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Rhinorrhea

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GCS of 15 in the trauma bay. Patient complains of right wrist pain. ... right wrist pain. ... EXT: Notable right wrist deformity. Vascular: Gustatory, Churg ... – PowerPoint PPT presentation

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Title: Rhinorrhea


1
Rhinorrhea
  • James Ridgway
  • 7/27/06

2
HPI
  • Patient is a 21 year old male s/p 30ft fall at a
    construction site with face strike to one of the
    support beams prior to ground impact. No LOC at
    the scene. GCS of 15 in the trauma bay. Patient
    complains of right wrist pain. Notable oozing
    from the left nares.

3
Primary Survey
  • A- airway intact
  • B- CTA B
  • C- RRR, no sites of hemorrhage, good perfusion.
  • Vitals 37.6 139/85 90 - 20

4
HP
  • Patient states right wrist pain. Further
    examination reveals left sided nasal obstuction,
    rhinorrhea (s/p epistaxis), malocclusion, minor
    upper lip and midface pain, taste of blood in
    mouth. Notable right wrist deformity.
  • He denies any SOB, dyspnea, diplopia, visual
    field defect, tinnitus, HL, dysphagia,
    odynophagia or vocal change.

5
HP
  • PMH None
  • PSH None
  • Medications None
  • Allergies NKDA
  • FH HTN, DM
  • SH EtOH, denies TOB, IVDU. No history of
    HBV/HCV/HIV/TB.

6
PE
  • Eyes PERRL, EOMI, no diplopia or visual field
    defects. Bilateral periorbital STS and
    ecchymosis.
  • Ears TM c/i/m AU without effusion/hemotympanum
    or EAC defect.
  • Nose Minor nose deviation to the left, nasal
    bones stable, crusted blood at the anterior
    nares, near total occlusion of the left nasal
    cavity 3.5 inside with cartilage/bone/mucosa
    disruption. Slow bleeding from the nose
    bilaterally. No septal hematoma.
  • OC/OP Non-occlusion of teeth, midface mobile,
    limited discomfort, sh palate intact, no other
    mass/lesions/defects.
  • Neck C-collar, trachea midline, no crepitus, no
    LAD/mass.
  • Face Step-offs along bilateral inferior orbital
    rims. Laceration along the left infraorbital rim
    and complex laceration of the patients lateral
    upper lip. Mandible stable.
  • CN VII intact bilaterally, XII intact
    bilaterally, V1 and V3 without compromise.
    Anesthesia of V2 on left.
  • EXT Notable right wrist deformity.

7
  • Vascular Gustatory, Churg-Strauss syndrome
  • Infection Viral (RSV, Coronavirus, Adenovirus,
    influenza, Parainfluenza ), Bacteria (Pertussis,
    Diphtheria, Group A Streptococcus, Chlamydia),
    Rhinoscleroderma,
  • Trauma CSF, foreign body
  • Autoimmune/immune Allergic rhinitis (seasonal,
    dust, occupational), NARES, Nasal Polyposis,
    Wegener's granulomatosis, SLE, Sjögren's syndrome
  • Metabolic Pregnancy, Hypothyroidism, Puberty
  • Iatrogenic/Idiopathic Mediciations (alpha
    antihypertensives, MAOI antidepressants, oral
    contraceptives, ASA, some benzodiazepines ),
    surgical (FESS), rhinitis medicamentosa,
    Idiopathic (vasomotor) rhinitis
  • Neoplasia Midline granuloma, CNS tumors (primary
    vs metastatic glioma, astrocytoma,
    oligiodendroglioma, ependymoma, meningioma,
    prostate CA, SCCA, lymphoma), osteoma
  • Congenital Choanal Atresia, Encephalocele,
    Meningocele, Meningoencephaloceles, Teratoma,
    Pseudomeningocele (Marfans syndrome,
    Neurofibromatosis)
  • Sarcoidosis

8
HP of Rhinorrhea
  • Character of Symptoms Onset, duration, constant
    vs intermittent, unilateral vs bilateral,
    obstruction, anosmia/hyposmia
  • Contributing factors toxin or allergen exposure,
    current medicitions, history of asthma,
    sinusitis, allergy, facial trauma or surgery.
  • Associated symptoms allergic component
    (sneezing, itchy and watery eyes, clear
    rhinorrhea), sinus involvement (facial pain, HA),
    acute infection (fever, malaise, pain, purulent
    discharge).
  • Other symptoms sore throat, postnasal drip,
    cough, ear complaints, hoarseness, salty or sweet
    taste.

9
Basic Principles of Cerebrospinal Fluid
  • physical support and buoyancy for the brain
  • autoregulation
  • by-products of metabolism
  • regulate the chemical environment

10
Volume and production
  • Monro-Kellie hypothesis
  • 75/150/1400
  • rate of 0.35 mL/min or 500 mL/d
  • Normal ICP ranges from 5 to 15 mm Hg
  • ICP If X Rout Pss
  • Increased protein concentration in the CSF or
    inflammatory changes in the dura create
    resistance to outflow by impairing CSF absorption
  • meningitis, subarachnoid hemorrhage, or
    iatrogenic entry of blood

11
CSF Rhinorrhea
  • Traumatic
  • Non-Traumatic
  • Spontaneous
  • Iatrogenic
  • Common S/S
  • Unilateral watery nasal discharge
  • Fluid discharge with valsalva
  • Positional variation
  • Hx of trauma, surgery, increased ICP
  • Hyposmia, anosmia
  • HA
  • Unexplained weight loss
  • History of bacterial meningitis and especially a
    history of multiple episodes of bacterial
    meningitis

