The Management of Spontaneous Cerebrospinal Fluid Rhinorrhea in Patients at Risk for Increased Intracranial Tension

Introduction: The exact pathophysiology of spontaneous CSF rhinorrhea is not always understood in some patients. Idiopathic intracranial hypertension (IIH) is now recognized as one of the causes of spontaneous CSF leak in the neurosurgical and ENT literature. Our aim was to set a management protocol for such cases according to the same setting intracranial tension (ICT). Methods: We prospectively managed patients with spontaneous CSF rhinorrhea who were admitted to our hospital between 1st of January 2014 and 31st of December 2017 with a prespecified treatment algorithm. Patients with a history of previous cranial or nasal surgery, trauma, skull base congenital malformations were excluded from the study. The patient’s demographics, clinical data, comorbidities, body mass index (BMI), first time or recurrent leakage and duration of the leak were collected. Results: 41 patients, 35 females and 6 males, presented with spontaneous CSF rhinorrhea with a mean BMI of 38 ± 4.16 Kg/m2. The mean pre-operative ICT manometry was 17.2 ± 5.9 cmH2O (range, 10 - 26 cmH2O). 43.9% of the patients were found to have an increased ICT (≥20 cmH2O) and underwent a permanent CSF diversion at the same setting of the endoscopic repair. None of the patients had a recurrence during the follow-up period. Conclusion: The prespecified treatment algorithm with measuring the ICT at the same setting of the endoscopic repair has a better result for control of spontaneous CSF rhinorrhea. This has led to no recurrence and decreased hospital stay.

Letter to the Editor: Postoperative Rhinorrhea without Intraoperative Cerebrospinal Fluid Leak after Endoscopic Transnasal Transphenoidal Surgery for Pituitary Macroadenomas

Postoperative Rhinorrhea without Intraoperative Cerebrospinal Fluid Leak after Endoscopic Transnasal Transphenoidal Surgery for Pituitary

Massive Rhinorrhea as a Complication of COVID-19 Nasopharyngeal Swab

The nasopharyngeal swab for COVID-19 testing is generally considered safe;however, it is primarily performed by staff that may not completely understand the anatomy of the nasal cavity and nasopharynx. We report the treatment of a 48-year-old man who developed unilateral left rhinorrhea after a nasopharyngeal swab sample. It is aimed to draw attention to this complication that can be prevented with the appropriate technique during nasopharyngeal swab sampling.

Prevention of postoperative intracranial infection in patients with cerebrospinal fluid rhinorrhea

Background Intracranial infection is a common postoperative complication of neurosurgery. This study aimed to identify risk factors of postoperative intracranial infection in patients with cerebrospinal fluid rhinorrhea and to suggest proposals for the prevention. Methods A total of 167 patients （113 males and 54 males, average age of 34.4 years） with cerebrospinal fluid rhinorrhea operated on by the senior author were retrospectively reviewed. The data collected included etiology, previous history, clinical manifestation, site of bone defect, operative approach, and postoperative complications. Risk factor（s） for postoperative infection were analyzed using the stepwise multiple Logistic regression. Results Eighteen （10.8%） patients were infected post-operatively. The independent risk factors for infection were the site of defect （RR=0.508, 95% Cl 0.306-0.843, P=0.009） and historical meningitis （RR=0.290, 95% Cl 0.094-0.893, P=0.031）. Patients with multiple defects and saddle floor defects had a higher infection rate. The germiculture was positive in 11 patients, and vancomycin was sensitive to all the pathogenesis. Nine infected patients needed lumbar drainage. Ten patients had hyponatremia, and hydrocephalus occurred in two patients with serious trauma. Conclusions To prevent the infection, we should pay closer attention to the high-risk patients pre-operation. During the operation, the methods those can improve wound healing, such as using blood-supply materials, reliable fixation, and eliminating dead space are all helpful. Conducting lumbar drainage and choosing effective prophylactic antibiotics in the early postoperative stage for the high-risk patients are methods of postoperative management.

Surgical Repair and Detection of Cerebrospinal Fluid Rhinorrhea using Magnetic Resonance Cisternography and Skull Base Coronal Thin-section Computed Tomography Scan

INTRODUCTION Cerebrospinal fluid （CSF） rhinorrhea is a common condition managed by neurosurgeons. The accurate identification of the site of leak plays a key role in facilitating successful surgical repair. We reported two surgery-proven cases of CSF rhinorrhea examined by magnetic resonance （MR） cisternography （Siemens, Berlin, Germany） and skull base coronal thin-section computed tomography （CT） scan （Siemens, Berlin, Germany） before surgical treatment.

