Diagnosis in persistent cerebrospinal fluid fistulas

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Abstract
Cerebrospinal fluid (CSF) rhinorrhea and otorrhea have presented difficult problems in both diagnosis and management; moreover, the threat of impending meningitis necessitates early localization of the source of the leak.The most common techniques for evaluation and isolation of CSF rhinorrhea and otorrhea have included X‐ray studies, intrathecal dyes, and radioactive cisternography. These studies, although useful, have not always demonstrated the area of the leak. Roentgenographic evaluations, including tomography, often have not isolated the fracture or defined the area of fluid accumulation. Dyes, consisting of methylene blue, Evans blue and fluorescein, injected intrathecally and recovered on nasal pledgets, have been used by a number of investigators with variable success. Radioactive tracers and cisternography used to isolate CSF fistulas, also on occasion have yielded inaccurate data.These various difficulties in diagnosis suggested a more recent review of the subject. To evaluate the efficacy of tomography, intrathecal tracers and cisternography, seven patients with persistent CSF otorrhea or rhinorrhea, and one patient with combined otorrhea and rhinorrhea were evaluated from Januaryy, 1970 to 1975. Analysis of the procedures revealed variable and inconsistent results. Problems were related to placement and removal of pledgets, positioning of the patient and different volumes and rates of flow. The difficulties encountered with the conventional diagnostic techniques were exemplified in one particular patient with multiple fistulas requiring one extracranial and several intracranial procedures for correction. A standard protocol applying X‐rays, tomography, intrathecal tracers with intranasal pledgets and cisternography is offered.

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