Document Sample
     Nino Zaya, MD
      May 4, 2006
   Understand the classification system for various
    causes of CSF rhinorrhea.
   Understand the pathophysiology and diagnosis
    of CSF rhinorrhea.
   Review diagnostic testing techniques (chemical
    markers and CSF tracers) as well as localization
   Review both medical and surgical strategies in
    treatment of CSF rhinorrhea.
                           Case EA
   EA is a 55 y.o. female referred to Dr. Garcia with Sx suggesting
    ETD. She also c/o unilateral rhinorrhea occurring on the left
    side. No previous history of head and neck surgery, or trauma.
    She has had intermittent headaches present. The unilateral
    rhinorrhea has been present for 3 years with no improvement
    with allergy medications. Other history non-contributory.
   Physical exam: Well-nourished female NAD, 160 pounds, 5’2”
    Ears: weber-left ear, minimal effusion on left ear. R ear nl.
    Nose: Anterior rhinoscopy negative. Prone, head-down position
    with valsalva lead to significant left-sided rhinorrhea. Fluid was
    collected for analysis. Remainder of patient’s exam was negative.
   Cerebrospinal fluid (CSF) rhinorrhea results
    from a direct communication between the CSF-
    containing subarachnoid space and the
    mucosalized space of the paranasal sinuses.
          Historical Perspective
   First reported in the 17th century.
   Dandy in 20th century, reported first successful
    repair utilizing a bifrontal craniotomy for
    placement of a fascia lata graft.
   Extracranial approaches introduced mid-20th
   Endoscopic approaches were introduced and
    popularized in the 1980s and early 1990s.
Classification of CSF Rhinorrhea
   Based on established pathophysiology of CSF
   This has important clinical implications for the
    selection of treatment strategies and patient counseling
    about prognosis.
   Initial schemes-traumatic leaks and nontraumatic leaks.
   Accidental Trauma-80% of all CSF rhinorrhea
   Non-traumatic-4% of all CSF rhinorrhea.
   Procedure related-16% of all CSF rhinorrhea.
    Traumatic
A.   Accidental
        1. Immediate
        2. Delayed
B.   Surgical
        1. Complication of neurosurgical procedures
                 a. Transsphenoidal hypophysectomy
                 b. Frontal craniotomy
                 c. Other skull base procedures
        2. Complication of rhinologic procedures
                 a. Sinus surgery
                 b. Septoplasty
                 c. Other combined skull base procedures
   Nontraumatic
         A. Elevated intracranial pressure
                   1. Intracranial neoplasm
                   2. Hydrocephalus
                              a. Noncommunicating
                              b. Obstructive
                   3. Benign intracranial hypertension
         B. Normal intracranial pressure
                   1. Congenital anomaly
                   2. Skull base neoplasm
                              a. Nasopharyngeal carcinoma
                              b. Sinonasal malignancy
                   3. Skull base erosive process
                              a. Sinus mucocele and Osteomyelitis
                   4. Idiopathic
   CSF produced by choroid plexus (20 mL/hour).
   CSF circulates from ventricles through foramina
    Luschka and Magendie to subarachnoid space.
   Total CSF volume is 140 mL=20 mL (ventricles)
    + 50 mL (intracranial subarachnoid space) + 70
    mL (paraspinal subarachnoid space).
   CSF pressure ranges 40 mm H2O (infants) - 140
    mm H2O (adults).
   CSF pressure maintained by relative balance between
    CSF secretion (choroid plexus) and CSF resorption
    (arachnoid villi).
   CSF resorption rate plays major role in determining
    CSF pressure.
   CSF rhinorrhea requires disruption of barriers that
    normally separate the contents of the subarachnoid
    space from the nose and paranasal sinuses
   Pressure gradient is also required to produce flow of
    Conditions with elevated ICP and associated
     CSF rhinorrhea.
    1.   Nontraumatic CSF rhinorrhea
    2.   Benign Intracranial Hypertension (BIH)
    3.   Empty Sella Syndrome (ESS)
    Abnormalities bony architecture of skull base
     and CSF rhinorrhea.
    1.   Lateral lamellar of the cribriform plate (LLCP)
   Meningocele or meningoencephalocele may
    occur in association with CSF rhinorrhea.
