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CSF Leak Repair
Rhinorrhea: The medical term for
A Runny Nose
When is it a sign of a more serious medical condition?
Lake Success, NY
Having a “runny nose “ is very common and is
frequently associated with a cold, virus, allergy or sinus infection. Thirty-seven million Americans suffer with chronic sinusitis and fifty million have some form of respiratory allergies. Recently, Cathy, a forty-three year old over weight diabetic woman called her primary care doctor (PCP) with a new problem. Her nose started to “run” without sustaining any trauma. She asked what should she do? She denied any symptoms of facial pressure, headache, fever, postnasal drip or congestion. Her PCP thought it sounded like allergies and told her to start the over the counter anti-histamine Loratidine. Cathy had some health issues which were controlled but had no history of sinusitis, asthma or allergies. She did note some increased blurring of vision but attributed this to requiring stronger glasses. After a few days the nasal discharge worsened especially when she leaned forward (Figure #2). She kept a tissue up by her nose for most of the day. She visited her ENT doctor who determined she had one-sided (unilateral) clear rhinorrhea consistent with a cerebro-spinal fluid leak (CSF). She was sent to the Emergency room at Long Island Jewish Hospital and came under the care of Dr. B. Todd Schaeffer, an endoscopic sinus and skull base surgeon and Dr. Steven Schneider, an endoscopic neurosurgeon. A CT scan showed a very large pneumatized lateral sphenoid sinus with a skull base defect (Figure #1). Inflammatory tissue was in the most lateral recess on the left side.
Cerebrospinal Fluid (CSF) is a clear fluid produced by the choroid plexus in the ventricles of the brain. It acts as a shock absorber and cushions the brain and spine. The CSF circulates around them in the sub-arachnoid space. A communication with this space through the arachnoid (thin layer), dura (thick fibrous layer) and a bony defect at the skull base, into the paranasal sinuses, leads to a leakage of clear fluid from one side of the nose.
Figure #1 Left Sphenoid
Bony defect in left lateral sinus
Figure #2: Clear rhinorhea.
Traumatic vs Spontaneous Elevated Intracranial Pressure
Motor Vehicle AccidentsPseudotumor Cerebri
Gun Shot Wounds
Surgery i.e tumor removal, sinus surgery
Figure # 3: Second patient with spontaneous cribriform CSF leak. Skull base defect with meningocele. This was repaired endoscopically transnasally with local mucosal flap. Repaired with Dr. Mark Eisenberg (Endoscopic Skull Base Neurosurgeon).
Diagnostic Testing For CSF Leak
Figure #4: Third patient with CSF leak at Left Supraorbital ethmoid. This was an encephalocele repaired through a transnasal endoscopic approach
Etiology of CSF Leaks Trauma Tumors Iatrogenic Spontaneous/Unknown
Key Points to CSF Repair
Transnasal endoscopic repair with navigation. Lumbar drain as needed
Materials used for multilayer closure
DuraSeal TM ( non-toxic hydrogel)
B. Todd Schaeffer, M.D., F.A.C.S
Endoscopic Sinus and Skull Base Surgeon Dr Schaeffer has been performing advanced endoscopic sinus surgery for twenty years. He has performed more endoscopic skull base surgery than any other sinus surgeon on Long Island. He commonly works with skull base neurosurgeon Dr. Mark Eisenberg. As a team, they have successfully treated pituitary tumor removal, closure of CSF leaks, removal of encephaloceles, chordomas, clival tumors, meningiomas, craniopharyngiomas, odontoidectomy, spinal cord decompression, biopsies at the skull base, removal of malignant sinus/nasal tumors and skull base reconstruction. The key to their success is collaboration together and the support staff of North Shore University Hospital and Long Island Jewish Medical Center. Experience and team collaboration counts.
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