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Emergency: requires immediate attention
Cerebrospinal fluid rhinorrhea
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Emergency: requires immediate attention

Cerebrospinal fluid rhinorrhea

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Contributors: Rachel Yestrebi, Abberly Lott-Limbach MD, Paul C. Bryson MD, Richard L. Barbano MD, PhD
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Synopsis

Cerebrospinal fluid (CSF) rhinorrhea is the result of one or more skull base defects permitting direct communication between the CSF-containing subarachnoid space and the paranasal sinuses. The vast majority of cases are thought to occur as the direct result of either accidental or iatrogenic trauma, the latter usually in the setting of rhinologic or neurosurgical procedures. Nontraumatic CSF rhinorrhea accounts for about 4%-5% of cases overall and is attributable to a variety of conditions linked to either intracranial hypertension (eg, obstructive hydrocephalus, intracranial mass) or direct erosion of the skull base (eg, osteomyelitis, sinonasal neoplasm). Most cases of so-called "spontaneous" CSF rhinorrhea are associated with abnormally elevated intracranial pressure (ICP) and occur in obese, middle-aged women.

CSF fistulae provide a route of intracranial access for a variety of microorganisms and are an important risk factor for ascending infection, with complication by bacterial meningitis accounting for the majority of morbidity in patients with active CSF rhinorrhea at an estimated annual risk of approximately 10%. Less frequently, larger skull base defects can lead to meningoencephalocele and/or pneumocephalus and secondary brain compression.

Codes

ICD10CM:
G96.0 – Cerebrospinal fluid leak

SNOMEDCT:
85638002 – Cerebrospinal fluid rhinorrhea

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Common rhinopathies (eg, seasonal allergic rhinitis, vasomotor rhinitis) – Present with associated signs and symptoms of mucosal congestion; rhinorrhea is usually bilateral.
  • CSF otorhinorrhea – There will be ipsilateral middle ear effusion.
  • Retained sinonasal irrigation fluid
Potential pitfalls:
  • Because many CSF leaks are intermittent, failure to reproduce CSF rhinorrhea in the office does not rule out the diagnosis, particularly when the history is otherwise strongly suggestive.
  • A CSF fistula may mask underlying intracranial hypertension by virtue of acting as a release value that decompresses the subarachnoid space. As such, normal opening pressure by lumbar puncture in a patient with active CSF rhinorrhea cannot reliably exclude elevated ICP as an etiological factor.

Best Tests

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Management Pearls

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Therapy

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References

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Last Reviewed: 05/07/2019
Last Updated: 05/07/2019
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Emergency: requires immediate attention
Cerebrospinal fluid rhinorrhea
Print 1 Images
Cerebrospinal fluid rhinorrhea : Hyposmia
Copyright © 2019 VisualDx®. All rights reserved.