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African Journal of Health Sciences
The Kenya Medical Research Institute (KEMRI)
ISSN: 1022-9272
Vol. 13, Num. 3-4, 2006, pp. 78-80
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African Journal of Health Sciences, Vol. 13, No. 3-4, July-Dec, 2006, pp. 78-80
Spontaneous closure of traumatic CSF otorrhoea following conservative management
Akeem O. Lasisi1, Mohammed A. Kodiya², David O. Udoh3
1. College of Medicine, University of Ibadan, P.O. Box 22040, Ibadan, Nigeria, Department of otorhinolaryngology, 2. College of Medicine, ,University of Ibadan. Neurosurgery Unit; 3. College of Medicine, University of Ibadan, Department of Surgery
*Author for Correspondence. Email: sakeemng@yahoo.com
Code Number: jh06032
SUMMARY
We present a 40 year-old male who sustained a head injury with left cerebrospinal fluid otorrhoea following a road traffic accident. Plain radiograph revealed a defect in the temporal bone extending in to the tympanomastoid area. Patient was managed conservatively with closure of the fistula and resolution of the leakage within 8 days after injury. We report this to further buttress the role of conservative management in CSF fistula.
Introduction
The commonest cause of CSF fistulae is trauma to
the skull base. Head trauma accounts for 50-80% of
all cases of CSF leak, and up to 16% are iatrogenic.
CSF otorrhoea complicates 6% - 30% of basilar skull
fractures [1, 2]. The management is dependent on
history, confirmation of CSF and identification of
bony defect. The treatment may be conservative or
surgical, the goal is repair of meningeal tears and
underlying bone defects [1-4]. Spontaneous healing
of CSF otorrhoea has been reported in 90% of cases
following conservative management [1-4]. We
hereby report a case of spontaneous closure following
conservative management of traumatic CSF
otorrhoea in a young African male.
Case summary
A 40 years old male, right handed Nigerian battery
charger presented to the Accident and Emergency
department of our hospital with a 6 day history of
watery left otorrhoea and hearing impairment
following a road traffic accident. He was riding a
motor bicycle when a fast moving vehicle knocked
him down; this was followed by a bloody left
otorrhoea and loss of consciousness. He regained
consciousness within 24 hours although bloody
otorrhoea continued, which later turned to clear,
colourless fluid. There was no evidence of bleeding
from other craniofacial orifices. He was referred to
our centre after 5 days of injury.
Examination revealed a conscious and welloriented
adult with a Glasgow Coma Scale score of
15/15. The left ear showed clear colourless fluid, filling the left concha. The tuning fork showed a left
conductive hearing loss. The facial nerves were
intact; and the right ear; nose and throat were normal.
There were healing abrasions and lacerations on the
face and a sutured left fronto-parietal injury. Plain
radiograph of the temporal bone reveals fracture line
extending through the lteral waal of the petrous bone
extending through the tegmen tympani into the
middle ear.
Patient was started on antibiotic and tetanus
prophylaxis; and a clean piece of gauze was left in
the concha area of the left pinna to soak the effluent.
He was nursed head – up position and advised to stop
or minimize action that can increase intravenous
pressure such as coughing, sneezing or bearing down.
Gradual reduction in the volume of the effluent was
observed on day 1 and 2, until day 3 (8 days post
trauma) when the concha was largely dry with only a
drop found around the opening of the external
auditory canal.
Discussion
Traumatic CSF fistulae have been described since the
middle ages. Willis was reported to be the first to
record instance of CSF fistula in 1676 [3] and Walter
Dandy was credited with the first successful repair of
traumatic dural laceration secondary to basilar skull
fracture [4]. Leakage through an enlarged
labyrinthine facial nerve canal and enlarged
geniculate fossa has been reported [5]. Other sites
include fractures of the petrous temporal bone,
developmental defects of the tegmen tympani or
petrous apex with meningocele formation and spontaneous or posttraumatic meningeal laceration, translabyrinthine fistula due to the Mondini developmental defect of the cochlear modiolus and/or lamina cribrosa, wide cochlear aqueduct syndrome and perilymphatic fistula from trauma with stapes fracture and torn round or oval window membrane [6-8]. Diagnosis of CSF otorrhoea is dependent on good history, physical examination and radiologic investigations.
In the background of head injury, a clear colourless fluid in the ear is suggestive of CSF otorrhoea. However, simple demonstration of glucose in the fluid using glucostix and absence of stickening of the handkerchief may strengthen the diagnosis of CSF [5, 6-9]. Radiology plays an important role in confirming the site, size and aetiology of the leakage. CT Scan demonstrates the fracture site that overlies the traumatic leak and provides information about the adjacent brain parenchyma. Intrathecal Fluorescein is the most accurate method of localizing site of leak, however it is associated with complications like transverse myelitis and allergic reactions [10]. Nuclear studies using radioisotopes e.g. iodine I131, radio iodinated serum albumin (RISA), Ytterbium YB169 diethylenetriamine penta acetic acid (DTPA), indium In 111 DTPA, technetium Tc 99m human serum albumin, and technetium Tc99 pertechnetate has been documented. Despite relative safety, they have limitations with false positive results of up to 33% [5–9]. Digital subtraction cisternography is useful when the conventional methods fail to identify the site of leak. Diagnostic yield may be improved by injection of metrizamide or omnipague [7-10]. A brisk CSF leakage may be demonstrated by MRI, it is however, not typically recommended for evaluation due to poor bone defect demonstration. The management could be conservative or surgical. Fifty to eighty-five percent of traumatic CSF leaks resolve spontaneously within 7 days, and almost all leaks cease within 6 months of conservative management [6-11].
It consists of measures to reduce CSF pressure to allow for approximation of dural tear and induction of healing by primary intention. This includes bed rest with patient in head - up position and avoidance of coughing, sneezing and heavy lifting. Therapeutic reduction of the spinal fluid production using agents such as acetazolamide and frusemide and repeated removal of CSF via lumbar tap or an indwelling catheter has also been tried with minimal success [10-12]. Laxatives have been used to decrease raised intracranial pressure associated with bowel movement [7]. Spontaneous closure observed with CSF otorrhoea has been explained to be due to the rich arachnoid mesh in the middle and posterior fossa area. However the period of waiting is arbitrary and this often requires close cooperation between neurosurgeons, neuroradiologist and otolaryngologist. A waiting period between 5 days and 8 weeks has been reported [7-12]. Posttraumatic CSF fistulas persisting beyond 7 days, spontaneous CSF leaks with skull-base defects, increasing pneumocephalus, and meningitis are positive indications for surgical intervention. Extracranial and endoscopic repair by the otolaryngologist has been reported, however, open craniotomy with intradural repair is necessary for large skull-base defects [10-13]. Prophylactic antibiotics used in this patient seem to be the widely accepted practice. This is to prevent the occurrence of infection, particularly meningitis. Meningitis has been reported in 25-50% of untreated traumatic CSF fistulas and in 10% of patients in the first week after trauma with head injury [10-12]. However, we were able to prevent this in the patient and hence successfully discharged for follow – up in the outpatient clinic.
Conclusion
This case has further reinforced the success of conservative management of CSF fistula, particularly otorrhoea, however, meticulous care is needed with proper application of guidelines in the management of skullbase defect.
References
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