C.S.F. rhinorrhea diagnosis and management

ABSTRACT

Cerebrospinal fluid [C.S.F] rhinorrhea has traditionally posed a difficult problem. The potential hazards include a meningitis rate of 40 percent. Most cases of primary spontaneous C.S.F rhinorrhea are associated with a localized defect in the skull base. This study presents a case of skull base defect [the roof of the sphenoid]. C.S.F rhinorrhea was diagnosed clinically and defect was confirmed by C.T. Endoscopic clousre of C.S.F. leak was done by using free graft of autogenous mucoperiosteum of the inferior turbinate. The second case of C.S.F rhinorrhea was postsurgical nasal polypectomy operation. This case presented with symptoms and signs of meningitis. C.T. showed a big defect in the cribriform plate. This patient was in immediate need for medical management for the complications of meningitis surgical anatomy of the sphenoid sinus and cribriform plate The sphenoid sinus is the most posteriorly located of paranasal sinuses. The sphenoid sinus, which is rudimentary at birth, develops with pneumatization of the sphenoid body from front to back during childhood, Sellers and Devilliers [1981]. The pneumatization progresses rapidly between 5 and 7 years of age to complete by age of 20-25 years. Raymond et al., [1993] described 3 varieties of pneumatization, sellar type [86%], presellar type [11%] and conchal type [3%] in which the sinus is virtually absent and entirely filled by cancellous bone. The sinuses may be very asymmetric, may be more than on septum [Fig. 1] and often no communications exist between the sinus parts. The sinus may extend beyond the body of the sphenoid into the base of the sphenoid wing or pterygoid processes or even into the basiocciput. Superiorly the anterior part of the roof of the sinus lies behind the cribriform plate of the ethmoid in the anterior cranial fossa and is related to the Optic chiasma, olfactory bulb and the undersurface of the frontal lobe of the brain. The posterior part of the roof of the sinus is the pituitary fossa in which lies the pituitary gl and. On the other h and, the roof of the nose slopes downward as one proceed posteriorly. The anteriorly high fovea ethmoidalis lowers and flattens out posteriorly toward the phenoid and posteriorly is at the level of the cribriform plate. The anterior ethmoid artery may pierce the cribriform plate and even be intracranial as it travels medially toward the septum. Kainz and Strammberger [1990] stated that the bone at that point is ten times thinner than in other areas of the cribriform plate and thus can be easily violated during polypectomy. To protect the cribriform plate the middle turbinate acts as an important l and mark. In addition measuring the anatomy is important tool to help and avoid complications. The distance from nasal spine or nasal opening to the frontal recess is 6 cm, to the base of the skull is 7 cm and to the anterior wall of the sphenoid 7 cm.