Preoperative management of spontaneous cerebrospinal fluid rhinorrhea with acetazolamide.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) rhinorrhea has been associated with elevated intracranial pressure (ICP). As such, ICP reducing measures are commonly employed to optimize repair. Although postoperative acetazolamide use has been described, no data currently exists on the potential for preoperative use. METHODS: A retrospective review was performed including patients treated for anterior spontaneous CSF leaks by a single surgeon over a 6-year period during which acetazolamide therapy (250 mg twice daily) was employed before considering surgical repair. The primary endpoint was whether the patient went on to require surgical repair. RESULTS: A total of 16 patients were identified who were pretreated with acetazolamide. Leak sites were noted as cribriform (5/16), sphenoid (8/16), ethmoid (1/16), multiple (1/16), and indeterminate (1/16). Five patients had resolution of their rhinorrhea without surgery (31.3%). Mean follow-up for these nonsurgical patients was 470 days (range, 64 to 857 days). There were no differences in the patients' age or site of leak between surgical and nonsurgical patients (p = 0.65, p = 0.52, respectively). Nonsurgical patients had a lower body mass index (BMI) than surgical patients (p = 0.04). CONCLUSION: This is the first study to report the use of acetazolamide therapy as a primary treatment option for spontaneous CSF rhinorrhea. This therapy enabled surgery to be avoided in 31.3% of patients. This would indicate that in the absence of other contraindications for delaying repair, a trial of acetazolamide therapy could be considered as an initial option in the management of isolated spontaneous CSF rhinorrhea.

Unilateral Rhinorrhea and Sneezing After Upper Gastrointestinal Endoscopy Under Intravenous Propofol Sedation With Supplemental Oxygen Administered via a Nasal Cannula: A Case Report.

We present a rarely described complication of unilateral rhinorrhea and sneezing in a patient who received intravenous sedation with propofol and supplemental oxygen via a nasal cannula during upper gastrointestinal endoscopy. The literature is reviewed and a mechanism is proposed. Mechanical irritation of the nasal mucosa is felt to be the trigger. Suggestions to avoid and to treat are offered.

Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura / Cerebrospinal fluid rhinorrhea from a transclival meningocele: a case report and literature review

El lugar más común de fístulas de líquido cefalorraquídeo (LCR) es el suelo de la fosa craneal anterior, menos comúnmente el seno esfenoidal. Solo el 3-4% de fístulas de LCR son espontáneas. Nosotros presentamos el cuarto caso clínico de rinorraquia secundaria a meningocele transclival, lugar muy poco común de asiento de estas lesiones, y discutimos la vía de abordaje. Varón de 39años, sin antecedentes de traumatismo previo, historia reciente de salida de líquido transparente a través de las ventanas nasales y cuadro de meningitis. La tomografía computarizada y la resonancia magnética mostraron el defecto óseo clival y meningocele transclival. El defecto fue reparado mediante abordaje endonasal endoscópico transesfenoidal transclival con resultado favorable. A pesar de la rareza del meningocele transclival, se recomienda considerarlo en el diagnóstico diferencial de las fístulas nasales espontáneas. El abordaje endonasal endoscópico es una técnica directa que ofrece resultados satisfactorios en la resolución de rinorrea de LCR

The most common site of CSF leakage is the floor of the anterior cranial fossa, and less commonly in the sphenoid sinus. Only 3-4% of CSF fistulas are spontaneous. The fourth case is presented of a CSF rhinorrhea due to a transclival meningocele, an extremely rare location for these lesions, and the surgical approach. The patient is a 39-year-old male with no history of trauma, and a recent history of watery rhinorrhe and meningitis. CT scan and MRI showed clival bone defect and trans-sphenoidal transclival meningocele. The defect was repaired by transclival trans-sphenoidal endoscopic endonasal approach with good results. Despite the rarity of transclival meningocele, it is recommended to consider it in the differential diagnosis of spontaneous nasal fistulas. The endoscopic endonasal approach is a direct technique that provides satisfactory results in the resolution of CSF rhinorrhea

Analysing the effect of early acetazolamide administration on patients with a high risk of permanent cerebrospinal fluid leakage.

In this study, we examined the role of early acetazolamide administration in reducing the risk of cerebrospinal fluid (CSF) leakage in patients with a high risk of permanent CSF leakage. In a randomised clinical trial, 57 patients with a high risk of permanent CSF leakage (rhinorrhea, otorrhea, pneumatocele or imaging-based evidence of severe skull-base fracture) were analysed. In the experimental group, acetazolamide, at 25 mg/kg/day, was started in the first 48 hours after admission. In the control group, acetazolamide was administered after the first 48 hours at the same dose administered to the patients in the experimental group. The following factors were compared between the two groups: duration of CSF leakage, duration of hospital stay, incidence of meningitis, need for surgical intervention and need for lumbar puncture (LP) and lumbar drainage (LD). All of the patients in the experimental group stopped having CSF leakage less than 14 days after the first day of admission, but 6 out of 21 patients (22%) in the control group continued having CSF leakage after 14 days of admission, which was a significant difference (P=0.01). This study showed that early acetazolamide administration can prevent CSF leakage in patients with a high risk of permanent CSF leak.

