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 »  Case report
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Year : 1999  |  Volume : 47  |  Issue : 1  |  Page : 65-7

CSF orbitorrhoea with tension pneumocephalus.


Department of Neurosurgery, Nizam's Institute of Medical Sciences Panjagutta, Hyderabad, Andhra Pradesh, 500482, India.

Correspondence Address:
Department of Neurosurgery, Nizam's Institute of Medical Sciences Panjagutta, Hyderabad, Andhra Pradesh, 500482, India.

  »  Abstract

A seventy eight year old man sustained penetrating injury to right orbit about 15 years ago. Later he developed right orbital infection leading to phthisis bulbi. Two months before admission he developed CSF leak from the right orbit, tension pneumocephalous and meningitis. A rare case of CSF orbitorrhoea is reported here along with the discussion on mechanisms and management.

How to cite this article:
Rao T N, Purohit A K, Dilnawaz, Murthy T V, Dinakar I. CSF orbitorrhoea with tension pneumocephalus. Neurol India 1999;47:65


How to cite this URL:
Rao T N, Purohit A K, Dilnawaz, Murthy T V, Dinakar I. CSF orbitorrhoea with tension pneumocephalus. Neurol India [serial online] 1999 [cited 2019 Mar 26];47:65. Available from: http://www.neurologyindia.com/text.asp?1999/47/1/65/1656




   »   Introduction Top


Injury to orbit with direct injury or indirect involvement of the cranial cavity is an extremely serious condition due to the potential danger of death or disability. The complications of the injury may be immediate or delayed. They may manifest as tension pneumocephalous, intracerebral haematomas, cranial nerve injuries, infections like meningitis or abscess, carotido-cavernous fistula and traumatic aneurysms.[1] Here we present a case of tension pneumocephalous, meningitis and CSF orbitorrhoea in a patient who sustained penetrating injury of the orbit 15 years ago. Only a few cases have been reported in the literature.[2] Possible mechanisms of CSF orbitorrhoea are discussed.


   »   Case report Top


A seventy eight year old man, not a know diabetic or hypertensive, presented with history of intermittent sanguinopurulent discharge from right eye of two years duration, excessive discharge of water like fluid from right eye of two months duration and altered sensorium, vomitings and intermittent fever of five days duration. There was history of injury to right eye with sharp wooden object while working in the fields 15 years ago. Subsequently within a span of few months he developed corneal opacification and diminution of vision and shrinkage of the eyeball. There was no history of chronic headache and seizures or weakness of limbs. There was also no history of tuberculosis or supportive otitis media.

General physical examination revealed right sided phthisis bulbi and leak of water like fluid from lateral canthus of the right eye. Neurological examination revealed altered sensorium. He had spontaneous eye opening, localization of pain and no verbalization. He had meningeal signs but no other focal deficits. Haematological examination showed total white cell count of 14,000/cumm with polymorphonuclear predominance. ESR was 45mm in 1st hour. Biochemical parameters were within normal limits. Orbital fluid analysis showed total cell count of 867 cells /cumm with 75% polymorphs and 25% lymphocytes; Sugar-30mg/dl, Proteins- 217mg/dl, Grams stain showed no organism and pus cells, the culture was sterile.

Plain X-ray of skull revealed pneumocephalous. Plain and contrast CT scan of head and orbit, revealed air in the right orbit which was in continuity with subarachnoid space. The cisterns and ventricles were full of air and were under tension [Figure 1],[Figure 2]. Two frontal burrholes, one on each side, were made and the air was evacuated. Two ventricular reservoirs were placed one in each ventricle through these burrholes. Ventricular CSF analysis showed the total cell count of 51 WBC with 55% neutrophils and 45% lymphocytes, 11 mg/dl sugar and 156mg/dl protein. Grams stain showed a few pus cells and no organism. The culture was sterile. Patient was put on antibiotics. He showed gradual improvement in general condition and sensorium. But CSF leak persisted and a defintive surgery was contemplated. However, it could not be performed because patient left against medical advice.


   »   Discussion Top


CSF leak from ear or nose is a common problem in neurosurgical practice. But CSF orbitorrhoea is a rare entity. The CSF orbitorrhoea due to penetrating transorbital injury with CSF leak was first reported by Ide and Webb in 1971.[2] The term penumatocoele was proposed in 1866 by Chevance Dewossy to define on extracranial collection of gas.[3] The principle of closing a dural defect was first proposed by Grant in 1923.[4]

Traumatic CSF orbitorrhoea develops following extensive orbito-cranial injuries which are caused by road traffic accidents or penetrating injuries. These potentially devastating intracranial injuries may go undetected by physicians despite careful neurological, orbital and roentgenographic examinations. Leakage of CSF may be obscured by bleeding or over shadowed by severe ocular injury.[1] The fundamental cause of CSF leak is a breach in the meninges which permit the escape of CSF from the subarachnoid space to extradural space.[5] The possible mechanisms of developing CSF leak from orbit were unclear. There should be communication between intracranial cavity and orbit via fracture of roof or medial wall of orbit. Roof fractures are usually associated with dural tears with intact conjunctiva. Conjunctival discontinuity is mandatory for the development of CSF orbitorrhoea. CSF leak may occur through cribriform plate and via ethmoids to the medial wall of orbit. Some times it may leak via optic canal when the arachnoid layer is damaged along with orbital roof and apex injury.[1],[6]
Any severe penetrating injury of the orbit may lead to a) chronic infection of orbit resulting in panophthalmitis. If an osteomyelitis of orbital cavity results, it may form a fistula with subarachnoid space by bonny erosion, b) another possible explanation is that deep orbitocranial penetrating injury may extend through the frontal lobe into the ventricular system. This results in CSF leak from ventricle to sub arachnoid space and/or then to extradural space and orbit via the fracture site; and external leak from the breach in the conjuctiva. All these possible mechanisms are hypotheses only.

