Abstract
Background
The treatment of cerebrospinal fluid rhinorrhea has evolved since the first recorded instance of this condition by Willis in 1676. The advancements in radiology and endoscopic nasal surgery have provided ways to solve this potentially dangerous condition. But even now quite a few questions remain unanswered while tackling this difficult clinical situation. Laboratory tests for confirming the presence of cerebrospinal fluid in nasal fluid can yield false positive results and radiological evaluation has never been foolproof when it comes to small leaks and multiple leaks. Also the postoperative recurrence needs to be brought within acceptable limits.
Objectives
We have tried to evaluate endoscopic repair of CSF rhinorrhea based on a combined diagnostic approach. The methods for diagnosis of CSF rhinorrhea have been reevaluated based on our experience with a view to prevent recurrences and complications.
Materials and methods
The study group included twenty patients of CSF rhinorrhea who have been treated by endoscopic repair and spans over a period of five years from January 2001 to December 2005. A combination of retrospective and prospective methods of study has been used. Patients have been subjected to laboratory, radiological and dye studies for confirmation and localization of leak. Endoscopic repair of CSF fistula with composite graft and fibrin glue has been performed. Postoperative management included intracranial pressure reducing measures and control of primary condition in cases of spontaneous leak.
Results
Endoscopic repair of CSF rhinorrhea produced a first time success rate of 92%. CT/MR Cisternogram could localize the defect in 85% cases while intrathecal fluorescein aided localization whenever it was used. The use of fibrin glue with composite graft and postoperative intracranial pressure reducing measures could improve the success rate.
Conclusion
Management of a suspected CSF leak requires a combined diagnostic approach. Endoscopic repair with composite graft and fibrin glue should be the first line of management in cases of CSF rhinorrhea requiring surgical closure. Intracranial pressure reducing measures play an important role in preventing postoperative recurrence.
Similar content being viewed by others
References
Mac Donald R (1945) The occurrence of spontaneous cerebrospinal rhinorrhea in the literature, the experience of the writer, and other diplomats of the American Boards of Otolaryngology and Neurosurgeons. Laryngoscope 55:552–586
Scott-Brown’s otorhinolaryngology; 6th ed, 4/14/.1
Thompson St C (1899) The cerebro-spinal fluid: its spontaneous escape from the nose. London: Cassell & Co.; p.1–140
Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB (1968) Non traumatic cerebrospinal fluid rhinorrhea. J Neurol Neurosurg Psychiatry 31:214–225
McCoy G (1963) Cerebrospinal rhinorrhea: a comprehensive review and a definition of the responsibility of the rhinologist in diagnosis and treatment. Laryngoscope 9:1125–1157
Calcaterra TC (1985) Diagnosis and management of ethmoid cerebrospinal rhinorrea. Otolaryngol Clin North Am 18:99–105
Ryall RG, Peacock MK, Simpson DA (1992) Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. J Neurosurg 77(5):737–739
Johnson DB, Brennan P, Toland J, O’Dwyer AJ (1996) Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistalae. Clin Radiol 51(12):837–841
MahaleyJr. MS, Odom GL (1966) Complication following intrathecal injection of fluorescein. J Neurosurg 25(3): 298–299
Wallace JD, Weintriaub MI, Mattson RH, Rosnagle R (1972) Status epilepcticus as a complications of intrathecal fluorescein. J Neurosurg 36:659–660
Moseley JI, Carton CA, Stern WE (1978) Spectrum of complications in the use of intrathecal fluorescein. J Neurosurg 48(5):765–767
Roberto E. S. Guimaraes et al. (2002) Localization of skull base cerebrospinal fluid leaks by using intrathecal fluorescein in a hypodense solution during the surgery; Revista Brasileira de Otorrinolaringologia 68(6):788–792
Lund VJ, Savy L, Lloyd G, et al. (2000) Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhea. J Laryngol Otol 114:988–992
Lund VJ (2002) Endoscopic management of cerebrospinal fluid leaks. Am J Rhinol 16:17–23
Muranjan MN, Bharucha BA, Kirtane MV, Deshmukh CT (1999) Mondini dysplasia of the inner ear with CSF leak — A rare cause of recurrent meningitis. Indian Pediatr 36:401–406
Biggers WP, Neil Howell N, Fischer ND, Himadi GM, Hill C (1973) Congenital ear anomalies associated with otic meningitis. Arch Otolaryngol 97:399–401
Carrion E, Hertzog JH, Medlock MD, et al. (2001) Use of acetazolamide to decrease cerebrospinal fluid production in chronically ventilated patients with ventriculopleural shunts. Arch Dis Child 84(1):68–71
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bhalodiya, N.H., Joseph, S.T. Cerebrospinal fluid rhinorrhea: endoscopic repair based on a combined diagnostic approach. Indian J Otolaryngol Head Neck Surg 61, 120–126 (2009). https://doi.org/10.1007/s12070-009-0049-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12070-009-0049-x