Spontaneous Cerebrospinal Fluid Rhinorrhea Research Articles

Comparative Cross Sectional Prospective Study of Anterior Skull Base Thickness in Spontaneous Cerebrospinal Fluid Rhinorrhoea vs Matched Controls

Comparative Cross Sectional Prospective Study of Anterior Skull Base Thickness in Spontaneous Cerebrospinal Fluid Rhinorrhoea vs Matched Controls

Spontaneous Clival Leaks and Their Management

Abstract Introduction Cerebrospinal fluid (CSF) leaks through the nasal cavity occurrence has a rising trend, of which primary spontaneous leak is 6 to 40% of all the CSF leaks. The most common site of CSF leak is ethmoid roof where the bone is thinner in the entire skull base. Clivus being the hard bone is a rare site for spontaneous leak. We present a case series from a single quaternary care center of this rare occurrence and study its reason and management strategy. Materials and Methods A retrospective surgical audit over a period of 10 years of all patients diagnosed with CSF rhinorrhea was done. A PubMed search was conducted with keywords of CSF leak, CSF rhinorrhea, spontaneous CSF rhinorrhea, clival leak, and clivus to identify the literature and these articles were compiled and their management reviewed. Results and Analysis A total of 100 patients underwent surgical management for spontaneous CSF leak, of which there were 5 patients who had spontaneous CSF rhinorrhea from the clivus. There were four female patients; four patients had high body mass index. The most common site of leak was mid-clivus and surgical technique employed was multilayer dural plasty with a nasoseptal flap and measures were taken to reduce the intracranial pressure intra-operatively and postoperatively. Conclusion Spontaneous clival leak is a rare entity with mid and lower clivus being the common site. A combined approach by ENT and neurosurgeons results in best outcome for the patients.

Spontaneous cerebrospinal fluid rhinorrhea: literature review

Due to its rarity and complex etiopathogenesis, spontaneous cerebrospinal fluid rhinorrhea remains an understudied problem. Similarity of symptoms with other disorders of the ENT organs, low vigilance of primary care specialists lead to delayed diagnosis and treatment increasing the risk of complications. In recent years, diagnosis and treatment of this pathology have received a higher level of attention as evidenced by increased number of publications on this topic.The review considers in detail the problems of etiopathogenesis, classification, diagnosis and treatment of spontaneous cerebrospinal fluid rhinorrhea based on current data from scientific literature.

Obstructive Sleep Apnea Syndrome Revealing an Osteomeningeal Breach: A Case Report

Osteomeningeal breach is a discontinuity in the osteomeningeal layer that allows cerebrospinal fluid to flow into an air-filled cavity at the base of the skull. Its severity is associated with the risk of central nervous system infection. The majority of breaches are traumatic in origin, either accidental or iatrogenic. Spontaneous cerebrospinal fluid rhinorrhea is less commonly found. Obesity, often coupled to obstructive sleep apnea syndrome, can lead to hypercapnia, increasing the pressure of cerebrospinal fluid and thereby facilitating the development of osteomeningeal breaches. In cases of intracranial hypertension, the displacement of the pituitary gland can occur, and as a result, its cavity can be filled with cerebrospinal fluid, which characteristically describes an empty sella turcica syndrome. We present the case of a 52-year-old woman initially admitted for the management of sleep apnea syndrome, along with a history of chronic rhinorrhea. Analysis of the rhinorrhea fluid and craniofacial imaging revealed a cerebrospinal fluid leak through a breach in the right cribriform plate, associated with an empty sella turcica syndrome. The patient underwent surgical repair of the meningeal breach via an endonasal approach, leading to a successful resolution of cerebrospinal fluid rhinorrhea.

Spontaneous delayed CSF rhinorrhea associated with encephalocele following surgical resection of a giant frontoparietal meningioma, an extremely rare entity and overlook of English literature

