cerebro spinal fluid rhinorrhoea

1. Dr. ADITYA GHOSH ROY
M.S. E.N.T.
PGT 2
N.R.S.M.C.H .

2. *
*CSF 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.

4. *
*CONGENITAL
*IDIOPATHIC
*SURGICAL
*INTRANASAL
*ENDOSCOPIC SINUS SURGERY
*TRANSCRANIAL
*TRAUMA
*INFLAMMATORY
*NEOPLASM

5. * 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.

6. *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(sternberg’s
canal)

7. *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.

8. *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

9. 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.

10. *
*CSF ottorhoea
*Sinonasal irrigation
*Rhinitis

11. *

12. *BEDSIDE TESTS FOR DETECTING CSF RHINORRHOEA
*QUECKENSTEDT’s 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.

13. *LABORATORY TEST
*Glucose oxidase test – Glucose oxidase strips show colour change on detection
of glucose.(high false negative so abandoned)
*β2 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)
*βTrace 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.

15. *

16. *

17. *STRICT BED REST
*HEAD END ELEVATION
*AVOID STRAIN
*LAXATIVES
*ORAL DIURETIC
*PROPHYLACTIC
ANTIBIOTICS
*ENDONASAL
ENDOSCOPIC REPAIR
OF CSF LEAK USING
VARIOUS GRAFT
MATERIAL BY
VARIOUS ENDOSCOPIC
TECHNIQUES
*

18. 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.

19. SURGICAL MANAGEMENT
OF CSF RHINORRHOEA
INTRACRANIAL EXTRACRANIAL
INTRADURAL EXTRADURAL ENDOSCOPICOPEN
INTRADURAL -EXTRADURAL

20. DEFECT LOCALISATION

22. FRESHEN MARGINS OF DEFECT

25. GRAFT BEING PLACED TO SEAL DEFECT

27. SURGICEL & TISSUE GLUE
BEING APPLIED

28. OVERLAY
UNDERLAY
BATH PLUG(2)
MULTIPLE
BLANKET
*

29. Overlay technique
Done when Dura is
adherent to the
defect and cannot
be elevated.
Graft is placed over
the defect after
making the edges
raw.

31. 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.

32. BATH PLUG TECHNIQUE

34. BATH PLUG TECHNIQUE

35. MULTIPLE TECHNIQUE
This comprises
of several layers
of graft
materials used
in cases of huge
defects.

37. *
*Dandy 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

38. *
*Dohlman used the naso orbital incision
*Dissection through sinus cavities – access to skull base
– defect identified – repair done
*Disadvantages
*Facial scar
*Facial numbness
*Orbital injury

39. *
*Hirsch
*Repair of sphenoidal sinus csf leak by this technique

40. • USE OF LUMBAR DRAIN
• AVERAGE DURATION OF KEEPING DRAIN
• IV ANTIBIOTICS
• ORAL DIURETICS
• STOOL SOFTENERS
• HEAD END ELEVATED
• AVOID STRAINING IN ANY FORM
*

41. 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
patient’s 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).
*

42.  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 APPROACHES
*

43. 1) STEP BY STEP CSF RHINORRHOEA(ENDOSCOPIC NASAL REPAIR)
BY NISHIT J SHAH
2) WORMALD-ENDOSCOPIC SINUS SURGERY 2ND ED
3) CLOSURE OF CEREBROSPINAL FLUID LEAKS PREVENTS
ASCENDING BACTERIAL MENINGITIS-BERNAL-SPREKELSEN,
ALOBID I, MULLOL J.
4) SPONTANEOUS CSF LEAK: DEFINITIVE REPAIR AND
MANAGEMENT-WOODWORTH BA, PRINCE A, COHEN NA.
*