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Csf rhinorrea / dental implant courses

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Csf rhinorrea / dental implant courses

  1. 1. Cerebrospinal fluid:Cerebrospinal fluid: Implications in oral andImplications in oral and maxillofacial surgerymaxillofacial surgery INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY Leader in continuing Dental EducationLeader in continuing Dental Education .. Seminar on,Seminar on, www.indiandentalacademy.com
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  3. 3. CONTENTS a) Introduction b) Physiology and anatomy c) Incidence d) Pathophysiology e) Classification f) Evaluation g) Clinical management www.indiandentalacademy.com
  4. 4. www.indiandentalacademy.comwww.indiandentalacademy.com Indian Dental academy • www.indiandentalacademy.com • Leader continuing dental education • Offer both online and offline dental courses
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  9. 9. INTRODUCTION Cerebrospinal fluid is an Essential Component of the central nervous system. It serves as a cushion and lubricant for the cerebral hemispheres, cerebellum and the layers of the meninges. CSF pathology, including leaks and fistulas are documented in a variety of clinical situations, ranging from trauma to skull based surgery including functional endoscopy. www.indiandentalacademy.com
  10. 10. Galen in the second century AD was the first to document a description of the CSF fistula (identified as rhinorrhea). The first co-relation between CSF rhinorrhea and craniomaxillofacial trauma was made in the 17th century by Bidloo the Elder. CSF fistula is a serious and potentially fatal condition. Successful management requires a thorough understanding of the pertinent anatomy and pathophysiology www.indiandentalacademy.com
  11. 11. PHYSIOLOGY AND ANATOMY CSF is a clear fluid bathing the brain and the meninges that is produced on a daily basis in the ventriculocisternal portion of the nervous system. Normally the intracranial volume is about 1700 ml of which CSF is approx 50 to 160 ml. It forms at the rate of 20 to 22 ml per hour, or approx to 500 ml per day. The CSF as a whole is renewed 4 or 5 times a day. www.indiandentalacademy.com
  12. 12. The choroid plexuses around the lateral ventricles are the main sites of CSF formation. CSF has been aptly termed as “THIRD CIRCULATION”, when compared to blood and lymph. Circulation begins from, Choroid plexuses in the lateral ventricles Third ventricle through the interventricular foramina of Monro www.indiandentalacademy.com
  13. 13. Fourth ventricle through the cerebral aqueduct of Sylvius The foramina of Megendie Luschka subarachonoid spaces Lateral and superior cerebral hemispheres www.indiandentalacademy.com
  14. 14. FUNCTIONS OF THE CSF It serves as the water cushion for the spinal cord and the brain, protecting them from the blunt force trauma. Provides buoyancy to the brain. Also serves to remove the cerebral metabolic wastes. www.indiandentalacademy.com
  15. 15. INCIDENCE 80% of CSF leaks are due to direct trauma. 16% occur secondary to surgery and the remaining 4% are spontaneous. Iatrogenic CSF fistulas most commonly occur after nasal, para nasal or skull based surgery. Anectodal reports suggests that the spontaneous leaks are associated with sellar masses,which erode through cranial base structures. The incidence of CSF leaks is much lower in the pediatric population. www.indiandentalacademy.com
  16. 16. PATHOPHYSIOLOGY CSF rhinorrhea or otorrhea results from communication between the intracranial contents and the nasal cavity or eustachian tubes. Leaks may occur directly from the anterior cranial fossa, through the nose, or indirectly from the middle cranial fossa or posterior cranial fossa through the eustachian tube. Commonly, this leakage occurs through the anterior fossa because the dura in this region www.indiandentalacademy.com
  17. 17. Tightly adherent to thin bone of the cribri form plate and the roof of the ethmoid. www.indiandentalacademy.com
  18. 18. CLASSIFICATON Ommaya’s classification of CSF leaks(1964) a) Traumatic i) Accidental ii) Iatrogenic b) Non traumatic i) High-pressure leaks ii) Tumours iii) Hydrocephalus iv) Benign intracranial hypertension c) Normal- pressure leaks i) Congenital anomalies ii) Focal atrophy iii) Osteomyelitic erosion www.indiandentalacademy.com
  19. 19. EVALUATION Clinical presentation CSF leaks regardless of etiology, other direct result of the compromise in the integrity of the dura that encloses the CNS. Once violated, direct passage of the CSF from the sub arachanoid space to the lower pressure regions may result. This manifests as rhinorrhea or otorrhea. www.indiandentalacademy.com
  20. 20. Maxillofacial trauma patients should be evaluated with high suspicion if epistaxis, pharyngorrhea, rhinorrhea hymotympanum, Battle’s sign, post traumatic serous otitis media, or otorrhea is present on examination. Battle’s sign is the indication of more serious skull fractures and should be assessed properly. www.indiandentalacademy.com
