Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

CSF Rhinorrhea

  • Author: Kevin C Welch, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 04, 2016
 

Background

Cerebrospinal fluid (CSF) consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). CSF is colorless, clear, and typically devoid of cells such as polymorphonuclear cells and mononuclear cells (< 5/µL).

The primary site of CSF production is the choroid plexus, which is responsible for 50-80% of its daily production. Other sites of production include the ependymal surface layer (up to 30%) and capillary ultrafiltration (up to 20%). CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. A basal layer Na+/K+ ATPase is responsible for actively transporting Na+ into epithelial cells, after which water follows across this gradient. Carbonic anhydrase catalyzes the formation of bicarbonate inside the epithelial cell. Another Na+/K+ ATPase lining the ventricular side of the epithelium extrudes Na+ into the ventricle, with water following across this ionic gradient. The resulting fluid is termed cerebrospinal fluid.

CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. At any given time, approximately 90-150 mL of CSF is circulating throughout the CNS. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. After circulating through the subarachnoid space, CSF is reabsorbed via the arachnoid villi.

Circulation of CSF is maintained by the hydrostatic differences between its rate of production and its rate of absorption. Normal CSF pressure is approximately 10-15 mm Hg, and elevated pressure constitutes an intracranial pressure (ICP) greater than 20 mm Hg.

CSF rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality for the patient. Disruption of the barriers between the sinonasal cavity and the anterior and middle cranial fossae is the underlying factor leading to the discharge of CSF into the nasal cavity. The resulting communication with the CNS can result in a multitude of infectious complications that impart significant morbidity and potentially disastrous long-term deficits for the patient.

This article discusses current concepts in the etiology, diagnosis, and treatment of CSF rhinorrhea, as well as long-term management of patients following successful treatment.

See the image below.

An axial CT of a patient with a spontaneous CSF le An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus.
Next

History Of The Procedure

From the first intracranial repair in the 1900s to the use of endoscopes and image-guidance systems, the management of cerebrospinal fluid (CSF) rhinorrhea has greatly evolved. Dandy is credited with the first surgical repair of a CSF leak via a frontal craniotomy approach in 1926. Various other authors, including Dohlman (1948), Hirsch (1952), and Hallberg (1964), subsequently reported successful repair of CSF rhinorrhea through different external approaches. In 1981, Wigand reported on the use of the endoscope to assist with the repair of a skull base defect. Since then, endoscopic repair has become the preferred method of addressing CSF rhinorrhea, given the high success rate of 90-95% and the decreased morbidity associated with this approach.

Previous
Next

Problem

The underlying defect responsible for cerebrospinal fluid (CSF) leaks, regardless of the etiology, is the same: disruption in the arachnoid and dura mater coupled with an osseous defect and a CSF pressure gradient that is continuously or intermittently greater than the tensile strength of the disrupted tissue.

Previous
Next

Epidemiology

Frequency

The frequency of cerebrospinal fluid (CSF) rhinorrhea is determined by the underlying etiology. Please refer to Etiology for further details.

Previous
Next

Etiology

Cerebrospinal fluid (CSF) leaks are generally classified as traumatic, iatrogenic, and spontaneous/idiopathic. Traumatic causes include both blunt and penetrating facial injuries. Iatrogenic causes include neurosurgical and otolaryngologic approaches to neoplastic disease, as well as functional endoscopic sinus surgery (FESS). Most spontaneous, or primary, causes of CSF rhinorrhea are now thought actually to be secondary to elevations in intracranial pressure (ICP) that might be seen in patients with idiopathic intracranial hypertension (IIH). Congenital skull base defects and certain tumors can also lead to CSF rhinorrhea.

Traumatic CSF rhinorrhea

Penetrating and closed-head trauma are responsible for 90% of all cases of CSF leaks. CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. The majority of patients with a CSF leak due to accidental trauma (eg, motor vehicle accident) present immediately. Most of the patients (95%) with a delayed CSF leak present within 3 months after the injury.

Iatrogenic CSF rhinorrhea

In contrast to traumatic leaks, only 50% of patients with iatrogenic CSF leaks present within the first week after the insult. In most cases, the patient will have been discharged when the leak presents itself. Hence, educating the patient regarding the common symptoms associated with a CSF leak such as salty or metallic taste is of paramount importance.

Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. Skull base injuries can vary from simple cracks in the bony architecture to large (>1 cm) defects with disruption of the dura and potentially brain parenchyma.

Otolaryngology procedures, including FESS and septoplasty, can lead to a skull base defect and CSF rhinorrhea. Certain neurosurgical procedures such as craniotomy and transsphenoidal pituitary resections are most commonly associated with an increased risk of CSF rhinorrhea.

In patients undergoing endoscopic sinus surgery, the site of injury is most frequently the lateral lamella of the cribriform plate, where the bone of the anterior skull base is thinnest. Other common locations include the posterior fovea ethmoidalis and the posterior aspect of the frontal recess.

Tumor-related CSF rhinorrhea

The growth of benign tumors does not commonly result in CSF rhinorrhea. However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. The enzymatic breakdown or destruction of the bony architecture results in inflammation and potential violation of the dura. Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. Hence, the surgical team should be prepared to repair the resulting CSF leak at the time of the resection, either transcranially or endoscopically.

Congenital CSF rhinorrhea

Defects in the closure of the anterior neuropore can result in the herniation of central nervous tissue through anterior cranial fossa. These are infrequently associated with CSF rhinorrhea. The embryologic defect is typically a patent fonticulus frontalis or foramen cecum. Meningoencephaloceles usually present in childhood as an intranasal/extranasal mass that transilluminates and expands with crying (Furstenberg sign). A high index of suspicion should be maintained with all pediatric intranasal masses, particularly those occurring at the midline. A biopsy should never be obtained unless a complete imaging workup has been conducted.

Spontaneous CSF rhinorrhea

Spontaneous CSF rhinorrhea occurs in patients without antecedent causes. This terminology seems to imply that spontaneous CSF leaks are idiopathic in nature; however, recent evidence has led us to realize that spontaneous CSF rhinorrhea may in reality be secondary to an intracranial process, namely elevated intracranial pressure (ICP). There are several causes of elevated ICP; however, the proposed mechanism underlying spontaneous CSF rhinorrhea is idiopathic intracranial hypertension (IIH). Obstructive sleep apnea (OSA) has also been linked to elevated ICP.

Despite the multifactorial causes of elevated ICP, once this problem ensues, the pressure exerted on areas of the anterior skull base such as the lateral lamella of the cribriform or lateral recess of the sphenoid sinus results in bone remodeling and thinning. Ultimately, a defect is formed. At this point, the dura herniates through the defect (meningocele). If the defect is large, brain parenchyma may also herniate through the defect (encephalocele).

Previous
Next

Pathophysiology

Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. A possible cause of a delayed traumatic leak is a previously intact dural layer that has slowly herniated through a bony defect, finally tearing and allowing the cerebrospinal fluid (CSF) to leak. According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves.

Spontaneous CSF rhinorrhea usually manifests in adulthood, coinciding with a developmental rise in CSF pressure with maturity. The dura of the anterior cranial base is subject to wide variations in CSF pressure because of several factors, including normal arterial and respiratory fluctuations. Other stresses include Valsalva-like maneuvers during nose blowing or straining. This can lead to dural tears in areas of abnormalities of the bony floor.

A study by Lieberman et al found evidence of a significant incidence of multiple simultaneous skull base defects in cases of spontaneous CSF rhinorrhea, reporting the existence of such defects in eight out of 44 patients (18.2%) in the study. The investigators suggested that intracranial hypertension may put patients at risk for developing these defects.[1]

However, increased intracranial pressure is not always present in the case of spontaneous CSF rhinorrhea. Other proposed mechanisms for nontraumatic CSF leaks include focal atrophy, rupture of arachnoid projections that accompany the fibers of the olfactory nerve, and persistence of an embryonic olfactory lumen.

Iatrogenic CSF rhinorrhea results from surgical disruption of the skull base and dura as previously discussed.