Cerebral venous sinus thrombosis associated with spontaneous intermittent cerebrospinal fluid rhinorrhea: a case report.

OBJECTIVES: To present a rare case of cerebral venous sinus thrombosis (CVST). CLINICAL PRESENTATION AND INTERVENTION: A 43-year-old woman presented with coma and was diagnosed as a case of CVST. She recovered in a few days with heparin treatment. Many possible risk factors for CSVT were negative in the patient but intermittent cerebrospinal fluid (CSF) rhinorrhea was accidentally noticed. Cerebral computed tomography and magnetic resonance imaging were done. The patient was diagnosed as having spontaneous intermittent CSF rhinorrhea due to a defect in the base of the skull. CONCLUSIONS: This case showed the importance of being aware that a defect in the base of the skull may lead to intermittent CSF rhinorrhea in patients with CVST.

Effects of phenytoin sodium on dura mater healing in a rat model of CSF leakage.

AIM: Cerebro-spinal fluid (CSF) leakage caused by defects on the dura mater after trauma or some neurosurgical interventions is an important issue. In this study, we investigated the effects of local and systemic use of phenytoin sodium on dural healing. MATERIAL AND METHODS: Thirty-six male Wistar rats were divided into control, local phenytoin and systemic phenytoin groups with 12 rats in each. For each group, a dura defect was created at thoracic segment. Subjects were sacrificed at following 1st and 6th weeks and damaged segments were isolated. The results were compared histopathologically by Hematoxylin-Eosin and Masson-Trichrome staining. Criteria for the rate of collagen, neovascularization, and granulation formation were assessed semi quantitatively according to the histological assessment scale modified by Ozisik et al. RESULTS: Better healing was achieved in the systemic and local phenytoin groups than in the control group. The level of healing was significantly higher in the systemic group in both early and late periods than in other groups (p < 0.01). The level of healing in the late-local group was also statistically significantly higher than that in the control group. CONCLUSION: We observed that both systemic and local uses of phenytoin sodium (especially systemic) have positive effects on dura healing.

Spontaneous CSF leaks: factors predictive of additional interventions.

OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks represent a significant challenge due to frequent association with elevated intracranial pressure (ICP) and higher risk of surgical failure. The study objective was to review management strategy and identify factors associated with need for acetazolamide and/or ventriculoperitoneal shunt (VPS) placement. STUDY DESIGN: Retrospective data analysis. METHODS: Chart review performed from 1999 to 2009 at a tertiary-care medical center. RESULTS: A total of 105 patients underwent CSF leak repair; 39 patients (37.1%) were treated for spontaneous CSF leaks. Mean age was 57.7 years and 33 were female (85%). Average body mass index (BMI) was 38.5 kg/m(2). The most common sites were cribriform plate (51%), sphenoid lateral pterygoid recess (31%), and ethmoid roof (8%). All patients underwent endoscopic repair utilizing image guidance with multilayered closure in most cases. Five patients (12.8%) developed recurrent CSF leak with mean ICP of 27.0 cm H(2)O, compared to 25.0 cm H(2)O for those without recurrence (P = .33). All had successful rerepair at mean follow-up of 2.8 years. Acetazolamide was used in nine patients, whereas six patients underwent VPS placement for elevated ICP management. Diagnosis of benign intracranial hypertension (BIH) was statistically associated with need for acetazolamide or VPS (P < .001), whereas elevated ICP reached borderline significance (P = .049). CONCLUSIONS: Management of spontaneous CSF leaks requires a comprehensive strategy after endoscopic repair. Diagnosis of BIH may be associated with requirement of further ICP treatment. Close ICP monitoring, coupled with selective use of acetazolamide and VPS, may decrease risk of failure.

A new porcine skull base model: fibrin glue improves strength of cerebrospinal fluid leak repairs.

