Diagnosis Of Cerebrospinal Fluid Rhinorrhea Research Articles

Multimodal diagnosis of cerebrospinal fluid rhinorrhea: State of the art review and emerging concepts.

Currently, diagnosis of cerebrospinal fluid (CSF) rhinorrhea relies on a multimodal approach, increasing costs and ultimately delaying diagnosis. In the United States and internationally, the crux of such a diagnosis relies on confirmation testing (via biomarkers) and localization (e.g., imaging). Biomarker testing may require analysis at an outside facility, resulting in delays diagnosis and treatment. In addition, specialized imaging may be nonspecific and often requires an active leak for diagnosis. There remains a clear need for innovative new technology. A comprehensive review was conducted on both foundational and innovative scholarly articles regarding current and emerging diagnosis modalities for CSF. Current modalities in CSF rhinorrhea diagnosis and localization include laboratory tests (namely, B2T immunofixation), imaging (CT and/or MRI) with or without intrathecal administration, and surgical exploration. Each of these modalities carry flaws, risks, and benefits, ultimately contributing to delays in diagnosis and morbidity. Promising emerging technologies include lateral flow immunoassays (LFI) and biologically functionalized field-effect transistors (BioFET). Nevertheless, these carry some drawbacks of their own, and require further validation. CSF rhinorrhea remains a challenging diagnosis, requiring a multimodal approach to differentiate from nonpathologic causes of rhinorrhea. Current methods in diagnosis are imperfect, as the ideal test would be a readily accessible, inexpensive, rapid, highly accurate point-of-care test without the need for excess fluid or specialized processing. Critical work is being done to develop promising, new, improved tests, though a clear successor has not yet emerged. N/A.

Spontaneous Cerebrospinal Fluid Rhinorrhea and Otorrhea: A Case Report and Literature Review.

Spontaneous cerebrospinal fluid (CSF) leak is a condition that commonly presents with unilateral watery drainage from the nose or ear, tinnitus, and stuffy ears or hearing loss. Spontaneous CSF rhinorrhea and otorrhea together are rare. A 64-year-old woman presented at our department with complaints of clear watery rhinorrhea and hearing loss on the right side persisting for 10months. Imaging and surgery were used to diagnose the condition. Through surgical treatment, she was eventually cured. Review of the literature has shown that patients with both nasal and aural CSF leaks are rare. When a patient presents with both unilateral watery drainage from both the nose and ear, a diagnosis of CSF rhinorrhea and otorrhea should be considered. This case report will benefit clinicians by providing more information to assist with diagnosing the disease.

Diagnostic value of computed tomographic cisternography and magnetic resonance hydrography in cerebrospinal fluid rhinorrhea

Objective:To evaluate the accuracy of preoperative computed tomographic cisternography（CTC） and magnetic resonance hydrography（MRH）in the diagnosis of cerebrospinal fluid（CSF） rhinorrhea. Methods:Retrospective analysis was made on the data of 38 patients diagnosed as cerebrospinal rhinorrhea who completed preoperative HRCT, CTC and MRH examinations in the Department of Otolaryngology Head and Neck Surgery of Tianjin Huanhu Hospital from October 2016 to January 2022. The diagnostic accuracy of preoperative imaging examinations was compared according to the leak location found during operation. Results:Among all the 38 cases with CSF rhinorrhea, the detection rates of HRCT, CTC, and cranial MRH were 31.58%, 89.47%, and 60.53%, respectively. The accuracy of CTC was significantlyhigher than that of MRH （ χ²=8.49, P=0.007）, and the accuracy of MRH was significantly higher than that of HRCT （χ²=6.41, P=0.01）. Subgroup analyses were performed according to the precise positioning of cerebrospinal fluid rhinorrhea leakage. In patients with cerebrospinal fluid rhinorrhea located in ethmoid sinus, the accuracy of CTC（80.95% vs. 14.29%，P<0.01）and MRH（52.38% vs. 14.29%，P=0.02）were significantly higher than that of HRCT, but the accuracy but the difference between CTC and MRH between CTC and MRH was not statistically significant （P=0.10）. The accuracy of CTC was significantly higher than that of MRH （100.00% vs. 61.54%, P=0.04） and HRCT （100.00% vs. 53.85%, P<0.01） in patients with CSF rhinorrhea located in sphenoid sinus. However, there was no significant difference in the accuracy between MRH and HRCT （ P=1.00）. However, There was no significant difference in the accuracy of CTC, MRH and HRCT in patients with cerebrospinal fluid rhinorrhea located in frontal sinus. The accuracy of CTC and MRH was 84.62% and 57.69% respectively in 26 patients who failed to detect a CSF rhinorrhea by HRCT, and the difference was not statistically significant（χ²=4.59, P=0.06）. Conclusion:The comprehensive application of the multiple imaging methods has important guiding significance for the accurate treatment and prognosis evaluation. CTC and MRH could improve the accuracy of the localization diagnosis of cerebrospinal fluid rhinorrhea.

