xRead - September 2022

Cerebrospinal Fluid Rhinorrhea and Otorrhea

185

Fig. 26. Pitfall: meningoceles can be multifocal and present with a canal-like appearance, particularly in the setting of IIH, with linear tracts connecting different areas of meningoceles, as in this patient with a meningocele in the left middle ear, medial to ossicles seen on Coronal temporal bone CT (A) and T2w MRI images (B). This me ningocele communicated via a tract to the region of the geniculate ganglion ( arrows ), a finding that was confirmed intraoperatively. Identifying the entire course of the meningocele is important to minimize the poten tial for recurrence postoperatively.

labor-intensive thorough investigation of the skull base on multiple modalities. It is important to have an algorithm for the approach to this chal lenging clinical problem, to be aware of potential pitfalls in imaging these patients, and to focus on what surgeons need to know to guide appropriate surgical planning.

Performing lumbar punctures for cisternogra phy on obese patients (commonly encoun tered in IIH) may be technically challenging. A standard-length 89-mm (3.5-inch) spinal needle is used to access the thecal sac in most patients. In obese patients, 127-mm (5-inch) and 178-mm (7-inch) needles may be needed; however, these can become diffi cult to steer. In these cases, clinicians can use an 18-gauge 89-mm needle to guide the longer needle using a coaxial technique. All of the following information should be included in the imaging reports of these patients, if possible: Location and size of defects measured in mul tiple planes; scrutinize entire skull base, including sinuses and mastoids. Anatomy of sinonasal cavity (ie, nasal septal deviation, perforation, variants) for surgical planning/approach. Presence of associated meningoencephalo celes (may need MR cisternogram). Presence of imaging features suggestive of underlying IIH. Sites that are actively leaking. Entire course of meningocele tract (heavily T2w images and CT). Opening pressure, if performing cisternogra phy. However, keep in mind that it is common for the opening pressure to be normal or only borderline increased in patients with IIH in the setting of an ongoing leak. WHAT SURGEONS WANT TO KNOW

REFERENCES

1. Daudia A, Biswas D, Jones NS. Risk of meningitis with cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol 2007;116(12):902–5. 2. Miner JR, Heegaard W, Mapes A, et al. Presentation, time to antibiotics, and mortality of patients with bac terial meningitis at an urban county medical center. J Emerg Med 2001;21(4):387–92. 3. Komotar RJ, Starke RM, Raper D, et al. Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a sys tematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013;74(4):239–50. 4. Sharma S, Kumar G, Bal J, et al. Endoscopic repair of cerebrospinal fluid rhinorrhoea. Eur Ann Otorhino laryngol Head Neck Dis 2016;133(3):187–90. 5. Locatelli D, Rampa F, Acchiardi I, et al. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 2006;58(4):ONS-246–56. 6. Ommaya AK, Di Chiro G, Baldwin M, et al. Non-trau matic cerebrospinal fluid rhinorrhea. J Neurol Neuro surg Psychiatr 1968;31(3):214–25. 7. Schlosser RJ, Wilensky EM, Grady MS, et al. Elevated intracranial pressures in spontaneous ce rebrospinal fluid leaks. Am J Rhinol 2003;17:191–5. 8. Oakley GM, Alt JA, Schlosser RJ, et al. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhi nol 2016;6:8–16.

SUMMARY

The work-up of CSF rhinorrhea and otorrhea can be complex, often requiring a time-intensive and

Downloaded for Anonymous User (n/a) at STANFORD UNIVERSITY from ClinicalKey.com by Elsevier on July 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.