Rhinorrhea

1
Rhinorrhea

• James Ridgway
• 7/27/06

2
HPI

• Patient is a 21 year old male s/p 30ft fall at a
  construction site with face strike to one of the
  support beams prior to ground impact. No LOC at
  the scene. GCS of 15 in the trauma bay. Patient
  complains of right wrist pain. Notable oozing
  from the left nares.

3
Primary Survey

• A- airway intact
• B- CTA B
• C- RRR, no sites of hemorrhage, good perfusion.
• Vitals 37.6 139/85 90 - 20

4
HP

• Patient states right wrist pain. Further
  examination reveals left sided nasal obstuction,
  rhinorrhea (s/p epistaxis), malocclusion, minor
  upper lip and midface pain, taste of blood in
  mouth. Notable right wrist deformity.
• He denies any SOB, dyspnea, diplopia, visual
  field defect, tinnitus, HL, dysphagia,
  odynophagia or vocal change.

5
HP

• PMH None
• PSH None
• Medications None
• Allergies NKDA
• FH HTN, DM
• SH EtOH, denies TOB, IVDU. No history of
  HBV/HCV/HIV/TB.

6
PE

• Eyes PERRL, EOMI, no diplopia or visual field
  defects. Bilateral periorbital STS and
  ecchymosis.
• Ears TM c/i/m AU without effusion/hemotympanum
  or EAC defect.
• Nose Minor nose deviation to the left, nasal
  bones stable, crusted blood at the anterior
  nares, near total occlusion of the left nasal
  cavity 3.5 inside with cartilage/bone/mucosa
  disruption. Slow bleeding from the nose
  bilaterally. No septal hematoma.
• OC/OP Non-occlusion of teeth, midface mobile,
  limited discomfort, sh palate intact, no other
  mass/lesions/defects.
• Neck C-collar, trachea midline, no crepitus, no
  LAD/mass.
• Face Step-offs along bilateral inferior orbital
  rims. Laceration along the left infraorbital rim
  and complex laceration of the patients lateral
  upper lip. Mandible stable.
• CN VII intact bilaterally, XII intact
  bilaterally, V1 and V3 without compromise.
  Anesthesia of V2 on left.
• EXT Notable right wrist deformity.

7

• Vascular Gustatory, Churg-Strauss syndrome
• Infection Viral (RSV, Coronavirus, Adenovirus,
  influenza, Parainfluenza ), Bacteria (Pertussis,
  Diphtheria, Group A Streptococcus, Chlamydia),
  Rhinoscleroderma,
• Trauma CSF, foreign body
• Autoimmune/immune Allergic rhinitis (seasonal,
  dust, occupational), NARES, Nasal Polyposis,
  Wegener's granulomatosis, SLE, Sjögren's syndrome
• Metabolic Pregnancy, Hypothyroidism, Puberty
• Iatrogenic/Idiopathic Mediciations (alpha
  antihypertensives, MAOI antidepressants, oral
  contraceptives, ASA, some benzodiazepines ),
  surgical (FESS), rhinitis medicamentosa,
  Idiopathic (vasomotor) rhinitis
• Neoplasia Midline granuloma, CNS tumors (primary
  vs metastatic glioma, astrocytoma,
  oligiodendroglioma, ependymoma, meningioma,
  prostate CA, SCCA, lymphoma), osteoma
• Congenital Choanal Atresia, Encephalocele,
  Meningocele, Meningoencephaloceles, Teratoma,
  Pseudomeningocele (Marfans syndrome,
  Neurofibromatosis)
• Sarcoidosis

8
HP of Rhinorrhea

• Character of Symptoms Onset, duration, constant
  vs intermittent, unilateral vs bilateral,
  obstruction, anosmia/hyposmia
• Contributing factors toxin or allergen exposure,
  current medicitions, history of asthma,
  sinusitis, allergy, facial trauma or surgery.
• Associated symptoms allergic component
  (sneezing, itchy and watery eyes, clear
  rhinorrhea), sinus involvement (facial pain, HA),
  acute infection (fever, malaise, pain, purulent
  discharge).
• Other symptoms sore throat, postnasal drip,
  cough, ear complaints, hoarseness, salty or sweet
  taste.

9
Basic Principles of Cerebrospinal Fluid

• physical support and buoyancy for the brain
• autoregulation
• by-products of metabolism
• regulate the chemical environment

10
Volume and production

• Monro-Kellie hypothesis
• 75/150/1400
• rate of 0.35 mL/min or 500 mL/d
• Normal ICP ranges from 5 to 15 mm Hg
• ICP If X Rout Pss
• Increased protein concentration in the CSF or
  inflammatory changes in the dura create
  resistance to outflow by impairing CSF absorption
• meningitis, subarachnoid hemorrhage, or
  iatrogenic entry of blood

11
CSF Rhinorrhea

• Traumatic
• Non-Traumatic
• Spontaneous
• Iatrogenic
• Common S/S
• Unilateral watery nasal discharge
• Fluid discharge with valsalva
• Positional variation
• Hx of trauma, surgery, increased ICP
• Hyposmia, anosmia
• HA
• Unexplained weight loss
• History of bacterial meningitis and especially a
  history of multiple episodes of bacterial
  meningitis