  21. 21. Laboratory Identification There are several methods to determine if fluid eminating from the trauma patient is CSF, Serum, nasal secretion. Quantitative comparison of glucose levels of the suspected fluid with that of the serum and nasal secretions. On evaluation CSF should have a glucose concentration that is equal to or greater than half the glucose concentration of serum. When compared www.indiandentalacademy.com
  22. 22. To nasal secretion the opposite hold good. Glucose oxidase tests (dipstick test) may give a false positive result because they are highly sensitive. Although glucose oxidase is one of the major laboratory tests for evaluating CSF comparison of the protein and potassium levels in the CSF with that of the nasal secretion. There is a specific iron binding trasferrin glyco protein which is found in the body fluids. www.indiandentalacademy.com
  23. 23. Its variant beta 2 to transferrin also known as tau transferrin, lacks a carbo hydrate side chain thereby increasing the positive charge. This is present only in the CSF making it an ideal marker for isolating it from the other secretions. It is detected by electrophoretic separation of the proteins and western blotting technique to detect concentration that exceeds 33 mg per ml. www.indiandentalacademy.com
  24. 24. Constituent CSF Serum Nasal Secretion Osmolarity 295mOsm/L 295mOsm/L 277mOsm/L Sodium 140 mEQ/L 140mEQ/L 150mEQ/L Potassium 2.5-3.5mEQ/L 3.3-4.8mEQ/L 12-14mEQ/L Chloride 120-130mEQ/L 100-106mEQ/L 119-125mEQ/L Glucose 58-90mg/100ml 80-120mg/100ml 14-32mg/100ml Albumin 50-75% 55% 57% Total Protein 5-45mg/dL 6-8.4 mg/dL 335-636mg/dL IgG 3.5mg/100ml 1140mg/100ml 51mg/100ml Beta 2 Transferrin 15% 0% 0% www.indiandentalacademy.com
  25. 25. Clinical Identification Aside from the laboratory evaluation there are clinical science and symptoms that suggests the potential leak. RESERVOIR SIGN: When the patient moves from the supine to upright position pooled CSF collected in the spinoid and ethmoid sinuses escapes through the nose. TARGET SIGN: When mixed fluid and blood is draining from the external auditory canal or nares. The ring test and the handkerchief test confirm the presence of CSF. www.indiandentalacademy.com
  26. 26. TRAMLINE PATTERN and HALO EFFECT: are due to the clear CSF spreading beyond the clotted blood components. CSF leaks may be associated with high or low pressure head aches. In addition, patients may also have anosmia secondary to olfactory tract damage, visual acuity changes, restriction of extra ocular movements, enopthalmus, and exopthalmus etc www.indiandentalacademy.com
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  29. 29. RADIOGRAPHIC EXAMINTION: a) Plain films and CT scans evaluate disruption in bony architecture, masses, or intracranial air and fluid levels. b) MRI offers a alternate modality for the source of the leak which could be a suspected soft tissue mass. c) Cysternography involves use of dyes and tracers in the identification of CSF leaks such as methylene blue, phenolsulfonpthalien, indigo carmine and fluorescein. www.indiandentalacademy.com
  30. 30. A similar technique uses radioactive agents such as indium 111-diethylene triaminic pentacetic acid (DPTA) and tecnetium 99m- DPTA. www.indiandentalacademy.com
  31. 31. CLINICAL MANAGEMENT 1) Nuerological assessment and stabilization. 2) Re-positioning and immobilization of the fractures helps to occlude the fistula. 3) Conservative management begins with strict bed rest, elevating the head of the bed 35-45degrees. 4) Avoiding activities that increase ICP such as coughing, nose blowing, sneezing and straining www.indiandentalacademy.com
  32. 32. 5) In view of the fact that CNS capillaries are impermeable to the larger molecules a blood brain barrier persists. Patients should receive prophylactic penicillin and sulphanamide or alternatively chloramphenicol in selected cases. This is continued for at least 7 days. 6) If the conservative management or the repairs of the fractures fails to slow the leak within 72 hours a LUMBAR SUBARACHONOID DRAIN is given when craniotomy or hamatoma evacuation is not indicated ( teflon epidural/ polyurethane catheters). www.indiandentalacademy.com
  33. 33. 7) Dandy in 1926 used the INTRACRANIAL REPAIR for CSF fistula. Its advantage is the direct visualization of the dural tear. 8) Dohlman in 1948 reported the first successful EXTRACRANIAL REPAIR. The approaches included external ethmoid spenoid, transmastoid, transseptospenoid and endoscopic surgery. 9) POSTOPERATIVE MANAGEMENT * Untreated intracranial hypertension can lead to failure of all procedures thus CSF shunts should be placed as an Ajunct to direct repair for 4 to 10 days. www.indiandentalacademy.com
  34. 34. * Antibiotics should cover normal upper airway pathogens and any bacteria associated with pre existing sinusitis. Nafcillin, gentamicin and/or cephazolin is an excellent choice. www.indiandentalacademy.com
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