Preoperative Topical Intranasal Fluorescein in Diagnosis of Cerebrospinal Fluid Rhinorrhea

Document Type : Original Article

Authors

1 Department of Otolaryngology, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran

3 Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

4 Poursina Hakim Digestive Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

10.4103/atr.atr_87_18

Abstract

Background and Objectives: The preoperative diagnosis of cerebrospinal fluid (CSF) leak site is necessary for the management of CSF rhinorrhea. At present, intrathecal fluorescein is a common approach for it; however, regarding drawbacks, its value is limited. This study aimed at examining the effects of topical intranasal fluorescein (TINF) on the preoperative diagnosis of CSF rhinorrhea and intraoperative localization of CSF fistula. Patients and Methods: In this cross‑sectional study, 32 consecutive patients with CSF rhinorrhea were recruited. Topical intranasal 10% fluorescein was placed in common sites of leakage, the middle turbinate meatus, the roof of the ethmoid plate, and sphenoethmoidal recesses. Change of the color of fluorescein indicated the presence of CSF, and thus, the site of the fistula could be outlined. The accuracy rates of diagnosis of leak site identified by TINF were compared with those by available imaging modalities, CSF analysis, intraoperative findings, and follow‑up. Results: The cause of the leak was traumatic in 22 patients and nontraumatic in 10 patients. Preoperative accuracy rate of the location of CSF fistula was estimated 58.3% by available imaging study. The preoperative diagnosis rate of CSF rhinorrhea and the CSF fistula site localization rate by TINF were both 100%. No recurrence was found during the follow‑up for 2–12 months. No complication had been reported. Conclusions: Preoperative TINF is an easy, quick, sensitive, safe, and accurate tool in localization of the site of the CSF fistulas and can be considered as a viable noninvasive alternative to the intrathecal fluorescein technique for preoperative diagnosis of CSF rhinorrhea.

Keywords


1. Aydin K, Terzibasioglu E, Sencer S, Sencer A, Suoglu Y, Karasu A, et al. Localization of cerebrospinal fluid leaks by gadolinium‑enhanced magnetic resonance cisternography: A 5‑year single‑center experience. Neurosurgery 2008;62:584‑9.
2. Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: The Medical College of Wisconsin experience. Laryngoscope 2004;114:969‑74.
3. Park JI, Strelzow VV, Friedman WH. Current management of cerebrospinal fluid rhinorrhea. Laryngoscope 1983;93:1294‑300.
4. Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: Critical review and surgical considerations. Laryngoscope 2004;114:255‑65.
5. Banu MA, Kim JH, Shin BJ, Woodworth GF, Anand VK, Schwartz TH. Low‑dose intrathecal fluorescein and etiology‑based graft choice in endoscopic endonasal closure of CSF leaks. Clin Neurol Neurosurg 2014;116:28‑34.
6. Kerr JT, Chu FW, Bayles SW. Cerebrospinal fluid rhinorrhea: Diagnosis and management. Otolaryngol Clin North Am 2005;38:597‑611. 7. Rice DH. Cerebrospinal fluid rhinorrhea: Diagnosis and treatment. Curr Opin Otolaryngol Head Neck Surg 2003;11:19‑22.
8. Javadi SA, Samimi H, Naderi F, Shirani M. The use of low‑ dose intrathecal fluorescein in endoscopic repair of cerebrospinal fluid rhinorrhea. Arch Iran Med 2013;16:264‑6.
9. Oh JW, Kim SH, Whang K. Traumatic cerebrospinal fluid leak: Diagnosis and management. Korean J Neurotrauma 2017;13:63‑7.
10. Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: Nine‑year experience. Neurosurgery 2006;58:246‑56.
11. Lue AJ, Manolidis S. Intrathecal fluorescein to localize cerebrospinal fluid leakage in bilateral Mondini dysplasia. Otol Neurotol 2004;25:50‑2. 12. Rodríguez‑Navarro MÁ, Díaz‑AlejoC, Padilla‑Del ReyML, AlcarazAB, González‑Pérez P, Benítez M, et al. Safe intrathecal fluorescein use for identification of cerebrospinal fluid leaks: Case‑report and perioperative algorithm description. Rev Esp Anestesiol Reanim 2017;64:533‑6.
13. Keerl R, Weber RK, Draf W, Wienke A, Schaefer SD. Use of sodium fluorescein solution for detection of cerebrospinal fluid fistulas: An analysis of 420 administrations and reported complications in Europe and the United States. Laryngoscope 2004;114:266‑72.
14. Saafan ME, Ragab SM, Albirmawy OA. Topical intranasal fluorescein: The missing partner in algorithms of cerebrospinal fluid fistula detection. Laryngoscope 2006;116:1158‑61.
15. Jones ME, Reino T, Gnoy A, Guillory S, Wackym P, Lawson W, et al. Identification of intranasal cerebrospinal fluid leaks by topical application with fluorescein dye. Am J Rhinol 2000;14:93‑6.
16. de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery 2002;51:699‑705.
17. Hegazy HM, Carrau RL, Snyderman CH, KassamA, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: A meta‑analysis. Laryngoscope 2000;110:1166‑72.
18. Liu HS, Chen YT, Wang D, Liang H, Wang Y, Wang SJ, et al. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. Surg Neurol 2009;72:341‑5.
19. Ozturk K, Karabagli H, Bulut S, Egilmez M, Duran M. Is the use of topical fluorescein helpful for management of CSF leakage? Laryngoscope 2012;122:1215‑8.
20. Ramsden JD, Corbridge R, Bates G. Bilateral cerebrospinal fluid rhinorrhoea. J Laryngol Otol 2000;114:137‑8.
21. Moseley JI, Carton CA, Stern WE. Spectrum of complications in the use of intrathecal fluorescein. J Neurosurg 1978;48:765‑7.
22. Anari S, Waldron M, Carrie S. Delayed absence seizure: A complication of intrathecal fluorescein injection. A case report and literature review. Auris Nasus Larynx 2007;34:515‑8.
23. Daele JJ, Goffart Y, Machiels S. Traumatic, iatrogenic, and spontaneous cerebrospinal fluid (CSF) leak: Endoscopic repair. B‑ENT 2011;7 Suppl 17:47‑60.
24. Chan DT, Poon WS, IP CP, Chiu PW, Goh KY. How useful is glucose detection in diagnosing cerebrospinal fluid leak? The rational use of CT and beta‑2 transferrin assay in detection of cerebrospinal fluid fistula. Asian J Surg 2004;27:39‑42.
25. Jeng S. 50 years ago in the journal of pediatrics: Diagnosis of cerebrospinal fluid rhinorrhea: Lack of specificity of the glucose oxidase test tape. J Pediatr 2017;190:48.
26. Zhu ZJ, Cheng L, Yang J, Huang Q, Meng GZ, Cao RP, et al. Clinical analysis of adult spontaneous cerebrospinal fluid rhinorrhea. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2018;32:457‑61.