Dr. Dankle,
I have had rhinoplasty surgery three times in the last five years. My
first surgery was in 92, and immediately after the surgery I had a clear and
constant drainage from my nose. My doctor said it was nothing and paid
little attention. After living with the conditions for quite some time, a
doctor finally took notice and ordered a cisternogram. So in Oct. of 96 the
cisternogram came back positive for a CSF Leak. The doctor then ordered a
CAT Scan. I went ahead and had surgery in Jan. of this year to repair the
leak. The problem was the doctor could not locate the leak. About a week
after the surgery the doctor had me catch the liquid in a tube. They ran a
test on the liquid, I'm not sure of the name, and it came back negative.
After the surgery my nose ran a lot. Then about a week after the surgery
there was a dramatic decrease in the drainage. Then about a week after that,
there was an increase in the drainage. At the present time the drainage is
not as bad as it was prior to the surgery, but it still is there. My doctor
would like for me to repeat the cisternogram, only ordering a more sensitive
test along with it. There are a few questions I have, and I was hoping you
could answer them for me.
1. Is there a possibility the cisternogram could have been wrong?
2. Is there a possibility the liquid test could have been wrong?
3. Should I repeat the cisternogram?
4. Why did the drainage increase, decrease, and then again increase after
the surgery?
5. Is there any information you can give me on a CSF Leak?
6. What advice can you give me on this situation?
I appreciate your time and help in this matter.
Tired of Kleenex
Reply: ----------------------------
In response to your question re cerebrospinal fluid leak:
1) It depends. Radio-isotope cisternograms do have a fair number of false positive test results for CSF leaks in the nose. On the other hand high resolution CAT scanning with metrizamide is fairly accurate.
2) It is possible that the "fluid test" could be inaccurate. It depends on what "fluid test" you had done. One test known as the glucose-oxidase test is reported to have as high as a 75% false negative rate. On the other hand a beta-transferrin test is highly specific and highly sensitive for CSF.
3) If you have had a positive cisternogram previously, and you have persistent clear watery nasal drainage, even if it fluctuates in severity, I absolutely would consider repeating some type of testing for CSF leak. One test is known as isotope cisternography and involves the use of radio-isotope tracers injected via spinal tap - then pledgets are placed in various locations in the nose to detect any radio-isotope. This test is somewhat limited by its inability to precisely locate the site of leakage and has a relatively high false positive rate. High resolution CAT scanning combined with intrathecal injection of metrizamide can very accurately identify and localize CSF leaks 85% of the time.
4) Waxing and waning of nasal drainage is quite common with spinal fluid leaks. This is because the spinal fluid pressure varies with certain activities, head positions, physiologic processes, etc. Furthermore, intranasal conditions may also affect the flow of CSF leakage.
5) CSF rhinorrhea would be considered a rare complication following rhinoplasty or septoplasty. It is more common to occur in sinus surgery than in septorhinoplasty. Presumably, CSF leakage occurs during septal surgery from removal or manipulation of the perpendicular plate of the ethmoid bone which forms part of the nasal septum up high and in back of the nasal chamber. It is rare to have CSF leaks in this type of surgery since it is rarely necessary to remove very much of the perpendicular plate of the ethmoid bone during septoplasty. CSF leakage is a serious problem since it can provide passageway for bacteria from the nose into the cranial cavity which can lead to meningitis - an infection of the lining surrounding the brain. Advances in surgery have now allowed for the successful closure of CSF leaks inside the nose by endoscopic nasal surgical techniques whereas previously craniotomy was often necessary. Endoscopic techniques for closing nasal or sinus CSF leaks are done by otolaryngologists, but neurosurgeons should be consulted for co-management in my opinion - I usually recommend the placement of a lumbar drain by a neurosurgeon- a lumbar drain is a catheter which is placed into the spinal fluid space in the spine to keep the CSF pressures very low for 3-7 days following surgery. Additionally, the patient is kept at strict bedrest for approx. 1 week - typically in a hospital.
6) I would suggest you be re-evaluated if you continue to have watery nasal drainage, particularly if you have no known allergic or sinus disease otherwise.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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