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Dr. ADITYA GHOSH ROY
*CSF RHINORRHOEA REFERS TO A FISTULA BETWEEN
THE SUBARACHNOID SPACE AND NASOPHARYNX.
*DESCRIBED FIRST BY GALEN IN 200B.C.
*DANDY WAS THE FIRST PERSON TO CLOSE A CSF
LEAK USING FRONTAL CRANIOTOMY APPROACH IN
*IN 1964 VRABEC AND HALLBERG DESCRIBED
ENDONASAL APPROACH TO REPAIR A CSF LEAK IN
* High pressure leaks (always associated with concommitant
*Encountered in the cribriform area. This is due to the fagility and unique
anatomy in this area
*The leak during these conditions functions as a safety valve alleviating
the increased intracranial pressure.
*These high pressure leaks are associated with slow growing tumors and
1/4 of them have hydrocephalus.
*Closure of these leaks may worsen the condition of the patient if the
causative lesion is left untreated.
*Normal pressure leaks –
*.Normal pressure leaks may result from congenital defects
such as ,preformedpathways ,fistulas, meningoceles,meningo
* Ostetis or osteomyelities of skull base bone may cause CSF
*Lateral lamellae of cribriform plate
*Persistence of the lateral craniopharyngeal canal(sternberg’s
*SPONTANEOUS CSF RHINORRHOEA
*True spontaneous leaks are really rare. There is almost always
some antecedent traumatic event.
*NUSS postulated the various causes of spontaneous CSF
rhinorrhoea. He named them as "4 P's".
*1. Increased intracranial pressure
*2. Brain pulsations which continuously occur along the skull
*3. Degree of pneumatisation of the paranasal sinuses
*4. Arachnoid pits / villi exist normally along the skull base.
Continued transmission of pulsation, erodes the bone until
the arachnoid communicates with a pneumatised space with
the potential to develop fistula.
*Elevated ICP is a primary characteristic of benign
intracranial hypertension (BIH),
*Benign intracranial hypertension, also known as idiopathic
intracranial hypertension and pseudotumor cerebri, is a
syndrome of increased ICP in the absence of specific
causes such as intracranial masses, hydrocephalus, and
dural sinus thrombosis.
* Clinical manifestations of BIH include headache, pulsatile
tinnitus, papilledema, and visual disturbances including
abducens nerve palsy.
*In fact, the demographics of the population with
spontaneous CSF leak are quite similar to those of the
average population of patients with BIH
*Normally, the pituitary gland fills the entire sella turcica
*arachnoid and CSF herniate through the sellar diaphragm, this CSF-
filled sac may partially or completely compress the pituitary gland.
*When this compression occurs, an “empty sella” results.
* The clinical manifestations and demographic profile of patients with
empty sella syndrome (ESS) are highly similar to those for patients with
BIH and patients with nontraumatic CSF leaks.
*The clinical presentation of ESS includes headache, memory losses,
cerebellar ataxia, papilledema, and visual field defects.
*BEDSIDE TESTS FOR DETECTING CSF RHINORRHOEA
*QUECKENSTEDT’s TEST – pressure on b/l jugular veins increases
*RESERVOIR SIGN – This test is ideally performed immediately on
rising from the bed. The patient is asked to place the chin over their
chest. The patient must stay in that position for one full minute. Clear
fluid dripping from the nose is CSF.
*HALO / DOUBLE RING SIGN – If rhinorrhea associated with blood.
Clear ring surrounds blood.
*Handkerchief test: Discharge from the nose is blown into a
handkerchief and is allowed to dry. If the discharge is CSF the
handkerchief will not stiffen, if the discharge is secretions from the
nose the handkerchief stiffens due to the presence of mucin in the
*Glucose oxidase test – Glucose oxidase strips show colour change on detection
of glucose.(high false negative so abandoned)
*β2 transferrin in the nasal secretions. In CSF Beta 2 transferrin is present, and it
is absent in normal nasal secretions. (100% Sensitivity and 95% specificity)
*βTrace Protein – 100% sensitive and specific
*Intrathecal radionucleotide test – Most Specific
*Tests that help to localise the CSF leak:
*CT Cysternography (Contraindicated in active meningitis or High ICP)
*Intra thecal administration of non ionic contrast with high resolution CT scan.