Reducing the risk of cerebrospinal fluid rhinorrhea following translabyrinthine surgery of the posterior fossa

Objective:To describe the procedure and results of an adapted closure and recon struction technique for translabyrinthine surgery that focuses on identifying and managing potential pathways for CSF egress to the middle ear and Eustachian tube.Methods:Retrospective review of a cohort of translabyrinthine acoustic neuroma cases that were reconstructed using this technique.Results:In addition to meticulous packing of potential conduits using soft tissue,hydroxyapatite cement is used to seal opened air cell tracts prior to obliteration of the mastoid defect using adipose tissue.Early results of a small patient cohort using this technique are encouraging and there were no wound infections.There was a single case of CSF rhinorrhea associated with incomplete sealing of opened petrous apex cells,with no recurrence after appropriate implementation of the described protocol during revision surgery.Conclusion:Proactive management of potential conduits of CSF egress including opened air cell tracts has a high likelihood of reducing rates of rhinorrhea and need for revision surgery after the translabyrinthine approach to the posterior fossa.

Prolactinoma coexisting with cerebrospinal fluid rhinorrhea and cavernous internal carotid aneurysm: Case report and literature review

Pituitary adenoma coexisting with cerebrospinal fluid(CSF) rhinorrhea and carotid aneurysm is extremely rare. CSF rhinorrhea may cause pneumocephalus and intracranial infection. Rupture of the aneurysm may cause fatal consequence. The authors report such a rare case to draw more attentions. A 55-year-old man presented with sexual dysfunction for 2 years. The serum prolactin was tested as 1,600 ng/ml(normal range, 1.39–24.2). Enhanced cranial MR showed an evident lesion at the sellar area, invading the right cavernous sinus. Prolactinoma was diagnosed. He took bromocriptine for one year and received gamma knife therapy thereafter. Four months after the treatment of gamma knife, he got CSF rhinorrhea and nasal bleeding. The endoscopic transnasalsphenoidal approach was performed to resect the tumor and repair the dura defect.The CSF rhinorrhea stopped after the surgery, however his nasal bleeding continued. The digital subtraction angiography(DSA) showed an aneurysm at the right cavernous internal carotid. The endovascular coil embolization was performed to treat the aneurysm. The patient recovered well. The coexistence of CSF rhinorrhea and pituitary adenoma is a high risk factor for the rupture of cavernous internal carotid aneurysm. When treating patients with pituitary adenoma and CSF rhinorrhea, doctors should exclude the aneurysm. When nasal bleeding occurs, the hemorrhage of internal carotid should be considered, and appropriate measures should be taken immediately.

Spontaneous cerebrospinal fluid rhinorrhea in a patient with tentorial meningioma

Spontaneous cerebrospinal fluid （CSF） rhinorrhea is rarely found, especially in patients with brain tumors.Similarly, reports of tentorial meningioma coexisting with acquired Chiari I malformation with hydromyelia are also few. No doubt, one patient with cerebrospinal fluid rhinorrhea, tentorial meningioma and Chiari I malformation with hydromyelia is hardly ever found. We reported one case of this rare condition.

Microsurgical treatment of cerebrospinal fluid rhinorrhea in sphenoidal sinus

Objective：To explore the clinical manifestation,diagnosis and surgical treatment of cerebrospinal fluid rhinorrhea in sphenoidal sinus.Methods： Nine cases of cerebrospinal fluid rhinorrhea in spenoidal sinus from 2007 to 2009 were retrospectivelyanalyzed consisting of their possible etiological factors,clinical manifestations, localization of the leakage site and treatment methods. Among them, there were 3 cases of traumatic rhinorrhea, 4 postoperative rhinorrhea and 2 spontaneous rhinorrhea. All 9 patients underwent 3-dimensional CT scan in sellar region including all para-nasal sinus. Leakage site was identified and repairing procedure was performed through trans-sphenoidal approach.Results：All cases were cured with the trans-sphenoidal microsurgical procedure. They were followed up for 9 months to 2 years. No recurrence, no infection and epilepsy complications were observed.Conclusion：For the cerebrospinal fluid rhinorrhea at sphenoidal sinus, it is critical to identify the leakage site accurately and the trans-sphenoidal approach is a microinvasive and effective way to repair the leakage, which is worthy to be advocated.

