Tag: CSF Rhinorrhea

CSF Rhinorrhea

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%) –

  • Approximately 80% of all traumatic leaks occur in the setting of accidental trauma, and the remaining traumatic leaks occur after neurosurgical and rhinological procedures.
  • 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

  • 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 intracranial pressure.

Biochemical tests:

  • Concentrations of glucose & protein are higher in CSF than in nasal discharge.
  • Glucose content > 30mg/dI (nasal discharge – < 10 mg/dl)

Immunoelectrophoresis

  • Beta-transferrin is the preferred biochemical marker of CSF. It helps in distinguishing CSF from other nasal secretions.
  • Beta-trace protein is another chemical marker that could be used for the detection of CSF

CSF tracers:

  • Intrathecal fluorescein dye administration, radionuclide cisternography, CT cisternography
  • Localization of CSF leak
  •  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
  1. Olfactory slit – cribriform plate (most common site)
  2. Middle meatus – frontal or ethmoidal sinus
  3. Sphenoethmoidal recess – sphenoid sinus
  4. Eustachian tube – temporal bone

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 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
  • Strict bed rest – Head elevation – Stool softeners
  • Advising patient to avoid coughing, sneezing, nose blowing, and straining
  • Prophylactic antibiotics to prevent meningitis.
  • Subarachnoid drainage through a lumbar catheter
  • Persistent cases of CSF rhinorrhoea are treated surgically through nasal endoscopic or intracranial approach.
  • Nasal endoscopic approach is useful for leaks from the frontal sinus, cribriform plate, ethmoid or sphenoid sinuses.
  • 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.
Don’t Forget to Solve all the previous Year Question asked on CSF Rhinorrhea

CSF Rhinorrhea

CSF Rhinorrhea

Q. 1

CSF rhinorrhea “immediate” management is

 A

Plugging with petrolleum jelly plugs

 B

Wait & watch for 7 days + antibiotics

 C

Blow the nose repeatedly

 D

Surgery

Q. 1

CSF rhinorrhea “immediate” management is

 A

Plugging with petrolleum jelly plugs

 B

Wait & watch for 7 days + antibiotics

 C

Blow the nose repeatedly

 D

Surgery

Ans. B

Explanation:

 

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.

 


Q. 2

CSF Rhinorrhea is usually due to fracture of cribriform plate. Cribriform plate is a part of: 

 A

Vomer

 B

Ethmoid

 C

Maxilla

 D Zygomatic bone
Q. 2

CSF Rhinorrhea is usually due to fracture of cribriform plate. Cribriform plate is a part of: 

 A

Vomer

 B

Ethmoid

 C

Maxilla

 D Zygomatic bone
Ans. B

Explanation:

Ethmoid


Q. 3

A patient is brought to the emergency department following head trauma. He is conscious and complaining of fluid is coming out of his nostrils. He didn’t have a running nose before the trauma. 

 
Assertion: CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in CSF Rhinorrhea.
 
Reason: 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.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 3

A patient is brought to the emergency department following head trauma. He is conscious and complaining of fluid is coming out of his nostrils. He didn’t have a running nose before the trauma. 

 
Assertion: CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in CSF Rhinorrhea.
 
Reason: 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.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. A

Explanation:

Halo sign/Handkerchief sign is a finding in CSF rhinorrhea when CSF is mixed with Blood.

The best ring is obtained with a 50: 50 mix of blood and CSF.

Ref: Diseases of Ear, Nose and Throat by PL Dhingra, 4th Edition, Pages 155, 156.

Q. 4

A female in the emergency department is found to have CSF rhinorrhea following a motor vehicle accident. What is the first line of treatment for CSF rhinorrhoea in this patient?

 A

Immediate plugging of nose with petroleum gauze

 B

Forceful blowing of nose

 C

Craniotomy

 D

Observation for 7 – 10 days with antibiotic therapy

Q. 4

A female in the emergency department is found to have CSF rhinorrhea following a motor vehicle accident. What is the first line of treatment for CSF rhinorrhoea in this patient?

 A

Immediate plugging of nose with petroleum gauze

 B

Forceful blowing of nose

 C

Craniotomy

 D

Observation for 7 – 10 days with antibiotic therapy

Ans. D

Explanation:

Early cases of post-traumatic CSF rhinorrhea are managed conservatively by placing the patient in semi-sitting position, avoiding blowing of nose, sneezing and straining. Prophylactic antibiotics are also administered to prevent meningitis. 

Persistent cases of CSF rhinorrhoea are treated surgically through nasal endoscopic or intracranial approach. Nasal endoscopic approach is useful for leaks from the frontal sinus, cribriform plate, ethmoid or sphenoid sinuses.


