The Rinorraquia Is the expulsion of cerebrospinal fluid through the nose. It can occur from a post-traumatic event such as a fracture or spontaneously.
It is a rare and very serious condition, which can lead the patient to death from complications such as infections in the nervous system; between them meningitis And abscesses of pus in the brain .
Causes of the rinorraquia
The main cause of rhinorrhea, also known as cerebrospinal fluid rhinorrhea, is the rupture of the barriers between the sinonasal cavity and the middle cranial fossa and the anterior cranial fossa. This leads to the discharge of cerebrospinal fluid into the nasal cavity.
The result of this communication between the central nervous system and the nasal cavity can cause a multitude of infectious complications of great morbidity and catastrophic effects in the patient.
Leaks from cerebrospinal fluid Are generally of traumatic cause, Iatrogenic - caused as an unwanted side effect of any treatment or surgical procedure - or even by causes Idiopathic And spontaneous.
Among the traumatic causes are penetrating and forceful facial wounds, iatrogenic causes such as those caused by neurosurgery or otorhinolaryngological processes aimed at approaching some neoplastic disease (cancer) that is in the area.
Functional sinus surgery may also lead to involuntary leakage of cerebrospinal fluid.
On the other hand, within the causes of spontaneous type appear the side effects of a significant increase of the intracranial pressure. This appears especially in patients with idiopathic intracranial hypertension.
Some congenital defects of the base of the skull and also the presence of certain tumors may cause rhinorrhea in the patient.
Ninety percent of patients with rhinorrhea have had a penetrating or closed trauma to the head. The rhinorrhea that precedes a traumatic injury is classified immediately (within 48 hours), or delayed.
The majority of patients with cerebrospinal fluid spills due to a traumatic event, such as an automobile accident, present this symptom immediately.
The remaining patients (95%) who did not present rhinorrhea at the time of the accident tend to manifest it within 3 months of the trauma.
On the other hand, iatrogenic rhinorrhea occurs during surgeries performed at the base of the skull. Any surgical manipulation in this area can result in a spillage of cerebrospinal fluid.
The damage can range from a crack in the bone structure to a large rupture of more than 1 centimeter that affects the dura and possibly also the parenchyma of the brain.
Any otorhinolaryngological procedure and also nasal surgeries can cause damage to the base of the skull and lead to a rhinorrhea. In the case of endoscopic surgery of the sinuses, the most frequent rupture is the lateral lamella of the cribiform plate.
In the case of tumors, malignant neoplasms such as inverted papillomas are usually those that erode the bones of the anterior fossa of the skull. It is very rare for a benign tumor to cause rhinorrhea.
If the tumor itself does not fracture the bones, at the time of removal it will immediately produce a spillage of cerebrospinal fluid. However, medical teams are prepared to repair the injury at the right time.
There are also cases of spontaneous rhinorrhea, with no previous history of the patient. These events are usually idiopathic. However, the latest evidence has shown a relationship between spills of cerebrospinal fluid and elevated intracranial pressure. Obstructive nocturnal apnea is one of the causes of this increase in intracranial pressure.
Diagnosis
Spillage of cerebrospinal fluid through the nasal cavity can be checked by collecting the nasal fluid. This check can be done based on two methods.
The first is the oldest and consists of identifying the presence of glucose. The second is to find out if there are much more specific components such as beta 2 transferrin, a protein found in the cerebrospinal fluid.
In addition to this, a complete physical examination of the head and neck and an endoscopy of the nasal cavity and adjacent regions is performed. An MRI is also performed, where any brain abnormality can be examined.
Another more specific examination that is done is a cisternography, that allows to identify the place where the cerebrospinal fluid spill occurs precisely. Contrast is used which is injected into the Dura mater .
symptom
One of the symptoms of rhinorrhea is headache, which worsens when incorporated and improves with rest. It can be associated with sensitivity, nausea and neck stiffness.
Unlike what you might think, spitting cerebrospinal fluid through the nose and ears is not a common symptom of this picture.
When rhinorrhea results in an infection, patients have symptoms such as fever, chills, or changes in mental status. At this time, the clinical picture is considered an emergency and should be treated with antibiotics.
Rhinosorrhea is a serious condition that must be treated immediately, to avoid complications such as meningitis, Brain abscesses (Pus in the brain) and other infectious diseases in the Central Nervous System .
Treatment
In case of rhinorrhea, the recommended treatment is repair of the crack through surgery.
In some cases it can be resolved spontaneously. Absolute bed rest is recommended for a few days, increase fluid intake, especially caffeinated beverages, which can help stop the spill or make it less intense. In addition, caffeine can alleviate the intense headache that patients present.
This migraine Is treated with analgesics and fluids. Lumbar punctures are also performed to remove cerebrospinal fluid.
Another option is to put a"blood patch", ie a small blood clot where the break is to seal it and with this stop the rhinorrhea. If rhinorrhea does not stop after 5 or 7 days, repair surgery is the alternative.
The prognosis of rhinorrhea depends on the case and the patient. If no infections occur, most cases resolve spontaneously without sequelae for the person.
References
- CSF Rhinorrhea. Retrieved from emedicine.medscape.com.
- Cerebrospinal fluid rhinorrhoea. Retrieved from Wikipedia.com.
- CSF Rhinorrhea: Symptoms, Definition, Diagnosis, Treatmente. Retrieved from nyee.edu.
- CSF Rhinorrhoea. Radiology Reference Article. Retrieved from radiopaedia.org.
- CFS Leaks. Kevin C.Welch MD. Retrieved from care.american-rhinologic.org.
- CFS Leak. Symptoms, Diagnosis, Treatment of CSF Leak. Retrieved from nytimes.com.
- CSF Leak. Retrieved from medlineplus.gov.