Previous
Next

Presentation

History

A thorough history is the first step toward accurate diagnosis. The typical history of a cerebropsinal fluid (CSF) leak is that of clear, watery discharge, usually unilateral. Diagnosis is made more easily in patients with recent trauma or surgery than in others. Delayed fistulas are difficult to diagnose and can occur years after the trauma or operation. These cases often lead to a misdiagnosis of allergic and vasomotor rhinitis. On occasion, the patient has a history of headache relieved by drainage of CSF. Drainage may be intermittent as the fluid accumulates in one of the paranasal sinuses and drains externally with changes in head position (ie, reservoir sign).

A history of headache and visual disturbances suggests increased intracranial pressure. Sometimes, associated symptoms can assist in localizing the leak. For example, anosmia (present in 60% of individuals with post-traumatic rhinorrhea), indicates an injury in the olfactory area and anterior fossa, especially when it is unilateral. Optic nerve deficits suggest a lesion in the region of tuberculum sellae, sphenoid sinus, or posterior ethmoid cells. Patients with recurrent meningitis, especially pneumococcal meningitis, should be evaluated for a defect that exposes the intracranial space to the upper airway, regardless of the presence or absence of CSF rhinorrhea.

Physical examination

Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. Endoscopy may reveal an encephalocele or meningocele. Drainage of CSF in some cases may often be elicited on endoscopy by having the patient perform a Valsalva maneuver or by compressing both jugular veins (Queckenstedt-Stookey test). However, most of the time physical examination is unrevealing, especially in patients with intermittent CSF rhinorrhea.

In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult. CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. However, the presence of a ring sign is not exclusive to CSF and can lead to false-positive results.[2] In contrast to unilateral rhinorrhea, bilateral rhinorrhea gives no clue of the laterality of the defect. However, even in this situation, exceptions can occur. Paradoxical rhinorrhea occurs when midline structures that act as separating barriers (eg, crista galli, vomer) are dislocated. This dislocation allows CSF to flow to the opposite side and manifest at the contralateral naris. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%).

Previous
Next

Indications

Unless medical or surgical contraindications exist, surgical repair is recommended in all patients with spontaneous or iatrogenic cerebropsinal fluid (CSF) rhinorrhea in order to prevent ascending meningitis.

In patients with nonsurgical trauma, waiting a period of 5-7 days to allow conservative measures (bed rest, stool softeners, and lumbar drainage) to assist with secondary closure of the traumatic defect is reasonable. However, if CSF rhinorrhea persists beyond this point, or if a large skull base defect is observed at the time of injury, surgical repair is warranted.

If an iatrogenic leak is detected intraoperatively, it should be repaired at the time of the original surgery. In most cases of iatrogenic injury presenting in a delayed fashion, surgical repair is necessary. A lumbar drain placed at the time of repair has not been shown to decrease recurrence of the CSF leak.

Previous
Next

Relevant Anatomy

The most common anatomic sites of spontaneous cerebrospinal fluid (CSF) leaks are the areas of congenital weakness of the anterior cranial fossa and areas related to the type of surgery performed. The lateral lamella of the cribriform plate appears to be involved in approximately 40% of the cases, whereas a defect in the region of the fontal sinus is detected 15% of the time. The sella turcica and sphenoid sinus are involved in 15% of the cases as well.

Common sites of injury secondary to endoscopic sinus surgery include the lateral lamella of the cribriform plate and the posterior ethmoid roof near the anterior and medial sphenoid wall. Rarely, the leak can originate in the middle or posterior cranial fossa and can reach the nasal cavity by way of the middle ear and eustachian tube. These patients typically present with aural fullness due to a serous middle ear effusion.

Previous
Next

Contraindications

Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care.

The management of CSF rhinorrhea depends on the cause, location, and severity of the leak. When trauma is the cause, the interval between trauma and the onset of the leak is important. The natural history of CSF rhinorrhea is highly dependant on the underlying etiology.

Traumatic leaks stop spontaneously in the majority of cases, thus a conservative approach is best. The leakage stops within 1 week in 70% of patients, within 3 months in 20-30%, and within 6 months in most patients. The leak almost never recurs. The opposite is true for nontraumatic leaks, as only one third stop spontaneously. Intermittent leakage over several years is characteristic.