12
Traumatic Non-Traumatic
  • Accidental Trauma 80 (2-4 of all head
    injuries)
  • HP CSF 45 (tumor, benign ICP or hydrocephalus)
  • NPL bone erosion, XRT, infection, fistula,
    encephalocele, meningocele, meningoencephaloceles,
    empty sella syndrome

13
Traumatic
14
Non-Traumatic
15
Spontaneous
  • Waste bucket term that refers to failed
    identification/ reason for CSF rhinorrhea

16
Iatrogenic
  • 50 present immediately postoperative
  • Delay 7 days to 1 month later
  • secondary to progressive maturation and
    contraction of wounds
  • devascularization
  • necrosis of the soft tissue or bony edges
  • slow resolution of edema
  • increased CSF pressure

17
Iatrogenic
  • CSF leaks Common Sites
  • Frontal recess
  • Anterior ethmoid artery
  • Cribiform plate
  • Avoid by staying lateral to the middle turbinate
  • Avoid fracture of middle turbinate
  • Posterior ethmoid sinus
  • Recognize Leaks
  • Clear or swirling fluid

18
Iatrogenic
  • most common cause of rhinorrhea from surgical
    trauma is transphenoidal management of pituitary
    tumors (0.515)
  • risk of CSF leak secondary to functional
    endoscopic sinus surgery varies from 0.5 to 3
  • weaknesses of the skull base may result from the
    development of extensive paranasal pneumatization
  • lateral lamella of the cribriform plate forms the
    weakest part of the skull base

19
Diagnosis Sometimes easy, sometimes not.
  • Halo Sign
  • Components of CSF
  • glucose, protein and electrolytes
  • Beta-2 transferrin

20
Other Studies
  • High-resolution coronal and axial CT
  • CT cisternograms
  • Fluorescin
  • Radionuclide cisternography
  • MRI cisternograms
  • T2 images highlight the CSF leak on MRI.

21
Conservative Management
  • Most CSF leaks resulting from accidental and
    surgical trauma heal with conservative measures
    over the course of 7 to 10 days.
  • Bed rest, head elevation, stool softeners
  • No blowing nose, sneeze with open mouth
  • Lumbar drain
  • Acetazolamide
  • Prophylactic antibiotic coverage

22
Surgery
  • Extensive intracranial injury
  • Intraoperative identification
  • Nonresponders to conservative measures

23
Transcranial
  • Pros
  • Success rates ranging from 60 - 95
  • Improved exposure
  • Ability to identify multiple defects
  • Ability to tamponade a leak in a high-pressure
    situation
  • Cons
  • inherent increased morbidity
  • length of hospitalization
  • permanent anosmia

24
Extracranial
  • Pros
  • Success rates of 86 on initial operation with a
    97
  • Decreased morbidity
  • No anosmia
  • Improved endonasal exposure of the sphenoid,
    parasellar and posterior ethmoids,cribriform
    plate, fovea ethmoidalis, and the posterior wall
    of the frontal sinus
  • Cons
  • facial scar
  • risk for facial numbness and orbital
    complications
  • cumbersome
  • Cerebral damage and the lateral extensions of the
    frontal and sphenoid sinuses cannot be assessed

25
Endoscopic
  • Currently the preferred method of repair
  • success rates of 92 to 96 have been documented
  • small defect can be closed with an overlay free
    mucosal graft or a free fascial graft
  • Larger defects at risk for a secondary
    encephalocele or small defects with elevated ICP
    are treated more appropriately with a bone graft
    placed in an underlay fashion within the epidural
    space and a fascial graft to provide a watertight
    seal placed in an overlay fashion
  • If the defect is more than 1 cm wide, the
    underlay technique with bone or cartilage is
    preferred to prevent herniation of cerebral
    tissue

26
Composite reconstruction technique using bone,
cartilage, or lyophilized dura. This technique is
used forlarger dural defects,multiple dural
defects, or large bony skull-base defects.
Free mucosal graft technique for smaller (lt3 mm)
dural defects
27
Other Methods
  • Composite grafts
  • Pedicled mucosal or mucochondral flaps
  • Bathplug technique
  • Lyophilized dura or fascia to sandwich the dural
    defect
  • Large dural closure with autografts such as
    fascia lata or temporalis fascia

28
Sealants
  • Fibrin
  • combination of fibrinogen, thrombin, and calcium
    cofactor
  • most commonly used sealant today
  • Tisseel
  • fibrin sealant that includes components of
    autologous cryoprecipitate from single-donor
    plasma, bovine thrombin, and an antifibrinolytic
    agent that yields a more stable clot
  • provides a temporary watertight closure and
    creates an additional barrier to CSF leakage
    during wound healing and fibrosis

29
Packing
  • Either absorbable or nonabsorbable
  • 86 of rhinologists use packing to repair CSF
    leaks

30
Post-Op
  • Postoperative follow-up with CT scanning is
    appropriate to rule out development of a mucocele
    when there is concern for sinius tract
    obstruction
  • Watchful of complications including meningitis,
    brain abscess, subdural hematoma, smell disorder,
    and HA.
  • Most common being meningitis at 1

31
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33
  • Lopatin AS, Kapitanov DN, Potapov AA.Endonasal
    endoscopic repair of spontaneous cerebrospinal
    fluid leaks. Arch Otolaryngol Head Neck Surg.
    2003 Aug129(8)859-63.
  • Han CY, Backous DD. Basic principles of
    cerebrospinal fluid metabolism and intracranial
    pressure homeostasis. Otolaryngol Clin North Am.
    2005 Aug38(4)569-76.
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