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Year : 2016  |  Volume : 4  |  Issue : 3  |  Page : 157-159

A rare case of cerebrospinal fluid rhinorrhea post external dacryocystorhinostomy surgery


Department of Ophthalmology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Date of Submission14-Apr-2015
Date of Acceptance16-Feb-2016
Date of Web Publication19-Sep-2016

Correspondence Address:
Chandana Chakraborti
Department of Ophthalmology, Calcutta National Medical College and Hospital, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.190786

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  Abstract 

Cerebrospinal fluid (CSF) leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery. We report a rare case of CSF rhinorrhea following external dacryocystorhinostomy (DCR) surgery. A 38-year-old healthy lady was diagnosed to have chronic dacryocystitis for which right side external DCR was done. At the evening of first postoperative day, the patient noticed a discharge of clear fluid coming through the right nostril, in sitting posture. The fluid was sent for biochemical analysis. Based on clinical and biochemical tests of fluid, a diagnosis of iatrogenic CSF rhinorrhea was made. Contrast enhanced computed tomography and computed tomography cisternography failed to reveal any site of active leakage. However, the patient improved with conservative management only. CSF leakage occurs very rarely in external dacryocystorhinostomies with only a few case reports found in the literature. Knowledge of anatomy and thorough preoperative assessment may predict areas at high-risk for encountering this problem.

Keywords: Cerebrospinal fluid rhinorrhea, CT Cysternography, external dacryocystorhinostomy


How to cite this article:
Chakraborti C, Barua N, Chandra K, Christi RK. A rare case of cerebrospinal fluid rhinorrhea post external dacryocystorhinostomy surgery. J Clin Ophthalmol Res 2016;4:157-9

How to cite this URL:
Chakraborti C, Barua N, Chandra K, Christi RK. A rare case of cerebrospinal fluid rhinorrhea post external dacryocystorhinostomy surgery. J Clin Ophthalmol Res [serial online] 2016 [cited 2019 Oct 18];4:157-9. Available from: http://www.jcor.in/text.asp?2016/4/3/157/190786

Cerebrospinal fluid (CSF) leakage, or rhinorrhea, is a very rare complication of dacryocystorhinostomy (DCR).[1] The causes of CSF rhinorrhea may be traumatic, postoperative, and spontaneous.[2] It is the leakage of CSF from the subarachnoid space into the nasal cavity due to a defect in both dura and bone.[3] Surgical procedures cause approximately 16% of cases. With the development of new surgical procedures such as endoscopic DCR, the etiology has changed and now, the incidence of iatrogenic CSF rhinorrhea has increased.[3]

The cause of CSF leak after external DCR can either be the direct or indirect mode of bone injury. Inadvertent extension of the osteotomy to the anterior part of the base of the skull can produce direct injury.[1] Indirect damage was first suggested by Neuhaus and Baylis, where the maxillary bone fracture spread to the base of the skull.[4] We report this case of CSF rhinorrhea as very few such cases are reported in the literature.


  Case Report Top


A 38-year-old healthy female patient presented with watering and mucopurulent discharge in right eye for 2 years. After detail ophthalmologic examination, a diagnosis of right side chronic dacryocystitis was made. After complete preoperative evaluation, she was admitted for right-sided external DCR. Surgery was done with good flaps and adequate ostium formation.

On the first postoperative day, nasal pack was removed, and she was apparently asymptomatic except the pain and swelling around the operative site. In the same evening, she started complaining of clear fluid coming through right nostril, which aggravated in sitting posture and reduced in the supine position. Fluorescein stained cotton swab turned yellowish-green when exposed to the nasal discharge [Figure 1]. Provisionally, it was diagnosed as a case of CSF rhinorrhea. Biochemical analysis of the collected fluid detected sugar content of 55 mg/l and chloride content of 111 mg/l. She was referred to an otorhinolaryngologist who advised conservative management after endoscopic examination. Contrast-enhanced computed tomography scan (2 mm section) of skull and orbit revealed nasal bone fractures corresponding the bony ostium but failed to detect any possible site of CSF leakage [Figure 2].
Figure 1: Fluroscein staining of nasal discharge. Fluid turning yellowish-green gives clue that fluid is cerebrospinal fluid

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Figure 2: Coronal view of computed tomography scan of brain and orbit showing the bony osteum

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The patient was advised complete bed rest with head end elevation, avoidance of straining such as nose blowing and coughing. Intravenous ceftriaxone 1 g twice daily for 5 days was administered along with oral ibuprofen 400 mg thrice a day and pantoprazole 40 mg once daily. Rhinorrhea gradually disappeared on the fourth postoperative day.

The patient was discharged and advised oral antibiotic, cefadroxil 500 mg twice daily for 7 days.