Post-traumatic cerebrospinal fluid rhinorrhea associated with craniofacial fibrous dysplasia:Case report and literature review

Objective: Fibrous dysplasia(FD) is an unusual developmental abnormality of the skeleton. When facial and cranial bones are involved in FD, it is termed craniofacial fibrous dysplasia(CFD). Although several reports have reported that CFD has a tendency for spontaneous cerebrospinal fluid(CSF) leakage, there have been no related English-language case reports. We present the first case of post-traumatic CSF rhinorrhea associated with CFD. Methods: A 30-year-old man presented with CSF rhinorrhea after a mild head trauma. Computed tomography cisternogram located a defect in the posterior wall of the right frontal sinus. Imaging examination also showed the evident expansion of multiple skull bones, spinal scoliosis, and multiple local enlargements of ribs.Without café-au-lait cutaneous spots and endocrine abnormalities, polyostotic FD was diagnosed instead of Mc Cune-Albright syndrome(MAS). The patient underwent craniotomy fistula repair surgery. The excised bone was contoured to be thinner to increase the cranial cavity. The patient recovered well and CSF leakage did not recur.But during a nineteen-month follow up, sight in the patient's left eye was decreased.MAS was suspected. Unfortunately the patient refused to take the proposed decompression surgery and laboratory tests of serum hormones. Conclusions: CFD, if the wall of the paranasal sinus is involved and the cranial cavity is decreased, may increase the risk of CSF rhinorrhea after head trauma.Expectant management is recommended in asymptomatic CFD patients even in the presence of optic nerve compression. As MAS may cause more problems, it should be precluded before polyostotic FD is diagnosed.

自发性脑脊液鼻漏误诊误治临床探讨

目的分析自发性脑脊液鼻漏误诊误治的原因,总结避免误诊误治的措施。方法回顾性分析2008年12月至2023年8月被误诊的11例自发性脑脊液鼻漏患者的临床资料。结果8例流清水样涕、鼻腔黏膜色泽苍白或淡红,被误诊为过敏性鼻炎。1例左侧鼻腔流水、中鼻道半透明荔枝肉状肿物,副鼻窦CT示“左上颌窦、筛窦炎,左中鼻道软组织密度影”,被误诊为左慢性鼻窦炎伴鼻息肉。1例上呼吸道感染后,头部不适,流清水样涕,被误诊为急性鼻炎。1例睡觉时鼻腔有液体流向喉部,鼻窦CT示“右侧上颌窦卵圆形肿物、边界清晰,考虑囊肿”,被误诊为右上颌窦囊肿。11例患者经对症治疗后症状无缓解,进一步行影像学及鼻流出液葡萄糖定量检查后确诊为自发性脑脊液鼻漏。误诊时间10~60(24.09±13.5)d。11例均行经鼻内镜脑脊液鼻漏修补术后痊愈。结论自发性脑脊液鼻漏起病隐匿、临床少见、多为单侧发病、鼻流出液多呈持续性且清亮无色,可因体位改变、咳嗽、喷嚏、便秘等致颅内压增加而加重。完善鼻窦CT和磁共振成像,可为该病的诊断提供证据,确诊需要鼻流出液葡萄糖定量检查。

自发性脑脊液鼻漏的临床特点与手术疗效分析

目的 分析自发性脑脊液鼻漏患者颅底硬膜缺损部位及其治疗选择的差异。方法 纳入2010年1月~2021年12月就诊于我科确诊为脑脊液鼻漏的患者,根据病因分为自发(例=41)和非自发性(例=83)脑脊液鼻漏两组。比较两组患者病史及影像学资料、治疗方式、手术入路及颅底重建方法的差异。结果 自发性脑脊液鼻漏多见于体重指数较高(P=0.024)的年长(P=0.019)女性(P=0.001),且多合并高血压病史;二元Logistic回归分析显示高体重指数是自发性脑脊液鼻漏的独立危险因素。自发性脑脊液鼻漏的漏口多见于蝶窦外侧隐窝(P=0.001)与嗅裂(P=0.019);而非自发性脑脊鼻液漏多见于额窦(P=0.023),且常合并多处颅底硬膜缺损(P=0.015)。自发组中,共40名患者采用了单纯经鼻内镜手术修补,而非自发组的16名患者需辅助外切口行手术修补(P=0.002)。自发性脑脊液鼻漏患者大多(39例)采用带蒂的鼻腔黏膜瓣,部分非自发性脑脊液鼻漏患者手术修补需联合使用鼻内及鼻外组织瓣。两组患者的手术成功率无统计学差异,且随访期间无复发。结论 自发性脑脊液鼻漏多见于嗅裂、蝶窦外侧隐窝;手术时根据脑漏不同分类对常见可疑部位重点探查,不易造成遗漏;采用血管化组织瓣进行内镜手术修补具有良好的临床疗效。

