Cure in a Case of Cerebrospinal Rhinorrhea

Abstract

The case in question is of twofold interest, first because of its occurrence during the course of a cold, and second because of the simplicity of treatment which resulted in an apparent cure. REPORT OF CASE Miss B. L., aged 33, gave the following history : In the early part of March, 1930, she contracted what appeared to be an ordinary cold in the head, of possibly a little more severity than she had ever previously had. Especially prominent were the symptoms of sneezing and nasal discharge. No headache had ever been present. The cold lasted for about two weeks, but she noted that after all other symptoms had subsided, a clear fluid continued to drip from her left nostril, particularly when she bent her head forward. The nasal drip had been present for about four weeks when the patient was first examined. Nasal examination gave entirely negative results, all of the changes from the previous cold having disappeared. However, a clear watery fluid was found to be dripping from the nose, so that a 20 cc. test tube was easily filled in about thirty minutes. This fluid was clear, having a specific gravity of 1,008. When acetic acid was added, no precipitate appeared. Boiling failed to produce a coagulum, but the addition of magnesium sulphate to the point of saturation caused precipitation. The addition of nitric acid caused a precipitate to form, which disappeared when the solution was boiled. With a trace of copper sulphate and excess of potassium hydroxide, the solution turned pink. When boiled with Fehling's solution, a reduction occurred.In order further to ascertain the character of the fluid, 5 cc. of 0.6 per cent indigo carmine was injected into the spinal canal. A bluish-green coloration of the nasal drip appeared after fifteen minutes and continued for about five hours. Nasal examination made at this time revealed that the colored material was dripping over the lateral wall of the left nasal cavity in the region of the carina and the agger areas. It was assumed that the separation in continuity of the cribriform plate had occurred anteriorly, where it might be easily accessible to intranasal treatment. In seeking an etiologic factor, several stereoscopic plates, both in the lateral and in the anteroposterior positions, were taken, but appeared negative. The eyegrounds and visual fields appeared normal. The obesity of the patient suggested hypophyseal disease, but no evidence of this had occurred. An attempt was made to set up a fibrosis in the area involved, which might result in occlusion of the separation, so the roof of the nose was swabbed every two weeks with a 20 per cent solution of silver nitrate. After six applications fibrous bands began to appear, and the discharge diminished until it entirely stopped, four months after treatment was begun. It has remained dry for eighteen months. The patient is apparently cured, without either nasal or intracranial symptoms.

Neuroendoscopic Transnasal Repair of Cerebrospinal Fluid Rhinorrhea

“…Various dyes like methylene blue, phenolsulfonphthalein, indigo carmine, and fluorescein have been used to demonstrate the osculum of the fistula. 23,24 Fluorescein is still in use but is not preferred because it is associated with complications like transverse myelitis and allergic reactions. 25 The Valsalva maneuver has been used to detect ambiguous sites of leakage in CSF rhinorrhea.…”

Cerebrospinal Fluid Rhinorrhoea in Pituitary Tumours

“…Localization of the site of the fistula can be difficult and many methods have been described (Fox 1933, Crow et al 1956, Kirchner & Proud 1960, Teng & Edalatpour 1963, Jungmann & Peyser 1963,Sinanan et al 1966.Radioactive iodinated serum albumen (RISA) cisternography is said to give good results (Di Chiro & Grove 1966, Ommaya et al 1968, Jacobson & Maran 1971, but has been superseded by indium (In l l l ) calcium OTPA injection (Hosain & Som 1972).The photon yield of RISA is low and there is a high incidence of febrile reactions. In II t is produced carrier free on the cyclotron and emits gamma radiation of 171 and 245 kev.…”

“…The leak has in some cases immediately followed an upper respiratory infection (Fox 1933, Wessels 1939) and in two hyperostosis frontalis interna was noted, although this may have been a coincidental finding (Titche 1941,Ameriso 1942. O'Connell (1964) described 2 cases and Ommaya et al (1968) found 4 patients out of a total of 19 with CSF rhinorrhoea, 3 of whom had leaks in the sella area and one through the cribriform plate.…”

The Utility of Computed Tomography and Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leak

“…In 1960, Kirchner and Proud reported a new method for the identification of CSF fistulae using intrathecal fluorescein (IF). 4,5 Since this initial description, IF has become commonly utilized in localization of CSF rhinorrhea. Despite its frequent use, IF lacks Food and Drug Administration (FDA) approval and requires additional consent for off-label usage.…”