Introduction and importance: Spontaneous cerebrospinal fluid (CSF) rhinorrhea without a history of head trauma is rare. The authors describe a scarce case of spontaneous, nontraumatic, delayed CSF rhinorrhea due to ethmoidal encephalocele associated with frontoparietal giant meningioma. Case presentation: A 49-year-old male complained of a slowly growing skull mass lasting 10 years since a blunt head trauma and progressive hemiparesis 3 months ago and was referred to our center. There was a heterogeneous extra-axial mass (77×77×70 mm) with calcified components at his right frontal lobe, demonstrating notable adjacent parenchymal edema and a midline shift to the left. There was a sizeable extra-axial mass (113×95×80 mm) in his right front-temporoparietal lobe associated with adjacent invasion to calvarium leading to the lytic and sclerotic appearance of the calvarial bone showing intense heterogeneous contrast enhancement and an adjacent enhancing dural tail. A considerable mass effect on the adjacent frontotemporal cortex is evident, with mild parenchymal edema leading to a notable midline shift to the left, right uncal herniation, and left ventriculomegaly. On postoperation day 5, the patient developed a recurrent CSF leak exacerbated by hydrocephalus. He was rescheduled to undergo endoscopic endonasal surgery and dural repair on postoperative day 7. The postoperative course was uneventful. Clinical discussion: Frontoparietal lobe encephaloceles represent the least common cause of spontaneous CSF rhinorrhea. Early diagnosis and surgical management remain crucial to minimize the subsequent complications. Conclusion: The ventricular anatomy and CSF fluid dynamics alteration following tumor surgical resection seem to contribute to an environment by which a herniated ethmoidal encephalocele developed a delayed nontraumatic CSF leak.

Gender Differences in Quality-of-Life Outcome in Patients Undergoing Endoscopic Endonasal Skull Base Surgery

Abstract Background Prior studies showed that female patients with chronic rhinosinusitis (CRS) suffer a worse disease-specific quality of life (QoL). Goal The aim of this study is to investigate gender differences in sinonasal QoL outcomes in patients requiring endoscopic endonasal skull base surgeries (EESBS). Methods Cross-sectional analysis of patients presenting to our clinic from August 2020 to December 2022 with skull base tumors, spontaneous cerebrospinal fluid (CSF) rhinorrhea, or Grave's orbitopathy (for orbital decompression) was performed. Baseline and postsurgical QoL were measured using the 22-item Sinonasal Outcome Test (SNOT-22). Patients' demographics and comorbidities were reviewed. Patients with concomitant CRS were excluded. Results Eighty-six patients were included (54 with skull base tumors, 17 Grave's orbitopathy, and 15 spontaneous CSF rhinorrhea). The mean age of the patients was 52 years (range: 12.4–81.5 years), and 51.6% of the patients were females. There was no age difference between female and male patients. Smoking history, asthma, and allergic rhinitis were also similar between the two groups. Female patients had a significantly higher incidence of depression (58.3 vs. 32.4%, p = 0.018) and migraine (50.0 vs. 21.6%, p = 0.007). Female patients had a significantly worse overall SNOT-22 scores at baseline (33.6 vs. 18.2, p = 0.001), at the 3-month follow-up (29.7 vs. 15.5, p = 0.002), and at the 6-month follow-up (33.5 vs. 14.9, p = 0.005). This worse QoL was seen mainly in the ear/facial, sleep, and psychological domains. Linear regression of the SNOT-22 scores and its subdomains adjusting for comorbidities showed that migraine was found to be the most significant determinant of gender differences in the QoL. Conclusion Female patients who undergo EESBS show higher overall SNOT-22 scores secondary to higher incidence of migraine.

Multiple skull base defects in the setting of spontaneous cerebrospinal fluid rhinorrhea; a dual institution view

PurposeIdiopathic intracranial hypertension (IIH) is a condition of high cerebrospinal fluid (CSF) pressure that presents with CSF leak. The implications of multiple skull base defects (SBD) and associated synchronous CSF leaks have not been previously explored. Materials and methodsA dual institutional case-control study examined multiple SBD's and encephaloceles on the risk of CSF leak and postoperative failures post-repair. IIH patients with CSF leaks and IIH controls without leaks were selected retrospectively. Chi square analysis evaluated for statistically significant alterations in probability with CSF leak development. Results192 patients were selected with 108 IIH controls and 84 spontaneous CSF leak cases. Signs and symptoms for IIH controls and CSF leak cases respectively were pulsatile tinnitus (60.2 % and 29.8 %), headaches (96.3 % and 63.1 %), papilledema (74.1 % and 12.5 %), visual field defects (60.8 % and 13 %) (p < 0.001). Encephalocele formation in controls was 3.7 % compared to cases at 91.6 % (p < 0.001). Multiple SBD's in controls compared cases was 0.9 % and 46.4 % respectively (p < 0.001). Subgroup analysis of CSF leak cases showed 15 patients with two CSF leak repairs due to a recurrence. 27 (39.1 %) single leak cases had multiple SDB's while 12 (80 %) recurrent leaks had multiple SDB's (p = 0.004). ConclusionsPatients with radiographic evidence of multiple SBD's and encephaloceles represent a high-risk population with a propensity for CSF leaks. Secondary SBD's are common in patients with spontaneous CSF rhinorrhea and higher in patients with a recurrence.

