![CSF RHINORRHEA
Dr. Jeet M. Amin
Resident Doctor, ENT Department, PDU Medical College & Hospital, Rajkot
Dr. Manoj G. Amin[M. S., ENT]
JEET ENT Hospital, Deesa
HOD, ENT, AASHKA Multispecility Hospital, Gandhinagar](https://image.slidesharecdn.com/csfrhinorrhea-210321134232/75/CSF-Rhinorrhea-1-2048.jpg)
![Clinically
• Watery Nasal Discharge [unilateral >> bilateral]
• Headache
• Anosmia
• Vertigo +/-
• Pulsatile Tinnitus
Lately Meningitis, Seizures, Fever](https://image.slidesharecdn.com/csfrhinorrhea-210321134232/75/CSF-Rhinorrhea-7-2048.jpg)
![Conservative Management
• Bed Rest
• Head Elevation (15 Degree)
• Stool Softeners
• Diuretics [Azetazolamide]
• Avoid Coughing, Sneezing , Blowing
• Prophylactic Antibiotics
• Lumber Drain for High Pressure Leak(Hourly 10 ml drainage)
• Mostly for 7-10 Days.
Post-Traumatic CSF Leak](https://image.slidesharecdn.com/csfrhinorrhea-210321134232/75/CSF-Rhinorrhea-19-2048.jpg)
![Post-Operative Care
• Nasal Packing
• Complete Bed Rest for At least 5 Days
• Higher Antibiotics
• Diuretics [Azetazolamide] to maintain the ICP
• FOLLOW UP CT SCAN @ 3 MONTHS to look for the Sinus Blockage](https://image.slidesharecdn.com/csfrhinorrhea-210321134232/75/CSF-Rhinorrhea-31-2048.jpg)
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- 1. CSF RHINORRHEA Dr. JeetM. Amin Resident Doctor, ENT Department, PDU Medical College & Hospital, Rajkot Dr. Manoj G. Amin[M. S., ENT] JEET ENT Hospital, Deesa HOD, ENT, AASHKA Multispecility Hospital, Gandhinagar
- 2. CSF (Cerebro Spinal Fluid) RHINORRHEA ClearColourless Body Fluid Found Surround the Brain & Spinal Cord. Excess Drainage , ranging from a clear Fluid to thick Mucus , from the Nose & Nasal Passages. CSF RHINORRHEA Leakage Of the CSF through a Communication of the Subarachnoid Space with the Sino- Nasal Cavity following Defect in the Skull Base
- 3. Physiology Of CSF •Total Volume = 90ml to 150ml • Formation Rate = 0.35-0.37ml/minute 20ml/hour 350-500ml/day • CSF Pressure = 5-15 cm H2O • Turnover = 3-5 times/day • Sites Of Production = 1) 50% Choroid Plexus In Ventricles 2) 30% Ependymal Surface 3) 20% Capillary Ultrafiltration
- 4. Anatomy For TheCSF Rhinorrhea
- 5. Etiology of CSFRhinorrhea
- 6. Sites Of CSFLeak • Over all --> Cribriform Plate Roof Of Ethmoid Sphenoid Sinus Frontal Sinus • Accidental trauma --> Fovea Ethmoidalis Sphenoid Sinus Frontal Sinus • Iaterogenic Trauma --> Lateral lamella of Cribriform Plate Roof Of Ethmoid Sphenoid Defects • Congenital --> Cribriform Plate • Spontaneous --> Cribriform Plate/Lateral wall Of Sphnoid
- 7. Clinically • Watery NasalDischarge [unilateral >> bilateral] • Headache • Anosmia • Vertigo +/- • Pulsatile Tinnitus Lately Meningitis, Seizures, Fever
- 8.
- 9. Halo Sign Blood StainedNasal Discharge Take It On Filter Paper Pale Surrounding Mostly in Traumatic CSF Leak
- 10. Handkerchief Test Nasal Secretion Takeit on Handkerchief Non – Sticky CSF Sticky Nasal Secretion (Mucin)
- 11.