鼻内镜下自体肌肉筋膜加脂肪组织修补脑脊液鼻漏

2002年6月～2005年8月对35例脑脊液鼻漏患者手术修补时,分别采用了联合肌肉筋膜与脂肪组织以及单独使用肌肉筋膜作为修补材料,前瞻性对比观察修补效果。

鼻内镜修补术对脑脊液鼻漏患者住院时间及并发症的影响

目的对比研究鼻内镜修补术与传统颅内修补术治疗脑脊液鼻漏的临床疗效。方法方便选取2021年1月—2022年12月南京医科大学附属江宁医院收治的162例脑脊液鼻漏患者为研究对象,采用随机数表法分为对照组(n=81)、研究组(n=81)。对照组行传统颅内修补术,研究组行鼻内镜修补术。分别于术前及术后2 d,检测两组肿瘤坏死因子-α(Tumor Necrosis Factor-α,TNF-α)、C反应蛋白(C-reactive Protein,CRP)、白介素-6(Interleukin-6,IL-6)水平,比较两组手术成功率、住院时间、并发症发生情况。结果研究组手术成功率(96.29%)高于对照组(87.65%),差异有统计学意义(χ^(2)=4.098,P<0.05);研究组住院时间短于对照组,差异有统计学意义(P<0.001);术前,两组炎性因子水平对比,差异无统计学意义(P>0.05);术后研究组TNF-α、CRP、IL-6水平均低于对照组,差异有统计学意义(P均<0.001);研究组并发症发生率低于对照组,差异有统计学意义(P<0.05)。结论鼻内镜修补术在治疗脑脊液鼻漏方面表现出显著的优势。手术成功率较高,手术过程对炎性因子水平影响较小,能够缩短患者住院时间,且术后并发症风险较低,对于改善患者的预后有积极作用。

游离中鼻甲黏膜瓣在神经内镜经鼻蝶低流量脑脊液鼻漏修补中的成功率及安全性分析

目的 分析神经内镜经鼻蝶修补术中采用游离中鼻甲黏膜瓣的成功率及安全性。方法 非随机选取南京医科大学附属江宁医院于2020年12月—2022年12月收治的218例脑脊液鼻漏患者作为研究对象,根据不同治疗方法分为对照组、观察组,每组109例。两组患者均采取神经内镜经鼻蝶修补术,对照组予以带血管蒂鼻中隔黏膜瓣进行修补,观察组予以游离中鼻甲黏膜瓣进行修补。比较两组患者的手术成功情况、不良事件发生情况及生活质量。结果 观察组的总成功率高于对照组,差异有统计学意义(P<0.05);观察组不良事件总发生率(2.75%)低于对照组(9.17%),差异有统计学意义(χ^(2)=4.008,P<0.05)。观察组各项生活质量评分均高于对照组,差异有统计学意义(P均<0.05)。结论 对于低流量脑脊液鼻漏患者而言,在神经内镜经鼻蝶术中采取游离中鼻甲黏膜瓣修补的手术成功率更高,且能提高患者生活质量,术后不良事件较少。

经鼻内镜修补自发性脑脊液鼻漏

自发性脑脊液鼻漏又称原发性脑脊液鼻漏,临床上较少见,机制亦未阐明,但多数认为与先天性颞骨、颅底及硬脑膜畸形和缺损有关。我科2000年1月～2007年6月诊治经鼻内镜修补自发性脑脊液鼻漏5例，均取得满意疗效。

Mondini畸形伴脑脊液耳鼻漏1例

1临床资料 患者,男性,5岁。2年前因车祸致左耳听力下降,当时对症治疗。7个月前无明显诱因出现化脓性脑膜炎,治疗后痊愈。1个月前再次出现化脓性脑膜炎,伴左鼻腔流“清水”,脑膜炎控制良好后转入我院。入院查体：神志清,发育正常,神经系统检查阴性。双侧外耳发育正常,鼓膜完整。鼓室压图左侧B型,右侧As型。听觉脑干诱发电反应（auditory brainstem response,ABR）左耳100dB未见明显反应波，

经鼻内窥镜筛蝶窦脑脊液鼻漏修补术

采用内窥镜鼻窦外科技术修补筛窦、蝶窦脑脊液鼻漏５例。其中４例是外伤性，经保守治疗无效者，１例是经鼻内窥镜筛板一前颅底进路切除浸入鼻腔的脑膜瘤时发生的严重脑脊液鼻漏。５例均一次手术治愈。介绍了修补术的方法，并就经鼻内窥镜脑脊液鼻漏修补术的有关问题进行了讨论。

经鼻蝶入路显微手术预防和修补脑脊液鼻漏

目的 探讨经鼻蝶入路显微手术脑脊液鼻漏的预防和修补方法。方法 将改良经鼻蝶显微手术用于200例鞍区病变,其中150例为大或巨大垂体腺瘤,术前合并脑脊液鼻漏4例,1例外伤性脑脊液鼻漏,通过治疗观察并进行围手术期评价。结果 发现脑脊液漏可在手术中和手术后出现,通过术中的预防措施及术后的及时处理可以得到治愈。结论 经鼻蝶入路显微手术为鞍区病变术中和术后预防和修补脑脊液鼻漏的良好方法。