Previous
 
 
Contributor Information and Disclosures
Author

Kevin C Welch, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, The Feinberg School of Medicine

Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

James Stankiewicz, MD Professor, Chair, Program Director, Department of Otolaryngology-Head and Neck Surgery, Loyola University Chicago School of Medicine

James Stankiewicz, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Nadieska Caballero, MD Fellow in Rhinology and Skull Base Surgery, Sinus and Nasal Institute of Florida

Nadieska Caballero, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society

Disclosure: Nothing to disclose.

Acknowledgements

Joseph M Scianna, MD   Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Scianna is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society

Disclosure: Nothing to disclose.

Srinivas Mukkamala, MD  Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center

Disclosure: Nothing to disclose.

 

References
  1. Lieberman SM, Chen S, Jethanamest D, Casiano RR. Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects. Am J Rhinol Allergy. 2015 Jan-Feb. 29 (1):77-81. [Medline].

  2. Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. Ann Emerg Med. 1993 Apr. 22(4):718-20. [Medline].

  3. Ray BS, Bergland RM. Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure. J Neurosurg. 1969 Apr. 30(4):399-405. [Medline].

  4. Chow JM, Goodman D, Mafee MF. Evaluation of CSF rhinorrhea by computerized tomography with metrizamide. Otolaryngol Head Neck Surg. 1989 Feb. 100(2):99-105. [Medline].

  5. Byrne JV, Ingram CE, MacVicar D, et al. Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry. 1990 Dec. 53(12):1072-5. [Medline].

  6. Eljamel MS, Pidgeon CN, Toland J, et al. MRI cisternography, and the localization of CSF fistulae. Br J Neurosurg. 1994. 8(4):433-7. [Medline].

  7. Liu HS, Chen YT, Wang D, Liang H, Wang Y, Wang SJ, et al. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. Surg Neurol. 2009 Oct. 72(4):341-5; discussion 346. [Medline].

  8. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015 Apr 28. 4:CD004884. [Medline].

  9. Gosal JS, Gurmey T, Kursa GK, Salunke P, Gupta SK. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. Neurol India. 2015 Mar-Apr. 63 (2):197-201. [Medline].

  10. Dodson EE, Gross CW, Swerdloff JL, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Otolaryngol Head Neck Surg. 1994 Nov. 111(5):600-5. [Medline].

  11. Hegazy HM, Carrau RL, Snyderman CH, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000 Jul. 110(7):1166-72. [Medline].

  12. Lee TJ, Huang CC, Chuang CC, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. Laryngoscope. 2004 Aug. 114(8):1475-81. [Medline].

  13. 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. [Medline].

  14. Marshall AH, Jones NS, Robertson IJ. CSF rhinorrhoea: the place of endoscopic sinus surgery. Br J Neurosurg. 2001 Feb. 15(1):8-12. [Medline].

  15. Ryall RG, Peacock MK, Simpson DA. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. J Neurosurg. 1992 Nov. 77(5):737-9. [Medline].

  16. Elmorsy SM, Khafagy YW. Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: a review of 31 cases. Ear Nose Throat J. 2014 Jun. 93(6):E14-9. [Medline].

  17. Lemonnier LA, Tessema B, Kuperan AB, et al. Managing cerebrospinal fluid rhinorrhea after lateral skull base surgery via endoscopic endonasal eustachian tube closure. Am J Rhinol Allergy. 2015 May. 29 (3):207-10. [Medline].

  18. Cappabianca P, Cavallo LM, Esposito F, et al. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery. 2002 Dec. 51(6):1365-71; discussion 1371-2. [Medline].

  19. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Neurosurgery. 2010 Sep. 67(3 Suppl Operative):ons150-8; discussion ons158. [Medline].

  20. Bolger WE, Kennedy DW. Nasal endoscopy in the outpatient clinic. Otolaryngol Clin North Am. 1992 Aug. 25(4):791-802. [Medline].

  21. Caballero N, Bhalla V, Stankiewicz JA, Welch KC. Effect of lumbar drain placement on recurrence of cerebrospinal rhinorrhea after endoscopic repair. Int Forum Allergy Rhinol. May-Jun;2012. 2(3):222-6. [Medline].

  22. Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope. 2005 Feb. 115(2):205-12. [Medline].

  23. Carrion E, Hertzog JH, Medlock MD, et al. Use of acetazolamide to decrease cerebrospinal fluid production in chronically ventilated patients with ventriculopleural shunts. Arch Dis Child. 2001 Jan. 84(1):68-71. [Medline].