- 12. Investigation •Biochemical CBC (total count) NasalSecretion Routine Micro Nasal Secretion Sugar & Protein ß2 Transferrin ß Trace Protein •Radiological HRCT PNS (1-2 mm cut) T2 Weighted MRI CT/MR Cisternography Radionuclide Cisternography Intrathecal Fluorescein
- 13. ß2 Transferrin • HighlySensitive & Specific • CSF , Perilymph , Vitreous • ß1 – cerebral neuraminidase – >ß2 • False –ve = high mucus content • False +ve = Chronic Alcohol Chronic Hepatic Glycoprotein Disorder Ca Rectum • 91% Sensitive & 99.9% Specific • CSF , Body Fluids including Serum • False +ve = Renal Insufficiency ß Trace Protein
- 14. HRCT Para NasalSinus(to look for leak) • False +ve = h/o Skull Base Surgery • Difficulty = To distinguish between mucosal thickening , meningocele & CSF Leak from Distal side with collection in sinus
- 15. MRI Brain withSkull Base & PNS(to look for leak) • Coronal T2 Weighted • To Differentiate between Inflammation & Meningoencephalocele without radiation exposure.
- 16. CT Cisternography • Usedin Doubts. • Intrathecal Radio-Opaque dye = iohexol &iopamidol ; metrizamide(older & toxic) • C/I in Active Meningitis & High ICP Active Leak Detect No Active Leak Put Cotton Pledges in Nose Wait for Sometime Check the Pledges If Dye Present = > Diagnosis √ BUT SITE CAN NOT BE DETECTED
- 17. Intrathecal Fluorescein • IntraNasal Pledges followed by Intrathecal Injection of Radio-Nuclide Agent = Tc99 • Limitation = High False +ve Rate, Variable Sensitivity , Low Specificity Radionuclide Cisternography • Pre-Operatively Intrathecal injection of 10ml CSF + 0.5ml of 5% Fluorescein • Green – Yellow Fluid Gives Site Of Leakage • Blue light Filter Improves the Result • Multiple Complications = Seizures , Dizziness , Nausea , Vomiting
- 18. Plan Of RadiologicalInvestigation
- 19. Conservative Management • BedRest • Head Elevation (15 Degree) • Stool Softeners • Diuretics [Azetazolamide] • Avoid Coughing, Sneezing , Blowing • Prophylactic Antibiotics • Lumber Drain for High Pressure Leak(Hourly 10 ml drainage) • Mostly for 7-10 Days. Post-Traumatic CSF Leak
- 20. Endoscopic Repair >>>>>>Craniotomy Supine Position Nasal Packing Part Prepare • Failure of Conservative Management • Delayed Post-Traumatic Leak • Very Large Defect • Persistent Pneumocephalus • SPONTANEOUS CSF LEAK Indication Surgical Management
- 21. Cribriform Plate ,Roof Of Ethmoid 1)Medial Lamella Lateralize Middle Turbinate Decongestion Medial Space 2)Lateral Lamella & Roof Of Ethmoid Trimming/Medialize Middle Turbinate Complete Ethmoidectomy
- 23.
- 24. Frontal Sinus • RoofAnd Posterior Wall = External Approach • Frontal Recess & Other Part Of Frontal Sinus = Endoscopic Approach • Awkward Region Endoscopically
- 25. Points To LookFor • Remove Whole Skull Base Mucosa • Expose the Bone to adhere The Graft • Abrade the Bone for Raw Surface • Multiple Defects In Sphenoid – Fat Obliteration • Bipolar Cautery Only. • Graft Slightly Larger than the Defect
- 26. Grafts • Hadad Flap(Naso-SeptalArtery) • Free Grafts = Conchal Cartilage Temporalis Facia Facia Lata Rectus Sheath Abdominal Fat
- 27. Types Of Reconstruction UnderLay Over Lay Small Defects < 5mm Combined Moderate (5-10 mm) Large (>10mm)
- 28. Bath Plug Technique 3-0Absorbable Suture along Length Of the Fat Plug And Knot it at the Inferior End Insert The Whole Fat Plug Gentle Pull Inferiorly
- 29. Fibrine Glu =Fibrinogen + Thrombin + Calcium Factor Gelatin Glu Microfibrillar Collage Surgicel with Abgel
- 30.
- 31. Post-Operative Care • NasalPacking • Complete Bed Rest for At least 5 Days • Higher Antibiotics • Diuretics [Azetazolamide] to maintain the ICP • FOLLOW UP CT SCAN @ 3 MONTHS to look for the Sinus Blockage
- 32. Conclusion • Diagnosis =Beta 2 transferrin • Radiology = Cisternography • Endoscopic Repair Preferable. • Complete Bed Rest.
- 33.