CSF RHINORRHOEA
BY
Wg Cdr M. Tahir Shah
What is CSF
• CSF consists of a mixture of water, electrolytes
(Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-
80% of blood glucose), amino acids, and various
proteins (22-38 mg/dL). CSF is colorless, clear, and
typically devoid of cells.
• CSF is produced mainly by the choroid plexus
epithelium and ependymal cells of the
ventricles and flows into interconnecting chambers;
namely, the cisterns and the subarachnoid spaces.
Functions of CSF
• CSF performs vital functions including: Support; Shock absorber;
Homeostasis; Nutrition; Immune function.
• Adult CSF volume is estimated to be 150 ml with a distribution of 125
ml within the subarachnoid spaces and 25 ml within the ventricles.
• Production is between 400 to 600 ml per day so complete csf renewal
occurs 4 to 5 times per day in young adult.
• Out-pouching of the arachnoid mater are responsible for the
resorption of CSF into the dural venous sinuses.
• Disequilibrium in synthesis and resorption or obstruction of circulation
results in CSF accumulation and raised intracranial pressure called
hydrocephalus.
What is CSF Rhinorrhoea
• Leakage of CSF in to the nose
- Clear /
- mixed with blood (in a/c head injuries)
Etiology
• Trauma (commonest)
• Accidental
• Surgical ( FESS, nasal polypectomy, trans sphenoidal
hypophysectomy,skull base surgery)
• Neoplasms (benign/malignant) invading skull base
• Inflammations (mucocele of sinuses ,sinu nasal polyposis,
fungal infections of sinusitis & osteomyelitis erode the bone &
dura)
• Congenital (meningocele,meningoencephalocele & glioma
with skull base defect)
• Idiopathic
Site of Leakage
• 1. anterior cranial fossa
a) Cribriform plate
b) Roof of ethmoid
c) Frontal sinus
• 2. Middle cranial fossa
1. injuries to sphenoid sinus
2. In # of temporal bone CSF ME ET
nose (CSF otorhinorhea)
Diagnosis
• clear watery discharge on bending head/ straining
• sudden gush can’t be sniffed back
• Reservoir sign ;-
When rising in morning csf collected in
sinuses on bending head
• Double target sign ;-
when collected on a piece of filter paper
with central blood & peripheral lighter halo
• Nasal endoscopy for localizing the site of CSF
leakage
• Otoscopic /microscopic examination of ear }
CSF otorrhinorhea
Lab Tests
• B2 transferrin
- Sensitive & specific
-Only few drops of csf is needed
-Perilymph & aqueous also contains it but not in nasal
discharge
• Beta trace protein
- Specific for CSF
• Glucose testing
- > 30 mg/dl in csf
- < 10 mg/dl in nasal discharge
Localization of site of leakage
• High Resolution CT Scan
• MRI
• Endoscopic examination
Treatment
• Conservative
• Bed rest
• Elevating the head
• Stool softeners
• Avoidance of nose blowing, sneezing & straining
• Prophylactic abx } meningitis
• Acetazolamide } ↓ form of CSF
Surgical Repair
• Neurosurgical intra cranial approach
• Extra dural approach
- External ethmoidectomy } cribriform plate
-Trans septal sphenoidal approach } sphenoid
- Osteoplastic flap } frontal
• Trans nasal endoscopic approach
- to localize site of leak and repair
Endoscopic repair
• Localization of site of leak
• Preparation of graft site
• Underlay placement of graft extra durally
(mucosa for small defect….. Septal cartilage
if>2cm)
• Surgical & gelfoam strengthen
• Lumbar drain if CSF pressure is high
• Intrathecal fluorescein study
- Invasive
-0.25-0.5 ml of 5% fluorescein mixed with patients own CSF
is injected & pt lies in 10 ’ head down position for some time
dye ca be detected intranasally with the help of
endoscope……….appears bright yellow but when seen with
blue filter } flurescent green
• CT cisternogram
-Intrathecal injection of iohexol & CT
- Where B2 transferrin can’t be done
