Clinical and Endoscopic Findings
Unilateral/bilateral watery persistent or intermittent rhinorrhea, a previous history of head trauma or surgery on the sinonasal tract, middle ear/mastoid or skull base, and recurrent meningitis are the clinical findings which should alert the physician to the diagnosis of CSF leak.
Nasal discharge usually increases or may be elicited by maneuvers elevating CSF pressure (i.e., compression of the internal jugular veins, Valsalva maneuver). In case of a leak through the temporal bone, CSF reaches the nasopharynx via the Eustachian tube and becomes evident in most cases as bilateral clear rhinorrhea. The onset of CSF rhinorrhea after trauma occurs within the first 48 h in 80% of patients, whereas 95% will present within 3 months of the accident. The so-called "reservoir sign" is a peculiar finding which is particularly suggestive for the presence of a CSF fistula: CSF tends to accumulate in the sphenoid sinus while the patient is recumbent, and remains in the sinus until the patient resumes the erect position and the head is leaned forward. At that moment, the fluid exits the sphenoid ostium and sudden profuse rhinorrhea becomes evident (Nuss and Costantino 1995).
Patients with intermittent CSF leak frequently complain of headache, which appears whenever rhinorrhea stops and CSF pressure increases (Beckhardt et al. 1991). Symptoms and signs such as headache, vomit, or edema of the papilla are suggestive for intracranial hypertension. If CSF leak is secondary to a neoplasm of the sinonasal tract invading the skull base, nasal obstruction, mucous rhinorrhea, epistaxis, visual impairment, and alterations of eye motility may be present. Both intracra-nial neoplasms and lesions involving the skull base from adjacent sites may cause neurologic signs and symptoms.
In case of a cephalocele, signs and symptoms depend on its location. Transethmoidal cephaloceles herniate into the nasal cavity and may be characterized by unilateral nasal obstruction; less frequently, this is the heralding symptom of transsphenoidal encephaloceles. Endoscopic evaluation may reveal a smooth isolated polypoid mass coming from the olfactory fossa (Fig. 7.1) or sphenoid sinus. In this setting, removal or biopsy of the lesion is contrain-dicated unless appropriate radiologic evaluation has been obtained. Fronto-ethmoidal and spheno-orbital cephaloceles herniate into the soft tissues of the nose region and of the orbit(s), respectively, and are characterized by swelling, proptosis, and hypertelorism. In these cases, an association with facial deformities and cleft palate is frequently observed (MahapatrA and Suri 2002).
In a patient with persistent CSF leak, rarely nasal endoscopy identifies the site of CSF leakage. Watery rhinorrhea and mucosal bulging at the olfactory fossa is the most favorable situation suggesting a CSF leak coming from a cephalocele. An unexpected sinonasal neoplasm can also be detected by endoscopy.
Recurrent meningitis, even in the absence of rhi-norrhea, should raise a suspicion of CSF leak. The prevalence of meningitis and brain abscess is reported to be up to 40% in traumatic non-intermittent fistulae, whereas their incidence greatly varies in spontaneous leaks (Beckhardt et al. 1991; EljameL 1994; Wax et al. 1997).
Fig. 7.1. Meningocele of the left nasal fossa. Endoscopic evaluation with a 0°-angled rigid endoscope: an isolated bluish polypoid mass (P) projecting from the left olfactory fossa is visible. Nasal septum, NS; middle turbinate, MT
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