[JM MY test]CSF rhinorrhea is rare, but real

Cerebrospinal fluid (CSF) rhinorrhea is an uncommon, but possible, finding in the clinical setting. Therefore, always keep it in mind as a possible diagnosis, says an expert.

The majority of CSF rhinorrhea cases are caused by accidental trauma, said Dr. Ashwamedsing Dinassing, a consultant ear, nose and throat (ENT) surgeon from Mauritius. Another etiology is non-traumatic causes ie, hydrocephalus, congenital anomalies and intracranial neoplasms. Dinassing said procedure-related etiology makes up for 16 percent of CSF rhinorrhea cases. This number can be reduced if doctors are more careful when performing facial procedures. Prior to a surgery, a computed tomography (CT) scan should be done and the depth of the olfactory fossa measured carefully using the Keros classification, he added.

Another example of a situation where doctors have to exercise extra care is when examining a polypoidal mass in the nasal region. This polypoidal mass might be accompanied by CSF discharge, hence an imaging study should be done prior to biopsy, said Dinassing.

Discussing his experience in managing a patient with CSF rhinorrhea, he said a diagnosis should be suspected in those with unilateral watery nasal discharge which tastes salty, has positional variation and history of single or multiple episodes of meningitis. Other symptoms that may occur include weight loss, headache and presence of inflammatory peripheral nervous system disease.

To diagnose a CSF leak, the beta-2-transferrin assay is the gold standard. Beta-2-transferrin is a protein found only in the perilymph and CSF. Besides this assay, other examinations that can be used to confirm diagnosis of CSF include high-resolution CT (HRCT) scan to localize the defect site in the skull base and magnetic resonance imaging (MRI) of soft tissues.

Dinassing said patient management is a multi-disciplinary effort and should optimally include an otorhinolaryngologist, neurosurgeon, neuroradiologist and infectious disease specialist.

In CSF rhinorrhea due to trauma, conservative therapy is the common treatment practiced. This therapy consists of strict bed rest, head elevation, stool softeners and subarachnoid drainage through lumbar catheter. The patient will also be advised to refrain from blowing his nose, sneezing, straining and coughing, said Dinassing.