Journal of Neuro-Ophthalmology, June 2013, Volume 33, Issue 2

Spontaneous Cerebrospinal Fluid Otorrhea and Rhinorrhea in Idiopathic Intracranial Hypertension Patients

Spontaneous cerebrospinal fluid (CSF) leakage may occur in patients with normal or increased intracranial pressure (ICP). We describe herein spontaneous CSF leakage as a result of chronic increased ICP in 4 patients with idiopathic intracranial hypertension (IIH). Although rhinorrhea previously has been described in IIH patients, to our knowledge this is the first report of otorrhea in these patients. Four patients with spontaneous CSF leakage were examined between 2001 and 2011; 3 presented with rhinorrhea and 1 with otorrhea. Clinical settings and manifestations were analyzed. All patients were found to have IIH. Three had been diagnosed with IIH several years earlier and had been noncompliant with their medical treatment, whereas in 1 patient, CSF rhinorrhea was the presenting symptom of IIH. CSF leak is a rare complication in IIH patients. We have shown that rhinorrhea can be the presenting sign in these patients and that rhinorrhea and otorrhea can be a late sign of the disease.

Spontaneous Cerebrospinal Fluid Otorrhea and Rhinorrhea in Idiopathic Intracranial Hypertension Patients Eldar Rosenfeld, MD, Gad Dotan, MD, Tali J. Kimchi, MD, Anat Kesler, MD Background: Spontaneous cerebrospinal fluid (CSF) leakage may occur in patients with normal or increased intracranial pressure (ICP). We describe herein spontaneous CSF leakage as a result of chronic increased ICP in 4 patients with idio-pathic intracranial hypertension (IIH). Although rhinorrhea previously has been described in IIH patients, to our knowledge this is the first report of otorrhea in these patients. Methods: Four patients with spontaneous CSF leakage were examined between 2001 and 2011; 3 presented with rhinorrhea and 1 with otorrhea. Clinical settings and manifestations were analyzed. Results: All patients were found to have IIH. Three had been diagnosed with IIH several years earlier and had been noncompliant with their medical treatment, whereas in 1 patient, CSF rhinorrhea was the presenting symptom of IIH. Conclusion: CSF leak is a rare complication in IIH patients. We have shown that rhinorrhea can be the presenting sign in these patients and that rhinorrhea and otorrhea can be a late sign of the disease. Journal of Neuro-Ophthalmology 2013;33:113-116 doi: 10.1097/WNO.0b013e18274b870 © 2012 by North American Neuro-Ophthalmology Society Cerebrospinal fluid (CSF) leakage is a rare complication of idiopathic intracranial hypertension (IIH). We describe four patients with this disorder. Although rhinorrhea previously has been reported in patients with this disorder, we describe three additional patients with IIH & CSF rhinorrhea, one as the initial chief complaint, and the others later in the clinical course. We also describe one patient with IIH who developed CSF otorrhea, and we are unaware of other reports of this association. MATERIALS AND METHODS Medical records, including patient history, examination find-ings, and neuroimaging results of four IIH patients who developed CSF leaks were reviewed. All patients were treated at the same medical institution and examined by the same neuro-ophthalmologist (AK). This study was performed in accordance with the principles set out in the Declaration of Helsinki. CASE REPORTS Case 1 A 48-year-old Caucasian woman with a body mass index (BMI) of 42 presented with headaches and transient visual obscurations of 2-month duration. Computed tomography (CT) of the brain was normal. For approximately 4 months, she noted a clear fluid discharge from the left nostril and occasionally, after an overnight sleep, her pillow was wet. Evaluation by an otolaryngologist was unremarkable. Because of persistent headaches, she was sent to a neuro-ophthalmologist, who found bilateral papilledema on examination. Lumbar puncture (LP) revealed an opening pressure of 280 mm of water, with normal CSF composi-tion. The patient was diagnosed with IIH and was treated with acetazolamide. Fluid collected from her nostril was found to be positive for beta-2 transferrin. Magnetic resonance imaging (MRI) of the brain revealed an encephalocele descending from the cribriform plate (Fig. 1). The patient underwent an endo-nasal reconstruction of the bony defect with a nasoseptal flap. Within 1 week, her symptoms and CSF rhinorrhea resolved. With weight loss (12 kg) and acetazolamide, there was gradual resolution of papilledema. Case 2 A 35-year-old Caucasian woman with a BMI of 39 had been diagnosed 9 years earlier with IIH. Since then, she