XX Observations on Cerebrospinal Fluid Rhinorrhea and Pneumocephalus

Abstract

Cerebrospinal fluid rhinorrhea was first reported in 1826, by James Miller of Edinburgh, Scotland." It is not uncommon and should be recognized more frequently, since Lewin" found that 2 per cent had this complication in a survey of 1,000 consecutive cases of head injury admitted to hospital.Cairns" listed the following major causes of cerebrospinal fluid rhinorrhea: 1) those that occur in the acute stage of head injury; 2) those that occur as delayed complication of head injury; 3) those produced during operation on the cranium, or accessory sinuses; 4) spontaneous cases of cerebrospinal fluid rhinorrhea.Ommaya*" has attempted to simplify the classification into two major groups: 1) traumatic, may be acute or delayed; 2) non-trau matic, due to tumors, hydrocephalus, infection, congenital anomalies, and "cerebrospinal fluid blow-out following sneezing" with the latter two conditions probably related. The rarer, nontraumatic group correlates with the classification of O'ConnelF® who recognized two sub groups: 1) secondary, in which the leak resulted from a gross lesion producing erosion of the cranial floor, e.g., osteoma of nasal From the Departments of Neurology, Wayne State University, Receiving and Harper Hospitals of Detroit and from the Wayne Center for Cerebrovascular Re search. This work was supported by grants from the Receiving Hospital Research Corporation and the USPHS. at DALHOUSIE UNIV on June 26, 2015 aor.sagepub.com Downloaded from 216 GOTHAM ET AL.sinus, intracranial neoplasm or internal hydrocephalus; 2) primary, in which no cause could be found. PNEUMOCEPHALUS OR CRANIAL PNEUMATOCELEThe association of cerebrospinal fluid rhinorrhea with air in the ventricular system, or in the brain substance, may give rise to second ary neurological signs and is known as pneumocephalus, or cranial pneumatocele. Chiari (1884) first described this condition in a case he autopsied." He located a fistula from an ethmoid air cell into a cavity of the frontal lobe and explained the passage of air due to the pressure of sneezing. Luckett,'" 1913, was the first to detect air by roentgenography in the ventricles, following a fracture of the skull.Dandy" collected 28 cases of pneumocephalus that had been reported up to 1928 (including 3 cases of his own), and stressed the occurrence of increased intracranial pressure on the production of neurologic symptoms. He was of the opinion that irritation by the air resulted in the production of serosanguineous cerebrospinal fluid edema of the brain and increased intracranial pressure. He found that death was due to two factors: 1) increased intracranial pressure and, 2) infection from a compound wound. At that time, before antibiotics were available, the mortality was around 40% in untreated cases.The present report summarizes our experience with 14 cases of cerebrospinal fluid rhinorrhea, including one case of pneumocephalus, and discusses newer methods of clinical investigation, diagnosis and treatment. CLINICAL INVESTIGATIONThe etiology, clinical features and treatment of cere...

Non-traumatic cerebrospinal fluid rhinorrhoea.

“…It is significant that in all three of these indirect rhinorrhoeas the fistula was in the cribiform plate; an indication of the fragility of this area. Previous reports on tumour-induced cerebrospinal fluid rhinorrhcea (Teng and Papatheodorou, 1965;Raskind, 1965;Gotham, Meyer, Gilroy, and Bauer, 1965) have emphasized that pituitary tumours are the commonest lesion and in our series of 10 patients with high pressure leaks there were four cases (Cases 9, 13, 14, and 15 in Table III). It should be stressed that cerebrospinal fluid rhinorrhoea is an extremely rare complication of such tumours.…”

“…Similarly x-ray therapy to the site of the fistula is of no value. Instillation of substances nasally to promote closure of the fistula from below-for example, silver nitrate-has not been successful, but a recent cure of a cerebrospinal fluid rhinorrheea has been reported following the application of Eastman 9-10 glue to the roof of the ethmoid sinus (Gotham et al, 1965). It is often recommended that following the identification of cerebrospinal fluid in a rhinorrhoea, expectant treatment, including nursing in a semi-Fowler position, discouragement of nose blowing, sneezing and straining, and antibiotic administration, be tried for six to eight weeks before surgery is considered.…”

Efficiency of Various Methods of Identifying Cerebrospinal Fluid in Oto- and Rhinorrhea

“…Bracewell [2], Breuninger [4], Gotham et al (11), Keller [15], Rollin [34], maintained that it was possible to differentiate with a high degree of certainty between cerebrospinal fluid (CSF) and rhinorrhea and nasal secretion. These statements only apply when fluid secretion is sufficient and.…”

Die Diagnose der Rhinoliquorrhoe mit dem 131J-Hippuran-Tupfertest

“…In den letzten Jahren wurden mehr und mehr radioaktive Isotopen zum Nachweis und zur Lokalisation von Liquorfisteln empfohlen mit anschließender Impulsratenmessung der in die Nase oder Ohren eingelegten Tampons. Verwendung finden 2 4 Na(20), 1 3 1 J-RISHA (49), radiojodiertes Humanalbumin (25,26,36,37) und 131 J-Hippuran (57). Der Liquoraustritt kann mit Hilfe der radiomarkierten Substanzen auch szintigraphisch dargestellt werden (25,29,54).…”