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Dr. ADITYA GHOSH ROY
M.S. E.N.T.
PGT 2
N.R.S.M.C.H .
*
*CSF RHINORRHOEA REFERS TO A FISTULA BETWEEN
THE SUBARACHNOID SPACE AND NASOPHARYNX.
*DESCRIBED FIRST BY GALEN IN 200B.C...
*
*CONGENITAL
*IDIOPATHIC
*SURGICAL
*INTRANASAL
*ENDOSCOPIC SINUS SURGERY
*TRANSCRANIAL
*TRAUMA
*INFLAMMATORY
*NEOPLASM
* High pressure leaks (always associated with concommitant
hydrocephalus)
*Encountered in the cribriform area. This is due...
*Normal pressure leaks –
*.Normal pressure leaks may result from congenital defects
such as ,preformedpathways ,fistulas, ...
*SPONTANEOUS CSF RHINORRHOEA
*True spontaneous leaks are really rare. There is almost always
some antecedent traumatic eve...
*Elevated ICP is a primary characteristic of benign
intracranial hypertension (BIH),
*Benign intracranial hypertension, al...
EMPTY SELLA
*Normally, the pituitary gland fills the entire sella turcica
*arachnoid and CSF herniate through the sellar d...
*
*CSF ottorhoea
*Sinonasal irrigation
*Rhinitis
*
*BEDSIDE TESTS FOR DETECTING CSF RHINORRHOEA
*QUECKENSTEDT’s TEST – pressure on b/l jugular veins increases
rhinorrhea.
*R...
*LABORATORY TEST
*Glucose oxidase test – Glucose oxidase strips show colour change on detection
of glucose.(high false neg...
*
*
*STRICT BED REST
*HEAD END ELEVATION
*AVOID STRAIN
*LAXATIVES
*ORAL DIURETIC
*PROPHYLACTIC
ANTIBIOTICS
*ENDONASAL
ENDOSCOP...
INDICATIONS OF SURGICAL INTERVENTION
 Traumatic or post-operative leaks that recur or persists
even after 2 weeks of cons...
SURGICAL MANAGEMENT
OF CSF RHINORRHOEA
INTRACRANIAL EXTRACRANIAL
INTRADURAL EXTRADURAL ENDOSCOPICOPEN
INTRADURAL -EXTRADUR...
DEFECT LOCALISATION
FRESHEN MARGINS OF DEFECT
GRAFT BEING PLACED TO SEAL DEFECT
SURGICEL & TISSUE GLUE
BEING APPLIED
OVERLAY
UNDERLAY
BATH PLUG(2)
MULTIPLE
BLANKET
*
Overlay technique
Done when Dura is
adherent to the
defect and cannot
be elevated.
Graft is placed over
the defect after
m...
UNDERLAY TECHNIQUE
Graft in form of fascia or
cartilage is put between
the intracranial structure
and defect
Rough epithel...
BATH PLUG TECHNIQUE
BATH PLUG TECHNIQUE
MULTIPLE TECHNIQUE
This comprises
of several layers
of graft
materials used
in cases of huge
defects.
*
*Dandy first successful repair
*Bifrontal craniotomy and fascia lata graft
*Access to cribriform plate region and roof o...
*
*Dohlman used the naso orbital incision
*Dissection through sinus cavities – access to skull base
– defect identified – ...
*
*Hirsch
*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 E...
CSF rhinorrhea can nowadays be more accurately localized
and diagnosed with the help of modern radiological
techniques.
Th...
 CSF RHINORRHOEA-POTENTIALLY LIFE THREATENING
OWING TO RISK OF MENINGITIS
 †MC SITE –CRIBRIFORM PLATE OF ETHMOID
 †DIAG...
1) STEP BY STEP CSF RHINORRHOEA(ENDOSCOPIC NASAL REPAIR)
BY NISHIT J SHAH
2) WORMALD-ENDOSCOPIC SINUS SURGERY 2ND ED
3) CL...
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
Power point csf leak
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cerebro spinal fluid rhinorrhoea

