Primary spontaneous cerebrospinal fluid rhinorrhea RUSSELL N. BECKHARDT, MD. MICHAEL SETZEN, MD. and ROBERT CARRAS, MD, Manhasset, New York
Spontaneous cerebrospinal fluid (CSFJ rhinorrhea constitutes only 3% to 4% of CSF fistulas. Nontraumatlc. normal pressure CSF fistulas wUh resultant rhinorrhea, In which no cause can be Identified, or primary spontaneous CSF rhinorrhea. Is considerably rarer. Presented here are two cases of CSF rhinorrhea of this nature. Including the diagnostic workup and treatment. Reviews of IUeraturesupport laboratory quantitative glucose determination as the most effective and least morbid method for confirming the presence of CSF. Iodine-contrast (metrizamlde/lohexolJ computerized tomographic clsternography has been shown to be the most effective and least morbid method for localizing the fistula. For Inactive, Intermittent. small, or questionable CSF leaks. radlonucllde clsternography has been shownto be more effective In Identifying the presence of these leaks. although not necessarily the location. Numerous reports provide evidence to support the useof an extracranlal rhinologic approach for surgical repair of the leak, as a more successful yet less morbid procedure than a craniotomy when used appropriately. (OTOLARYNGOL HEAD NECK SURG 1991;104:425.}
Approximately 80% of cerebrospinal fluid (CSF) fistulas with resultant rhinorrhea are caused by head trauma with skull base fractures. Approximately 16%
are the result of operations in the nasal and paranasal cavities and skull base. Only 3% to 4% are considered spontaneous fistulas.' Spontaneous can be a misleading term, however. since CSF rhinorrhea caused by tumor, tumor erosion, hydrocephalus. hydrocephalus resulting from tumor, etc., is considered sponraneous.i' The number of CSF fistulas that could be considered truly spontaneous, or primary spontaneous, for which no cause for the fistulas can be found. is considerably rarer. 1-17 Presented here are two cases ofCSF rhinorrhea of this nature. The clinical presentation and diagnostic workup, with a pertinent literature review, is presented to provide a simple and straightforward approach to diagnosis and resolution of the problem.
From the Departments of Surgery (Drs. Beckhardt and Setzen) and the Division of Neurosurgery (Or. Carras). North Shore University Hospital. and the Departments of Surgery (Dr. Beckhardt), Otolaryngology-Head and Neck Surgery (Dr. Sctzcn). and Neurosurgery (Dr. Carras), Cornell University Medical College. Presented at the Annual Meeting of the American Rhinologic Society. New Orleans. La.• Sept. 23. 1989. Received for publication April 19. 1990; accepted July 19. 1990. Reprint requests: Russell Beckhardt, MD. Department of Otolaryngology-Head and Neck Surgery. F4/218. University of Wisconsin Hospital. 600 Highland Ave.. Madison. WI 53792.
23/1/24054
CASE REPORTS
Case 1. A 50-year-old woman had a 2-week history of a clear fluid dripping from her right nares on leaning forward and a salty taste in the mouth. The patient had no medical history of trauma. infection, surgery. or neoplasm. Physical examination was unremarkable, except for a deviated septum and the drainage of clear fluid from the right nares. Chemical analysis of the fluid revealed a glucose concentration of 65 mg/dl., consistent with CSF. Computerized tomography (CT) revealed no evidence of bone destruction or mass lesion, but an air-fluid level was present in the right sphenoid sinus (Fig. I). lohexollumbar cistemography with coronal CT sections demonstrated a considerable amount of contrast material within the sella anteriorly. suggesting a partial empty sella, with active leakage of CSF into the right sphenoid sinus (Figs. 2 and 3). The exact point of leakage was not clearly demonstrated. The patient was taken to the operating room for a sublabial transseptal approach to the sphenoid sinus. The entire right and left sphenoid sinus was opened. As seen on cistemography, clear CSF was noted welling up from multiple small pores on the lateral wall of the right sphenoid sinus, where the bone was thin. No definite defect was identified in the floor of the sella turcica. No leakage was detected from the left sphenoid sinus. The area of the leak was covered with microfibrillar collagen-impregnated muscle and fascia from the lateral thigh. and then the entire sphenoid sinus was filled with a fat graft. The posterior mucosa was placed so that it covered the fat graft. Finally. a' lumbar-spinal drain was placed, which was removed on postoperative day 4. The patient has done well since. with no recurrence of the leak or any infectious complications at 2 years. 4 months after operation. 425
