Journal of Otolaryngology and Ophthalmology, Shandong University:2007,21(2)
Advances in the treatment of cerebrospinal fluid nasal leakage
Reviewed by Chunmei Tu, Reviewed by Xiaolan Cai
(Department of Otorhinolaryngology and Head and Neck Surgery, Qilu Hospital, Shandong University, Jinan 250012, Shandong, China)
[Abstract] Early symptoms of cerebrospinal fluid rhinorrhea are often not obvious, but its complications have serious effects on patients. This study reviewed and summarized the early symptom characteristics, clinical diagnosis and differentiation techniques, treatment experience and perioperative related issues in patients with cerebrospinal fluid rhinorrhea, in order to provide a basis for further research progress of the disease. Cai Xiaolan, Department of Otolaryngology, Qilu Hospital, Shandong University
[Keywords] Cerebrospinal fluid rhinorrhea; localization and diagnosis; endoscopy
With the development of transportation facilities and the increase of traffic accidents, cerebrospinal fluid rhinorrhea, in which trauma is the main causative factor, is on the rise in clinical diseases. Cerebrospinal fluid rhinorrhea is formed when a defect of the skull and meninges causes communication between the subarachnoid space and the nasal cavity or sinuses. The main danger is that it can lead to intracranial infections, pneumocephalus and other complications, which can endanger the patient’s life. How to detect the presence of this disease early, accurately locate the fistula and provide timely and effective treatment has been the subject of exploration by neurosurgeons and otorhinolaryngologists. With the continuous maturation of nasal endoscopy technology, nasal endoscopic treatment of cerebrospinal fluid rhinorrhea has become one of the important research contents for otolaryngology and head and neck surgeons. The progress of treatment of cerebrospinal fluid rhinorrhea in otorhinolaryngology and head and neck surgery in recent years is now analyzed.
1. Application of anatomy and classification
1.1 According to the anatomical location and the location of the sinus opening, the sinuses are divided into two groups: the anterior group includes the maxillary sinus, the anterior septal sinus and the frontal sinus, and the sinus opening is located in the middle nasal tract; the posterior group includes the posterior septal sinus and the pterygoid sinus, and the sinus opening is located in the upper nasal tract and the pterygoid septal fossa above it respectively. Of these, the septal sinus occupies an important position in complex cerebrospinal fluid rhinorrhea because it is located between the anterior skull base, the orbit, and the nasal cavity, and is adjacent to the frontal, maxillary, and pterygoid sinuses. The external septal sinus is adjacent to the orbit; the upper part of the inner wall is attached to the superior and middle turbinates; the parietal wall, the medial part of the frontal orbital plate, and the medial part of the orbital plate is adjacent to the septal sieve plate; the anterior wall is adjacent to the maxillary frontal process and the frontal sinus; and the posterior wall is the pterygoid sieve plate, adjacent to the pterygoid sinus. The septal sinus baseplate continues posteriorly and inferiorly from the septal roof to the septal sinus floor, and the anterior and posterior septal sinuses are separated anteriorly and posteriorly above the baseplate, respectively. The baseplate is connected to the middle turbinate medially, and the front end of the connection is the connection between the parietal wall of the sieve sinus and the sieve plate, which is thin and porous, and is easily fractured by external forces.
1.2 Classification of cerebrospinal fluid nasal leakage In 1968, Ommaya divided cerebrospinal fluid nasal leakage into two categories: traumatic and non-traumatic, which was further supplemented in 1976 and is now clinically accepted.
Among the various types of cerebrospinal fluid nasal leaks, traumatic cases are the most common. 50% or more develop within 48 h and 90% within 1 month. In a few cases, cerebrospinal fluid nasal leakage can occur several years or even longer after the injury, in which the sieve plate of the septum and the posterior wall of the frontal sinus are very thin and most likely to rupture during trauma. Fractures of the base of the middle fossa of the skull can damage the wall above the pterygoid sinus and lead to cerebrospinal fluid nasal leakage. Cerebrospinal fluid leakage from a fracture of the middle ear mastoid skull or the bony part of the eustachian tube can flow to the nasal cavity via the eustachian tube, which is then called cerebrospinal fluid auricular-nasal leakage. Medically induced injuries are mainly seen after transsphenoidal pituitary tumor or sinus surgery, but postoperative radiotherapy is also a cause of medically induced cerebrospinal fluid nasal leakage, because radiotherapy can cause local dural dystrophy, atrophy, and decrease in biomechanical properties, which can lead to rupture and nasal leakage under other triggers. Rhinorrhea can also occur after surgery for anterior skull base tumors if they are not handled properly. The pathological mechanism of nasal leakage due to benign intracranial pressure increase is not clear, but it may be due to chronic cerebrospinal fluid pressure increase, which causes cerebrospinal fluid pulsation wave to act on the fragile sieve plate and arachnoid membrane around the olfactory filament, resulting in a rupture of the arachnoid membrane and the flow of cerebrospinal fluid into the nasal cavity along the olfactory filament.
2 . Clinical manifestations
The most common manifestation of cerebrospinal fluid nasal leakage is continuous or intermittent flow of clear liquid from one or both nostrils, which does not crust after drying, and the symptoms are aggravated when the head position is tilted to one side, head is lowered or the jugular vein is compressed; or the leakage is less frequent, but the pillow is found to be moist in the morning. There are also nasal leakage symptoms that are not obvious and only show the corresponding symptoms of recurrent intracranial bacterial infections (purulent bacterial meningitis, etc.). Intracranial infections occur in 15%-25% of traumatic cerebrospinal fluid rhinorrhea. The onset is usually after craniocerebral trauma, surgery or paranasal sinus surgery, while a few patients have only a history of minor craniocerebral trauma or nasal leakage after sneezing.
3. Diagnosis and differential diagnosis
3.1 Qualitative diagnosis is based on the above clinical manifestations of the patient, combined with the history of craniocerebral trauma, surgery or other precipitating factors, which means that the disease should be highly suspected. Before making clinical diagnosis, it should be differentiated from allergic rhinitis and sinusitis. The quantitative determination of glucose in nasal leaks exceeding 30 mg/L is an important basis for the diagnosis of cerebrospinal fluid rhinorrhea. Recently, some scholars believe that there is a certain false-positive rate in the quantitative test of sugar in the leakage fluid, and propose the qualitative electrophoretic determination of desialic acid transferrin in the leakage fluid, which exists in the cerebrospinal fluid and is absent in the serum and nasal secretions, and both false-positive and false-negative nasal leakage tests are rare, and only a small amount of leakage fluid is required (