Intra thecal administration of low quantities of Fluorescein can also be used.
*STRICT BED REST
*HEAD END ELEVATION
OF CSF LEAK USING
INDICATIONS OF SURGICAL INTERVENTION
Traumatic or post-operative leaks that recur or persists
even after 2 weeks of conservative management.
Delayed or intermittent leaks.
High pressure leaks that act as safety valve for
Leaks associate with erosion, destruction, disruption
or combination of these at skull base and para nasal
Leaks associated with congenital anomalies.
Recurrent attacks of meningitis.
Done when Dura is
adherent to the
defect and cannot
Graft is placed over
the defect after
making the edges
Graft in form of fascia or
cartilage is put between
the intracranial structure
Rough epithelial surface
faces the cranial surface
while the smooth
endothelial surface faces
of several layers
in cases of huge
*Dandy first successful repair
*Bifrontal craniotomy and fascia lata graft
*Access to cribriform plate region and roof of ethmoid
*Exposure — brain retracted –- defect identified –- repair
by tissue material
*Dohlman used the naso orbital incision
*Dissection through sinus cavities – access to skull base
– defect identified – repair done
*Repair of sphenoidal sinus csf leak by this technique
• USE OF LUMBAR DRAIN
• AVERAGE DURATION OF KEEPING DRAIN
• IV ANTIBIOTICS
• ORAL DIURETICS
• STOOL SOFTENERS
• HEAD END ELEVATED
• AVOID STRAINING IN ANY FORM
CSF rhinorrhea can nowadays be more accurately localized
and diagnosed with the help of modern radiological
The repair of CSF rhinorrhea has changed from open
craniotomy to minimally invasive techniques i.e. endonasal
endoscopic techniques. Endoscopic technique is practiced by
many ENT surgeons and gaining popularity due to overall
The presence of CSF rhinorrhea entails a significant risk to
patient’s life (3).
The clinical confirmation should be performed by nasal
inspection and determination of CSF markers like beta 2
transferrin which has high sensitivity and specificity (4).
CSF RHINORRHOEA-POTENTIALLY LIFE THREATENING
OWING TO RISK OF MENINGITIS
†MC SITE –CRIBRIFORM PLATE OF ETHMOID
†DIAGNOSIS BY A VARIETY OF CLINICAL & RADIOLOGICAL
TECHNIQUES, THOUGH MR CISTERNOGRAPHY WITH
HEAVILY T2W AND 3D CISS SEQUENCES BEING THE
MODALITY OF CHOICE
†CONSERVATIVE AND SURGICAL MANAGEMENT
DEPENDING ON THE CAUSE, SITE AND DURATION OF CSF
†VARIETY OF INTRACRANIAL/ EXTRACRANIAL , OPEN/
ENDOSCOPIC APPROACHES AVAILABLE
†FUTURE TREND IS TOWARDS MINIMALLY INVASIVE
1) STEP BY STEP CSF RHINORRHOEA(ENDOSCOPIC NASAL REPAIR)
BY NISHIT J SHAH
2) WORMALD-ENDOSCOPIC SINUS SURGERY 2ND ED
3) CLOSURE OF CEREBROSPINAL FLUID LEAKS PREVENTS
ASCENDING BACTERIAL MENINGITIS-BERNAL-SPREKELSEN,
ALOBID I, MULLOL J.
4) SPONTANEOUS CSF LEAK: DEFINITIVE REPAIR AND
MANAGEMENT-WOODWORTH BA, PRINCE A, COHEN NA.