C.S.F
RHINORRHEA
Lt Col Mian Amer Majeed
Classified ENT Specialist
MH Rawalpindi
INTRODUCTION


It is the failed containment of the
cerebrospinal fluid in the subarachnoid
compartment.
It indicates a communication with the
subarachnoid space & therefore an opening of
the arachnoid, the dura and the bone to permit
exit of the CSF through the nose.
Cont….

The actual loss of CSF is of no particular consequence
however the persistent dural fistula represents a persistent
hazard for a potentially fatal purulent meningitis leading
to death if unrecognized.

Persistent CSF rhinorrhea is therefore an
absolute indication for a surgical repair of the
leak.
ORIGIN
Origin may be from any
cranial fossa i.e



Anterior,
Middle, or
Posterior
CSF PRESSURE

Normal CSF pressure is
40 mm in infants & 140
mm in adults.
CAUSES OF CSF RHINORRHEA

TRAUMATIC
Accidental
Acute
Delayed
Iatrogenic
Acute
Delayed
Cont….

NON TRAUMATIC
High pressure
Tumours (direct/ indirect effect )
Hydrocephalus
Normal pressure
Congenital anomalies
Focal atrophy of olfactory/sellar area
Osteomyelitic erosion
Idiopathic
CAUSES….Traumatic



80 %....secondary to head trauma with
associated skull base #.
16%....operations on nose , paranasal sinuses,
skull base.
Mostly occur through anterior cranial fossa. As
the bone of the anterior skull is thin & densly
adherent to the dura so dural tears also occur.
Cont….

Sites commonly involved in the anterior cranial
fossa are
Cribriform plate (commonest )
Fovea ethmoidalis
Posterior wall of frontal sinus
Cont….

Middle cranial fossa fractures are less likely to
cause CSF leakage into the nose however
common routes are
Via the sphenoid sinus
Eustachian tube
Cont….

CSF rhinorrhea may occur from the posterior
fossa in fractures of
Clivus
Petrous temporal bone
Cont….


Post traumatic CSF rhinorrhea is immediate in
most of the cases
When delayed, it appears within 3 months in
95% cases, probably due to
initial inflammation & edema
resorption of bone/soft tissue
disrupted blood supply
weakening of pia arachnoid seal
NONTRAUMATIC CAUSES





Uncommon
Mostly in adults
4th decade
♂ : ♀ ratio is 1:2
May occur after an episode of coughing,
sneezing or straining.
High pressure leaks




Arise from the cribriform area in 75 % of cases
They act as a safety valve to decrease the raised
ICP
84% are associated with slow growing intra
cranial tumours (Pituitary neoplasms are the
commonest)
16 % are related to hydrocephalus
Normal pressure leaks



Mostly are from the cribriform area and the sella
turcica but may be from the middle fossa.
90 % are due to potential congenital pathways
10 % are due to direct erosion of skull base due
to infections/ tumours like Osteomas of the
fronto ethmoidal region, Nasopharyngeal
angiofibromas, Nasopharyngeal CA,
Osteomylitic erosion
Diagnostic Aims

Is the fluid CSF?

Cause of leakage

Site of leakage
Presence of CSF leak

History
In cases of trauma any persistant rhinorrhea should be
considered CSF until proved otherwise.
Patient with recurrent pneumococcal meningitis
Bending the head forward will increase the rate of flow
Headache
Salty taste
Anosmia
Associated Symptoms
Cont…
Examination
May be unremarkable except for the
rhinorrhea.
Positional change or jugular compression
can increase the flow
Reservoir sign: After being supine for sometime
the patient is brought in an upright position,
with the neck flexed. A sudden rush of clear
fluid is indicative of CSF fistulae.

Cont….



Hankerchief Test: Fluid in rhinitis contains
mucous which stifins while CSF doesnot.
Halo Sign: When CSF rhinorrhea is blood
stained it dries out with a central blood stain
surrounded by a clear ring.
Nasal endoscopy with or without intrathecal
floresein for leak presence or localization
Cont…..


Biochemistry/ Immunochemistry
Estimation of glucose, proteins and
electrolytes can be done. A concentration of
30mg/dl or 1.6mmol/l of glucose is considered
confirmatory of CSF, however active meningitis
can lower the CSF glucose level.
β-2 Transferrin is pathognomonic of CSF
Demonstrate the Cause


Over ½ the cases of nontraumatic rhinorrhea
are high pressure leaks, majority related to
intracranial tumours.
CT scans and MRI have their diagnostic role
Localization of the leak





Radiology plays the key role to see the
anatomical site, size, side of the fistula
Bone defects, air fluid levels and erosions can be
seen.
Plain X rays… Pneumocephalus/ air fluid levels
CT scan in axial/ coronal views… Skull Base #s,
CSF fistulae
MRI… is not used as it is unable to show bone
windows
Cont…

Isotope studies
In case of inactive, intermittent, small or
doubtful leak, CT scan with contrast will not
reveal the leak. In such cases radio nuclied
cisternography is more effective. Indium IIIDPTA is generally used.
Cont…

Intrathecal dyes
Intrathecal floreciene with nasal endoscopes
are used for anterior fossa leaks
Management

Management consists of cooperation between
Neurosurgeon
Neuroradiologist
Otolaryngologist
depending upon severity, etiology, extent of
injury & anatomical site of leak.
Cont….
Treatment can be divided into
Medical &
Surgical
MEDICAL
In the acute CSF leak an initial trial of
conservative treatment should be considered as
majority of acute traumatic leaks heal
spontaneously.

Cont….





Bed rest in head up position
Avoiding coughing, sneezing, nose blowing &
straining.
Drugs to decrease spinal fluid production like
acetazolamide and frusemide.
Repeated removal of CSF via lumbar taps or an
indwelling lumbar subarachnoid drain.
Antibiotics
Cont….

If conservative treatment fails after 10 to 14 days
or if the leak recurs then surgical treatment is
indicated.
Surgical management



Intracranial approach
Extra cranial approach
Endoscopic repair
CSF rhinorrhea?
Confirm presence of leak
History
examination
Traumatic/Atraumatic
Nasal endoscopy
conservative
failure
localization
Surgical closure
successful
Glucose/ β2 transferrin
Thank you