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LETTER TO THE EDITOR
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 136-137

Post-traumatic cerebrospinal fluid leak: Challenge for cranio-maxillofacial surgeons


Department of Oral and Maxillofacial Surgery, Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, India

Date of Web Publication22-Nov-2013

Correspondence Address:
Mohammad Akheel
Department of Oral and Maxillofacial Surgery, Block 5, 4H, 309/310, VGN Laparasiene, Nolambur, Mogappair West, Chennai - 600 037
India
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DOI: 10.4103/1118-8561.121930

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How to cite this article:
Akheel M, Tomar SS. Post-traumatic cerebrospinal fluid leak: Challenge for cranio-maxillofacial surgeons. Sahel Med J 2013;16:136-7

How to cite this URL:
Akheel M, Tomar SS. Post-traumatic cerebrospinal fluid leak: Challenge for cranio-maxillofacial surgeons. Sahel Med J [serial online] 2013 [cited 2021 Jul 31];16:136-7. Available from: https://www.smjonline.org/text.asp?2013/16/3/136/121930

Sir,

Cerebrospinal fluid (CSF) is a very common entity in cranial and facial trauma. CSF leak is seen in 80% of cranio-maxillofacial injuries which complicates 2% of head injuries. [1] Management of these patients poses a challenge, which is most often overlooked by a cranio-maxillofacial surgeon. Fain and colleagues [2] advocated that CSF leak is more frequent with anterior skull base fractures associated with Lefort II, III and in frontal bone fractures. This is due to the firm attachment of the dura to the anterior skull base. The duration of symptoms may be as early as 2 days or can be seen after 3 months of injury. Depressed maxillofacial injuries fractures the cribriform plate of ethmoid bone, which gets fractured more easily than frontal, sphenoid and temporal bones. Ommaya et al. [3] classified CSF leak based upon etiology, site and size. [4],[5] The brain is enclosed in a sterile environment suspended in CSF. Th blood-cerebrospinal-fluid barrier (B-CSF-B) prevents noxious drugs or bacteria to reach the brain, thus making it very rarely susceptible for infections.

However cranio-maxillofacial injuries may result in a communication between the intracranial cavity and surrounding facial structures and increases the intracranial pressure (ICP) which manifests as CSF rhinorrhea, otorrhea and orbitorrhea. Cranio-maxillofacial trauma is associated with contamination of wounds with various virulent pathogens like  Streptococcus pneumoniae Scientific Name Search Haemophilus influenzae. The retrograde entry of these pathogens in a sterile environment may cause meningitis, a life-threatening complication that canthat may be complicated by cerebral abscess and/or further increases the ICP. The risk of meningitis during the first 3 weeks after trauma is estimated to be 2% to 50%. [6] Evaluation of CSF leak in cranio-maxillofacial injuries includes halo sign, metallic taste, dripping of CSF posterior to uvula, CT and MRI cisternograms, intrathecal fluorescein and identification of beta 2 transferrin and beta trace protein in the CSF.

Management of traumatic CSF leak, which may be conservative or surgical. Small CSF fistula that is less than 0.4 mm will heal spontaneously within 7 days. Conservative treatment includes complete bed rest, elevation of bed by more than 30°, refraining from coughing, sneezing and nose blowing, providing stool softeners, and placement of subarachnoid lumbar drain to drain 10 mL of CSF per hour. Acetazolamide should be administered to reduce the formation of CSF by inhibiting the reverse conversion of water and carbon-dioxide to bicarbonate and hydrogen ions. The main reason of delayed surgical fixation in cranio-maxillofacial injuries is to prevent or reduce the risk of retrograde or ascending meningitis, which is occurs in about 29% of cases. Appropriate prophylactic antibiotic therapy using 3 rd and 4 th generation cephalosporin and amphotericin B is often. However certain studies show that prophylactic antibiotic therapy does not reduce the risk of meningitis. [6] Unpublished observation in our hospital shows that of 120 patients with cranio-maxillofacial injuries, 56 (46.7%) had CSF leak. Prophylactic antibiotics therapy with 3 rd generation cephalosporin and conservative management protocol led to complete resolution of symptoms in a period of 3 to 7 days.

CSF fistulas larger than 0.4 mm which fail to heal in 7 days must be treated surgically. Surgical approach for CSF rhinorrhea dates back to 1926 when Dandy [7] reported the first successful repair with bifrontal craniotomy approach for access and fascia lata graft for repair of the damaged dura. The types of graft materials includes temporalis fascia, fascia lata and pericranial grafts to repair the dura and provide a water tight seal of brain. Due to potential complications like hematoma/edema partly from excess brain retraction, anosmia and seizures, extracranial techniques are more preferred.This procedure dates back to 1948 when Dohlman [8] performed trans-sinus access to repair skull base defects. Further advancements in approaches include transnasal approach by Hirsch [9] and endoscopic endonasal approach by Wigand. [10]

 
  References Top

1.Loew F, Pertuiset B, Chaumier EE, Jaksche H. Traumatic, spontaneous and postoperative CSF rhinorrhea. Adv Tech Stand Neurosurg 1984;11:169-207.  Back to cited text no. 1
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2.Fain J, Chabannes J, Péri G, Jourde J. Frontobasal injuries and CSF fistulas. Attempt at an anatomoclinical classification. Therapeutic incidence. Neurochirurgie 1975;21:493-506.  Back to cited text no. 2
    
3.Ommaya AK. Spinal fluid fistulae. Clin Neurosurg 1976;23:363-92.  Back to cited text no. 3
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4.McMains KC, Gross CW, Kountakis SE. Endoscopic management of cerebrospinal fluid rhinorrhea. Laryngoscope 2004;114:1833-7.  Back to cited text no. 4
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5.Germani RM, Vivero R, Herzallah IR, Casiano RR. Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft. Am J Rhinol 2007;21:615-8.  Back to cited text no. 5
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6.Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae: A meta-analysis. Arch Otolaryngol Head Neck Surg 1997;123:749-52.  Back to cited text no. 6
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7.Dandy WE. Pneumocephalus (intracranial pneumocele or aerocele). Arch Surg 1926;12:949-82.  Back to cited text no. 7
    
8.Dohlman G. Spontaneous cerebrospinal fluid rhinorrhea. Acta Otolaryngol Suppl (Stockh) 1948;67:20-3.  Back to cited text no. 8
    
9.Hirsch O. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery. Arch Otolaryngol 1952;56:1-13.  Back to cited text no. 9
    
10.Wigand ME. Transnasal ethmoidectomy under endoscopic control. Rhinology 1981;19:7-15.  Back to cited text no. 10
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