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Traumatic Non-Traumatic

• Accidental Trauma 80 (2-4 of all head
  injuries)
• HP CSF 45 (tumor, benign ICP or hydrocephalus)
• NPL bone erosion, XRT, infection, fistula,
  encephalocele, meningocele, meningoencephaloceles,
  empty sella syndrome

13
Traumatic
14
Non-Traumatic
15
Spontaneous

• Waste bucket term that refers to failed
  identification/ reason for CSF rhinorrhea

16
Iatrogenic

• 50 present immediately postoperative
• Delay 7 days to 1 month later
• secondary to progressive maturation and
  contraction of wounds
• devascularization
• necrosis of the soft tissue or bony edges
• slow resolution of edema
• increased CSF pressure

17
Iatrogenic

• CSF leaks Common Sites
• Frontal recess
• Anterior ethmoid artery
• Cribiform plate
• Avoid by staying lateral to the middle turbinate
• Avoid fracture of middle turbinate
• Posterior ethmoid sinus
• Recognize Leaks
• Clear or swirling fluid

18
Iatrogenic

• most common cause of rhinorrhea from surgical
  trauma is transphenoidal management of pituitary
  tumors (0.515)
• risk of CSF leak secondary to functional
  endoscopic sinus surgery varies from 0.5 to 3
• weaknesses of the skull base may result from the
  development of extensive paranasal pneumatization
  
• lateral lamella of the cribriform plate forms the
  weakest part of the skull base

19
Diagnosis Sometimes easy, sometimes not.

• Halo Sign
• Components of CSF
• glucose, protein and electrolytes
• Beta-2 transferrin

20
Other Studies

• High-resolution coronal and axial CT
• CT cisternograms
• Fluorescin
• Radionuclide cisternography
• MRI cisternograms
• T2 images highlight the CSF leak on MRI.

21
Conservative Management

• Most CSF leaks resulting from accidental and
  surgical trauma heal with conservative measures
  over the course of 7 to 10 days.
• Bed rest, head elevation, stool softeners
• No blowing nose, sneeze with open mouth
• Lumbar drain
• Acetazolamide
• Prophylactic antibiotic coverage

22
Surgery

• Extensive intracranial injury
• Intraoperative identification
• Nonresponders to conservative measures

23
Transcranial

• Pros
• Success rates ranging from 60 - 95
• Improved exposure
• Ability to identify multiple defects
• Ability to tamponade a leak in a high-pressure
  situation
• Cons
• inherent increased morbidity
• length of hospitalization
• permanent anosmia

24
Extracranial

• Pros
• Success rates of 86 on initial operation with a
  97
• Decreased morbidity
• No anosmia
• Improved endonasal exposure of the sphenoid,
  parasellar and posterior ethmoids,cribriform
  plate, fovea ethmoidalis, and the posterior wall
  of the frontal sinus
• Cons
• facial scar
• risk for facial numbness and orbital
  complications
• cumbersome
• Cerebral damage and the lateral extensions of the
  frontal and sphenoid sinuses cannot be assessed

25
Endoscopic

• Currently the preferred method of repair
• success rates of 92 to 96 have been documented
• small defect can be closed with an overlay free
  mucosal graft or a free fascial graft
• Larger defects at risk for a secondary
  encephalocele or small defects with elevated ICP
  are treated more appropriately with a bone graft
  placed in an underlay fashion within the epidural
  space and a fascial graft to provide a watertight
  seal placed in an overlay fashion
• If the defect is more than 1 cm wide, the
  underlay technique with bone or cartilage is
  preferred to prevent herniation of cerebral
  tissue

26
Composite reconstruction technique using bone,
cartilage, or lyophilized dura. This technique is
used forlarger dural defects,multiple dural
defects, or large bony skull-base defects.
Free mucosal graft technique for smaller (lt3 mm)
dural defects
27
Other Methods

• Composite grafts
• Pedicled mucosal or mucochondral flaps
• Bathplug technique
• Lyophilized dura or fascia to sandwich the dural
  defect
• Large dural closure with autografts such as
  fascia lata or temporalis fascia

28
Sealants

• Fibrin
• combination of fibrinogen, thrombin, and calcium
  cofactor
• most commonly used sealant today
• Tisseel
• fibrin sealant that includes components of
  autologous cryoprecipitate from single-donor
  plasma, bovine thrombin, and an antifibrinolytic
  agent that yields a more stable clot
• provides a temporary watertight closure and
  creates an additional barrier to CSF leakage
  during wound healing and fibrosis

29
Packing

• Either absorbable or nonabsorbable
• 86 of rhinologists use packing to repair CSF
  leaks

30
Post-Op

• Postoperative follow-up with CT scanning is
  appropriate to rule out development of a mucocele
  when there is concern for sinius tract
  obstruction
• Watchful of complications including meningitis,
  brain abscess, subdural hematoma, smell disorder,
  and HA.
• Most common being meningitis at 1

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• Lopatin AS, Kapitanov DN, Potapov AA.Endonasal
  endoscopic repair of spontaneous cerebrospinal
  fluid leaks. Arch Otolaryngol Head Neck Surg.
  2003 Aug129(8)859-63.
• Han CY, Backous DD. Basic principles of
  cerebrospinal fluid metabolism and intracranial
  pressure homeostasis. Otolaryngol Clin North Am.
  2005 Aug38(4)569-76.