HEAD AND NECK

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The flow of clear, like water liquid, from one nostril must always cause suspicion of the possibility of cerebrospinal rhinorrhea.  This situation means the existence of open communication between the brain cavity and the nasal cavity.  The brain floats within the cerebrospinal liquid which is clear like water.  If at some point of the base of the scull there is a bone deficit and pathological communication with the nasal cavity, then the cerebrospinal liquid will pass into the nasal chamber and come out the nostril or we will swallow it.

The rhinorrhea of cerebrospinal liquid is not a common case.  It is, however, potentially dangerous for the live of the patient.  From the same point through which passes the cerebrospinal liquid, may enter microbes into the brain cavity and cause meningitis, with lethal consequences.  For this reason, we must be able to promptly diagnose and treat this situation, sealing the point of leaking.

The patient mentions the flow of clear liquid from the nostril.  Other times, he/she may feel that he/she swallows it and also mentions a rather salty taste.  The flow is small to minor.  It may be discontinuous, but take place or get aggravated when the patient bends or is under pressure.  The appearance of the symptoms is rather recent, the history, however, must be checked back to a decade.  What we look for are mild or serious injuries in the area of the head, or previous operations in the nose and the area around it.  Small, asymptomatic, fractures in the base of the scull and other such events may in time lead to the flow of cerebrospinal liquid.  The pressure which cerebrospinal liquid exercises on these weak areas, like a liquid hammer, may gradually cause their rapture.

With the same mechanism, there may be caused a flow from other areas as well, which by their nature are thin and weak.  In this case the history of the patient does not show any event which could explain this turnout.  Another possible cause may be serious obesity which recent studies relate to an increased pressure of the cerebrospinal liquid.  Also, we may be led to such a hypothesis by symptoms which may be caused by an increased pressure of the cerebrospinal liquid, such as headaches, distortions in vision, humming in the ears etc.

Other symptoms, on the other hand, may lead to a possible development of growths or neoplasm in the nasal cavity or the brain.  The patient’s mention of difficulty in breathing from a nostril or of smelling disorders may be indicative of the fact that the leaking of the cerebrospinal liquid is associated with the development of neoplasia in the area.

The clinical examination may not reveal any pathological findings.  The main examination is the endoscopy of the nose.  It is rather unlikely to find the spot of leaking, unless this is due to meningocele or some other lesion.  Nevertheless, endoscopy will give us useful information which will help us to design the surgical operation which will follow.

The patient is advised to collect a sample of the liquid.  This sample will be sent to a specialized biochemical laboratory, in order to be verified that it is indeed cerebrospinal liquid.

It is, of course, vital for the treatment of cerebrospinal rhinorrhea to identify the spot of leaking.  The main examination in this effort of ours is CT.  We believe that this examination has to have certain specifications.  To begin with, before the examination the patient must receive cortisone and possibly antibiotics, so that the paranasal sinuses are as clean as possible, with the exception of that in which cerebrospinal liquid is collected.  Shortly before the examination, the patient is advised to perform those movements which he/she has identified to increase the flow of cerebrospinal liquid.  Finally, the CT must be done with very fine cuts and the possibility of three-dimensional reconstruction of high resolution.  As we have mentioned, the flow of cerebrospinal liquid is usually very small and thus the bone fracture, which we seek, is of the length of very few millimeters.

The same procedure and similar specifications also characterize the MRI which is a   very important examination as well.  In the MRI the bones are not shown, we can, however, see the traces of the cerebrospinal liquid in the area of leakage.

Despite the imaging examination, the spot of the leakage may remain undetected.  For such cases, but others also, the surgical treatment is helped by the injection of fluorescein into the subdural area.  Fluorescein colors the cerebrospinal liquid yellow-green, a fact that facilitates its tracing, especially if the special blue filter is also used.

The endoscopic, endonasal treatment of cerebrospinal rhinorrhea is the procedure of choice. The operation is done under general anesthesia and is perfectly tolerable by the patient.  Hospitalization usually lasts for two days and in many cases we do not apply tamponing of the nose.  A series of grafts have been proposed as suitable for the sealing of the leaking.  As more common, and which we use in our cases too, are considered the nasal mucosa, the fat tissue and the fascia lata.  The kind of graft and the way of its application mainly depend on the dimensions of the bone deficit.   In addition, fibrin glue has been recommended and is used as sealing.