   Obtain imaging studies prior to blind biopsies.
          Differential Diagnosis
   CSF otorrhea presents as CSF rhinorrhea
   Sinonasal saline irrigations
   Seasonal & perennial allergic rhinitis
   Vasomotor rhinitis
   Unilateral watery nasal discharge (laterality)
   Salty taste.
   Positional variation.
   History trauma or surgery.
   Weight loss.
   Presence of inflammatory paranasal sinus disease.
   Headache.
   History of single or multiple episodes bacterial
           Physical Examination
   Position testing.
   Halo sign.
   Glistening moist nasal mucosa on side of CSF leak.
   Clear fluid stream.
   Papilledema.
   Abducens nerve palsy.
   Traumatic CSF rhinorrhea and physical stigmata of
    recent or distant maxillofacial trauma.
              Diagnostic Testing
    2 types of testing:
    1.   Identification substance serves as marker CSF.
    2.   Agent administration that documents
         communication (intradural and extradural space).
   Chemical markers
     1.   Glucose
     2.   Beta-2 transferrin
   CSF Tracers
     1.   Visible dyes (Intrathecal fluorescin)
     2.   Radionuclide markers (Radioactive iodine (I131) serum
          albumen (RISA), technetium (99mTc)-labeled serum
          albumen and diethylenetriamterinepentaacetic acid
          (DTPA), and Indium (In111)-labeled DTPA)
     3.   Radiopaque dyes (metrizamide)
                Localization Studies
    Limitations
    1.   Radionuclide cisternography
            Poor spatial resolution.
    2.   MR cisternography
            Long scan acquisition times required that produce thick image slices
             that cannot identify small skull base defects.
    3.   CT cisternography (Metrizamide)
            Difficult to reliably interpret, even with slices of 1 mm.
    4.   All above studies assume presence active CSF flow
         (intermittent or very small leaks may not be identified)
    Nasal endoscopy after intrathecal fluorescin infusion
    Multidisciplinary approach:
    1.   Otolaryngologist
    2.   Neurosurgeon
    3.   Neuroradiologist
    4.   Infectious disease specialist
    1.   Subarachnoid drainage through a lumbar catheter
    2.   Strict bed rest
    3.   Head elevation
    4.   Stool softeners
    5.   Patient advised to avoid coughing, sneezing, nose
         blowing, and straining
    Transcranial Techniques
    1.   After craniotomy, defect site identified, and tissue
         graft placed to close the defect.
    2.   Materials used: Fascia lata grafts, muscle plugs, and
         pedicled galeal flaps may be used.
    3.   A tissue sealant, such as fibrin glue, may be used to
         hold the grafts into position.
4.   Access to the cribriform plate region and roof of
     the ethmoid requires a frontal craniotomy.
5.   Extended craniotomy and skull base techniques
     with even greater brain compression provide
     access to the sphenoid sinus defects.
6.   Potential morbidities include brain compression,
     hematoma, seizures, and anosmia.
7.   High failure rates (25%) despite direct access.
   Extracranial Techniques
    1.   Endoscopic repair of CSF rhinorrhea provides
         adequate visualization of defect.
    2.   Intrathecal fluorescin facilitates defect identification.
    3.   Prepare defect site for grafting.
    4.   Bipolar cautery or KTP laser used to fulgurate any
         coincidental meningoencephalocele.
    5.   Mucosa within 5 mm of the margins of the skull
         base defect must be removed to facilitate mucosal
6.   Graft material:
        Temporalis fascia, fascia lata, muscle plugs,
         pedicled middle turbinate flaps (mucosa alone or
         mucosa and bone), autogenous fat, free cartilage
         grafts (from the nasal septum or the cartilaginous
         auricle), and free bone grafts (from the nasal
         septum or calvarium).
        Acellular dermal allograft.
        Higher failure with with pedicled intranasal grafts
         versus free grafts.
   Underlay technique
   Larger defects require layered reconstruction less
    risk of delayed recurrence and
    meningoencephalocele formation.
   Never place mucosal grafts intracranially
    (intracranial mucocele after repair can occur).
   Surgical sealant (fibrin glue) may be used to help
    hold the grafts in place.
   Absorbable nasal packing is placed adjacent to
    the grafts, and nonabsorbable packing used to
    support absorbable packing.
