Saturday, December 17, 2016

CSF rhinorrhea and meningitis treatment

Today I was asked a question in ENT viva that- in a patient of CSF rhinorrhea due to traumatic aetiology, what measures will you take to prevent the onset of meningitis and how will you manage the condition?


The answer to this was prophylactic antibiotics and acetazolamide along with other measures so as to reduce the pressure. But that got me thinking because the antibiotics are not much effective in preventing the onset of meningitis in the cases of non- surgical traumatic CSF rhinorrhea. So what should be the correct way to manage the case?

Management of CSF rhinorrhea (conservative) -
                           > Bed rest, head elevation
                           > Avoid coughing, sneezing, nose blowing
                           > Lumbar puncture
                           > stool softeners

All the above measures are associated with a high incidence of ascending meningitis.

Basically, prophylactic antibiotics (broad- spectrums: ampicillin, 3rd generation cephalosporins, vancomycin) are prescribed because the communication between sterile (intracranial vault) and non- sterile (sinonasal cavity) environments results in spread of infection to the sterile environment. However, recently many randomized control trials and case- control studies have shown that prophylactic treatment with antibiotics after fracture of base of skull (due to trauma) is not effective in decreasing the risk of ascending meningitis which may be caused by Streptococcus pneumoniae (most common). In conclusion, perioperative use of antibiotics is beneficial and is indicated for surgical repair of CSF leaks. In case of bacterial rhinosinusitis and grossly contaminated intracranial cavity, antibiotic treatment is a must.

Also, no doubt acetazolamide, a diuretic plays role in decreasing CSF pressure by reducing the concentration of hydrogen ions and thus decreased efflux of water into CSF. But it also leads to harmful metabolic and electrolyte disturbances. Thus it may worsen the situation!

Lumbar drainage (5-10ml per hour) is generally indicated in this case as a method of CSF diversion. It decreases CSF pressure and is recommended in case of skull base defects and iatrogenic leaks. However, it is contraindicated if there is raised intracranial pressure (trauma) which may increase the risk of meningitis.

Surgical management
Persistent csf leaks for 7 days or more inspite of conservative management is a sure- shot indication of surgical repair of defects. In such cases, conservative treatment may be associated with a higher incidence of meningitis (8-10 fold rise).
The use of prophylactic antibiotics in traumatic cases during endoscopic sinus surgery is a must because of the underlying sinus infection and inflammatory pathology. 

Approaches for surgical treatment and prophylaxis:
1. Intracranial approach (high failure rates)
2. External approach
3. Transnasal approach
4. Endoscopic sinus surgery (endonasal approach)


Thats all

- Jaskunwar Singh

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