OBJECTIVES: Fibrin glue is used in addition to grafts and flaps to repair cerebrospinal (CSF) leaks. We designed a porcine model to test the hypothesis that fibrin glue increases biomechanical strength. STUDY DESIGN: A randomized experimental animal study. METHODS: Ten pigs underwent craniotomy with creation of a fistula through the cribriform plate into the nasal cavity. CSF leaks were endoscopically confirmed and repaired using pericranial grafts. The animals were randomized into a fibrin glue group (n=5) and a control group (n=5). Seven days later, endoscopic examination assessed for CSF leaks. The skull bases were harvested and examined for the degree of graft adherence (graded I-V) and subjected to burst pressure testing and histopathological analysis. RESULTS: Eight animals survived, four in each group. There were no CSF leaks in the fibrin glue group and one in the control group. The fibrin glue group showed greater graft adherence (P=0.029) and higher burst pressures (13.8+/-5.4 vs 4.6+/-3.1 psi, P=0.021). Histopathological analysis revealed no difference in inflammation and bone remodeling. CONCLUSIONS: The porcine model is a good model for anterior skull base defects. The model confirmed that fibrin glue reduces the rate of CSF leak by improving graft adherence and strength of repair.

Pneumocranium secondary to halo vest pin penetration through an enlarged frontal sinus.

We present a case report of a patient with pneumocranium secondary to halo vest pin penetration and a review of literature. The objectives of this study are to report a rare complication of halo vest pin insertion and to discuss methods of prevention of this complication. Halo vest orthosis is a commonly used and well-tolerated upper cervical spinal stabilizing device. Reports of complications related to pin penetration is rare and from our review, there has been no reports of pneumocranium occurring from insertion of pins following standard anatomical landmarks. A 57-year-old male sustained a type 1 traumatic spondylolisthesis of C2/C3 following a motor vehicle accident. During application of the halo vest, penetration of the left anterior pin through the abnormally enlarged frontal sinus occurred. The patient developed headache, vomiting and CSF rhinorrhoea over his left nostril. He was treated with intravenous Ceftriaxone for 1 week. This resulted in resolution of his symptoms as well as the pneumocranium. In conclusion, complications of halo vest pin penetration are rare and need immediate recognition. Despite the use of anatomical landmarks, pin penetration is still possible due to aberrant anatomy. All patients should have a skull X-ray with a radio-opaque marker done prior to placement of the halo vest pins and halo vest pins have to be inserted by experienced personnel to enable early detection of pin penetration.

CSF rhinorrhea secondary to use of a Mayfield head clamp.

Various complications with use of a Mayfield head clamp have been reported, from minor skin necrosis and lacerations to the more significant extradural hematomas and meningitis. To the best of our knowledge, our report describes for the first time in the medical literature, the uncommon complication of frontal sinus fracture and cerebrospinal fluid leak caused by a scalp pin of a head clamp used during a frontal craniotomy. The cerebrospinal fluid leak settled with conservative management, and no surgical intervention was necessary. Clinicians should appreciate the possibility of such a complication and assess preoperative scans for frontal sinuses that extend to a high level, as in our patient.

Arcanobacterium haemolyticum: two case reports.

Two uncommon presentations of Arcanobacterium Haemolyticum infection (sinusitis and pharyngitis) are described, emphasizing the poor response to commonly used antibiotics and the possibility of serious local and systemic complications. The difficulties still encountered in the clinical diagnosis are underlined, since this organism could easily pass unrecognized in bacteriological cultures.

[A rare case of cerebrospinal fluid rhinorrhea]. / Rzadki przypadek plynotoku nosowego.

INTRODUCTION: Cerebrospinal fluid rhinorrhea is a result of a damage to bones and dura mater of the anterior cranial fossa base. In more than 90% it is of trauamatic etiology. AIM: The aim of the study was to present a case of a 23 year old female patient with post-traumatic rhinorrhea. Cerebrospinal fluid rhinorrhea occured as a result of unintentional damage of cribriform plate of the ethmoid bone on the right side when the patient was opening a box of cosmetic with the use of a screwdriver. MATERIAL AND METHODS: Two days after the accident she was admitted to our Department with apparent cerebrospinal fluid rhinorrhea and forehead headache. Radiological and laboratory testing were performed, than she was consulted by a neurologist and a neurosurgeon. It was decided to introduce conservative management in the ENT department. RESULTS: During 24 days of hospitalization with medical management including avoidance of activities that increased the intracranial pressure, head elevation and antibiotics the cerebrospinal fluid rhinorrhea decreased and ceased. This was confirmed by physical examination, nasal endoscopy, radiological studies and neurosurgical consultation. CONCLUSIONS: After more than 3 months of follow-up, there was no evidence of rhinorrhea.

Petrous apex aspergillosis as a long-term complication of cholesterol granuloma.

Aspergillus infection of the petrous apex is a rare and devastating condition. To date, only two such cases have been reported, which resulted from direct extension of chronic Aspergillus otitis media. We present a case of petrous apex aspergillosis occurring years after surgical drainage of a petrous apex granuloma cyst. Because of the potential lethal nature of this condition, aggressive surgical therapy should be considered early in this illness and may provide the best chance for survival.

