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Takao N, Sakurai K, Hino S, Yamano Y. [A case of nasal discharge resulting in recurrent bacterial meningitis]. Rinsho Shinkeigaku 2021; 61:177-181. [PMID: 33627580 DOI: 10.5692/clinicalneurol.cn-001505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 47-year-old man who was previously hospitalized three times due to bacterial meningitis experienced a headache and posterior neck pain in May. He was admitted to our hospital because of a fever 3 h later. He was fully conscious and febrile, with a headache and signs of meningeal irritation. A cerebrospinal fluid examination showed an increased number of cells with polynuclear cell predominance and decreased glucose levels, leading to the diagnosis of bacterial meningitis. Steroid and antibiotic treatment was initiated, at which time, large amounts of nasal discharge were observed. Cisternal scintigraphy was performed, and cerebrospinal fluid was detected in the nasal discharge. The cause was idiopathic, and endoscopic repair was performed. The nasal fluid leakage was suggested to be the cause of the recurrent bacterial meningitis in this case.
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Affiliation(s)
- Naoki Takao
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Kenzo Sakurai
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Sakae Hino
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
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Shelesko EV, Kravchuk AD, Kapitanov DN, Chernikova NA, Zinkevich DN. [A modern approach to the diagnosis of nasal liquorrhea]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:103-111. [PMID: 29927432 DOI: 10.17116/neiro2018823103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nasal liquorrhea is cerebrospinal fluid leakage from cerebrospinal fluid spaces of the cerebral cavity into the nasal cavity or paranasal sinuses due to congenital or acquired abnormalities of the skull base bones and meninges of various etiologies. The severity of liquorrhea varies from hidden manifestations to profuse leakage of cerebrospinal fluid from the nasal cavity. The diagnosis of overt nasal liquorrhea is not problematic, but the diagnosis of latent liquorrhea is a challenge. In this case, the disease leads to potentially fatal complications, such as meningitis (the risk amounts to 10-37%), pneumocephaly, pneumonia, etc. These peculiarites give rise to two main tasks: early diagnosis confirming liquorrhea and accurate identification of the CSF fistula location when planning further surgical management. PURPOSE The study purpose was to review and comparatively analyze all modern methods of diagnosing nasal liquorrhea as well as to substantiate the most effective and promising approaches and algorithms. MATERIAL AND METHODS The study included papers in English and Russian found in the Pubmed database and related to the diagnosis of basal liquorrhea of different etiology and localization. RESULTS This review demonstrates that diagnostic tests vary widely in sensitivity, specificity, accuracy, invasiveness, and cost. Given all the criteria, detection of beta-2 transferrin or beta-trace protein is the best method for confirming nasal liquorrhea, and high-resolution computed tomography is the best technique for localization of the abnormality. CONCLUSION Based on the review, we suggest a diagnostic algorithm for nasal liquorrhea. However, the evidence presented in this review is unfortunately not very reliable, which indicates the existing need for more accurate studies.
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Affiliation(s)
- E V Shelesko
- Burdenko Neurosurgery Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - A D Kravchuk
- Burdenko Neurosurgery Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - D N Kapitanov
- Burdenko Neurosurgery Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - N A Chernikova
- Burdenko Neurosurgery Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - D N Zinkevich
- Burdenko Neurosurgery Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
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Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage. Nucl Med Mol Imaging 2017; 51:193-194. [PMID: 28559947 DOI: 10.1007/s13139-015-0389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/25/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022] Open
Abstract
We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.
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Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2015; 6:8-16. [PMID: 26370330 DOI: 10.1002/alr.21637] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/29/2015] [Accepted: 08/04/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Gretchen M Oakley
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Richard J Harvey
- Faculty of Health Sciences, Macquarie University, Sydney, Australia.,Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Richard R Orlandi
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT
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Rapid Spontaneous Cerebrospinal Fluid Leak Detected in the Gastrointestinal Tract. Clin Nucl Med 2014; 39:198-9. [DOI: 10.1097/rlu.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bowel Visualization as a Sign of Cerebrospinal Fluid Leakage on Radionuclide Cisternography. Clin Nucl Med 2008; 33:811-2. [DOI: 10.1097/rlu.0b013e318187eee0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis. Clin Microbiol Rev 2008; 21:519-37. [PMID: 18625686 DOI: 10.1128/cmr.00009-08] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.
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Limawararut V, Valenzuela AA, Sullivan TJ, McNab AA, Malhotra R, Davis G, Jones N, Selva D. Cerebrospinal Fluid Leaks in Orbital and Lacrimal Surgery. Surv Ophthalmol 2008; 53:274-84. [DOI: 10.1016/j.survophthal.2008.02.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wise SK, Schlosser RJ. Evaluation of spontaneous nasal cerebrospinal fluid leaks. Curr Opin Otolaryngol Head Neck Surg 2007; 15:28-34. [PMID: 17211180 DOI: 10.1097/moo.0b013e328011bc76] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Spontaneous nasal cerebrospinal fluid (CSF) leaks represent a distinct clinical entity that presents important diagnostic and therapeutic challenges. Recognition of the proper demographic group and presenting symptoms, as well as the radiologic features of this disease process, are integral to making the appropriate diagnosis. In addition, this patient group requires special perioperative and intraoperative considerations for suitable management. RECENT FINDINGS Current literature echoes previously published success rates for endoscopic repair of CSF leaks at or above 90%. Success rates for closure of spontaneous CSF leaks, however, continue to be the lowest in comparison with other CSF leak etiologies. The increased failure rate for spontaneous CSF leak repair is likely due to the increased intracranial pressure present in this patient group. Patients with spontaneous CSF leaks are increasingly being recognized as belonging to a group inclusive of patients with benign intracranial hypertension and empty sella syndrome. SUMMARY In this review, we highlight the demographic characteristics, clinical presentation and radiologic findings that distinguish spontaneous nasal CSF leak patients from those with other CSF leak etiologies. We also discuss perioperative measures advocated for patients with spontaneous nasal CSF leaks that may aid in the success of their surgical repair.
