • Brain herniation 
  • Pneumocephaly.

Summary and key points:

  1. CSF rhinorrhea is not uncommon condition. It may be traumatic or nontraumatic.
  2. Traumatic conditions are more common.
  3. The mainstay of the diagnosis is by confirming the presence of extracranial CSF and by accurately determining the site and size of the defect.
  4. Accidental trauma patients may resolve spontaneously. Otherwise, endoscopic multilayered repair is the mainline of treatment.
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Dr.Tamer Mobarak

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