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 »  Introduction
 »  Case reports
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Year : 1999  |  Volume : 47  |  Issue : 2  |  Page : 152-4

CSF rhinorrhoea from unusual site : report of two cases.


Departments of Neurosurgery and Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, 29, India.

Correspondence Address:
Departments of Neurosurgery and Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, 29, India.

  »  Abstract

CSF rhinorrhoea is associated with high morbidity and mortality. Bone and dural defects may result from trauma or enlarging 'pitholes' or breach in lateral recess of sphenoid sinus. Unless surgically corrected, they tend to cause meningitis and rhinorrhoea. Unusually delayed rhinorrhoea is a diagnostic problem.

How to cite this article:
Devi B I, Panigrahi M K, Shenoy S, Vajramani G, Das B S, Jayakumar P N. CSF rhinorrhoea from unusual site : report of two cases. Neurol India 1999;47:152


How to cite this URL:
Devi B I, Panigrahi M K, Shenoy S, Vajramani G, Das B S, Jayakumar P N. CSF rhinorrhoea from unusual site : report of two cases. Neurol India [serial online] 1999 [cited 2020 Aug 7];47:152. Available from: http://www.neurologyindia.com/text.asp?1999/47/2/152/1631




   »   Introduction Top


The morbidity and mortality from cerebrospinal fistulas (CSF fistula) either from nontraumatic or traumatic origin is high, unless diagnosed and treated early. A trivial head trauma is usually forgotten. The interval between the accident and the onset of fistula or the complications may be long enough to be thought of as incidental trauma. We present two unusual cases where the attention was drawn to the CSF fistula only after meningitis. Both patients had bone and dural defects at unusual sites.


   »   Case reports Top


1. A 45 year old man presented with thin watery discharge, more after overnight rest, for the previous two years. Twenty years ago he fell down from a mobike and hit his forehead against the handle bar. Two months prior to presentation at our centre he was admitted and treated elsewhere for meningitis. His general physical examination was unremarkable except for occasional drops of clear watery discharge from nostril, which was positive for sugar. Iohexol cisternography of the head with axial and coronal cuts showed a para sellar defect with encephalocoel measuring 1 cm by 5 cm [Figure 1]. He underwent frontotemporal craniotomy and repair of the dural defect. There was a bone dural defect with adherent and herniating gliotic brain. The defect was defined. Dural margins were freshened and closed with a pericranium patch graft. Postoperative period was uneventful. He was symptom free at 48 months follow up.

2. A 59 year old male presented with history of watery nasal discharge for the last 10 years. 20 years ago he had a minor trauma when he hit his forehead against the frame of a door, which was followed by a nasal bleed for a day. There were periods of excessive watery discharge and discharge free periods of varying intervals. Three months prior to referral to neurosurgery he had two episodes of meningitis. On examination there was no nasal discharge or meningeal signs. Iohexol cisternography of head showed the bone dura defect of 2 cm by 4 cm, in parasellar region, with encephalocoel. He underwent right fronto temporal craniotomy and repair of dural defect with pericranial graft.


   »   Discussion Top


Bone dural defects of the skull base resulting in CSF fistulas are usually in the anterior cranial fossa and mostly into the ethmoidal or frontal sinus. Other rare sites of bone dural defects producing CSF fistulas have been reported.[1],[2] It is now well accepted that the middle fossa bone dural defects may be either acquired[3] or post traumatic.[4] Acquired, non traumatic middle fossa fistulas may result from rupture of acquired meningocoels or meningoencephalocoels. `Pitholes' on the anteromedial middle fossa may enlarge from normally occurring elevations in the intracranial CSF pressure[5] or from enlarged arachnoid villi.[6] The dura overlying the `pithole' is generally deficient. Autopsy studies have noted presence of pitholes in patients without known history of CSF rhinorrhoea. Their significance is not known, except in the symptomatic cases.

CSF fistula may form if the anteromedial portion of the middle fossa, sometimes upto foramen ovale, is pneumatised due to lateral recess of sphenoid sinus. The importance of lateral recess of sphenoid air sinus in middle fossa, has been described by Morley and Wortzman.[7] `Pitholes' or fractures of middle fossa may overlie a pneumatised lateral recess of sphenoid sinus. When a dural arachnoid defect develops over a pneumatised middle fossa bone due to any reason, cerebrospinal fluid leak can occur with or without raised pressure or head trauma. A bone dura dehiscence may result from fracture of base of skull. The brain overlying such a defect may also be injured. This gliotic brain may plug the defect temporarily. But fistula may result whenever unplugging occurs due to postural changes. There is a chance for the fracture to grow due to continued pulsations of the brain against the defect as in a growing skull fracture. Either the pseudo meningocoel or encephalocoel may unplug or rupture resulting in episodic rhinorrhoea.[5],[8],[9]

In the present case, both the patients had minor head trauma 20 years ago. Both had a long period of symptom free interval. There was nasal discharge for two years in one and for 10 years in the other. Neither sought expert medical help earlier, since the symptoms were not very distressing; and there was no headache or anosmia. Presence of any one of these complaints either singly or in combination would have prompted expert medical consultation. Once hospitalised for meningitis, the nasal discharge was suspected to be CSF and investigated and confirmed. Sometimes, occurrence of an attack of meningitis may arrest the CSF discharge. But the healing of bone dura dehiscence is not satisfactory and requires a surgical repair. The second patient had two episodes of meningitic illness. After the first episode, though the nasal discharge stopped, he had a second episode of meningitis a month later. There have been previous reports of unusually delayed onset of CSF rhinorrhoea after trauma.[4],[10]

It is difficult to say with certainty whether the fistulae in these two patients were of acquired defects or post traumatic. Probably, they were a mixture of the two. In case 1 there were two defects, one in the middle fossa, measuring 1 cm, with shaggy dura and irregular bone margin, the other was para foramen ovale measuring 2 cm. There was encephalocoel and adhesions between the temporal lobe and the base at the defect sites. These findings were suggestive of post traumatic origin. In the second patient the defect had smooth margins, with fewer adhesions than one would expect from two recent meningitic episodes. Hence, this patient probably had a congenital bone defect in the middle fossa.

Meningitic illness may occur at any time in the events as seen in our patients. Recurring meningitis may occur before bone defects are investigated. Recurrent meningitis has been reported by other authors.[11],[12] Therefore, a long history of uneventful rhinorrhoea does not guarantee freedom from meningitis. Also, disappearance of rhinorrhoea does not signify satisfactory healing of dehiscence. This was seen in both the patients presented here.

In both the patients being reported, intrathecal contrast with axial and coronal CT cuts of anterior and middle cranial fossa were adequate to demonstrate the bone dural defects. In inactive cerebrospinal fistulae MRI may be a better choice.[13] We suggest that in all cases of so called `persistent rhinitis', simple tests to detect the presence of CSF be carried out to rule out potential CSF rhinorrhoea.

 

 

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Online since 20th March '04
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