CSF Rhinorrhoea: An Overview Of Endoscopic Repair
Samir Joshi, Rahul Telang, Rahul Thakur
Department of Otorhinolaryngology & Head-Neck Surgery, B.J Medical College & Sassoon general hospital,
Pune-411001, Maharashtra. (INDIA)
ABSTRACT
A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is communication between the subarachnoid
space and the nasal cavity. CSF rhinorrhoea commonly occurs following head trauma (fronto-basal skull
fractures), and as a result of intracranial surgery. The aim of our article was to emphasize the importance of
endonasal endoscopic surgery using multilayer autograft technique. A total of 06 cases of CSF rhinorrhoea
were treated. A retrospective study was undertaken to analyze the characteristics of 06 patients. After
detailed otorhinolaryngoscopic examination, DNE and radiological evaluation by CT and MRI, all
underwent endonasal endoscopic surgery. This article reviews the causes, diagnosis and treatment of CSF
leakage of cases done with a 0 degree 4mm sinoscope using fascia lata septal cartilage and fat as a graft
material. The defects as large as 1.5 cm could be safely treated with this technique. The overall success rate
of endoscopic repair for CSF rhinorrhoea has been 100%.
Keywords: CSF rhinorrhoea, endoscopic repair, cerebrospinal fluid, multilayer autograft.
INTRODUCTION
Surgical management of patients with head trauma requires highly skilled personnel and the success
depends on a number of factors including etiology, intracranial pressure, concomitant injuries, patient age
and the possibility of an Interdisciplinary procedure. The other critical factor is impaired tissue repair,
which may be due to lack of proper closure, inadequate support of weak healing tissues, and poor healing of
tissue owing to infection, metabolic disorders and other chronic disease.CSF leak is an escape of the fluid
Page 1
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
that surrounds the brain and spinal cord, from the cavities within the brain or central canal in the spinal
cord. A CSF rhinorrhoea occurs when there is a communication between the subarachnoid space and the
nasal cavity and discharge of CSF from the nose. A spinal fluid leak from the intracranial space to the nasal
respiratory tract is potentially very serious because of the risk of an ascending infection which could
produce fulminant meningitis1. Endoscopic repair of these defects is widely practiced, and has led to 90%
success rate after first repair 2. The first repair of CSF leak was performed by Dandy in 1926 using a frontal
craniotomy. Although traumatic leakage of CSF is more common, the first published case of CSF
rhinorrhoea was a non traumatic high pressure type due to hydrocephalus reported by Miller in 18263,
followed by reports by King in 18344. .
ETIOLOGY
The etiologic classification of CSF leak was developed by Ommaya et al 5 He classified CSF rhinorrhoea
into traumatic and nontraumatic, subdividing the latter into nontraumatic with normal pressure and
nontraumatic with increased CSF pressure. Fain et al6 classified in five types. Type I: involves only the
anterior wall of the frontal sinus. Type II: involves the face (craniofacial disjunction of the Lefort II type or
crush face) and extend upward to the cranial base and, in occurrence, to the anterior wall of the frontal
sinus, because of the facial retrusion. Type III: involves frontal part of the skull and extend down to the
cranial base.TypeIV: is a combination of types II and III. Type V: involves only ethmoidal or sphenoidal
bones. The most common locations for injury are the lateral lamella of the cribriform plate and the posterior
ethmoids near the anteromedial wall of the Sphenoid. Traumatic CSF leaks have no relationship with age or
sex, whereas the non traumatic variety affects adults mainly over 30 and female twice as common as male.
AIMS AND OBJECTIVES
Page 2
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
To emphasize the importance of endonasal endoscopic approach by using multilayer autograft technique
i.e.: septal cartilage, fascia lata and fat and to discuss the cause and treatment of persistent CSF rhinorrhoea.
MATERIAL AND METHODS
A total of six cases of CSF rhinorrhoea of rhinologic origin were treated (1 year).
A retrospective study was undertaken to analyze the characteristics of six patients with CSF rhinorrhoea.
Cases were selected from the patients coming to ENT OPD of our institute. After detailed
otorhinolaryngoscopic examination, Diagnostic Nasal Endoscopy and radiological evaluation by CT and
MRI,
all
underwent
endonasal
endoscopic
surgery
using
multilayer
autograft
technique
SELECTION CRITERIA
Cases were selected from patients coming to ENT OPD with defect less than 1.5 cm.
Cases with CSF rhinorrhoea of rhinologic origin.
EXCLUSION CRITERIA
Cases with CSF rhinorrhoea with defect size more than 1.5 cm.