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Power point csf leak

  1. 1. Dr. ADITYA GHOSH ROY M.S. E.N.T. PGT 2 N.R.S.M.C.H .
  2. 2. * *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 1926. *IN 1964 VRABEC AND HALLBERG DESCRIBED ENDONASAL APPROACH TO REPAIR A CSF LEAK IN CRIBRIFOM AREA.
  3. 3. * *CONGENITAL *IDIOPATHIC *SURGICAL *INTRANASAL *ENDOSCOPIC SINUS SURGERY *TRANSCRANIAL *TRAUMA *INFLAMMATORY *NEOPLASM
  4. 4. * High pressure leaks (always associated with concommitant hydrocephalus) *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.
  5. 5. *Normal pressure leaks – *.Normal pressure leaks may result from congenital defects such as ,preformedpathways ,fistulas, meningoceles,meningo encephaloceles . * Ostetis or osteomyelities of skull base bone may cause CSF rhinorrhoea infrequently. *Lateral lamellae of cribriform plate *Persistence of the lateral craniopharyngeal canal(sternberg’s canal)
  6. 6. *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 base *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.
  7. 7. *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
  8. 8. EMPTY SELLA *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.
  9. 9. * *CSF ottorhoea *Sinonasal irrigation *Rhinitis
  10. 10. *
  11. 11. *BEDSIDE TESTS FOR DETECTING CSF RHINORRHOEA *QUECKENSTEDT’s TEST – pressure on b/l jugular veins increases rhinorrhea. *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 nasal secretions.
  12. 12. *LABORATORY TEST *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: *MR Cysternography *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.
  13. 13. *
  14. 14. *
  15. 15. *STRICT BED REST *HEAD END ELEVATION *AVOID STRAIN *LAXATIVES *ORAL DIURETIC *PROPHYLACTIC ANTIBIOTICS *ENDONASAL ENDOSCOPIC REPAIR OF CSF LEAK USING VARIOUS GRAFT MATERIAL BY VARIOUS ENDOSCOPIC TECHNIQUES *
  16. 16. 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 hydrocephalus.  Leaks associate with erosion, destruction, disruption or combination of these at skull base and para nasal sinuses.  Leaks associated with congenital anomalies.  Recurrent attacks of meningitis.
  17. 17. SURGICAL MANAGEMENT OF CSF RHINORRHOEA INTRACRANIAL EXTRACRANIAL INTRADURAL EXTRADURAL ENDOSCOPICOPEN INTRADURAL -EXTRADURAL
  18. 18. DEFECT LOCALISATION
  19. 19. FRESHEN MARGINS OF DEFECT
  20. 20. GRAFT BEING PLACED TO SEAL DEFECT
  21. 21. SURGICEL & TISSUE GLUE BEING APPLIED
  22. 22. OVERLAY UNDERLAY BATH PLUG(2) MULTIPLE BLANKET *
  23. 23. Overlay technique Done when Dura is adherent to the defect and cannot be elevated. Graft is placed over the defect after making the edges raw.
  24. 24. UNDERLAY TECHNIQUE Graft in form of fascia or cartilage is put between the intracranial structure and defect Rough epithelial surface faces the cranial surface while the smooth endothelial surface faces nasal cavity.
  25. 25. BATH PLUG TECHNIQUE
  26. 26. BATH PLUG TECHNIQUE
  27. 27. MULTIPLE TECHNIQUE This comprises of several layers of graft materials used in cases of huge defects.
  28. 28. * *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
  29. 29. * *Dohlman used the naso orbital incision *Dissection through sinus cavities – access to skull base – defect identified – repair done *Disadvantages *Facial scar *Facial numbness *Orbital injury
  30. 30. * *Hirsch *Repair of sphenoidal sinus csf leak by this technique
  31. 31. • USE OF LUMBAR DRAIN • AVERAGE DURATION OF KEEPING DRAIN • IV ANTIBIOTICS • ORAL DIURETICS • STOOL SOFTENERS • HEAD END ELEVATED • AVOID STRAINING IN ANY FORM *
  32. 32. CSF rhinorrhea can nowadays be more accurately localized and diagnosed with the help of modern radiological techniques. 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 success. 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). *
  33. 33.  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 LEAK  †VARIETY OF INTRACRANIAL/ EXTRACRANIAL , OPEN/ ENDOSCOPIC APPROACHES AVAILABLE  †FUTURE TREND IS TOWARDS MINIMALLY INVASIVE ENDOSCOPIC APPROACHES *
  34. 34. 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. *
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cerebro spinal fluid rhinorrhoea

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