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Affiliation(s)
- Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Kerr JT, Chu FWK, Bayles SW. Cerebrospinal Fluid Rhinorrhea: Diagnosis and Management. Otolaryngol Clin North Am 2005; 38:597-611. [PMID: 16005720 DOI: 10.1016/j.otc.2005.03.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Advances in imaging and endoscopic techniques have improved the ability to diagnose, localize, and treat in a less morbid fashion CSF leaks of the anterior skull base. An appreciation for the mechanism of leak and of the relationship between CSF production and absorption must be kept in mind when individualizing a repair. Increased CSF pressure caused by overproduction or underabsorption may result in persistence of a leak despite one's best efforts. Numerous advances in dural replacement grafts and tissue sealants have improved the ability to achieve watertight closure of the cranial vault. Microvascular techniques have allowed larger defects previously not reconstructable to be handled with relative ease by trained personnel. With expanded reconstructive techniques, the ability to handle larger disease processes of the skull base continues to expand.
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Affiliation(s)
- Julie T Kerr
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, WA, USA
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Abstract
Endoscopic sinus surgery has an impressive and continually im-proving safety record. Increasing surgical experience and improved techniques and equipment make this procedure fundamentally safe. Anatomic variations, extensive disease, and the tight confines that the sinuses occupy between the skull base and orbits, however, do allow the possibility of untoward events. Many of these complications are minor, but the potential for significant morbidity, including blindness, diplopia, cerebrospinal fluid fistula with or without meningitis, intracranial brain injury, and hemorrhage from internal carotid artery injury, is real. This article discusses the avoidance and management of these complications.
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Affiliation(s)
- Deborah Schnipper
- Department of Otolaryngology--Head and Neck Surgery, Boston University School of Medicine, 88 East Newton Street, D-616, Boston, MA 02118, USA
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Wax MK, Ramadan HH, Ortiz O, Wetmore SJ. Contemporary Management of Cerebrospinal Fluid Rhinorrhea. Otolaryngol Head Neck Surg 1997; 116:442-9. [PMID: 9141392 DOI: 10.1016/s0194-59989770292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.
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Affiliation(s)
- M K Wax
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown 26506-9200, USA
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Abstract
Eighteen consecutive patients with cerebrospinal fluid (CSF) rhinorrhoea investigated by computed tomographic cisternography (CTC) are reported and the literature is reviewed. Twenty-one CTC studies were performed without complications on nine patients presenting with spontaneous CSF rhinorrhoea, six with head injury and three who had undergone craniotomy. Two meningoceles and two encephaloceles were found in patients with spontaneous rhinorrhoea. The site of the CSF leak was identified in 17 examinations (81%) and verified at operation in 14 patients--no surgery was performed following two examinations--and in one the site of leakage was not identified at operation. No defect was identified in three (14.3%) examinations and in one the result was equivocal (4.7%). CTC is an accurate, well-tolerated procedure and should be regarded as the method of choice for investigation of this condition.
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Affiliation(s)
- I R Colquhoun
- Department of Radiology, Charing Cross Hospital, London
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Stewart BT, Kaye AH. Delayed cerebrospinal fluid rhinorrhoea: a case report. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1992; 62:818-20. [PMID: 1445065 DOI: 10.1111/j.1445-2197.1992.tb06927.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Post-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a well recognized complication of closed head injury. Most cases occur soon after injury and a delay in presentation of more than 1 month is unusual. A case is reported of CSF rhinorrhoea presenting 15 years after initial trauma which was complicated by meningitis after 12 months. The management of this condition is reviewed.
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Affiliation(s)
- B T Stewart
- Department of Neurosurgery, Royal Melbourne Hospital, Victoria, Australia
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Abstract
Non-traumatic 'spontaneous' CSF fistulae are uncommon. The clinical features of 23 patients treated for non-traumatic CSF fistulae are presented. Twenty of these patients had normal CSF pressure and six developed meningitis. Surgical repair of these fistulae is recommended in order to reduce the risk of meningitis. For this their localization is essential.
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Affiliation(s)
- M S Eljamel
- Mersey Regional Department of Neurosciences, Liverpool, UK
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Jeffery PJ, Sostre S, Scherer LR, Kasecamp W, Camargo EE. Bowel visualization during indium-111-labelled diethylene triamine penta-acetic acid cisternography due to massive cerebrospinal fluid leak. Case report and review of the literature. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1990; 17:365-8. [PMID: 2286209 DOI: 10.1007/bf01268028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We report a case of massive cerebrospinal fluid (CSF) leakage where the tracer injected intra-thecally for radionuclide cisternography was later visualized in the bowel as well as the nasopharynx. We discuss the potential implications of this finding in patients with CSF leaks. A brief review of the diagnosis of CSF leaks is included.
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Affiliation(s)
- P J Jeffery
- Division of Nuclear Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21205
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