Reliability of High-resolution Gadolinium-enhanced MR Cisternography and Gasket-seal Technique for Management of Anterior Skull Base Defects

PurposePrecise preoperative localization of anterior skull base defects is important to plan surgical access, increase the success rate and reduce complications. A stable closure of the defect is vital to prevent recurrence of cerebrospinal fluid (CSF) rhinorrhea. The purpose of this retrospective case series was to evaluate the reliability of a new high-resolution gadolinium-enhanced compressed-sensing SPACE technique (CS T1 SPACE) for magnetic resonance (MR) cisternography to detect cerebrospinal fluid leaks of the anterior skull base and to assess the long-term success rate of the gasket-seal technique for closure of skull base defects.MethodAll patients with spontaneous or postoperative cerebrospinal fluid rhinorrhea and defects of the anterior skull base presenting to the Departments of Otorhinolaryngology and Neurosurgery between 2019 and 2020, receiving a computed tomography (CT) cisternography and MR cisternography (on a 3T whole-body MR scanner using a 64-channel head and neck coil) with CS T1 SPACE sequence and closure of the defect with the gasket-seal technique, were enrolled in the study. For the cisternography, iodinated contrast agent (15 ml Solutrast 250 M®), saline (4 mL) mixed with a 0.5 mL of gadoteridol was injected into the lumbar subarachnoid space.ResultsA total of four patients were included in the study and MR cisternography with CS T1 SPACE sequence was able to precisely localize CSF leaks in all patients. The imaging results correlated with intraoperative findings. All defects could be successfully closed with the gasket-seal technique. The mean follow-up was 35.25 months (range 33–37 months).ConclusionMR cisternography with CS T1 SPACE sequence could be a promising technique for precise localization of CSF leaks and the gasket-seal technique resulted in good closure of the CSF fistula in this case series.

Predictors of failure of recurrent spontaneous CSF rhinorrhea repair: a prospective cohort study

BackgroundTo identify and predict risk factors associated with recurrent spontaneous cerebrospinal fluid (CSF) rhinorrhea, a cohort study included a total of 37 adult patients with spontaneous CSF rhinorrhea were analyzed.ResultsOver a 2-year period, 37 patients of spontaneous CSF leak with exclusion of other etiologies (traumatic, congenital) were enrolled: primary (non-recurrent) (n = 20) and secondary (recurrent) (n = 17), where 83.8% were females with an average body mass index (BMI) of 36.4 kg/m2. Associated symptoms of high intracranial pressure (ICP) namely, blurred vision and unsteadiness (P-value = 0.006 and 0.01, respectively), multiparity (92.3%), and failure to localize the defect (17.6%) contributed to patients having more recurrence. Although the cribriform plate was detected frequently (n = 29.4%), they were associated with lower recurrence compared to lateral recess of sphenoid (66.6% vs 20%).ConclusionDirect endoscopic visualization and repair of skull base defects achieve a high success rate, but failure is still a possibility especially in spontaneous etiology of leaks. In a multiparous female, with high CSF pressure, lateral sphenoid recess, large size, or unidentified defect, the incidence of recurrence is much higher.Level of evidence4

The Etiology, Diagnosis, and Management of Cerebrospinal Fluid Rhinorrhea: A Tertiary Center Experience.

Introduction The aim of the present study was to describe our institution's nine years of experience in the endoscopic endonasal management of cerebrospinal fluid (CSF) rhinorrhea and to discuss the causes, sites, and outcomes. Methodology The medical records of patients diagnosed with CSF rhinorrhea in King Abdulaziz Medical City-Jeddah (KAMC-J) between 2014 and 2023 were retrospectively reviewed, and all relevant information including body mass index, medical and surgical history, and postoperative outcomes were obtained. Results A total of 20 cases were included in the present study, sixteen (80%) of which were females and four (20%) were males. The mean age of participants was 42.59±13.9 years. Nine cases (45%) were spontaneous CSF rhinorrhea and 11 (55%) were traumatic; within the traumatic group, six cases (54%) were iatrogenic either following previous neurosurgery or functional endoscopic sinus surgery, while the remaining five cases were related to motor vehicle accidents. The mean body mass index for the spontaneous CSF leak was 32 Kg/m2, and 33 Kg/m2 for the traumatic leaks, no statistically significant difference was noted. The cribriform plate was the most common site of leakage (65%). A multilayer surgical technique using facia lata graft with nasoseptal flap was the most common choice for reconstruction with a first-attempt success rate approximating 90%. A recurrence was observed in two patients only. No major complications were reported. The average length of stay was nine days. Conclusion The endoscopic endonasal repair of CSF leak is a safe and reliable procedure and is associated with high success rates and low risk of complications. Therefore, it should be preferred as a first-line treatment for CSF rhinorrhea.

