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  1. 1. Rhinorrhea James Ridgway 7/27/06
  2. 2. HPI • Patient is a 21 year old male s/p 30ft fall at a construction site with face strike to one of the support beams prior to ground impact. No LOC at the scene. GCS of 15 in the trauma bay. Patient complains of right wrist pain. Notable oozing from the left nares.
  3. 3. Primary Survey A- airway intact B- CTA B C- RRR, no sites of hemorrhage, good perfusion. Vitals: 37.6 – 139/85 – 90 - 20
  4. 4. H&P • Patient states right wrist pain. Further examination reveals left sided nasal obstuction, rhinorrhea (s/p epistaxis), malocclusion, minor upper lip and midface pain, taste of blood in mouth. Notable right wrist deformity. • He denies any SOB, dyspnea, diplopia, visual field defect, tinnitus, HL, dysphagia, odynophagia or vocal change.
  5. 5. H&P • PMH: None • PSH: None • Medications: None • Allergies: NKDA • FH: HTN, DM • SH: +EtOH, denies TOB, IVDU. No history of HBV/HCV/HIV/TB.
  6. 6. PE • Eyes: PERRL, EOMI, no diplopia or visual field defects. Bilateral periorbital STS and ecchymosis. • Ears: TM c/i/m AU without effusion/hemotympanum or EAC defect. • Nose: Minor nose deviation to the left, nasal bones stable, crusted blood at the anterior nares, near total occlusion of the left nasal cavity 3.5 inside with cartilage/bone/mucosa disruption. Slow bleeding from the nose bilaterally. No septal hematoma. • OC/OP: Non-occlusion of teeth, midface mobile, limited discomfort, s&h palate intact, no other mass/lesions/defects. • Neck: +C-collar, trachea midline, no crepitus, no LAD/mass. • Face: Step-off’s along bilateral inferior orbital rims. Laceration along the left infraorbital rim and complex laceration of the patient’s lateral upper lip. Mandible stable. • CN: VII intact bilaterally, XII intact bilaterally, V1 and V3 without compromise. Anesthesia of V2 on left. • EXT: Notable right wrist deformity.
  7. 7. • Vascular: Gustatory, Churg-Strauss syndrome • Infection: Viral (RSV, Coronavirus, Adenovirus, influenza, Parainfluenza ), Bacteria (Pertussis, Diphtheria, Group A Streptococcus, Chlamydia), Rhinoscleroderma, • Trauma: CSF, foreign body • Autoimmune/immune: Allergic rhinitis (seasonal, dust, occupational), NARES, Nasal Polyposis, Wegener's granulomatosis, SLE, Sjögren's syndrome • Metabolic: Pregnancy, Hypothyroidism, Puberty • Iatrogenic/Idiopathic: Mediciations (alpha antihypertensives, MAOI antidepressants, oral contraceptives, ASA, some benzodiazepines ), surgical (FESS), rhinitis medicamentosa, Idiopathic (vasomotor) rhinitis • Neoplasia: Midline granuloma, CNS tumors (primary vs metastatic – glioma, astrocytoma, oligiodendroglioma, ependymoma, meningioma, prostate CA, SCCA, lymphoma), osteoma • Congenital: Choanal Atresia, Encephalocele, Meningocele, Meningoencephaloceles, Teratoma, Pseudomeningocele (Marfan’s syndrome, Neurofibromatosis) • Sarcoidosis
  8. 8. H&P of Rhinorrhea • Character of Symptoms: Onset, duration, constant vs intermittent, unilateral vs bilateral, obstruction, anosmia/hyposmia • Contributing factors: toxin or allergen exposure, current medicitions, history of asthma, sinusitis, allergy, facial trauma or surgery. • Associated symptoms: allergic component (sneezing, itchy and watery eyes, clear rhinorrhea), sinus involvement (facial pain, HA), acute infection (fever, malaise, pain, purulent discharge). • Other symptoms: sore throat, postnasal drip, cough, ear complaints, hoarseness, salty or sweet taste.
