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Author Topic: CSF leaking down nose - if it dries soft its csf....  (Read 27169 times)
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dabirg
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« on: June 21, 2011, 06:54:57 PM »

http://www.utmb.edu/oto/Grand%20Rounds%20Files/CSF_Leaks_1989.txt




-------------------------------------------------------------------------------
TITLE:   DIAGNOSIS AND TREATMENT OF CSF LEAKS
SOURCE:  Dept. of Otolaryngology, UTMB, Grand Rounds
DATE:    19 April 1989
RESIDENT PHYSICIAN:      Amy Coffey, M.D.
FACULTY:                 F. B. Quinn, Jr., M.D.
DATABASE ADMINISTRATOR:  Melinda McCracken, M.S.
-------------------------------------------------------------------------------

"This material was prepared by resident physicians in partial
fulfillment of educational requirements established for the
Postgraduate Training Program of the UTMB Department of
Otolaryngology/Head and Neck Surgery and was not intended for
clinical use in its present form.  It was prepared for the purpose
of stimulating group discussion in a conference setting.  No
warranties, either express or implied, are made with respect
to its accuracy, completeness, or timeliness.  The material
does not necessarily reflect the current or past opinions of
members of the UTMB faculty and should not be used for purposes
of diagnosis or treatment without consulting appropriate
literature sources and informed professional opinion."

Causes of CSF fistulas:

  80% head injuries with skull base fractures- M>F
  16% surgery - nasal and paranasal cavities, skull base
  4%  spontaneous fistulas- F>M
  I.   RHINORRHEA
  A.   Traumatic
  2-3% of all head injuries; >11% with skull base fractures.
  Occurs in areas of thinness of bone and adherence of the
  dura to the skull:  cribiform plate, posterior wall of  frontal
  sinus, sphenoid, sella floor or the great sphenoidal wing (large
  lateral development of sinus).
  Compound fractures more commonly associated with persistent leaks
  than linear fractures
  Late appearance of a fistula provoked by an elevation of
  the intracranial pressure and by an enlargement of the  frontal
  ventricular horn as consequence of a frontal lobe contusion.
  Appearance occurs by the 1st or 2nd day in 55%, one week
  in 15%, and up to 20 years later in 10%.  The remainder present
  with meningitis.
  Treatment- stops spontaneously or under treatment usually in 3-5
  days when detected on the day of or after the injury;   treated
  usually by "head-up" position, avoidance of coughing sneezing, nose
  blowing and straining, laxitives, restricting oral intake, use of
  steroids, diuretics or osmotically active medications and by
  repeated lumbar CSF drainage with removal of about 150ml daily
  (should not be done with marked brain edema, increased ICP). 
  Spontaneous cure not likely if persist longer than one week;   
  all should be treated operatively.  If leak stops within one week,
  no fracture or only a small linear fracture on X-ray, and no 
  anosmia then operative treatment is probably not necessary but
  patient should be followed closely for at least one year for signs
  of recurrent or occult rhinorrhea and warned about the increased
  risk for meningitis.  If anosmic, surgery is probably better 
  performed.  Some authors feel all cases with compound fractures,
  a defect within the posterior wall of the frontal sinus, the 
  cribiform plate and ethmoidal region, or fractures of the sphenoid
  should be operated upon even if rhinorrhea has stopped spontaneously
  due to high risk of recurrence and meningitis.  All bullet wounds
  of the anterior cranial fossa with rhinorrhea require operative
  treatment.
  B.   Postoperative
  Most frequently from transsphenoidal approach to pituitary
  adenomas due to intraoperative damage of the pituitary  tentorium
  diaphragma sellae.
  Following removal of tumors of the base of the skull.
  During ENT operations:  endoscopic sinus surgery(bone
  often dehiscent in long standing or severe polypoid  disease),
  septoplasty (must not crack the cribiform plate- most often occurs
  using the Jansen-Middleton forceps and a rocking motion)
  Fistulas produced unintentionally during ENT operations
  can usually be closed from the same approach.  Repair  should be
  undertaken at once;  use temporalis fascia tucked in through the bony
  defect after dural edges carefully detached from the bone-covered
  with second piece of fascia and possibly a mucoperiosteal flap from
  the nasal septum rotated and allowed to cover the  second piece of
  fascia then packed with Gelfoam and antibiotic-impregnated gauze
  left in place 10-14 days.  Transseptal  sphenoidectomy offers a
  limited approach for repairs in this area requiring radiologic
  control for orientation.  Treatment of choice  for CSF leaks
  associated with empty sella syndrome.  The external ethmoid approach
  to the sphenoid may give better visualization. 
  Posterior ethmoidal lesions are better closed via a transfrontal
  intradural approach.
  If leak diagnosed during the immediate postoperative
  period, a subarachnoid lumbar drain may be used to  decompress; 
  kept in place 1 to 2 weeks;  may use prophylactic antibiotics.
  If unrecognized until patient develops meningitis,
  external ethmoidectomy approach indicated.  If this approach  fails,
  may need anterior craniotomy (morbidity much higher with this
  approach due to invariable damage to the olfactory nerve).  May 
  need to identify site of lesion to help with planning using
  diagnostic study.
  C.   Spontaneous
  Nasal CSF fistula with no evidence of traumatic origin,
  are not the result of operation, or for no clear reason escapes
  through or along the olfactory nerves.
  Almost always located in the ethmoidal region.
  Seen with high pressure hydrocephalus of markedly raised
  intracranial pressure from other reasons, tumours of the base of
  the skull, ethmoidal encephalomeningocele and sphenoidal defects
  such as the empty sella syndrome (10% associated with CSF rhinorrhea)
  II.  OTORRHEA
  A.   Most frequently following temporal bone fractures.
  B.   Second most frequently seen after intracranial surgery
  involving the temporal bone.
  C.   Spontaneous CSF otorrhea - two different subgroups
  72% childhood type with congenital defects of the otic
  capsule.
  1.   median age 4 years old.
  2.   meningitis occurs in 92% (usually pheumococcal,
  recurrent)
  3.   follows myringotomy for a presumed serous effusion
  4.   Mondini deformity; uni- or bilateral absence of
  cochlear and vestibular function usually
  5.   CSF usually enters inner ear through a dural
  defect in the lateral aspect of the internal auditory canal and
  exits through the oval window.
  Treatment- most effective operation is stapedectomy and
  packing of the vestibule with a muscle graft.  If hearing is present,
  subtotal petrosectomy including a radical mastoidectomy with
  exenteration of the hypotympanic and pericarotid air cells, 
  obliteration of the eustachian tube, middle ear and mastoid, and
  blind sac closure of the external auditory canal.
  28% adult type with bony dehiscenses, most commonly of the
  tegmen tympani or tegmen mastoideum (floor of the  middle cranial
  fossa), less commonly of the posterior fossa plate
  1.   range from 27 to 72 years old; median age 56.
  2.   Women > men.
  3.   present after myringotomy for effusion with
  conductive hearing loss;  CSF rhinorrhea;  meningitis.
  4.   meningeal defects are either meningoencephaloceles
  (associated with middle cranial fossa floor defects,  none found
  in posterior defects) or holes in the dura.
  5.   6% of routine autopsies have small, often multiple, bony
  defects in the floor of the middle fossa yet  incidence of
  spontaneous CSF otorrhea is low.  Other factors are size of the
  defect, the length of time that it is present, and the presence of
  increased intracranial pressure.
  Treatment- combined mastoid and transtemporal
  supralabyrinthine approach.  Tiny defects can then be repaired
  through this approach.  If a meningoencephalocele is protruding
  through the tegmen, it is safer to perform a middle fossa 
  craniotomy.  Also possible to do a combined mastoid and
  mini-craniotomy approach for repair of tegmen defects.
III. ANTIBIOTICS
  A.   Used for prophylaxis - controversial.
  1.   infection rates do not differ significantly
  comparing treated to nontreated using penicillin (8 and 5%).
  2.   few antibiotics penetrate the normal meninges in
  sufficient concentration to be of value
  3.   increase the risk of antimicrobial resistance
  4.   may mask the appearance of an acute infection
  B.   Pneumococcus (Streptococcus pheumoniae) frequent cause of
  meningitis secondary to temporal bone fractures;  may be  solated on
  culture in up to 50% of cases.
IV.  DIAGNOSIS
  A.   Observation of clear watery fluid
  look for hidden leak: comatose- place in lateral position
  and bend the face downward; conscious-pressure test, valsalva, etc.
  B.   Handkerchief test
  moistened with nasal secretions dries stiff; with CSF dries soft.
  C.   Nasal rhinorrhea usually thin, watery, and opalescent and
  throws down a stringy precipitate secondary to mucin when tested
  with alcohol or acetic acid;  CSF is clear and watery and does not
  precipitate when tested with alcohol or acetic acid.
  D.   Halo test
  great amount of CSF discharge is necessary
  E.   Glucose oxidase test
  Clinistix or Tes-tape introduced into the nares;  positive
  indicates CSF rhinorrhea, negative indicates rhinal or  allergic
  discharge.
  many false positives and false negatives documented.
  F.   Chemical analysis of glucose and protein content
  collect several cubic centimeters in test tube;  positive
  when the glucose content exceeds 0.4 g/l and the protein  content is
  from less than 1 g/l to a maximum of 2 g/l;  not reliable when CSF
  is contaminated with blood or wound secretion or  excessive nasal
  or lacrimal secretions (>20%).
  G.   Dyes- Fluorescein
  can use intaoperatively with darklight
  high sensitivity
  some complications (i.e. status epilepticus, etc.)
  H.   Radioisotope cisternography
  radioactive tracers injected into the lumbar subarachnoid
  space followed by scintigraphy
  compare count of cotton pledgets and blood; normal maximum
  ratio is 0.3;  Indium or TC pertechnetate most  frequently used; 
  choice for scanning CSF fistulae when identifying questionable,
  very small, or intermittent leaks.  Very sensitive-
  false-positives (detected in patients with no CSF leak by
  circulation to nasal mucosa through blood stream after 
  absorption via the arachnoid villi), large amount of technical
  equipment
  I.   Radiopaque contrast material
  metrizamide- water soluble;  used in conjunction with
  computerized axial and sagittal tomography; may be performed 
  in "head up" position
  relatively free of neurotoxicity
  sensitive
  scan of choice in localizing active CSF leaks
  J.   Immunofixation techniques- identify B2-transferrin
  pathognomonic for CSF fluid; has not been found in any
  other body fluid
  collected in test tube, on Merocel sponges, or by
  aspiration through the TM
  procedure:  measure the protein concentration - if >5g/l,
  precipitation with ammonium sulfate; precipitate  dissolved in
  distilled water; electrophoresis; immunofixation by soaking sample
  in monospecific antiserum against human transferrin;  rinsed,
  fixed and stained with silver staining solution(more sensitive
  than earlier used Coomassie brilliant blue dye).
  must examine the patient's serum also therefore avoiding
  false positives (liver cirrhosis, genetic protein  variance); 
  if high levels of contamination with blood or wound secretions,
  Merocel sponge is centrifuged; if blood contamination is  above
  3g/l hemoglobin, the hemoglobin content is reduced by column
  chromatography.  High sensitivity (4ul sample volume sufficient),
  high level of accuracy, speed of testing (in biochemical lab), 
  can be repeated and it is not hazardous to the patient.
------------------------------------------------------------------------------
            BIBLIOGRAPHY