Q. 5

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Q. 5

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Ans. A

Explanation:

A i.e. CSF Rhinorrhea

Nasal (naso-tracheal) intubation is required when oral (orotracheal) tube will interfere with surgery (eg intraoral surgery) and may be indicated when oral intubation is difficult (eg inability to open month). It provides good oral hygiene and more secure fixation with less chances of displacement and extubation. But it is more commonly a/w significant nasaVmucosal bleeding, submucosal placement, transient bacteremia (infection), sinusitis and otitis mediaQ. These side effects make nasotracheal intubation contraindicated in base of skull fracture, CSF rhinorrheaQ, nasal abnormalities and trauma and coagulopathy.


Q. 6

Which is not seen in fracture maxilla:

 A

CSF rhinorrhea

 B

Malocclusion

 C

Anesthesia upper lip

 D

Surgical emphysema

Q. 6

Which is not seen in fracture maxilla:

 A

CSF rhinorrhea

 B

Malocclusion

 C

Anesthesia upper lip

 D

Surgical emphysema

Ans. D

Explanation:

 

Clinical Features of Maxilla—Common to All Types

  • Malocclusion of teeth                                                    
  • Elongation of mid face
  • Undue mobility of maxilla

Specific Clinical Features

  • CSF rhinorrhea is seen in Le Fort II and Le Fort III fracture as cribriform plate is injured.
  • Injury to infraorbital nerve is seen in Le Fort II fracture.                                                                                          
  • So anesthesia will be seen in area of supply of infraorbital nerve injury viz. cheek and upper lip (area of supply of infraorbital nerve).

Q. 7

CSF rhinorrhea is seen in:

 A

Lefort’s fracture Type I

 B

Nasal fracture

 C

Nasoethmoid fracture

 D

All

Q. 7

CSF rhinorrhea is seen in:

 A

Lefort’s fracture Type I

 B

Nasal fracture

 C

Nasoethmoid fracture

 D

All

Ans. C

Explanation:

 

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



Q. 8

True about CSF rhinorrhea is:

 A

Occurs due to break in cribriform plate

 B

Contains glucose

 C

Requires immediate surgery

 D

a and b

Q. 8

True about CSF rhinorrhea is:

 A

Occurs due to break in cribriform plate

 B

Contains glucose

 C

Requires immediate surgery

 D

a and b

Ans. D

Explanation:

 

 

 

– Early cases of post traumatic CSF rhinorrhea are managed conservatively. Only those cases where CSF rhinorrhea occurs persistently

– Surgical management should be done


Q. 9

Immediate treatment of CSF rhinorrhea requires:

 A

Antibiotics and observation

 B

Plugging with paraffin guage

 C

Blowing of nose

 D

Craniotomy

Q. 9

Immediate treatment of CSF rhinorrhea requires:

 A

Antibiotics and observation

 B

Plugging with paraffin guage

 C

Blowing of nose

 D

Craniotomy

Ans. A

Explanation:

 

  • 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


Q. 10

CSF rhinorrhea is diagnosed by:

 A

Beta-2 microglobulin

 B

Beta-2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Q. 10

CSF rhinorrhea is diagnosed by:

 A

Beta-2 microglobulin

 B

Beta-2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Ans. B

Explanation:

Q. 11

Management of persistent cases of CSF rhinorrhea is:

 A

Head low position on bed

 B

Endoscopic repair

 C

Straining activities

 D

All of the above

Q. 11

Management of persistent cases of CSF rhinorrhea is:

 A

Head low position on bed

 B

Endoscopic repair

 C

Straining activities

 D

All of the above

Ans. B

Explanation:

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.

Q. 12

True about CSF rhinorrhea:       

UP 09

 A

Commonly occurs due to break in cribriform plate

 B

Contains less amount of proteins

 C

Decreased glucose content confirms diagnosis

 D

Immediate surgery is required

Q. 12

True about CSF rhinorrhea:       

UP 09

 A

Commonly occurs due to break in cribriform plate

 B

Contains less amount of proteins

 C

Decreased glucose content confirms diagnosis

 D

Immediate surgery is required

Ans. A

Explanation:

Ans. Commonly occurs due to break in cribriform plate


Q. 13

CSF rhinorrhea is diagnosed by:

MP 07

 A

Glucose estimation

 B

Halo sign

 C

Immunoelectrophoresis

 D

All

Q. 13

CSF rhinorrhea is diagnosed by:

MP 07

 A

Glucose estimation

 B

Halo sign

 C

Immunoelectrophoresis

 D

All

Ans. D

Explanation:

Ans. All


Q. 14

Diagnostic test for CSF rhinorrhea is ‑

 A

Beta – 2 microglobulin

 B

Beta – 2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Q. 14

Diagnostic test for CSF rhinorrhea is ‑

 A

Beta – 2 microglobulin

 B

Beta – 2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Ans. B

Explanation:

Ans. is ‘b’ i.e., Beta-2 transferrin



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