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otolaryngologv-
4126 BECl
Spontaneous cerebrospinal fluid (CSFJ rhinorrhea constitutes only 3% to 4% of CSF fistulas. Nontraumatlc. normal pressure CSF fistulas wUh resultant rhinorrhea, In which no cause can be Identified, or primary spontaneous CSF rhinorrhea. Is considerably rarer. Presented here are two cases of CSF rhinorrhea of this nature. Including the diagnostic workup and treatment. Reviews of IUeraturesupport laboratory quantitative glucose determination as the most effective and least morbid method for confirming the presence of CSF. Iodine-contrast (metrizamlde/lohexolJ computerized tomographic clsternography has been shown to be the most effective and least morbid method for localizing the fistula. For Inactive, Intermittent. small, or questionable CSF leaks. radlonucllde clsternography has been shownto be more effective In Identifying the presence of these leaks. although not necessarily the location. Numerous reports provide evidence to support the useof an extracranlal rhinologic approach for surgical repair of the leak, as a more successful yet less morbid procedure than a craniotomy when used appropriately. (OTOLARYNGOL HEAD NECK SURG 1991;104:425.}
Approximately 80% of cerebrospinal fluid (CSF) fistulas with resultant rhinorrhea are caused by head trauma with skull base fractures. Approximately 16%
are the result of operations in the nasal and paranasal cavities and skull base. Only 3% to 4% are considered spontaneous fistulas.' Spontaneous can be a misleading term, however. since CSF rhinorrhea caused by tumor, tumor erosion, hydrocephalus. hydrocephalus resulting from tumor, etc., is considered sponraneous.i' The number of CSF fistulas that could be considered truly spontaneous, or primary spontaneous, for which no cause for the fistulas can be found. is considerably rarer. 1-17 Presented here are two cases ofCSF rhinorrhea of this nature. The clinical presentation and diagnostic workup, with a pertinent literature review, is presented to provide a simple and straightforward approach to diagnosis and resolution of the problem.
From the Departments of Surgery (Drs. Beckhardt and Setzen) and the Division of Neurosurgery (Or. Carras). North Shore University Hospital. and the Departments of Surgery (Dr. Beckhardt), Otolaryngology-Head and Neck Surgery (Dr. Sctzcn). and Neurosurgery (Dr. Carras), Cornell University Medical College. Presented at the Annual Meeting of the American Rhinologic Society. New Orleans. La.• Sept. 23. 1989. Received for publication April 19. 1990; accepted July 19. 1990. Reprint requests: Russell Beckhardt, MD. Department of Otolaryngology-Head and Neck Surgery. F4/218. University of Wisconsin Hospital. 600 Highland Ave.. Madison. WI 53792.
23/1/24054
CASE REPORTS
Case 1. A 50-year-old woman had a 2-week history of a clear fluid dripping from her right nares on leaning forward and a salty taste in the mouth. The patient had no medical history of trauma. infection, surgery. or neoplasm. Physical examination was unremarkable, except for a deviated septum and the drainage of clear fluid from the right nares. Chemical analysis of the fluid revealed a glucose concentration of 65 mg/dl., consistent with CSF. Computerized tomography (CT) revealed no evidence of bone destruction or mass lesion, but an air-fluid level was present in the right sphenoid sinus (Fig. I). lohexollumbar cistemography with coronal CT sections demonstrated a considerable amount of contrast material within the sella anteriorly. suggesting a partial empty sella, with active leakage of CSF into the right sphenoid sinus (Figs. 2 and 3). The exact point of leakage was not clearly demonstrated. The patient was taken to the operating room for a sublabial transseptal approach to the sphenoid sinus. The entire right and left sphenoid sinus was opened. As seen on cistemography, clear CSF was noted welling up from multiple small pores on the lateral wall of the right sphenoid sinus, where the bone was thin. No definite defect was identified in the floor of the sella turcica. No leakage was detected from the left sphenoid sinus. The area of the leak was covered with microfibrillar collagen-impregnated muscle and fascia from the lateral thigh. and then the entire sphenoid sinus was filled with a fat graft. The posterior mucosa was placed so that it covered the fat graft. Finally. a' lumbar-spinal drain was placed, which was removed on postoperative day 4. The patient has done well since. with no recurrence of the leak or any infectious complications at 2 years. 4 months after operation. 425
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otolaryngologv-
4126 BECl
