CSF Rhinorrhea

CSF RHINORRHEA
CSF Rhinorrhea is usually due to fracture of cribriform plate which is a part of Ethmoid.
CLASSIFICATION OF CSF RHINORRHEA
Traumatic and non-traumatic
  • Traumatic (>90%) -
  1. Approximately 80% of all traumatic leaks occur in the setting of accidental trauma, and the remaining traumatic leaks occur after neurosurgical and rhinological procedures. 
  2.  Le Fort II and Le Fort III Maxillary fracture and Nasoethmoid fracture.
  • Nontraumatic (Nontraumatic etiologies include neoplasms and hydrocephalus
High pressure and low pressure flow
  • High pressure flow- intracranial tumours & hydrocephalous
  • Low pressure flow- congenital defects
. SITES OF CSF LEAK
  • Most common site for leak is through cribrtform plate and ethmoidal air sinuses.
  • Less common sites are through frontal and sphenoidal sinuses.
  • Rarely, the leak can originate in the middle or posterior cranial fossa and can reach the nasal cavity by way of the middle ear and eustachian tube.
CLINICAL FEATURES
  • Discharge is clear, watery, appears suddenly in a gush of drops when bending forward (tea pot sign) or straining
  • Uncontrollable and cannot be sniffed back
  • No associated sneezing, nasal congestion or lacrimation
  • When collected in a test tube and allowed to stand, it remains clear (nasal discharge leaves a sediment)
DIAGNOSIS OF CSF RHINORRHEA
  • Basic clinical tests
  1. Rhinoscopy-visualisation of CSF leakage from paranasal sinuses
  2. Tissue test-unlike nasal mucous ,CSFdoes not cause a tissue to stiffen
  3. Filter paper test-sample of nasal discharge on a filter paper exhibits a light CSF border and a dark central area of blood 'double ring sign' or ' halo sign' (in cases of traumatic CSF leak where blood and CSF are mixed.) -
  4. Queckenstedt test-compression of jugular veins leads to increased CSF leakage d/t increase in intracranial pressure.
  • Biochemical tests:
  1. Concentrations of glucose & protein are higher in CSF than in nasal discharge.
  2. Glucose content > 30mg/dI (nasal discharge - < 10 mg/dl)
  3. Immunoelectrophoresis
  4. Beta-transferrin is the preferred biochemical marker of CSF. It helps in distinguishing CSF from other nasal secretions.
  5. Beta-trace protein is another chemical marker that could be used for the detection of CSF
  • CSF tracers:
  1. Intrathecal fluorescein dye administration, radionuclide cisternography, CT cisternography
  2. Localization of CSF leak
  3. Intrathecal injection of a dye or a radioisotope and placing pledges of cotton in the olfactory slit, middle meatus, Sphenoethmoidal recess and near the Eustachian tube and examine the pledges for radioactivity
  4. Olfactory slit – cribriform plate (most common site)
  5. Middle meatus – frontal or ethmoidal sinus
  6. Sphenoethmoidal recess – sphenoid sinus
  7. Eustachian tube – temporal bone
  • Radiological studies:
  1. High-resolution CT provides detailed information about the bony skull base anatomy, and MR1 assesses soft tissues , including unrecognized tumors and coincidental 
  2. meningoencephaloceles
TREATMENT OF CSF RHINORRHEA
  • Traumatic rhinorrhea often stops spontaneously
  • Early cases of post-traumatic CSF rhinorrhea are managed conservatively consisting of 1-2 weeks trial of
  1. Strict bed rest - Head elevation - Stool softeners
  2. Advising patient to avoid coughing, sneezing, nose blowing, and straining
  3. Prophylactic antibiotics to prevent meningitis.
  4. Subarachnoid drainage through a lumbar catheter
  • Persistent cases of CSF rhinorrhoea are treated surgically through nasal endoscopic or intracranial approach.
  1. Nasal endoscopic approach is useful for leaks from the frontal sinus, cribriform plate, ethmoid or sphenoid sinuses.
  2. Nasal intubation is contraindicated in CSF Rhinorrhea.
Exam Question
  • CSF rhinorrhea immediate management is wait & watch for 7 days + antibiotics.
  • CSF Rhinorrhea is usually due to fracture of cribriform plate which is a part of Ethmoid.
  • CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo. Blood alone does not produce a ring.
  • CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in CSF Rhinorrhea.
  • Most probable diagnosis in a patient brought to the emergency department following head trauma who is conscious and complaining of fluid coming out of his nostrils without having running nose before the traumais CSF Rhinorrhea.
  • Nasal intubation is contra indicated in CSF Rhinorrhea.
  • CSF rhinorrhea is seen in Le Fort II and Le Fort III Maxillary fracture and Nasoethmoid fracture.
  • CSF rhinorrhea occurs due to break in cribriform plate and contains glucose.
  • CSF rhinorrhea is diagnosed by Beta-2 transferrin.
  • Management of persistent cases of CSF rhinorrhea is Endoscopic repair.
  • CSF rhinorrhea is diagnosed by Glucose estimation,Halo sign,Immunoelectrophoresis.

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