had Neuro-Ophthalmology Unit, Department of Ophthalmology (ER, GD, TJK, AK) and Neuroradiology Unit (ER, GD, TJK, AK), Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. The authors report no conflicts of interest. Address correspondence to Eldar Rosenfeld, MD, Neuro-Ophthalmology Unit, Department of Ophthalmology, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel; E-mail: [e-mail] Rosenfeld et al: J Neuro-Ophthalmol 2013; 33: 113-116 113 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. been poorly compliant with treatment. She had a history of recurrent sinusitis, and 3 years previously, she experienced 2 episodes of tonic-clonic seizures. At that time, brain CT and computed tomographic venography (CTV) were unremark-able. She had normal visual function but bilateral papilledema. During routine follow-up, the patient complained of exacerbation of headaches and the appearance of a watery discharge from her nose. CT revealed an eroded cribriform plate, with an encephalocele and CSF in the left nasal cavity. The nasal fluid was positive for beta-2 transferrin. The patient underwent an endonasal closure of the eroded cribriform plate and was maintained on acetazol-amide. CSF rhinorrhea and headache promptly resolved. Case 3 A 42-year-old Caucasian woman with a BMI of 25 had been diagnosed 4 years earlier with IIH. At that time, she had normal neuroimaging, and on LP, the opening pressure was 270 mm of water. Because of allergic reactions to acetazolamide and topiramate, she was treated with furosemide. On a follow-up visit, the patient reported a clear fluid discharge from her nose for the past 3 weeks. She had been examined by an otolaryngologist, who found no abnormality and recommended a decongestant nasal spray. However, her neuro-ophthalmologist had the nasal fluid tested for beta-2 transferrin, and it was found to be present. While brain CT was unremarkable, MRI revealed CSF leakage in the region of the left cribriform plate. The patient underwent lumboperitoneal shunt surgery, with prompt resolution of CSF rhinorrhea and headaches. Case 4 A 44-year-old Caucasian woman with a BMI of 33 had undergone gastric bypass surgery 13 years previously. Two years later, she was diagnosed with IIH, following pre-sentation with headaches and bilateral papilledema. At that time, MRI of the brain was normal, and opening pressure on LP was 370 mm of water, with normal CSF constitu-ents. Treatment with acetazolamide was begun. During follow-up, the patient was noncompliant, often discontinuing her medication and gaining weight. She occasionally complained of tinnitus and transient visual obscurations, but her visual function remained stable. Repeat LPs revealed opening pressures as high as 410 mm of water. Eleven years after being diagnosed with IIH, the patient began complaining of fullness, pain, and autophonia in the left ear. MRI and magnetic resonance venography did not show any interval changes. She was examined by an otolaryngologist and was treated with antibiotic drops for mild left otitis. Because of lack of improvement over the next 2 weeks, she was reexamined by the same otolaryngologist, who found fluid and air in her left middle ear, as well as pulsatile movement of the tympanic membrane. Additional neuroimaging studies confirmed a CSF leak into the left middle ear (Fig. 2). Fluid from the ear was collected and was found to contain beta-2 transferrin. The patient underwent a lumboperitoneal shunt, with resolution of her headaches, autophonia, and the sensation of left ear fullness. During follow-up, she has remained stable. DISCUSSION Spontaneous CSF leakage occurs in patients without a history of head trauma, sinus surgery, or craniotomy (1). Such leaks occur with approximately equal frequency in the settings of normal and increased ICP (2). The most FIG. 1. Case 1. Coronal T2 MRI shows an encephalocele (arrow) descending from the anterior cranial fossa through the cribriform plate. FIG. 2. Case 4. A. Coronal T2 MRI demonstrates a small encephalocele (arrow) surrounded by cerebrospinal fluid (arrow-head). B. Coronal reconstructed computed tomography with bone settings reveals dehiscence of the floor of middle cranial fossa (white arrow) overlying the middle ear. The floor of the right middle cranial fossa (black arrow) is intact. 