Two weeks later, she came back with severe throbbing headache associated with vomiting and occasional discharge of clear fluid through the right nostril. She was examined thoroughly by a neurologist, but no signs of meningitis were seen. A computed tomography cisternography (CTC) of the brain was done, but no leakage site was detected. The patient was asymptomatic until 6 months of follow-up [Figure 3].
Figure 3: Normal computed tomography cisternography without any localization of leak

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  Discussion Top


The incidence of CSF leaks associated with orbital and lacrimal surgery is relatively low. A bony fracture of the anterior cranial fossa floor or cribriform plate can be the result of caused by, either applying a rotational force with the Kerrison rongeur while enlarging the posterior nasal wall or fracturing a thin superior wall of an ethmoid air cell which was encroaching on the superior orbital wall.[4] A spiral fracture of maxillary bone may occur due to inadvertent manipulations while making the bony ostium, which may impair the integrity of the base of the skull. Posterior extension of osteotomy should be limited within 3 mm above medial canthal tendon, to avoid its extension to anterior cranial fossa.[5] Extra precaution should be taken while creating posterosuperior aspect of osteotomy as it is nearest to cribriform plate.[4] Proper illumination and visualization in each step of surgery are crucial for analyzing the tissue plane. The forceful introduction of nasal pack has been reported to injure the cribriform plate of ethmoid bone leading to CSF rhinorrhea.[1] In our case, we could not detect the exact site of CSF leak, as the CTC was done after 2 weeks of surgery. We presume, inadvertent small fracture of cribriform plate occurred during the DCR that healed spontaneously without any active interference.

Special caution has to be taken while operating in an eye with previous trauma, surgery; deformed bones in cases of osteoma, fibrous dysplasia osteoporotic bones in hyperparathyroidism, postmenopausal patients, vitamin deficiency, and alcoholism, etc.

The presence of CSF in clear nasal drainage should be established by analysis for CSF markers.[6] The laboratory tests for glucose more than 30 mg/dl or two-thirds of blood glucose and chloride concentration more than 110 mg/l in clear nasal fluid indicates the presence of CSF. Beta-2 transferrin is highly sensitive and specific in identifying CSF fluid as it is produced predominantly in the leptomeninges. Our patient could not afford this test. In early stage, high-resolution CT (0.5 mm section) or magnetic resonance imaging (MR) along with CT/MR assisted cisternography should be done for accurate localization of the leakage site.[7],[8]

Most of the iatrogenic CSF leaks resolve within 7–10 days with conservative management. The main goal of management of CSF rhinorrhea is to prevent ascending meningitis. Systemic antibiotics are administrated with caution as only 25% of untreated CSF rhinorrhea ultimately leads to meningitis. Indications of early surgery are penetrating injury with gunshot injury, associated anterior cranial fossa intervention, treated meningitis, large intracerebral aerosol, herniation of brain tissue into the nose, radiological evidence suggest low possibility of spontaneous dural closure. Indications for delayed repair are failed conservative management, persistent rhinorrhea after 10 days. Various intra- and extra-cranial approach to repair the dural defect with or without grafts by neurosurgeons have been discussed in literature.[9]

CSF leakage occurs very rarely in external DCR with only a few case reports found in the literature. Knowledge of anatomy and thorough preoperative assessment of high-risk cases can avoid such catastrophe. Proper surgical technique further minimizes the risk for this complication. Prompt diagnosis and management usually result in uncomplicated recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Fayet B, Racy E, Assouline M. Cerebrospinal fluid leakage after endonasal dacryocystorhinostomy. J Fr Ophtalmol 2007;30:129-34.  Back to cited text no. 1
    
2.
Landeiro JA, Lázaro B, Melo MH. Endonasal endoscopic repair of cerebrospinal fluid rhinorrhea. Minim Invasive Neurosurg 2004;47:173-7.  Back to cited text no. 2
    
3.
May M, Levine HL, Mester SJ, Schaitkin B. Complications of endoscopic sinus surgery: Analysis of 2108 patients – Incidence and prevention. Laryngoscope 1994;104:1080-3.  Back to cited text no. 3
    
4.
Neuhaus RW, Baylis HI. Cerebrospinal fluid leakage after dacryocystorhinostomy. Ophthalmology 1983;90:1091-5.  Back to cited text no. 4
    
5.
Limawararut V, Valenzuela AA, Sullivan TJ, McNab AA, Malhotra R, Davis G, et al. Cerebrospinal fluid leaks in orbital and lacrimal surgery. Surv Ophthalmol 2008;53:274-84.  Back to cited text no. 5
    
6.
Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: The Medical College of Wisconsin experience. Laryngoscope 2004;114:969-74.  Back to cited text no. 6
    
7.
Schievink WI, Meyer FB, Atkinson JL, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 1996;84:598-605.  Back to cited text no. 7
    
8.
Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal fluid leaks in adults. Radiology 2008;248:725-36.  Back to cited text no. 8
    
9.
Citardi MJ, Fakhri S. Cerebrospinal Fluid Rhinorrhea. In: Flint PW, Haughey BH, Lund VJ. editors. Cummings Otolaryngology Head and Neck Surgery, 5th ed. Mosby Elsevier: Philadelphia, PA; 2010.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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