Efficacy of Imaging Methods in the Detection and Diagnosis of Cerebrospinal Fluid Rhinorrhea.

To assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea. The PubMed, EMBASE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar databases were searched up to December 2021. Diagnostic accuracy was compared among seven radiological methods: computed tomography (CT), CT cisternography (CTC), magnetic resonance imaging (MRI), magnetic resonance cisternography (MRC), CT + MRI, radionuclide cisternography, and intrathecal gadolinium (Gd)-MRC. Sensitivity, specificity, and accuracy were used as outcomes of the analysis. Both a traditional pairwise meta-analysis and a network meta-analysis were performed. Twenty-three trials were included in the analysis. The results of a network meta-analysis performed on a network consisting of seven diagnostic methods showed that all imaging modalities had greater diagnostic accuracy than CT, with the exception of CTC, which had lower sensitivity. Only intrathecal Gd-MRC was significantly superior to other imaging methods with regard to sensitivity and accuracy. Gd-MRC also showed the greatest surface under the cumulative ranking curve values for all of the outcomes (sensitivity: 0.9200; specificity: 0.8364; accuracy: 0.8920). This network meta-analysis demonstrates that intrathecal Gd-MRC is the most useful diagnostic method to detect CSF rhinorrhea. Laryngoscope, 133:1281-1287, 2023.

The value of magnetic resonance hydrography in the localization of fistula in patients with cerebrospinal fluid rhinorrhea

Objective:To evaluate the application value of magnetic resonance hydrography in determine the leak location of patients with cerebrospinal fluid rhinorrhea. Methods:Clinical data of 58 patients with cerebrospinal fluid rhinorrhea treated in Tianjin Huanhu Hospital from February 2015 to February 2021 were analyzed retrospectively. The leak position was judged by three methods: nasal sinus coronal CT, magnetic resonance hydrography and magnetic resonance hydrography combined with nasal sinus coronal CT. The consistency of the leak position among groups determined by different imageological examination pre-operation was compared with the real leak position found during the operation. Results:The positive rate of magnetic resonance hydrography combined with coronal CT in paranasal sinuses（91.4%） was significantly higher than that of magnetic resonance hydrography（74.1%）（P>0.05）. The positive rate of magnetic resonance hydrography（74.1%） was higher than that of CT（43.1%）（P>0.01）. Conclusion:The comprehensive application of imaging examination technology has important clinical guiding significance for the correct diagnosis of cerebrospinal fluid rhinorrhea. Magnetic resonance hydrography combined with coronal CT of paranasal sinus can effectively find the leak location, which was suggested as the first choice for preoperative localization of cerebrospinal fluid rhinorrhea.

Usefulness of imaging studies for diagnosing and localizing cerebrospinal fluid rhinorrhea: A systematic review and meta-analysis.