114 Rosenfeld et al: J Neuro-Ophthalmol 2013; 33: 113-116 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. common causes of increased ICP are intracranial tumors, hydrocephalus, and IIH. Table 1 summarizes previous reports of patients with IIH who developed a CSF leak. Many had received medical therapy, including weight loss, acetazolamide, diuretics, cor-ticosteroids, multiple LPs, and some had undergone a CSF diversion procedure. Once identified, not all had resolution of their CSF leakage following initial surgery. In addition, there are other reports of patients presenting with a CSF leak, yet the diagnosis of IIH had not been established. These patients had clinical features such as high BMI and neuroimaging abnormalities, including empty sella, making the diagnosis of IIH likely. Most patients experi-enced CSF rhinorrhea (11-14), a few experienced CSF otor-rhea (15,16), some experienced both (17), and other studies did not mention the location of the leak (18,19). The basic cause of CSF leak is disruption in the arachnoid and dura mater, coupled with an osseous defect, and a CSF pressure gradient that is continuously or intermittently greater than the tensile strength of the disrupted tissue (20). Disruption of the barrier between the sinonasal cavity and the anterior and middle cranial fossae can lead to the discharge of CSF into the nasal cavity. Otorrhea may be serous, serosanguineous, or purulent. Associated symptoms include ear pain, fever, vertigo, tinni-tus, and hearing loss. The resulting communication within the central nervous system can lead to a multitude of infec-tious complications, with significant morbidity, potenti-ally disastrous long-term neurologic deficits, and even death (21). When serous discharge from the ear or nose is considered to be CSF, the initial diagnostic test is examination of the fluid for the presence of beta-2 transferrin. This is a carbohydrate-free isoform of transferrin produced by cerebral neuro-transaminase from beta-1 transferrin by desialization. This substance is present only in the CSF, perilymph, and vitreous of the eye (22,23). Localization of the bony defect is the second diagnostic step. High-resolution CT is considered the method of choice for evaluating the bony integrity of the skull base (24). Arachnoid pits, secondary to bony impressions from the arachnoid villi at the base of the skull, are present in 63% of patients with spontaneous CSF leakage (25). The lateral recess of the sphenoid bone and the ethmoid roof are also common sites of skull base dehiscence (26,27). The initial step in repairing a CSF leak is to lower the ICP, if possible before repair of the site of CSF leakage. Lumboperitoneal or ventriculoperitoneal shunt procedures are generally performed. In some patients, the fistula may not close completely after a shunt procedure, and the patient may be exposed to increased risk of infection because the pressure gradient across the fistula has been reversed. In cases of rhinorrhea where the fistula has not closed and the ICP is controlled by the shunt, surgical repair can be undertaken, either by intracranial and extracranial endoscopic approaches. Extracranial techniques carry reduced morbidity compared to intracranial repair (5,28). In cases of CSF otorrhea, the tegmen mastoideum and tegmen tympani are the most common locations of middle fossa defects. A craniotomy gives maximum exposure to the entire floor of the middle cranial fossa, including defects adjacent to the zygomatic root and over the internal auditory canal. A transmastoid approach is appropriate for posterior fossa and tegmen mastoideum defects. Successful TABLE 1. Reported cases of spontaneous CSF rhinorrhea in patients with IIH Reference Patient/Age/Sex Treatment Outcome Brisman et al (3) 44/F Craniotomy with bilateral cribriform plate repair Resolved Eljamel and Foy (4) Patient 1 Craniotomy Resolved Patient 2 L-P shunt Persistent rhinorrhea Tolley and Brookes (5) 41/F NR NR Clark et al (6) 33/F L-P shunt Intermittent CSF rhinorrhea 44/F L-P shunt Resolved 42/F Craniotomy Resolved 34/F Craniotomy Resolved Camras et al (7) 46/F VP shunt and craniotomy Owler et al (8) 38/F Craniotomy; L-P shunt; right transverse sinus stent Resolved Schlosser et al (9) Eight patients Extracranial repair of sinusoidal skull base defect Resolved Suryadevara et al (10) 45/F Craniotomy, with repair of right cribriform plate Resolved CSF, cerebrospinal fluid; IIH, intracranial hypertension; L-P, lumboperitoneal; NR, not reported; VP, ventriculoperitoneal. Rosenfeld et al: J Neuro-Ophthalmol 2013; 33: 113-116 115 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. repair is achieved in most cases using autologous materials and alloplastic bone cement (17). In conclusion, the clinician should be aware of CSF leak as a rare complication of IIH. Because most patients do not relate a clear fluid discharge from the nose or ear with their IIH, they usually do not provide this information. Initial patient evaluation includes analysis of the fluid discharge for the presence of beta-2 transferrin. Maxillofacial and brain neuro-imaging with CT or MRI is essential, carefully searching for a defect of the skull base. Optimal therapy includes lowering of ICP and surgical repair of the bony defect. REFERENCES 1. Ransom ER, Komotar RJ, Mocco J, Connolly ES, Mullins KJ. Shunt failure in idiopathic intracranial hypertension presenting with spontaneous cerebrospinal fluid leak. J Clin Neurosci. 