Iatrogenic CSF leak from orbit may be possible after intra orbital surgery which opens up subarachnoid space. It is an infrequent complication of orbital surgery.[7] The CSF fistula can cause direct communications between brain and the outside atmosphere, resulting into complications like fulminating meningitis, brain abscess and tension pneumocephalus. A direct deep penetrating injury itself can cause injury to cavernous sinus, cranial nerves, optic and oculomotor nerve and intracerebral haematomas.

CSF leak from orbit simulates tears. In such cases watery discharge from the eye should be differentiated from CSF by biochemical analysis of collected fluid. Lewis was the first to note presence of glucose in CSF but the nasal secretion and lacrimal fluid can both contain glucose, hence the glucose oxidase test is only helpful if it is negative. Collected fluid must show more than 30mg/dl of sugar to be labelled as CSF.[2],[5],[8] Detection of B2 transferrine in the secretion by immunoelectrophoresis is the most reliable method of diagnosing CSF leak, since the enzyme is pathognomonic for CSF.[9] Pulsating CSF leak with ball valve mechanism causes the trapping of air intracranially resulting in tension pneumocephalous which needs emergency decompression.[1]

CT scan is very useful in the detection of injuries with intracranial penetration. A CT scan can detect as less as 0.5ml of air, whereas in conventional roentgenographic studies a larger quantities of air is necessary and the patient has to be put in special positions. There are many procedures for localisaiton of CSF fistula. The CT metrizamide cisternography is a very sensitive investigation to demonstrate CSF fistula.

The primary aim of treatment is to seal the breach in dura.[10] The successful operative repair of CSF fistula causing rhinorrhoea was first reported by Dandy in 1926.[4] The available surgical procedures involve either extracranial or intracranial approaches. Some dural fistulas close spontaneously over a period of days. Hence, patient should be treated conservatively with antibiotics, diuretics and anticonvulsants. The intracranial intradural approach is recommended for most traumatic and non traumatic CSF fistulas with careful patching of the defect, preferably with autologus, pericranium or fascia lata. Tension pneumocephalous warrants emergency decompression.

In the present case, the pneumocephalous was relieved by evacuation of air through bifrontal burrholes and placement of reservoirs [Figure 3]. Patient was treated with anticonvulsants and antibiotics. The patient gradually improved. The authors contemplated the definitive surgery in the form of enucleation of orbit and repair of fistula by intracranial approach, but the patient left against advice. This case is reported here to give a message that any severe orbito-cranial penetrating injury requires careful evaluation by CT scan and regular followup to tackle its complications early.

 

  »   References Top

1.Wesley RE and Mc Cord CD : Tension pneumocephalous from orbital roof fractures. Ann Ophthatmology 1982; 14 : 184-190.  Back to cited text no. 1    
2.lde CH and Webb RW : Penetrating trans-orbital injury with cerebrospinal orbitorrhoea. Am J Ophthalmol 1971; 71 :1037-39.  Back to cited text no. 2    
3.Mosely JI, Calcaterra TC and Rand RW : Cerebrospinal fluid leak In : Microneurosurgery, Rand RW (Ed). The C.V.Mosby company, Missouri 1978; 140-155.  Back to cited text no. 3    
4.Spetzer RF and Zabramski JM : CSF Fistulae : Their management and repair In : Neurological Surgery, (Ed). Youmans JR : WB.Saunders company Philadelphia 1990; 2227-2286.  Back to cited text no. 4    
5.Ommaya AK : Cerebrospinal Fluid Fistula In : Neurosurgery,: Wilkins RH and Rengachary SS (Eds.) McGraw-Hill Book Company. New york 1985; 16371647.  Back to cited text no. 5    
6.Joshi KK and Crockard HA : Traumatic Cerebrospinal fluid fistula simulating tears. J Neurosurg 1978; 49 : 121-123.  Back to cited text no. 6    
7.David T.Tse, Panje WR, Anderson Rl : Cyanocrylate adhesive used to stop CSF leaks during orbital surgery. Arch Ophthalmol 1984; 102 : 1337-1339.  Back to cited text no. 7    
8.Flanagan JC, MC Lachian DL, Shannon GM : Orbital roof fractures. Ophthalmology l980; 87 : 325-329.  Back to cited text no. 8    
9.Meurman OH, lrjala K, Suonpaa J, Laurent B : A new method for the identification of CSF leak. Acta Otolaryingologica 1979; 87 : 366-369.  Back to cited text no. 9    
10.Cantore GP, Defini R, Ganbacorta D, Consorti P : Cranioorbitofacial injuries, Technical suggestions. J Trauma 1979; 19 : 370-375.  Back to cited text no. 10    

 

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