Our aim in this study was to determine the usefulness of diagnosis by imaging studies for the localization of cerebrospinal fluid (CSF) rhinorrhea. PubMed, SCOPUS, Embase, Web of Science, and Cochrane Library databases were searched up to July 2021. True and false positive and negative data were collected along with the characteristics of each study. Methodologic quality was assessed using the QADAS-2 tool. Sixteen studies involving 472 patients were included. The diagnostic odds ratio (DOR) of imaging studies was 13.6195 (95% confidence interval [CI], 7.4756-24.8129; I2 =28.1%). The area under the summary receiver-operating characteristic curve was 0.712. Sensitivity, specificity, negative predictive value, and positive predictive value were 0.8507 (0.7773-0.9029), 72.1%; 0.7827 (0.6865-0.8556), 26.8%; 0.5828 (0.4398-0.7132), 67.4%; and 0.9407 (0.8935-0.9678), 59.1%, respectively. In the subgroup analysis, there were significant differences for sensitivity (computed tomography [CT], 0.7421; computed tomography cisternography [CTC], 0.8872; magnetic resonance imaging [MRI], 0.8365; magnetic resonance cisternography [MRC], 0.8565; intrathecal gadolinium magnetic resonance cisternography [GaMRC], and 0.9307; radionuclide cisteronography [RNC], 0.7097; p=0.0481) and for negative predictive value among imaging modalities (CT, 0.3028; CTC, 0.4848; MRI, 0.4658; MRC, 0.7465; GaMRC, 0.8611; and RNC, 0.5263; p=0.0046). There were no significant differences among imaging modalities for specificity, positive predictive value, or DOR (p>0.05). Imaging studies can be used in the diagnosis of CSF rhinorrhea. Gadolinium magnetic resonance cisternography showed the highest diagnostic accuracy. MRC showed fair diagnostic accuracy without intrathecal injection.

Preoperative topical intranasal fluorescein in diagnosis of cerebrospinal fluid rhinorrhea

Background and Objectives: The preoperative diagnosis of cerebrospinal fluid (CSF) leak site is necessary for the management of CSF rhinorrhea. At present, intrathecal fluorescein is a common approach for it; however, regarding drawbacks, its value is limited. This study aimed at examining the effects of topical intranasal fluorescein (TINF) on the preoperative diagnosis of CSF rhinorrhea and intraoperative localization of CSF fistula. Patients and Methods: In this cross-sectional study, 32 consecutive patients with CSF rhinorrhea were recruited. Topical intranasal 10% fluorescein was placed in common sites of leakage, the middle turbinate meatus, the roof of the ethmoid plate, and sphenoethmoidal recesses. Change of the color of fluorescein indicated the presence of CSF, and thus, the site of the fistula could be outlined. The accuracy rates of diagnosis of leak site identified by TINF were compared with those by available imaging modalities, CSF analysis, intraoperative findings, and follow-up. Results: The cause of the leak was traumatic in 22 patients and nontraumatic in 10 patients. Preoperative accuracy rate of the location of CSF fistula was estimated 58.3% by available imaging study. The preoperative diagnosis rate of CSF rhinorrhea and the CSF fistula site localization rate by TINF were both 100%. No recurrence was found during the follow-up for 2–12 months. No complication had been reported. Conclusions: Preoperative TINF is an easy, quick, sensitive, safe, and accurate tool in localization of the site of the CSF fistulas and can be considered as a viable noninvasive alternative to the intrathecal fluorescein technique for preoperative diagnosis of CSF rhinorrhea.

50 Years Ago in The Journal of Pediatrics: Diagnosis of Cerebrospinal Fluid Rhinorrhea: Lack of Specificity of the Glucose Oxidase Test Tape

50 Years Ago in The Journal of Pediatrics: Diagnosis of Cerebrospinal Fluid Rhinorrhea: Lack of Specificity of the Glucose Oxidase Test Tape

Reliability of multidetector CT in the diagnosis of cerebrospinal fluid rhinorrhea with operative correlation

PurposeTo evaluate the role of non-contrast multidetector CT (MDCT) reliability in localizing CSF leaks and skull base defects in correlation to operative findings. Materials and methodsTwenty patients clinically diagnosed to have CSF rhinorrhea; 8 spontaneous and 12 post-traumatic patients were evaluated using 64-rows MDCT with slice section 0.6mm. CT is considered accurate if correctly determine the site and size of bony defect as matched with operative findings. ResultsMDCT accurately detected the site of presumed CSF leak in 19 out of 20 cases with sensitivity 95%. Cribriform plate defect is the most common site of defect in 40% of cases with 75% of cases categorized as Keros type II. The consensus image with fair agreement (K=0.38) shows that coronal reformat has the highest diagnostic performance in 75% of cases while the least diagnostic value is encountered with the axial plane in 15% of cases (p=0.095). There is almost a perfect agreement (K=0.810) between the MDCT measurements and operative size of bony defect with minimal difference in 10% of patients (P<0.001). ConclusionNon-contrast MDCT is an accurate reliable non-invasive imaging modality for preoperative evaluation of CSF rhinorrhea.

Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.

Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches.

Cerebrospinal fluid rhinorrhea: An institutional perspective from Pakistan

Background:The management of cerebrospinal fluid (CSF) rhinorrhea has evolved over the last two decades. We present here a review of our 11-year data on CSF rhinorrhea and its management at a tertiary care hospital in a developing country, with particular reference to the diagnosis, surgical management and outcome of the disease.Methods:The medical charts of all patients with a diagnosis of CSF rhinorrhea over an 11-year period were reviewed. The etiology of CSF rhinorrhea was classified into three categories: spontaneous, iatrogenic and traumatic. All the patients were divided into three categories based on the type of management as conservative, intracranial and transnasal endoscopic groups.Results:A total of 43 patients fulfilled our inclusion criteria and were included in the final analysis. Eleven of the 43 patients were managed conservatively, while 22 underwent intracranial repairs; 10 patients had transnasal endoscopic repairs. The primary success rate for the transnasal approach was 70% compared to 86% for the intracranial repair. Blood loss, special care unit (SCU) stay and total cost were found to be significantly less in the transnasal endoscopic group. Computed tomography (CT) cisternography was found to have the highest sensitivity and specificity. Further, no postoperative complications were found in the transnasal endoscopic group, while five patients from the intracranial group developed various complications.Conclusions:We conclude that the transnasal endoscopic approach has comparable success rates with the intracranial approach and significantly lower morbidity.

Endoscopic Management of Cerebrospinal Fluid Leaks

Cerebrospinal fluid (CSF) rhinorrhea is an uncommon but important medical condition. It can result from trauma, intracranial hypertension, or be idiopathic in origin. If left untreated, significant sequelae can result including infectious meningitis. Beta-2 transferrin is a sensitive and specific protein marker for CSF. Various radiographic modalities have been used to localize defects, including computed tomography (CT), magnetic resonance imaging, and CT cisternography. In recent years, surgical management of this condition has evolved significantly, primarily being performed endoscopically. Reconstruction can be performed with fat, free mucosal, or fascial grafts, or with vascularized flaps. The endoscopic surgeon should have a thorough understanding of the pathophysiology and diagnosis of CSF rhinorrhea as well as several surgical options in his or her armamentarium available to treat the patient suffering from CSF rhinorrhea.

Role of MR cisternography in the diagnosis of cerebrospinal fluid rhinorrhoea with diagnostic nasal endoscopy and surgical correlation

AbstractObjectives : To study the usefulness and accuracy of MR cisternography as noninvasive study in the diagnosis of cerebrospinal fluid (CSF) fistula with diagnostic sinonasal endoscopy and surgical correlation. Material and Methods: Twenty four patients with clinically suspected CSF rhinorrhoea were examined for CSF fistula with MR cisternography. The MR imaging technique included 3mm thin T2 weighted coronal and sagittal sections using Fast spin echo. In addition 1.5mm thin T2 weighted coronal sections were also obtained using CISS (Constructive Interference in Steady State) sequence. MR findings were correlated with diagnostic sinonasal endoscopy and surgical findings. Results : MR cisternography demonstrated the presence of fistula in 17 patients, absence of fistula in seven patients. Out of 17 patients with fistula, the diagnosis could be confirmed in 14 patients by diagnostic sinonasal endoscopy/surgery. Out of the seven patients without fistula, there was positive correlation in six patients when they were followed up clinically and by diagnostic nasal endoscopy. However in one patient, fistula was demonstrated on CT cisternography and was confirmed on sinonasal endoscopic surgery. The accuracy, sensitivity of MR cisternography was 96, 94% respectively. Conclusion : MR cisternography is a useful and accurate noninvasive study in localizing the site and extent of CSF fistula.

Cerebrospinal fluid rhinorrhea: diagnosis and treatment.

The diagnosis of cerebrospinal fluid rhinorrhea is usually straightforward. It need not be. The location of the leak is usually clear. It need not be. With modern rigid endoscopes, the repair is usually technically straightforward. It need not be. When a cerebrospinal fluid leak is suggested and the fluid is collectable, testing for beta 2 transferrin will usually settle the issue. The site of the leak is usually obvious. If it is not, but the leak is active, an isoview computed tomography scan will reveal it. Once the leak is established and located, the experienced endoscopic sinus surgeon can generally repair it using the instruments and materials currently available.

