CSF Rhinorrhoea

Management and Practice

Jyotirmay S. Hegde, Hemanth Vamanshankar, Jyotirmay S. Hegde, Hemanth Vamanshankar

• Publisher: CRC Press
• Year: 2020
• Print ISBN: 9780367029586
• eBook ISBN: 9780429670992
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina di famiglia e medicina generale

Cerebrospinal fluid (CSF) rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality. CSF Rhinorrhea: Management and Practice covers the current concepts in the etiology, diagnosis, and treatment of the condition, as well as long-term management of patients following successful treatment. It provides broad insight into the causes for leakage of CSF from the nose and helps in diagnosis and subsequent treatment. Its multidimensional approach caters to medical undergraduates and postgraduates along with specialists in various fields such as ENT, neurosurgery, neurology, medicine and endocrinology, thus providing a comprehensive plan for management of CSF rhinorrhea.

Key features

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• Focuses on trans-nasal endoscopic repair of CSF rhinorrhea

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• Explores minimally invasive techniques and recent advances in CSF rhinorrhea

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• Reviews clinical presentation and case diagnosis with special emphasis pertaining to general practitioners

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• Discusses post-operative care in an exclusive chapter

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• Includes videos of surgical procedures

Dr Jyotirmay S Hegde is currently a consultant ENT, head and neck and endoscopic skull base surgeon at Columbia Asia Hospital, Whitefield, Bangalore, India. He has also worked as a faculty member in various capacities at the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India. Dr Hegde completed his Masters in Otolaryngology-Head & Neck Surgery at Karnataka Institute of Medical Sciences, Hubli, Karnataka, India and his Fellowship in Rhinology and Endoscopic skull base surgery from Aintree University Hospital, Liverpool, UK. Dr Hegde is a fellow of the European Board of Otolaryngology (FEBORL). He has published in several peer-reviewed scientific publications and presented in national and international conferences, courses, and workshops.

Dr Hemanth Vamanshankar graduated from K.S. Hegde Medical Academy, Mangalore, India in 2008 and completed a diploma in Otolaryngology from St John's Medical College, Bangalore, India in 2011 and DNB-ENT from Southern Railway Hospital, Ayanavaram, Chennai, India in 2014. He was awarded MRCS-ENT from the Royal College of Surgeons, Edinburgh, UK. He has to his credit 25 indexed publications of national and international repute. He is currently working as a medical officer and consultant ENT surgeon at the Divisional Railway Hospital, Bangalore, India (South Western Railway).

1
History of CSF rhinorrhea

Hemanth Vamanshankar and Jyotirmay S Hegde

St Clair Thomson, a British surgeon and professor of laryngology, gave the first description of a CSF rhinorrhea following a skull fracture in 1899¹ (Figure 1.1). The first description of a spontaneous CSF leak was given by Charles Miller.² In 1884, after a post mortem, Chiari incidentally discovered a communication of the brain with the ethmoids, with the presence of an aerocele in one of his patients.³ Although these were merely clinical diagnoses, the first radiological description of an aerocele performed by X-ray technique was given by Luckett in 1913.⁴

Figure 1.1 St Clair Thomson (1859–1943). © Jyotirmay S Hegde, Hemanth Vamanshankar.

Walter Edward Dandy, considered one of the founding fathers of neurosurgery from Johns Hopkins University (Figure 1.2), is credited as the first person to undertake an external CSF leak repair through a bifrontal craniotomy in 1926⁵ (the fascia lata was used to plug a leak in the posterior wall of the frontal sinus). This continued to be the treatment of choice until Dohlman in 1948, who described the extracranial naso-orbital incision used in order to repair an anterior cranial fossa leak.⁶ An unsuccessful attempt of leak repair for a traumatic aerocele was performed by Grant in 1923.⁷ A transnasal approach to sphenoid sinus leaks using septa1 flaps was reported by Hirsch in 1952.⁸ An intranasal approach for cribriform plate leaks was described by Vrabec and Hallberg in 1964.⁹ The use of endoscopes for the repair of small CSF leaks occurring during ethmoidectomy began only in 1981, popularized by Wigand.¹⁰

Figure 1.2 Walter Edward Dandy (1886–1946). © Jyotirmay S Hegde, Hemanth Vamanshankar.