2006;13:598-602. 2. Ramsden JD, Corbridge R, Bates G. Bilateral cerebrospinal fluid rhinorrhoea. J Laryngol Otol. 2000;114:137-138. 3. Brisman R, Hughes JEO, Mount LA. Cerebrospinal fluid rhinorrhea. Arch Neurol. 1970;22:245-262. 4. Eljamel MSM, Foy PM. Non-traumatic CSF fistulae; clinical history and management. Brit J Neurosurg. 1991;5: 275-279. 5. Tolley NS, Brookes GB. Surgical management of cerebrospinal fluid rhinorrhea. J R Coll Surg Edinb. 1992;37:12-15. 6. Clark D, Bullock P, Hui T, Firth J. Benign intracranial hypertension: a cause of CSF rhinorrhoea. J Neurol Neurosurg Psychiatry. 1994;57:847-849. 7. Camras LR, Ecanow JS, Abood CA. Spontaneous cerebrospinal fluid rhinorrhea in a patient with pseudotumor cerebri. J Neuroimaging. 1998;8:41-42. 8. Owler BK, Allan R, Parker G, Besser M. Pseudotumour cerebri, CSF rhinorrhoea and the role of venous sinus stenting in treatment. Br J Neurosurg. 2003;17:79-83. 9. Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE. Spontaneous cerebrospinal fluid leaks: a variant of benign intracranial hypertension. Ann Otol Rhinol Laryngol. 2006;115:495-500. 10. Suryadevara AC, Faltal M, Woods CI. Nontraumatic cerebrospinal fluid rhinorrhea as a result of pseudotumor cerebri. Am J Otolaryngol. 2007;28:242-246. 11. Banks CA, Palmer JN, Chiu AG, O'Malley BW Jr, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg. 2009;140:826-833. 12. Saifudheen K, Gafoor A, Arun G, Abdurahiman P, Jose J. Idiopathic intracranial hypertension presenting as CSF rhinorrhea. Ann Indian Acad Neurol. 2010;13:72-73. 13. Seth R, Rajasekaran K 3rd, Luong A, Benninger MS, Batra PS. Spontaneous CSF leaks: factors predictive of additional interventions. Laryngoscope. 2010;120:2141-2146. 14. Yang Z, Wang B, Wang C, Liu P. Primary spontaneous cerebrospinal fluid rhinorrhea: a symptom of idiopathic intracranial hypertension? J Neurosurg. 2011;115:165-170. 15. Prichard CN, Isaacson B, Oghalai JS, Coker NJ, Vrabec JT. Adult spontaneous CSF otorrhea: correlation with radiographic empty sella. Otolaryngol Head Neck Surg. 2006;134:767-771. 16. Goddard JC, Meyer T, Nguyen S, Lambert PR. New considerations in the cause of spontaneous cerebrospinal fluid otorrhea. Otol Neurotol. 2010;31:940-945. 17. Kutz JW Jr, Husain IA, Isaacson B, Roland PS. Management of spontaneous cerebrospinal fluid otorrhea. Laryngoscope. 2008;118:2195-2199. 18. Schlosser RJ, Wilensky EM, Grady MS, Bolger WE. Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol. 2003;17:191-195. 19. Silver RI, Moonis G, Schlosser RJ, Bolger WE, Loevner LA Radiographic signs of elevated intracranial pressure in idiopathic cerebrospinal fluid leaks: a possible presentation of idiopathic intracranial hypertension. Am J Rhinol. 2007;21:257-261. 20. Wang EW, Vandergrift WA 3rd, Schlosser RJ. Spontaneous CSF leaks. Otolaryngol Clin North Am. 2011;44:845-856. 21. Kevin C. Welch, Medscape references, drugs, diseases and procedures. Available at: http://emedicine.medscape.com/ article/861126. Accessed May 21, 2012. 22. Ridley F. The intraocular pressure and drainage of aqueous humor. Br J Exp Path. 1930;11:214-250. 23. Papadea C, Schlosser RJ. Rapid method for beta2-transferrin in cerebrospinal fluid leakage using an automated immunofixation electrophoresis system. Clin Chem. 2005;51:464-470. 24. Zuckerman JD, DelGaudio JM. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks forendoscopic repair. Am J Rhinol. 2008;22:151-154. 25. Shetty PG, Shroff MM, Fatterpekar GM, Sahani DV, Kirtane MV. A retrospective analysis of spontaneous sphenoid sinus fistula: MR and CT findings. AJNR Am J Neuroradiol. 2000;21:337-342. 26. Kirtane MV, Gautham K, Upadhyaya SR. Endoscopic CSF rhinorrhea closure: our experience in 267 cases. Otolaryngol Head Neck Surg. 2005;132:208-212. 27. Schlosser RJ, Bolger WE. Management of multiple spontaneous nasal meningoencephaloceles. Laryngoscope. 2002;112:980-985. 28. Woodworth BA, Prince A, Chiu AG, Cohen NA, Schlosser RJ, Bolger WE, Kennedy DW, Palmer JN. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg. 2008;138: 715-720. 116 Rosenfeld et al: J Neuro-Ophthalmol 2013; 33: 113-116 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.