  9. 9. Basic Principles of Cerebrospinal Fluid • physical support and buoyancy for the brain • autoregulation • by-products of metabolism • regulate the chemical environment
  10. 10. Volume and production • Monro-Kellie hypothesis • 75/150/1400 • rate of 0.35 mL/min or 500 mL/d • Normal ICP ranges from 5 to 15 mm Hg • ICP = If X Rout + Pss • Increased protein concentration in the CSF or inflammatory changes in the dura create resistance to outflow by impairing CSF absorption – meningitis, subarachnoid hemorrhage, or iatrogenic entry of blood
  11. 11. CSF Rhinorrhea • Traumatic • Non-Traumatic • Spontaneous • Iatrogenic • Common S/S: – Unilateral watery nasal discharge – Fluid discharge with valsalva – Positional variation – Hx of trauma, surgery, increased ICP – Hyposmia, anosmia – HA – Unexplained weight loss – History of bacterial meningitis and especially a history of multiple episodes of bacterial meningitis
  12. 12. Traumatic & Non-Traumatic CSF Rhinorrhea Traumatic Non-Traumatic Non-Surgical Surgical High Pressure Leaks Normal Pressure Leaks • Accidental Trauma: 80% (2-4% of all head injuries) • HP CSF – 45% (tumor, benign ICP or hydrocephalus) • NPL – bone erosion, XRT, infection, fistula, encephalocele, meningocele, meningoencephaloceles, empty sella syndrome
  13. 13. Traumatic Traumatic Accidental Surgical Immediate Delayed Neurosurgical Procedure Complication of rhinologic procedures Transsphenoidal hypophysectomy Frontal craniotomy Other combined skull base procedures Sinus surgery Septoplasty Other combined skull base procedures
  14. 14. Non-Traumatic Non-Traumatic Elevated ICP Normal ICP Intracranial Neoplasm Hydrocephalus Congenital anomaly Skull base neoplasm NPC Sinonasal malignancy Non-communicating Obstructive Benign intracranial HTN Skull base erosive process Sinus mucocele Osteomyelitis Idiopathic
  15. 15. Spontaneous • Waste bucket term that refers to failed identification/ reason for CSF rhinorrhea
  16. 16. Iatrogenic Surgical CSF Rhinorrhea Unplanned Injury Planned Surgical Defect (failure of reconstruction) Immediate Delayed Immediate Delayed • 50% present immediately postoperative • Delay: 7 days to 1 month later • secondary to progressive maturation and contraction of wounds • devascularization • necrosis of the soft tissue or bony edges • slow resolution of edema • increased CSF pressure
  17. 17. • CSF leaks – Common Sites: – Frontal recess – Anterior ethmoid artery – Cribiform plate • Avoid by staying lateral to the middle turbinate • Avoid fracture of middle turbinate – Posterior ethmoid sinus • Recognize Leaks – Clear or swirling fluid Iatrogenic
  18. 18. • most common cause of rhinorrhea from surgical trauma is transphenoidal management of pituitary tumors (0.5–15%) • risk of CSF leak secondary to functional endoscopic sinus surgery varies from 0.5 to 3% • weaknesses of the skull base may result from the development of extensive paranasal pneumatization • lateral lamella of the cribriform plate forms the weakest part of the skull base Iatrogenic
  19. 19. Diagnosis – Sometimes easy, sometimes not. • Halo Sign • Components of CSF • glucose, protein and electrolytes • Beta-2 transferrin
  20. 20. Other Studies • High-resolution coronal and axial CT • CT cisternograms • Fluorescin • Radionuclide cisternography • MRI cisternograms • T2 images highlight the CSF leak on MRI.
  21. 21. Conservative Management • Most CSF leaks resulting from accidental and surgical trauma heal with conservative measures over the course of 7 to 10 days. – Bed rest, head elevation, stool softeners – No blowing nose, sneeze with open mouth – Lumbar drain – Acetazolamide – Prophylactic antibiotic coverage
  22. 22. Surgery • Extensive intracranial injury • Intraoperative identification • Nonresponders to conservative measures
  23. 23. Transcranial • Pros: – Success rates ranging from 60 - 95% – Improved exposure – Ability to identify multiple defects – Ability to tamponade a leak in a high-pressure situation • Cons: – inherent increased morbidity – length of hospitalization – permanent anosmia
  24. 24. Extracranial • Pros: – Success rates of 86% on initial operation with a 97% – Decreased morbidity – No anosmia – Improved endonasal exposure of the sphenoid, parasellar and posterior ethmoids,cribriform plate, fovea ethmoidalis, and the posterior wall of the frontal sinus • Cons: – facial scar – risk for facial numbness and orbital complications – cumbersome – Cerebral damage and the lateral extensions of the frontal and sphenoid sinuses cannot be assessed
  25. 25. Endoscopic • Currently the preferred method of repair – success rates of 92% to 96% have been documented – small defect can be closed with an overlay free mucosal graft or a free fascial graft – Larger defects at risk for a secondary encephalocele or small defects with elevated ICP are treated more appropriately with a bone graft placed in an underlay fashion within the epidural space and a fascial graft to provide a watertight seal placed in an overlay fashion – If the defect is more than 1 cm wide, the underlay technique with bone or cartilage is preferred to prevent herniation of cerebral tissue
  26. 26. Composite reconstruction technique using bone, cartilage, or lyophilized dura. This technique is used forlarger dural defects,multiple dural defects, or large bony skull-base defects. Free mucosal graft technique for smaller (<3 mm) dural defects
  27. 27. Other Methods • Composite grafts • Pedicled mucosal or mucochondral flaps • Bathplug technique • Lyophilized dura or fascia to sandwich the dural defect • Large dural closure with autografts such as fascia lata or temporalis fascia
  28. 28. Sealants • Fibrin: • combination of fibrinogen, thrombin, and calcium cofactor • most commonly used sealant today • Tisseel: • fibrin sealant that includes components of autologous cryoprecipitate from single-donor plasma, bovine thrombin, and an antifibrinolytic agent that yields a more stable clot • provides a temporary watertight closure and creates an additional barrier to CSF leakage during wound healing and fibrosis
  29. 29. Packing • Either absorbable or nonabsorbable • 86% of rhinologists use packing to repair CSF leaks
  30. 30. Post-Op • Postoperative follow-up with CT scanning is appropriate to rule out development of a mucocele when there is concern for sinius tract obstruction • Watchful of complications including meningitis, brain abscess, subdural hematoma, smell disorder, and HA. – Most common being meningitis at ~1%
  31. 31. • Lopatin AS, Kapitanov DN, Potapov AA.Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg. 2003 Aug;129(8):859-63. • Han CY, Backous DD. Basic principles of cerebrospinal fluid metabolism and intracranial pressure homeostasis. Otolaryngol Clin North Am. 2005 Aug;38(4):569-76.