Understanding CSF Rhinorrhea and Its Etiology
Cerebrospinal fluid (CSF) rhinorrhea is caused by an osseous defect at the skull base, leading to a leak due to disruption of the dura mater and arachnoid. Trauma and iatrogenic factors are common causes, with non-traumatic cases often linked to high-pressure leaks or tumor growth. Diagnosis involves a thorough work-up including history, physical examination, and nasal endoscopy. Treatment varies based on the underlying etiology. Understanding the mechanisms and etiology of CSF rhinorrhea is essential for effective management.
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CSF Constituents CSF consists of a mixture of : Water Electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-) Glucose (60-80% of blood glucose) Amino acids, and various proteins (22-38 mg/dL) It is colorless & clear Devoid of cells such as polymorphonuclear cells and mononuclear cells (< 5/ L).
CSF Production CSF is produced by choroid plexus (50 to 80%) at a rate of approximately 20 mL/h (500 mL daily). At any given time, approximately 90-150 mL of CSF is circulating throughout the CNS. Normal CSF pressure is 10-15 mm Hg
CSF rhinorrhea Result of an osseous defect at the skull base coupled with a disruption of the dura mater and arachnoid with a resultant pressure gradient that leads to a CSF leak.
Etiology: Trauma Most common area - anterior cranial fossa: (cribiform and roof of ethmoid) Iatrogenic: Endoscopic sinus surgery most common cause
Etiology Non-traumatic High Pressure Leaks Tumor growth (typically pituitary tumors) Hydrocephalus
Etiology Non-traumatic Normal Pressure Leaks: 55% of non-traumatic cases Tumors and other osteolytic causes Tumors invade and erode skull base: Nasopharyngeal carcinoma, angiofibroma, inverting papilloma, osteomas Other osteolytic lesions Sinusitis Syphilis Mucoceles
Work-up History Physical Nasal endoscopy Have patient lean forward and strain may elicit a leak Compression of both jugular veins may elicit a CSF leak Clear, watery discharge from a single nare Supine positioning -> increased postnasal drip Salty taste in mouth Headaches relieved when CSF begins to drain