Pediatric Spontaneous Cerebrospinal Fluid Leak Repair: An Endoscopic Endonasal Approach.

Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea in the pediatric population is an exceedingly rare condition that occurs when the dura mater is breached, resulting in CSF drainage from the subarachnoid space into surrounding sinonasal tissue. Objective: This work delineates a step-by-step surgical approach to visually demonstrate the feasibility of an uninarial endoscopic endonasal approach for pediatric spontaneous CSF leak repair. Postoperative Outcome: A 2-year-old male with a 6-month history of clear rhinorrhea, intermittent headaches, and a previous episode of bacterial meningitis was evaluated as an inpatient consultation. Computed tomography cisternography revealed active CSF extravasation at the right sphenoid sinus roof. An endoscopic endonasal approach was performed including a complete sphenoethmoidectomy plus middle turbinectomy to provide access to the skull base defect. Once identified, a middle turbinate free mucosal graft was placed for cranial base reconstruction given the child's young agre. Sinonasal debridement 3 weeks following surgery under anesthesia revealed an intact viable graft with no evidence of CSF leak. There was no evidence of CSF leak recurrence or complications 1 year following surgery. Conclusion: The uninarial endoscopic endonasal approach is a safe and effective option for the surgical management of spontaneous CSF leak rhinorrhea in the pediatric population.

Correlation between Pneumatization Variants of Paranasal Sinuses and Skull Base and Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case-Control Study

Introduction: Spontaneous cerebrospinal fluid rhinorrhea (SCSFR) is the most common type of cerebrospinal fluid leakage and may cause serious cerebral complications. The aim of this research was to investigate the relationship between the degree of pneumatization variants of the paranasal sinus and skull base and the incidence of SCSFR. Methods: In total, 131 patients with SCSFR were analyzed, and 50 patients suffering from the nasal septal deviation were selected as controls. The pneumatization of the paranasal sinus and skull base was observed by CT scan. Results: Among the 137 fistulas, 55 (40.15%) were found in the ethmoid sinus. The incidences of Onodi cells (27.27 vs. 8%) and type 3 lateral recess of the sphenoid sinus (LRSS, 70.37 vs. 22%) in the SCSFR subgroups were significantly higher than those in the control group (p < 0.05). Moreover, the occurrence of SCSFR was linearly correlated with the classification of Onodi cells and LRSS (p < 0.05). There was no significant difference in the incidence of frontal cells, anterior clinoid process pneumatization, and posterior clinoid process pneumatization between the SCSFR patients and the controls. Conclusion: The most common site of SCSFR is the ethmoid sinus. The excessive pneumatization of the Onodi cell and LRSS increases the risk for the occurrence of SCSFR in the ethmoid sinus and sphenoid sinus, respectively. The possible association between the paranasal sinus ontogeny and SCSFR pathophysiology needs further studies.

Chronic cerebrospinal fluid rhinorrhea as an initial presentation of chordoma: illustrative case.

Skull base chordomas are typically extradural and present with cranial nerve deficits, headache, and visual disturbances. Clival chordoma involving the dura and presenting as a spontaneous cerebrospinal fluid (CSF) leak is extremely rare and can be mistaken for other skull base lesions. Here the authors present a case of chordoma with an unusual presentation. A 43-year-old female who presented with clear nasal drainage was diagnosed with CSF rhinorrhea secondary to a clival defect previously thought to be ecchordosis physaliphora. The patient subsequently developed bacterial meningitis and underwent endoscopic, endonasal, transclival gross-total resection of the lesion with repair of the dural defect. Pathology revealed brachyury-positive chordoma. She received adjuvant proton beam radiotherapy and has remained stable for 2 years. Spontaneous CSF rhinorrhea can occur as a rare primary presentation of clival chordoma, requiring careful radiological interpretation and a high index of suspicion for diagnosis. Chordoma cannot be reliably differentiated from benign notochordal lesions based on imaging alone; thus, intraoperative exploration and immunohistochemistry play key roles. Clival lesions presenting with CSF rhinorrhea should undergo prompt resection to facilitate diagnosis and prevent complications. Future studies on connections between chordoma and benign notochordal lesions may help to establish management guidelines.

