CSF Rhinorrhea - Causes, Symptoms, Diagnosis, and Management

Introduction:

CSF (cerebrospinal fluid) is a clear, colorless fluid that is present in the brain and the spinal cord. The cerebrospinal fluid acts as a protective layer for the brain and spinal cord and provides a cushion effect in case of sudden body movements. CSF (cerebrospinal fluid) is formed in the choroid plexus of the third and fourth ventricles of the brain. The brain is surrounded by a three-layer membrane called the pia mater (innermost layer), the arachnoid mater (middle layer), and the dura mater (outermost layer). Above these three layers lies the skull bone. CSF (cerebrospinal fluid) is present in the arachnoid space that cushions the brain along with other layers. Any opening in these intracranial layers to the external environment due to genetic cause or trauma to the brain causes leakage of the cerebrospinal fluid from the brain through the nose, referred to as CSF (cerebrospinal fluid) rhinorrhea in clinical terms.

What Is the Prevalence of CSF (Cerebrospinal Fluid) Rhinorrhea?

The prevalence of CSF (cerebrospinal fluid) rhinorrhea ranges from 12 to 50%.

Which Age Group Is Affected More by Spontaneous CSF Leaks?

People in the age group between 30 to 45 are affected more by spontaneous CSF leaks.

What Are the Causes of the CSF (Cerebrospinal Fluid) Rhinorrhea?

• Skull base fractures.

• Head injury.

• Fracture of orbit, nose, and temporomandibular joints.

• Skull base deformities/ pathologies like skull base cancerous or non-cancerous tumors.

• Frontal sinus infections.

• Trauma during brain surgery.

• Cranio-facial anomalies due to genetic variations.

• Intracranial hypertension (increased pressure in the skull).

• Hydrocephalus (fluid accumulation between brain tissues leading to increased intracranial pressure).

• Injury to ears (due to trauma or during surgery).

• After radiotherapy of the skull base.

• Lumbar puncture (CSF leak can occur while performing a lumbar puncture procedure due to damage to the spinal canal).

What Are the Signs and Symptoms of CSF (Cerebrospinal Fluid) Rhinorrhea?

• Vomiting and nausea.

• Light sensitivity.

• Sensitivity to sound.

• Frequent headaches.

• Loss of balance.

• Ringing sensation in the ears.

• Dizziness or vertigo.

• Blurred vision.

• The salty taste of cerebrospinal fluid in the mouth.

• Watery drainage from the nose.

• Stiffness in the neck.

• Fever.

• Seizures.

• Loss of smell sensation.

• Continuous throat clearing due to drainage of fluid in the throat.

How to Diagnose CSF (Cerebrospinal Fluid) Rhinorrhea?

Various diagnostic criteria for cerebrospinal fluid rhinorrhea are:

• Clinical Examination and History: A clinical examination is performed by the doctor by asking the patient to bend the head down, and a handkerchief or tray is placed below the nose. A clear watery, or blood-tinged discharge coming from the nose into the tray gives the diagnosis of CSF rhinorrhea. A complete history of any head injury or trauma and past brain surgery should be recorded.

• Computed Tomography (CT) Scan: A computed tomography (CT) scan of the head is one to evaluate the presence of any skull fracture or any skull bone defects.

• Magnetic Resonance Imaging (MRI) Scans: It is done to check any soft tissue tumors or involvement of the paranasal sinus.

• Cisternography: It is done by using radioactive isotopes (water-soluble-iodine contrast material) by intrathecal route to check for the presence of any hole or puncture in the skull base and abnormal flow of cerebrospinal fluid from the brain or spinal cord. Other substances like Metrizamide and Fluorescein are used more frequently for cisternography.

• Myelography: It is an imaging technique in which contrast material is injected into the spinal canal through a lumbar puncture, and scans are performed for the spinal cord and spinal nerves to detect any deformity related to the spinal cord. It is done on the person who has symptoms of neck stiffness.

What Are the Lab Investigations Done to Confirm the Presence of CSF (Cerebrospinal Fluid) Rhinorrhea?

The beta-transferrin test is one of the gold standard diagnostic tests that is performed to confirm the CSF (cerebrospinal fluid) leak. In this test, the fluid draining from the nose is collected in the tray by asking the patient to bend the head down, and the fluid is sent to a lab for investigation.

The presence of beta -2-transferrin in the fluid confirms the CSF (cerebrospinal fluid) leak from the brain (beta- 2- transferrin is a protein or enzyme which is present in the cerebrospinal fluid) into the nose as it is absent in the normal nasal discharge.

What Is the Treatment of CSF (Cerebrospinal Fluid) Rhinorrhea?

Numerous modern techniques have been developed for the treatment of CSF (cerebrospinal fluid) rhinorrhea:

• Conservative Management: Minor CSF (cerebrospinal fluid) leak can be managed by conservative treatments like

1. Head elevation.

2. Bed rest.

3. Avoid excess straining exercises.

4. Medications (antibiotics are given in case of infections like meningitis).

• Surgical Repair: If the cerebrospinal fluid leakage is in large volume and the conservative management fails, and the symptoms persist, surgical intervention is done by:

1. Open Craniotomy: It is a surgical method in which the outer cranium is removed surgically to locate any dural tear or injuries and is repaired under direct vision. After the dural opening is repaired, the outer cranium is placed back and stabilized with the help of screws and a plate.

2. Endoscopic Repairs: It is done through a nasosinusal track using an endoscope. As soon as the defect or opening is detected, it is filled or closed using a graft material like blood patch, collagen, tissue sealant, gelatin, tissue sponge, cellulose, or fibrin glue.

What Are the Complications That Can Happen After Surgery?

• Intracerebral hemorrhage (bleeding between brain tissues and skull) after open craniotomy surgery.

• Cerebral edema (swelling of the brain tissue with fluid accumulation can occur after Craniotomy).

• Longer duration of recovery.

• Cosmetic defects like skull bone depression.

Can We Prevent CSF (Cerebrospinal Fluid) Rhinorrhea?

CSF (cerebrospinal fluid) rhinorrhea is a rare and uncertain condition that cannot be prevented. It can be avoided by taking the protective measure against injuries and accidents or falls by using safety equipment like helmets.

Conclusion:

CSF (cerebrospinal fluid) rhinorrhea is a rarely seen clinical condition but can be faced by anyone due to internal brain injuries, skull fractures, brain infections, facial trauma, or after brain or ENT (ear, nose, and throat) surgeries. It is a serious clinical condition, so quick and effective management is essential. Any spontaneous or nonspontaneous symptoms like vertigo, frequent headaches, watery nasal discharge, vomiting, loss of smell or vision, and metallic or salty taste in the mouth after an injury or fall should be brought to the notice of the doctor as an emergency so that the diagnosis and the early intervention of CSF leak can be made.