This document discusses cerebrospinal fluid (CSF) rhinorrhoea, or leakage of CSF into the nose. It defines CSF rhinorrhoea, describes the physiology of CSF production and absorption, and discusses the etiology, clinical features, diagnosis, and management of CSF leaks. The key causes are traumatic injuries or fractures that disrupt the barrier between the brain/spinal cord and nose. Diagnosis involves clinical exams and tests like the beta-2 transferrin immunoassay. Treatment focuses on conservative management initially but may require surgical repair using endoscopic or open approaches to graft the defect.

1. Dr Anjana Mohite
Assoc Professor ENT.
DY Patil Medical College,Kolhapur,Maharashtra
INDIA

2. Definition
 Leakage of cerebro spinal fluid into the nose is called
CSF rhinorrhoea.
 Clear fluid.
 Serosanguinous- head injuries.

3. Physiology
 CSF forms a cushion of fluid around brain and spinal
cord acting as buffer against jerks.
 Secreted by choroid plexuses in 3rd 4th and lateral
ventricle.
 Absorbed by arachnoid villi (which have 1 way channel
allowing CSF of SASp to be absorbed into blood) into
dural sinuses.
 Total volume:90 to 150ml.
 Rate:20ml/hr.
 Total CSF replaced 3 to 4 times a day.
 Pressure:50 to 150mm H2O
 Pr increases on coughing,sneezing, nose blowing,
straining on stools or lifting weights.

4. Etiology
 Traumatic
 1. Accidental-
Facial injuries
Head injuries
2. Iatrogenic-
FESS
Neurosurgery
Polypectomy
Skull base surgery
 Non traumatic
 1.High pressure-
Tumours
Hydrocephalus
2. Normal pressure-
Congenital anomalies
Meningocele
Meningoencephalocele
Glioma
Osteomylitis skull base

5. Sites of leak
 1. From Anterior cranial fossa to nose:
 A) Cribriform plate of ethmoid bone(commonest site).
 B) Roof of ethmoid sinus.
 C) Posterior wall of frontal sinus.
 2. From middle cranial fossa to nose:
 A) Injuries to sphenoid sinus.
 B) Fracture in temporal bone: CSF reaches the middle
ear and then escapes through the eustachian tube into
the nose- referred to as CSF oto-rhinorrhoea.

7. Clinical Features:
 1. History of clear watery discharge from nose
increased by bending forwards and straining.
 2. Salty taste in the mouth when ever the discharge
comes out.
 3. Headache(low pressure which is relieved by bending
forwars or straining.
 4. Anosmia.
 5. In head trauma CSF is mixed with blood and shows
double target sign or Halo sign.

9. Difference between CSF and nasal
secretions
 CSF
 1.H/O nasal or sinus Sx,
head injury or SOL.
 2.Few drops or gush of
fluid more on bending and
straining that cannot be
sniffed back.
 3. thin ,watery, clear.
 4. tastes sweet
 5.Sugar >30mg/dl
 6. beta 2 transferrin always
+
 Nasal secretion
 1.Allergic symptoms
 2.Continuous, no change
on posture or straining,
can be sniffed back.
3. mucoid.
4. Tastes salty.
5. <10mg/dl
6 .absent

10. Diagnosis
 1. History and clinical features.
 2. Reservoir sign: Pt is made to lie down with head end
elevated for sometime and then suddenly asked to
bend head forwards. A sudden gush of watery
discharge is noticed.
 3. Handkerchief test: CSF does not stiffen a
handkerchief but nasal discharge owing to its mucus
content does.
 4. Halo sign or double target sign: When CSF is mixed
with blood in cases of head trauma, then on placing a
drop on a filter paper, there is a central zone of dry
blood and peripheral lighter halo or clear ring.

12. Laboratory Tests:
 1. Immuno electrophoretic demonstration of beta 2
transferrin is the diagnostic test.
 Beta 2 transferrin is a protein seen in CSF . Its presence
is a specific and sensitive for CSF. Perilymph and
aqueous humour are the only other 2 fluids than CSF
that contain this protein
 2.Radiological tests: to localize the site of defect.
 HRCT,
 MRI for active leaks and in cases of encephalocele and
SOL.
 CT cisternogram: It requires intra thecal inj of
iohexol dye and CT to localise the site.

14.  3. Intrathecal fluorescein study
 Done pre operatively to diagnose the site or intra
operatively at the time of repair.
 Invasive procedure where in 0.25 to 0.5ml of 5%
fluorescein diluted with 10 ml of CSF is injected intra
thecally.
 The dye is detected by nasal endoscopy using a blue
filter and it appears fluorescent green.
 Areas to be examined are: cribriform plate,olfactory
cleft, middle meatus ie frontal and ethmoid sinuses,
spheno-ethmoidal recess for spenoid sinus and area of
torus tubaris for temporal bone fracture.

16. Management
 In traumatic cases, conservative treatment is advisable to
allow the fistula to heal spontaneously. This includes:
 1. Bed rest in head up position.
 2. Stool softners.
 3. Avoidance of straining , nose blowing, coughing and
sneezing.
 4. Avoid use of nasal decongestant drops.
 5. Prophylactic antibiotics to prevent meningitis.
 6. Acetazolamide to decrease CSF secretion.
 7. Indwelling Lumbar subarchnoid drain to decrease CSF
pressure and allows torn dural flaps to approximate and
heal.

17.  Most traumatic leaks seal with this treatment by 2 to 3
weeks. If it fails to heal beyond this time, surgical
intervention should be considered.
 Closure of leak by:
 1.Intra cranial approach-by neuro surgeon.
 2. Extra cranial approaches-Ext ethmoidectomy for
cribriform plate and ethmoid area, trans septal
sphenoid approach for sphenoid and osteoplastic flap
approach for frontal sinus leak.
 3.Trans nasal endoscopic approach.

19. Advantages of Trans nasal
endoscopic repair of CSF leak
 1. Allows accurate localization of leak.
 2. Better positioning of graft is possible.
 3. Does not increase size of defect.
 4. Less morbidity.
 5. Duration of stay in hospital is reduced.
 6. Avoids craniotomy.
 7. Revision surgeries are possible in failed and
recurrent leaks.

21. Graft materials used to seal defect
 1. Abdominal fat.
 2. Temporalis fascia.
 3. Fascia lata.
 4. Conchal mucoperiostium
 5. Conchal cartilage.
 6. Septal flaps.
 7. Muscle
 If defect is large(1cm) closure is done in multiple
layersusing cartilage or bone and fascia is preferred
called as sandwich graft.

22. Procedure:
 Define the site.
 Preparation of graft site.
 Underlying grafting of fascia(fat) extra durally.
 Placement of mucosa as free graft or pedicled flap.
 Repair of large bone defect with septal cartilage or conchal
cartilage & then placement of mucosa.
 Placement of surgicel and gelfoam for reinforcement.
 Placement of high antibiotic smeared nasal pack.
 Lumbar drain if pressure is high.
 Antibiotics.
 Leaks from frontal sinus require osteoplastic flap and
obliteration of sinus with fat.

23. Thank you