CSF rhinorrhea is a
potentially devastating condition that can lead to a myriad of complications
leading to morbidity and mortality. CSF formed by the choroid plexus and
drained through the arachnoid villi, circulates in a closed system. Any
disruption between the sino-nasal cavity and the anterior and middle cranial
fossae will result in discharge of CSF into the nasal cavity. Complications
include intracranial infections, cranial nerve palsies and pneumocephalus.
CASE REPORT
We report a case of 15 – year old Pakistani male
referred from medical department for evaluation of double vision and drooping
of his right eyelid for four days. It was associated with fever, severe
headache and running nose. Probing into past history revealed that he had a
fall from roof eleven years back. He had loss of consciousness for ten minutes.
It was relieved without any medical support but was followed by an episode of
vomiting which contained blood. Years passed by without any investigations and
medication except some drugs for rhinorrhea. The patient continued to have recurrent
attacks of meningitis during the last eleven years, which settled with
medications without any residual morbidity. This time he had fever but it was
associated with drooping of right eye and double vision. On examination, there
was visual acuity of 6/6 and intra-ocular pressures of 10mm of mercury in each
eye. Right pupil was fixed and dilated. Left pupil was round, regular and
normally reacting to light and accommodation. Slit lamp examination and
fundoscopy was unremarkable. Both optic discs were normal (no signs of
papilledema). We diagnosed it as ‘pupil involving third nerve palsy’ in right
eye. Other cranial nerves were intact except Olfactory, which was damaged on
both sides. No other neurological deficit was detected. Other systems were
normal. Nasal discharge was clear, watery and increased with bending and
straining. We referred our patient to ENT department for rhinorrhea. CSF
rhinorrhea was suspected and nasal discharge was sent for chemical examination.
Chemistry of nasal discharge was consistent with CSF. We performed MRI, which showed
fluid tract from cribriform plate of left ethmoid sinus through left frontal
sinus, left anterior ethmoidal cells into left nasal cavity. There was dural
tear and fracture of cribriform plate of left side. Medical management for his
fever was sought and we referred the patient to neuro-surgery department for
surgical management of fractured cribriform plate.
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Fig. 1: Patient with right third nerve palsy.
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Fig. 2: Dilated and fixed pupil of right eye.
DISCUSSION
Approximately 500 ml of CSF is produced
daily. CSF produced at the choroid plexus, circulates through the subarachnoid
space and is reabsorbed via the arachnoid villi. Normal CSF pressure is
approximately 10 – 15 mm Hg. Any breach in this closed loop of CSF circulation
will lead to its leakage resulting in different conditions; e.g, otorrhea,
rhinorrhea and oculorhea.1 CSF leaks are broadly classified as
spontaneous, traumatic and iatrogenic.2 Traumatic CSF leak is either
immediate or delayed. Immediate CSF leaks are easy to diagnose but delayed
fistulas may remain undetected. Our patient had delayed CSF rhinorrhea and it
remained undetected for almost eleven years. Such delayed cases may result in
complications, which include intracranial hypotension (ICH), headache and
cranial nerve (CN) disorders. It is presumed that these complications are
related to sagging of the brain and brainstem and traction on the dura3.
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Fig. 3: T2 weighted MRI showing tract of CSF leak on
left side
This particular
patient had intermittent CSF leak and chronic headache. CSF leak was taken as
allergic rhinitis and he continued to take medicines for that purpose. Prior to
presenting in our department he had severe headache and profuse discharge from
the nose which led to third nerve palsy. There are many case reports of cranial
nerve palsies due to intracranial hypotension irrespective of the cause. Although
trauma is the most discussed cause of ICH, other causes are also described in
literature which include; lumbar discectomy4, CSF shunt procedures5,
spontaneous intracranial hypotension6.
The most commonly
encountered cranial nerve deficit from Intracranial hypotension is sixth nerve
palsy7. It is proposed that sixth nerve due to its long course is
more vulnerable to damage when brainstem sags down as a result of decreased
intracranial pressure8. Second common nerve to be involved in ICH is third nerve as in our case9,10.
Sometimes cranial nerve palsy is the only presenting sign of spontaneous ICH Multiple
cranial nerve palsies can also occur. In the absence of any cranial nerve
palsy, diagnosis of a delayed CSF leak becomes difficult unless an accurate
history is taken and proper examination is done. Intermittent cases of CSF leak
(as in our case) might be due to accumulation of CSF in one of the paranasal
sinuses which later drain with changes in head position. This is called
reservoir sign.
There are other signs which can help in
localizing site of CSF leak. Our patient had anosmia on both sides, which
pointed towards a defect in the anterior cranial fossa. Optic nerve function deficits are indicative of lesions in
posterior ethmoid sinuses but this nerve was spared in our case.
Meningitis is a very important complication
of CSF leak. This particular patient had multiple attacks of meningitis but
only conservative management was done without looking for the cause of
recurrent attacks. Hence, cases of recurrent attacks of meningitis must be
thoroughly investigated for any CSF leak to prevent mortality and morbidity.
CONCLUSION
The patient was
referred to us for management of third nerve palsy. Prompt referral to ENT and
neurosurgical department saved patient from morbidity and mortality. Careful history,
examination and investigations remain key to the sensible management of
patients. Patients with recurrent meningitis should be evaluated for a CSF
leak.
Author’s Affiliation
Dr. Tayyaba Gul Malik
Associate Professor of Ophthalmology
Lahore Medical and Dental College,
Lahore.
Dr. Muhammad Khalil
Associate Professor of Ophthalmology
Lahore Medical and Dental College,
Lahore.
Dr. Qurrat ul Ain
Medical Officer
Ghurki Trust Teaching Hospital, Lahore
Role of Authors
Dr. Tayyaba Gul Malik
Data collection & Manuscript writing
Dr. Muhammad Khalil
Manuscript writing
Dr. Qurrat ul Ain
Data acquisition
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