A case of rhino-orbital cerebral mucormycosis presenting with spontaneous cerebrospinal fluid rhinorrhoea

Rhino orbital cerebral mucormycosis has increased in the recent second wave of post COVID 19 illness, mainly in tropical countries like India.

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.

Spontaneous cerebrospinal fluid rhinorrhoea during pregnancy-case report and review of literature

Abstract Objectives Rhinoliquorrhea is a condition where cerebrospinal fluid (CSF) leaks due to a liquor fistula formation of traumatic or non-traumatic origin. It can be associated with increased intracranial pressure often due to idiopathic intracranial hypertension (IIH), typically found in young and obese female patients. Case presentation A 27-year-old woman, 2 gravida, 1 para, presented with clear rhinorrhoea. After a beta-trace-protein test the diagnosis of CSF leakage was determined. The woman had had a traumatic car accident in 2018 but had never developed clear rhinorrhoea, especially not in her first pregnancy after the accident. Due to stable condition of the mother further diagnostics were postponed until after the birth. An elective caesarean section was performed in 40 + 0 weeks of gestations. The structural bone defect in the posterior wall of the sphenoid sinus was surgically repaired by defect coverage postpartum. Conclusions Nasal CSF leakage in pregnancy has previously been described in four other case reports with mostly traumatic etiology. Additionally, IIH is an important diagnosis to keep in mind. So far there are no guidelines or evidence-based recommendations regarding to optimal fistula treatment of pregnant women available. For therapy a prophylactic antibiotic therapy, surgical reconstruction with sealing and a wait-and-see strategy should be considered and discussed.

Leaking Skull Base - Imaging of Two Cases of Spontaneous Cerebrospinal Fluid (CSF) Rhinorrhea Involving Sphenoid Sinus.

Leaking Skull Base - Imaging of Two Cases of Spontaneous Cerebrospinal Fluid (CSF) Rhinorrhea Involving Sphenoid Sinus.

A conservative surgical strategy for spontaneous cerebrospinal fluid leakage: a rare case report

A 59-year-old male with no history of trauma or surgery presented with clear rhinorrhea occurring when he bent his head forward. A CT scan revealed localized fluid accumulation and a lateral wall defect involving the left sphenoid sinus. Using the transpterygoid approach, we widened the anterior wall of the sphenoid sinus inferolaterally to expose the lesion as much as possible. Reconstruction involved placing an interposition graft between the dura and the bony defect using the underlay technique, followed by free mucosal grafting. Histopathological examination revealed neuroglial cells, confirming the diagnosis of spontaneous cerebrospinal fluid rhinorrhea due to a meningoencephalocele.

A CASE SERIES ON MANAGEMENT OF SPONTANEOUS CEREBROSPINAL FLUID RHINORRHEA

Introduction: Cerebrospinal fluid (CSF) rhinorrhea is defined as leakage of cerebrospinal fluid that occurs from a direct communication between the CSF-containing subarachnoid space and the paranasal sinuses. Non traumatic or spontaneous CSF rhinorrhea is very rare and reported to have occurred in only 4% of the CSF leak cases. Materials and Methods: A retrospective hospital-based study was conducted in a tertiary care centre on seven cases of spontaneous CSF Rhinorrhea. Observation and Results: Among seven cases, five patients were of age less than 45 years and two patients were more than 45 years old. All subjects were females and were diagnosed with spontaneous CSF rhinorrhea. CT paranasal sinuses and CT Cisternogram were the most common imaging modalities used for diagnosis in all patients. All patients underwent Transnasal endoscopic repair of CSF rhinorrhea. Conclusion: Transnasal endoscopic repair of the defect gives a successful outcome following failure of the conservative management in spontaneous CSF rhinorrhea.

Surgical Management of Spontaneous Cerebrospinal Fluid Rhinorrhea

Cave, Taylor MD; Marino, Michael J. MD; Lal, Devyani MD; Soler, Zachary M. MD, MSc; Bendok, Bernard R. MD; Miglani, Amar MD Author Information