Treatment of the common cold.

The common cold is a viral illness that affects persons of all ages, prompting frequent use of over-the-counter and prescription medications and alternative remedies. Treatment focuses on relieving symptoms (e.g., cough, nasal congestion, rhinorrhea). Dextromethorphan may be beneficial in adults with cough, but its effectiveness has not been demonstrated in children and adolescents. Codeine has not been shown to effectively treat cough caused by the common cold. Although hydrocodone is widely used and has been shown to effectively treat cough caused by other conditions, the drug has not been studied in patients with colds. Topical (intranasal) and oral nasal decongestants have been shown to relieve nasal symptoms and can be used in adolescents and adults for up to three days. Antihistamines and combination antihistamine/decongestant therapies can modestly improve symptoms in adults; however, the benefits must be weighed against potential side effects. Newer nonsedating antihistamines are ineffective against cough. Topical ipratropium, a prescription anticholinergic, relieves nasal symptoms in older children and adults. Antibiotics have not been shown to improve symptoms or shorten illness duration. Complementary and alternative therapies (i.e., Echinacea, vitamin C, and zinc) are not recommended for treating common cold symptoms; however, humidified air and fluid intake may be useful without adverse side effects. Vitamin C prophylaxis may modestly reduce the duration and severity of the common cold in the general population and may reduce the incidence of the illness in persons exposed to physical and environmental stresses.

Rhinorrhea not responding to nasal corticosteroids.

A woman with multiple illnesses including allergic rhinitis presented for a follow-up visit at our clinic with constant rhinorrhea for 2 weeks despite regular use of nasal corticosteroids. Two weeks earlier, after alcohol drinking and doubling some of her medications for missed doses, she fell on her face. The Emergency Department records documented headache, bradycardia, hypotension, dehydration, and right infraorbital swelling. She was admitted for hydration and observation, and was discharged after two days without radiologic evaluation of the head. At our clinic, physical examination revealed pale turbinates bilaterally and clear watery discharge from the right nostril. Cerebrospinal fluid (CSF) rhinorrhea was suspected, but glucose testing was not available at our clinic. The patient was immediately admitted into the hospital. A beta-2-transferrin test confirmed CSF from the right nostril. High resolution sinus CT revealed fluid in the right sphenoid sinus, a large cyst in the left maxillary sinus, a cribriform plate dehiscence on the right side, and fluid collection adjacent to the middle turbinate. A lumbar drain was placed to release the pressure and antibiotic prophylaxis was started. Nasal endoscopy revealed CSF leak from the cribriform plate with bone dehiscence and a dural tear. A graft from nasal septal cartilage and temporalis fascia was applied using Tisseal fibrin glue. The persistent rhinorrhea resolved and on follow-up visits, the patient remained asymptomatic. Thinking of CSF rhinorrhea in the differential diagnosis of rhinitis would lead to early diagnosis and prevention of serious medical complications and potential legal liabilities.

Posttraumatic pseudo-cerebrospinal fluid rhinorrhea.

OBJECTIVE AND HYPOTHESIS: Posttraumatic clear rhinorrhea should result in immediate concern for a suspected cerebrospinal fluid (CSF) fistula in patients with skull base injuries, including surgical trauma. However, in addition to CSF rhinorrhea, the differential diagnosis may also include postinjury autonomic dysfunction. Pseudo-cerebrospinal fluid rhinorrhea (PCSFR) is a term used to describe rhinorrhea resulting from injury to preganglionic parasympathetic fibers supplying the sphenopalatine ganglion. This ganglion plays a critical role in this pathway secondary to its anatomic course and physiologic function. Differentiating between PCSFR and true CSF rhinorrhea can be a diagnostic challenge and may result in unnecessary and costly invasive testing and treatment. CASE STUDY: The authors present an illustrative case of noniatrogenic posttraumatic PCSFR in a previously healthy patient who experienced a head injury in a horseback riding accident. DISCUSSION: Features of PCSFR include a history of skull base surgery or trauma with involvement of autonomic structures in this region, rhinorrhea within months or years after injury, decreased lacrimation on the involved side, absence of clinical signs of meningitis, and a negative beta2-transferrin test result. Management of PCSFR is aimed at restoring the normal autonomic homeostasis in the nasal cavity. Treatment options include topical medicines such as anticholinergics and the various surgical procedures aimed at disruption of parasympathetic preganglionic fibers proximal to or at the sphenopalatine ganglion. CONCLUSION: This case and its diagnosis and management provide an additional mechanism of PCSFR, a clinical entity that must be considered in the evaluation of all patients with previous skull base trauma.