For closure of CSF leaks, fascia lata was the primary choice, as described by Dandy. This was similarly described by others like Cushing (1927), McKinney (1932), Cairns (1937), Gissane and Rank (1940), Eden (1942), and Campbell, Howard, and Weary (1942).^{11– 16} Echols and Holcombe (1941)¹⁷ described closure by using muscle. German (1944)¹⁸ described using flaps of dura covering the crista galli and falx to repair five cases. The use of a free periosteal graft over the cribriform plate was described by Ecker in 1947.¹⁹ The use of absorbable gelatin sponge (Gelfoam) was first mentioned by Cloward and Cunningham in 1947.²⁰ The use of wax after stripping the dura on either side of the CSF leak and subsequent suturing was successfully described by Love and Gay.²¹ Coleman described the release of air and suturing dura over cribriform plate – which he successfully performed in a case of pneumatocele with CSF rhinorrhea following trauma.²²

It is, however, interesting to note the other anecdotal forms of treatment used for CSF leaks.

50% chromic acid has been used for cauterizing the CSF, which had been said to cure a CSF leak by B. de Almeida.²³

Lumbar puncture, attempted during an episode of meningitis, is said to have stopped a CSF leak, as described by Singleton.²⁴ Similar cases were described by Schroeder and Frenzel (who along with lumbar puncture also started the patient on sulfonamides).^{25, 26}

Radiation has also been described as a possible cure for CSF leaks, with Sgalitzer describing cure in nine out of ten patients.²⁷ This he ascribed to the fact that X-ray irradiation to the choroid plexus causes inhibition of CSF production, and hence halts the leaks.

Learmouth is said to have inserted cotton packs soaked in tincture of iodine extradurally over the cribriform plate for nine days, causing a cessation of drainage.²⁸

References

1. 1. Thomson St. C. The Cerebro-Spinal Fluid: Its Spontaneous Escape from the Nose. London, UK: Cassell & Co., Ltd., 1899, p. 8.
2. 2. Thomson S and Negus VE. Diseases of the Nose and Throat (5th edition). New York: Appleton-Century-Crofts, Inc., 1947, p. 104.
3. 3. Chiari H. Ueber einen Fall von Luftansammlung in den Ventrikeln des menschlichen Gehirns. Ztschr f Heilk 5:383, 1884.
4. 4. Luckett WH. Air in the ventricle of the brain following fracture of the skull. Surgery, Gynecology & Obstetrics 17:237, 1913.
5. 5. Dandy WE. Pneumocephalus (Internal pneumocele or aeroscele). Archives of Surgery 12:949–982, 1926.
6. 6. Dohlman G. Spontaneous cerebrospinal rhinorrhea. Acta Otorrinolaringologica 67:20–23, 1948.
7. 7. Grant FC. Intracranial aerocele following a fracture of the skull. Surgery, Gynecology & Obstetrics 36:251, 1923.
8. 8. Lanza DC, O'Brien DA and Kennedy DW. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope 106:1119–1125, 1996.
9. 9. Vrabec DP, Hallberg OE. Cerebrospinal fluid rhinorrhea. Archives of Otolaryngology 80:218–229, 1964.
10. 10. Wigand WE. Transnasal ethmoidectomy under endoscopic control. Rhinology 19:7–15, 1981.
11. 11. Cushing H. Experiences with orbito-ethmoidal osteomata having intracranial complications, with the report of four cases, Surgery, Gynecology & Obstetrics 44:721–742, 1927.
12. 12. McKinney R. Traumatic pneumocephalus. The Annals of Otology, Rhinology, and Laryngology 41:597–600, 1932.
13. 13. Cairns H. Injuries of the frontal and ethmoidal sinuses with special reference to cerebro-spinal rhinorrhoea and aeroceles. The Journal of Laryngology an...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgments
• Editors
• List of contributors
• 1 History of CSF rhinorrhea
• 2 Basics of CSF production
• 3 Classification of CSF rhinorrhea
• 4 Spontaneous CSF rhinorrhea
• 5 Traumatic CSF rhinorrhea
• 6 Iatrogenic CSF rhinorrhea
• 7 Idiopathic intracranial hypertension and CSF rhinorrhea
• 8 Systemic causes of CSF rhinorrhea
• 9 Endoscopic management of CSF rhinorrhea
• 10 Transcranial management of CSF rhinorrhea
• 11 Role of navigation in CSF rhinorrhea
• 12 Role of radiodiagnosis in CSF rhinorrhea
• 13 Complications of CSF rhinorrhea
• 14 Reconstruction of skull base defects
• 15 Recent advances in the management of CSF rhinorrhea
• Index