CLINICAL PICTURE
In most traumatic cases (>50%), rhinorrhoea stops within one week and in most within
six months. Out of the six patients presented to OPD four patients had complaints of
Recurrent meningitis more than two episodes, Recurrent headache, fever, malaise,
Fig 01 showing CSF leak from
Right Nostril
Page 3
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
giddiness, vomiting. Two patients presented with trauma along with complaint of watery discharge from
single nare since then.
DIAGNOSIS
Accurate identification of the site of CSF leakage is necessary for a
successful surgical repair. Diagnosis through nasal endoscopy can give
an exact diagnosis in some cases. However the dimensions, boney
anatomy of the surrounding area cannot be assessed on a simple
diagnostic nasal endoscopy. Fluid leaking from the nose if placed on
absorbent filter paper may result in the double-ring sign, which is a
central circle of blood and an outer ring of CSF. Beta-2 transferrin assay
Fig 02 (Diagnostic nasal endoscopy
showing defect in Ant. Ethmoids)
is more specific For CSF, but in case of associated orbital injuries this can be unreliable due to the presence
of beta-2 transferrin in vitreous humour7. Beta-2 transferrin is a
carbohydrate-free (desialated) isoform of transferrin, which is almost
exclusively found in the CSF8. Beta-2 transferrin has a sensitivity of near
100% and a specificity of about 95% 9.. Glucose detection using
Glucostix test strips is not recommended as a confirmatory test due to its
lack of specificity and sensitivity 10.
Intrathecal injection of Fluorescein dye is utilized by some surgeons for
Fig 03 (CT Cisternography showing
leak in Rt. Sphenoid sinus)
identifying the area of a CSF leak. Injection involving a solution of 0.5%-10% Fluorescein dye is
injected and the patient is then examined roughly 30 minutes to an hour later with an endoscope.
High resolution, thin section axial and Coronal cranial and facial CT includes all of the paranasal sinuses
and petrous temporal bones in the scans is helpful in defect localization. CT Cisternography: the use of less
irritating water soluble positive contrast media such as metrizamide combined with CT scanning and
Page 4
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
suitable image reconstruction can often be useful in pinpointing leak location. CT Cisternography cannot be
undertaken in presence of meningitis. In such cases, MRI with CT is done.
TREATMENT
MEDICAL
The use of antibiotics in the treatment of CSF rhinorrhoea remains controversial.
The reason for their use is to prevent intracranial infection (meningitis). Villalobos
et al published a meta-analysis in 1998 that reviewed 12 studies and 1241 patients
with CSF leaks. 719 patients were treated with antibiotics while 522 patients were
not treated with antibiotics. They found that patients were 1.34 times more likely to
Fig 04 showing use of fat for closure
develop meningitis without the use of antibiotics when a basilar skull fracture had
resulted in a CSF leak. With all causes of CSF leak, patients were only 1.10 times more likely to develop
meningitis without the use of antibiotics. For this reason, they recommended not using antibiotics when
CSF leaks are present11.However conservative management with stool softeners, bed rest, head elevation,
avoid straining, avoiding lifting of heavy objects can be considered.
SURGICAL
The surgical management of CSF rhinorrhoea is categorized into open and closed approach.
TECHNIQUE:
Page 5
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
All the patients gave written informed consent; they underwent
Endonasal endoscopic surgery using multilayer autograft technique
under General anesthesia.
Antibiotics along with IV mannitol, Antihistaminics, Stool softeners like
syrup cremaffin, Cough suppressants were administered to the patients.
Merocel nasal pack was kept for 48 hrs. Strict bed rest was given to pt Fig 05 showing schematic diagram
for 2 weeks.
Head elevation was given at 30 degrees.
RESULTS
Between 2010 and 2011, seven patients visited to the ENT OPD of our institute. Out of which six
underwent endoscopic repair of CSF rhinorrhoea at our institution. One patient was referred to
Neurosurgeon for open repair as the defect was more than 1.5 cm. Age of the patients ranged from 09-40
yrs. With male predominance. The durations of symptoms ranged from 2 months to 10 months. Post
traumatic leak was present in five patients, spontaneous leak was seen in one patient. Four patients had
defect in Anterior ethmoids. One each in posterior ethmoids and sphenoid respectively. Size of the defect
ranged from 0.5 cm to 1.5 cm. Repair was successful in 100 %patients; Mean follow-up was 6 months with
a range of 2 months to 12 months. Our results are comparable to that reported in literature (Table1).