CSF rhinorrhoea: the place of endoscopic sinus surgery

Cerebrospinal fluid (CSF) rhinorrhoea has been managed by both neurosurgeons and otorhinolaryngologists, with neurosurgeons often choosing an intracranial approach and otorhinolaryngologists an extracranial approach. Recently, transnasal endoscopic techniques have been introduced that significantly reduce the morbidity of surgical repair when compared with previous techniques. The sense of smell was preserved in all patients who underwent an endoscopic repair of their CSF leak where it was present preoperatively. The results of transnasal endoscopic repair now make it the treatment of choice for most anterior cranial and sphenoid CSF leaks, with the exception of defects in posterior wall of the frontal sinus or defects larger than 5 cm. It is vital that a diagnosis of a CSF leak is confirmed by immunofixation of beta 2 transferrin as unilateral rhinorrhoea can masquerade as a CSF leak. We illustrate our experience with 78 patients who were referred with a diagnosis of CSF rhinorrhoea.

Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea.

Imaging is an important component in the investigation of unilateral watery rhinorrhoea suspicious of cerebrospinal fluid (CSF). Whilst the demonstration of the presence of beta 2 transferrin confirms that CSF is present it may prove difficult to demonstrate the exact site of origin. Fine detail coronal computed tomography (CT) with sections of 1-2 mm thickness through the anterior skull base may show small dehiscences and fractures. The commonest site for congenital dehiscences is the cribriform niche adjacent to the vertical attachment of the middle turbinate anteriorly and the superior and lateral walls of the sphenoid posteriorly. In the presence of frequent or constant CSF rhinorrhoea a CT cisternogram can be helpful in defining the exact site of the leak. Magnetic resonance imaging (MRI) is reserved for defining the nature of soft tissue i.e. inflammatory tissue, meningoencephalocele or tumour. Finally, per-operative intrathecal fluorescein is helpful when imaging does not prove positive. A management algorithm for CSF rhinorrhoea is presented.

髄液鼻漏の診断と治療

Cerebrospinal fluid (CSF) rhinorrhea is potentially serious because it may lead to recurrent meningitis. Therefore, early diagnosis and appropriate treatment of CSF rhinorrhea are required.We treated 13 patients with CSF rhinorrhea during the past 15 years. Four of them had meningitis. All 13 were successfully treated surgically with a rhinological approach in 12 and an intracranial approach in one. On the basis of our experience, RI counts of intranasal pledgets and detection of tau-transf errin in the nasal discharge were helpful in the diagnosis of CSF rhinorrhea. A coronal CT scan was useful in the determination of the precise location of the fistula.For a surgical treatment, a rhinological approach with minimal morbidity was indicated in most patients. Key points of the operation are: 1) careful observation of the fistula under an operating microscope or a rigid nasal endoscope, 2) water-tight closure of the fistula with fibrin glue and two or three layers of autogenous fascia, 3) intra-and postoperative CSF drainage to prevent an increase of intracranial pressure.

Cerebrospinal fluid rhinorrhea

A case of a complicated penetrating nasal injury is presented. The rapid diagnosis of cerebrospinal fluid rhinorrhea, with appropriate bedside tests and imaging techniques, is essential for the prevention of bacterial meningitis.

Glucorrhea Revisited

Glucose oxidase test strips were used to evaluate the presence of glucose in nasal secretions and tears in a group of normal children. Substantial amounts of glucose were present in 15 of 17 samples of nasal discharge and 10 of 15 samples of tears. The use of glucose oxidase test strips for diagnosis of cerebrospinal fluid rhinorrhea, therefore, is without merit.

The significance of fluid-gas displacement in the sphenoid sinus in post-traumatic cerebrospinal fluid rhinorrhea.

A pneumonencephalographic technique is described for the diagnosis of cerebrospinal fluid rhinorrhea and localization of the precise site of leak. The procedure is a modification of routine pneumoencephalography with no additional discomfort to the patient. The advantages of this technique in comparison with others are discussed.