  24. Eljamel MS, Foy PM. Post-traumatic CSF fistulae, the case for surgical repair. Br J Neurosurg. 1990. 4(6):479-83. [Medline].

  25. Hubbard JL, McDonald TJ, Pearson BW, 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 Mar. 16(3):314-21. [Medline].

  26. Jones DT, McGill TJ, Healy GB. Cerebrospinal fistulas in children. Laryngoscope. 1992 Apr. 102(4):443-6. [Medline].

  27. Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience. Laryngoscope. 2004 Jun. 114(6):969-74. [Medline].

  28. Naidich TP, Moran CJ. Precise anatomic localization of atraumatic sphenoethmoidal cerebrospinal fluid rhinorrhea by metrizamide CT cisternography. J Neurosurg. 1980 Aug. 53(2):222-8. [Medline].

  29. Nuss D, Constantino P. Diagnosis and management of cerebrospinal fluid leaks. Otolaryngology Head and Neck Surgery. St Louis, Mo: Mosby-Year Book; 1996. 79-95.

  30. Ommaya AK, Di Chiro G, Baldwin M, et al. Non-traumatic cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry. 1968 Jun. 31(3):214-25. [Medline].

  31. Persky MS, Rothstein SG, Breda SD, et al. Extracranial repair of cerebrospinal fluid otorhinorrhea. Laryngoscope. 1991 Feb. 101(2):134-6. [Medline].

  32. Porter MJ, Brookes GB, Zeman AZ, et al. Use of protein electrophoresis in the diagnosis of cerebrospinal fluid rhinorrhoea. J Laryngol Otol. 1992 Jun. 106(6):504-6. [Medline].

  33. Rontal M, Rontal E. Studying whole-mounted sections of the paranasal sinuses to understand the complications of endoscopic sinus surgery. Laryngoscope. 1991 Apr. 101(4 Pt 1):361-6. [Medline].

  34. Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope. 2004 Feb. 114(2):255-65. [Medline].

  35. Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery. 2008 May. 62(5):991-1002; discussion 1002-5. [Medline].

  36. Stone JA, Castillo M, Neelon B, et al. Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography. AJNR Am J Neuroradiol. 1999 Apr. 20(4):706-12. [Medline].

  37. Woodworth BA, Prince A, Chiu AG, et al. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg. 2008 Jun. 138(6):715-20. [Medline].

  38. Woodworth BA, Schlosser RJ, Faust RA, et al. Evolutions in the management of congenital intranasal skull base defects. Arch Otolaryngol Head Neck Surg. 2004 Nov. 130(11):1283-8. [Medline].

  39. Woodworth BA, Schlosser RJ, Palmer JN. Endoscopic repair of frontal sinus cerebrospinal fluid leaks. J Laryngol Otol. 2005 Sep. 119(9):709-13. [Medline].

  40. Yerkes SA, Thompson DH, Fisher WS 3d. Spontaneous cerebrospinal fluid rhinorrhea. Ear Nose Throat J. 1992 Jul. 71(7):318-20. [Medline].

  41. Yessenow RS, McCabe BF. The osteo-mucoperiosteal flap in repair of cerebrospinal fluid rhinorrhea: a 20-year experience. Otolaryngol Head Neck Surg. 1989 Nov. 101(5):555-8. [Medline].

  42. Zlab MK, Moore GF, Daly DT, et al. Cerebrospinal fluid rhinorrhea: a review of the literature. Ear Nose Throat J. 1992 Jul. 71(7):314-7. [Medline].

 
Previous
Next
 
An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus.
After intrathecal fluorescein is administered, an exposed frontal recess encephalocele is seen.
A defect in the skull base is measured with a sterile ruler.
A small cribriform plate encephalocele is observed only after removing the middle turbinate.
Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. (Defect measured approximately 7mm.)
Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele.
This image represents an endoscopic view with a 70-degree telescope through the left frontal recess. A large defect is noted, and the meningocele has been resected. Repair of the leak can be performed with an underlay fascia graft and an anterior-based pedicled mucosa flap.
Triplanar images of a patient with a left lateral recess meningoencephalocele. The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.