Adkins, WY, et.al.  Mini-Craniotomy for Management of CSF Otorrhea
from Tegmen Defects,  LARYNGOSCOPE August 1983, 93:1038-1040.

Bret, P., et.al.  Treatment of Cerebrospinal Fluid Rhinorrhea by
Percutaneous Lumboperitoneal Shunting:  Review of 15 Cases, 
NEUROSURGERY  1985, 16:44-47.

Cannon, C.R., & R.A. Jahrsdoerfer  Temporal Bone Fractures: Review of
90 Cases,  ARCH OTOLARYNGOL  May 1983, 109:285-288.

Curnes, J.T. et.al.  CSF Rhinorrhea: Detection and Localization Using
Overpressure Cisternography with Tc-99m-DTPA.  RADIOLOGY 1985,
154:795-799.

Hasegawa, M. et.al.  Transfer of Radioisotope from CSF to Nasal
Secretion.  ACTA OTOLARYNGOL 1983, 95:359-364.

Hubbard, J.L. et.al.  Spontaneous Cerebrospinal Fluid Rhinorrhea:
Evolving Concepts in Diagnosis and Surgical Management Based on the
Mayo Clinic Experience from 1970 through 1981.  NEUROSURGERY  1985,
16:314-320.

Katz, R.T. and P.E. Kaplan  Glucose Oxidase Sticks and Cerebrospinal
Fluid Rhinorrhea.  ARCH PHYS MED REHABIL 1985, 66:391-393.