   Pure endoscopic approaches provide excellent
    access to the ethmoid roof, cribriform plate, and
    most of the sphenoid sinus.
   Lateral sphenoid leaks may require an extended
    approach, which incorporates endoscopic
    dissection of the medial pterygomaxillary space.
   Osteoplastic flap or a simple trephine might be
    required for repair of defects through the
    posterior table of the frontal sinus.
   Postoperative care includes strict bedrest for several days and
    antistaphylococcal antibiotics.
   Observation in ICU for first 24 hours.
   Continue lumbar drain for 4 to 5 days.
   Nasal packing removed after several days.
   Operative site may be checked through serial nasal endoscopy.
   Patients advised to avoid strenuous activity, sneezing, coughing
    for 6 weeks after repair.
   Primary cases successful repair: 85%-90%
   Secondary endoscopic repair also has high likelihood of success.
   Endoscopic techniques offer several advantages.
   Excellent visualization afforded by nasal
    endoscopy facilitates identification of the defect
    and graft placement.
   Endoscopic repair is also well tolerated,
    especially compared with intracranial techniques.
   Report outcomes are excellent for both primary
    and secondary endoscopic repairs.
            Management Strategy
    Indications
    1.   Failed conservative management
    2.   Intraoperative recognition of a leak (during sinus
         surgery, skull base surgery, and craniotomy)
    3.   Large defects/leaks (especially in association with
    4.   Idiopathic leaks (spontaneous leaks)
    5.   Open traumatic head wounds with CSF leakage
    Traumatic (Nonsurgical) Etiology
    1.   Conservative measures (reduces ICP and promotes
         spontaneous closure).
    2.   Persistent rhinorrhea-explore and repair.
    3.   Extracranial endoscopic techniques and open
         transcranial procedures (massive head injury
         requiring urgent operative exploration) might be
    Intraoperative Injury with Immediate
    1.   CSF leaks noted intraoperatively should be
         repaired immediately during FESS.
    2.   Intracranial and skull base procedures include
         deliberate violations of the dura; provide a
         watertight seal at the end of the procedure.
    Operative Injury with Delayed Recognition
    1.   Conservative therapy for a few days warranted
         since some leaks will close.
    2.   Can pursue operative intervention for massive
         leaks early.
    3.   Significant delay between time of surgery and CSF
         leak diagnosis-conservative measures less
         successful, and early surgical intervention
    Nontraumatic Leaks
    1.   Usually require surgical repair.
    2.   Can attempt conservative measures.
    3.   Treat underlying etiology along with CSF
         rhinorrhea (neoplasm, hydrocephalus, etc.).
    4.   Always consider unrecognized elevation of ICP
         (ESS or BIH) in cases of spontaneous CSF leaks.
    5.   Operative repair in ESS and BIH usually necessary.
          Case EA Revisited…..
   Patient EA’s fluid analysis-positive Beta-2
   CT-Scan showed fluid/soft tissue in left
    sphenoid sinus.
   CSF tracer study utilizing intrathecal omnipaque
    along with CT scanning-positive in left sphenoid
    sinus for CSF leak.
Case Continued….
              Case Continued….
   Patient taken to operating room and underwent left
    sphenoidotomy with closure of CSF leak.
   Small pinpoint defect in left sphenoid sinus had been
   Fascia lata and lateral rectus muscle were utilized for
    closure along with fibrin glue.
   Patient had intraop lumbar drain placed for
    decompression by Neurosurgery
   Post-operatively-CSF leak resolved and area where leak
    located healed.
   Categorize leaks
   Beta-transferrin assay and several CSF tracer studies available,
    but have limitations.
   High-resolution CT provides detailed information about the
    bony skull base anatomy
   MR assesses soft tissue issues, including unrecognized tumors
    and coincidental meningoencephaloceles.
   Many CSF leaks respond to conservative management
    (observation plus measures to minimize ICP).
   Traumatic CSF rhinorrhea tends to resolve with conservative
    measures alone.
   Nontraumatic CSF rhinorrhea require operative repair.
   Extracranial techniques are first line for CSF rhinorrhea.
   Halo sign
   Cummings Otolaryngology: Head and Neck
    Surgery. Chapter 55. CSF Rhinorrhea
   Fluorescin CSF Leak