CSF Rhinorrhoea

CSF rhinorrhea may be classified as:

• Traumatic (>90%) – Approximately 80% of all traumatic leaks occur in the setting of accidental trauma, and the remaining traumatic leaks occur after neurosurgical and rhinological procedures
• Nontraumatic (Nontraumatic etiologies include neoplasms and hydrocephalus

High pressure flow- intracranial tumours & hydrocephalous

Low pressure flow- congenital defects

• 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

Diagnosis:

• Basic clinical tests

– Rhinoscopy-visualisation of CSF leakage from paranasal sinuses

– Tissue test-unlike nasal mucous ,CSFdoes not cause a tissue to stiffen

– 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.) – Queckenstedt test-compression of jugular veins leads to increased CSF leakage d/t increase in 1CP

• Biochemical tests:

– Concentrations of glucose & protein are higher in CSF than in nasal discharge.

– 12-transferrin is the preferred biochemical marker of CSF. It helps in distinguishing CSF from other nasal secretions.

– Beta-trace protein (11TP) is another chemical marker that could be used for the detection of CSF

• CSF tracers:

Intrathecal fluorescein dye administration, radionuclide cisternography, CTcisternography

• Radiological studies:

High-resolution CT provides detailed information about the bony skull base anatomy, and MR1 assesses soft tissues , including unrecognized tumors and coincidental meningoencephaloceles

Treatment:

• Traumatic rhinorrhea often stops spontaneously
• Conservative treatment consists of 1-2 weeks trial of?

– Strict bed rest – Head elevation – Stool softeners

– Advising patient to avoid coughing, sneezing, nose blowing, and straining

– Prophylactic antibiotics

– Subarachnoid drainage through a lumbar catheter

• Surgical repair is generally advocated in patients with large fistulas especially in the presence of pneurnocephalous.

• In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult.
• CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign.
• It shows a central red spot (blood) and a peripheral lighter halo. 

• Early cases of post-traumatic CSF rhinorrhea are managed conservatively by placing the patient in a semi-sitting position, avoiding blowing of the nose, sneezing and straining. Prophylactic antibiotics are also administered to prevent meningitis.  
• Acetazolamide decreases CSF formation. 
• These measures can be combined with lumbar drain if indicated. 

Surgical repair can be done by the following: 

          1.  Neurosurgical intracranial approach

          2.  Extradural approaches 

          3.  Transnasal endoscopic approach.

CSF Rhinorrhea Occurs in fracture of maxilla in Le Fort type II and type III. (as cribriform plate is injured here) and also in nasal fracture class III

• Early cases of post traumatic CSF rhinorrhea are managed conservatively (by placing the patient in propped up position, avoiding blowing of nose, sneezing and straining) and
• Prophylactic antibiotics (to prevent meningitis).
• Persistent cases are treated surgically by nasal endoscopy or by intracranial route.

Endoscopic closure of (SF leak is now the treatment of choice in majority of patients but it should not be done immediately. First patient should be subjected to diagnostic evaluation and after site of leakage is confirmed, it should be closed endoscopically. – Scott-Brown

CSF rhinorrhoea

• It refers to the drainage of cerebrospinal fluid through the nose.
• Measures of CSF components such as beta-2 transferrin has been shown to have a high positive predictive value.
• It has also been noted to be characterized by unilateral discharge.
• It is a sign of basal skull fracture.
• Management includes watchful waiting – leaks often stop spontaneously; if this does not occur then neurosurgical closure is necessary to prevent the spread of infection to the meninges.

Ans. B: Cribriform Plate

CSF rhinorrhoea can follow a head injury.

CSF from anterior cranial fossa reaches the nose by way of cribriform plate, ethmoid air cells or frontal sinus. CSF from middle cranial fossa reaches the nose via sphenoid sinuses.

Sometimes, injuries of the temporal bone result in leakage of CSF into the middle ear and thence via the Eustachian tube into the nose (otorhinorrhoea).

The meninges are torn and cerebrospinal fluid leaks down the nose.

Ascending infection may cause meningitis

Ans. Commonly occurs due to break in cribriform plate

Ans. All

Ans. is ‘b’ i.e., Beta-2 transferrin

• Beta-2 transferrin is a CSF-specific variant of transferrin and is used as an endogenous marker of CSF leakage.
• Beta-2 transferrin is formed by loss of sialic acid due to the presence of neuraminidase in the central nervous system.
• Beta-2 transferrin has also been called CSF-specific transferrin and tau protein.

Ans: A. Ethmoidal sinus

• The cribriform plate and air cells of the ethmoid sinus account for maximum number of CSF leaks, i.e., through anterior cranial fossa.
• Other sites are frontal sinus, area of sellatursica and sphenoid sinus.
• Rare sites of leak are middle or posterior cranial fossa and CSF can reach the nasal cavity by way of the middle ear and Eustachian tube.
• Traumatic leak → Cribriform plate and ethmoidal air cells.
• Spontaneous (non-traumatic) leak →  Cribriform plate.