Sr No
Series
No Of Cases
Success Rate
1
Stan Kiewich et al 12
06
06(100%)
2
Lanza et al 13
36
34(94%)
3
Papay et al 14
04
04(100%)
4
Present study
06
06(100%)
Page 6
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
DISCUSSION
Most neurosurgeons prefer the intracranial approach. Exposure of the skull base and the necessity of brain
retraction during intracranial procedures are associated with a significant risk of anosmia, postoperative
intracerebral hemorrhage, and brain edema. Multiple approaches to the management of CSF rhinorrhoea
can be successful. An endoscopic repair results in resolution of CSF rhinorrhoea in majority of the cases.
Endoscopic repair provides best exposure of the sphenoid, parasellar, and posterior ethmoidal regions and
offer excellent visualization of fistulas in the posterior wall of the frontal sinus, the cribriform plate, and the
fovea ethmoidalis.Transnasal endoscopic surgery minimizes intranasal trauma and preserves the bony
framework supporting the frontal recess and other critical areas. Patients with spontaneous CSF
rhinorrhoea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for
recurrence. Alternative management options may need to be considered in these cases. In our study lumbar
drain was not used as advocated by neurosurgeon of our institute. Fibrin glue was not used as it has high
cost and patients were non affording.
CONCLUSION
The success rate of repair was 100 %. We conclude that it is reasonable in majority of cases to proceed with
endoscopic approach rather than going for external approach. Endonasal approach is less morbid compared
with external approach. Endoscopic surgery gives better visualization. As Revision surgery can be done
with ease. Healing can be observed in follow up with endoscopic evaluation. Patient undergoing primary
endoscopic repair have less likely chance of developing anosmia or other neurodeficit as compared to
patients undergoing open surgery.
We emphasize the importance of multilayer auto graft material as CSF rhinorrhoea is notorious for graft
displacement.
Page 7
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
REFERENCES
1.Calcaterra TC, Moseley JI, Rand RW. Cerebrospinal rhinorrhea:
basis of detection of beta 2-transferrin by polyacrylamide gel
extracranial surgical repair. West J Med 1977;127:279-83.
electrophoresis
and immunoblotting. Clin Chem Clin Biochem 1989;27:169-72.
9. Skedros DG, Cass SP, Hirsch BE, Kelly RH. Sources of error in
2. Lanza DC, O’Brien DA, Kennedy DW. Endoscopic repair of
use of beta-2 transferrin analysis for diagnosing perilymphatic and
cerebrospinal fluid fistulae and encephaloceles.
cerebral spinal fluid leaks. Otolaryngol Head Neck Surg
Laryngoscope 1996;106:1119-25.
1993;109:861–4.
3. Mullar C. Case of hydrocephalus chronicus, with some unusual
10. Chan DT, Poon WS, IP CP, Chiu PW, goh KY. How useful is
symptoms and appearances on dissection.
glucose detection in diagnosing cerebrospinal fluid leak? The
Trans Med Chir Soc Edinb 1826; 2:243-8.
rational use of CT and Beta-2 transferrin assay in detection of
cerebrospinal fluid fistula.
4. King D. Report to Westminster Medical Society.
Asian J Surg 2004;27:39-42.
Lond. Med Surg J 1834; 4:823-5.
11. Villalobos T, MD et al. Antibiotic prophylaxis after basilar skull
fractures: A meta-analysis. Clinical Infectious Diseases, 27:3645. Ommaya AK, Di Chiro et al. Hydrocephalus and leaks. In
369, 1998.
Wager H (ed) Principles of nuclear medicine, 2nd edition
Phildelphia Saunder 1995.
12. Stankiewicz JA. Cerebrospinal fluid fistula and endoscopic
6. Fain J, Chabannes J, Peri G, Jourde J. Frontobasal injuries and csf
sinus surgery. Laryngoscope 1991; 101:250-6.
fistulas. Attempt at an anatomoclinical classification. Therapeutic
incidence.
13. Lanza DC, O’Brien DA, Kennedy DW. Endoscopic repair of
Neurochirurgie 1975;21:493-506.
cerebrospinal fluid fistula and encephalocele.
Laryngoscope 1996; 106:1119-25
7. Ryall RG, Peacock MK, Simpson DA. Usefulness of beta
2-transferrin assay in the detection of cerebrospinal fluid leaks
14. Papay FA, Benninger MS, LevineHL. Transnasal
following head injury.
transseptal endoscopic repair of sphenoidal cerebrospinal
J Neurosurg 1992; 77:737-9.
fluid fistula.
8. Reisinger PW, Hochstrasser K. The diagnosis of CSF fistulae on
the
Page 8
Otolaryngol Head Neak Surg 1989; 101:595-7.
CSF Rhinorrhoea: An Overview Of Endoscopic Repair
Page 9