Loew, F. et.al.  Traumatic, Spontaneous and Postoperative CSF
Rhinorrhea.

Luotonen, J. et.al.  Localisation of a CSF Fistula by Metrizamide CT
Cisternography.  1986, 100:955-958.

Maniglia, A.J.  Fatal and Major Complications Secondary to Nasal and
Sinus Surgery.  LARYNGOSCOPE  1989, 99:276-283.

Nishihira, S. and T.V. McCaffrey  The Use of Fibrin Glue for the
Repair of Experimental CSF Rhinorrhea.  LARYNGOSCOPE 1988, 98:625-627.

Oberascher, G.  Cerebrospinal Fluid Otorrhea-New Trends in Diagnosis. 
AM J OTOLOGY  1988, 9:102-108.

Oberascher, G. and E. Arrer  Efficiency of Various Methods of
Identifying Cerebrospinal Fluid in Oto- and Rhinorrhea.  ORL 1986,
48:320-325.

Park, J. et.al.  Current Management of Cerebrospinal Fluid Rhinorrhea. 
LARYNGOSCOPE  1983, 93:1294-1300.

Wetmore, S.J. et.al.  Spontaneous Cerebrospinal Fluid Otorrhea.  AM J
OTOLOGY  1987, 8:96-101.

Yokoyama, K. et.al.  Diagnosis of CSF Rhinorrhea:  Detection of
tau-Transferrin in Nasal Discharge.  OTOLARYNGOL H & N SURG  1988,
98:328-332.
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TRINITY1
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« Reply #1 on: June 21, 2011, 07:15:05 PM »

So basically -

Diagnosis - The hankerchief test - moistened with nasal secretions it dries stiff - with CSF it dries soft....

Nice find Gill  cool

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Rachie
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« Reply #2 on: June 21, 2011, 07:24:30 PM »

 cool
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Rachie  x

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« Reply #3 on: June 21, 2011, 11:17:35 PM »


Great info/post and  smiley: thanks for clarifying too  Smiley: smiling
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« Reply #4 on: June 21, 2011, 11:26:35 PM »

So basically -

Diagnosis - The hankerchief test - moistened with nasal secretions it dries stiff - with CSF it dries soft....

Nice find Gill  cool



Was gonna say the same thing.. lol
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dabirg
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« Reply #5 on: June 22, 2011, 01:49:47 PM »

Its amazing what you can find when you are looking for something else entirely!!!! whistling
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Mum of Pickles
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« Reply #6 on: July 23, 2011, 08:48:27 PM »

I have had a runny nose for ages now and getting very annoyed by it is the Ih what is causing it i dont suffer with hayfever or anything like that, I do have a shunt which my docs think might be blocked, Help its driving me crazy  Smiley: headache smiley: thanks
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« Reply #7 on: July 24, 2011, 03:43:39 PM »

Hi
I personally carn't offer you any advice but I have found a piece on the internet about csf leakage. Hope its of some use.

Quote
Spontaneous cerebrospinal fluid leak syndrome (SCSFLS) is a medical condition in which the cerebrospinal fluid (CSF) held in and around a human brain and spinal cord leaks out of the surrounding protective sac, the dura, for no apparent reason. The dura, a tough, inflexible tissue, is the outermost of the three layers of the meninges, the system of meninges surrounding the brain and spinal cord. (The other two meningeal layers are the pia mater and the arachnoid mater).

A spontaneous cerebrospinal fluid leak is one of several types of cerebrospinal fluid leaks and occurs due to the presence of one or more holes in the dura. A spontaneous CSF leak, as opposed to traumatically caused CSF leaks, arises idiopathically. A loss of CSF greater than its rate of production leads to a decreased volume inside the skull known as intracranial hypotension (ICH). A CSF leak is most often characterized by a severe and disabling headache and a spectrum of various symptoms which occur as a result of ICH. These symptoms can include: dizziness, nausea, fatigue, a metallic taste in the mouth (indicative of a cranial leak), myoclonus, tinnitus, tingling in the limbs, facial weakness amongst others. A CT scan can identify the site of a cerebrospinal fluid leakage. Once identified, the leak can often be repaired by an epidural blood patch, an injection of the patient's own blood at the site of the leak. (From Wikipedia, the free encyclopedia)

I have also merged you post with a older one regarding CSF leakage.
« Last Edit: July 24, 2011, 03:46:48 PM by Toni » Logged

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