6) Moreover, the lacrimal secretion can also be tested even if the concentration is less than 5 mg/dL. However, it is only to be used as reference as it has high false positive and negative rates depending on the patients' other medical conditions. Nasal discharge has a normal concentration of 10 mg of glucose, thus, if the glucose test is negative then it can be ruled out. In general, the glucose oxidase strips show positive result when the sample has a concentration over 20 mg/dL. Glucose oxidized test: The CSF glucose from nasal or ear secretions has long been a classical method in testing CSF leak. Handker chief test: When the discharge from the nose is buried in a handkerchief or dry gauze, the CSF is more likely to be clear if it is not sticky The Handker chief test is a test to determine the nasal discharge, which is unclear and sticky due to mucin secretion from the nose. This is called a target sign, a double ring sign, or a Halo sign Target sign: When the CSF is mixed with a blood or nasal discharge, the CSF moves away on the filter paper, and the blood moves closer, so two rings are visible. Early detection of CSF leak will be critical for the patient in order to prevent possible bacterial meningitis and intracranial abscess formation. High-pressure type is a symptom in which headache continues to increase and relived when CSF was drained out. The headache could be classified as a high pressure type and low pressure type. Most patients of the CSF leakage complained of headache. There may also be a ‘Reservoir sign’ in which the CSF goes out when taking a head up position in the lying position. Patients may experience a salty taste or may have ear fullness or hearing loss. Furthermore, other otolaryngeal diseases must be differentiated such as allergic rhinitis or vasomotor rhinitis prior to the diagnosis of CSF leak.
The clear and non-mucoid fluid drainage from nose and ear can be presented with mixed nature of bleeding, however, this can be further tested for a ‘double-ring’ or ‘halo’ sign on a filter paper. 14) If the patient is alert, a complaint of the salty postnasal drip is presented. The most common clinical symptom is the leak of clear and watery drainage from the nose and ear with a positional dependency. 4, 11)Ĭlinical presentation: symptoms and signs The decision of whether to observe or to surgically intervene is most likely to be dependent on the cause, site of leak, and timing of the leak. Thus, early detection of CSF leaks is important as it determines the outcome of the patient. 12) The traditional treatment involves intravenous antibiotics treatment as well as primary repair of dural defect if the definite injury is suspected. Except the cases with spontaneous diseases, traumatic CSF leak can be potentially detrimental with various complications such as bacterial meningitis if not self-resolved. 22, 28) The risk of meningitis from the traumatic CSF leak can present with high morbidity and even mortality depending on the cause and site of CSF leak. Post-traumatic CSF leaks are seen 1% to 3% of all closed traumatic brain injuries (TBI) in adults and 80% to 90% of all the causes of CSF leaks in adult patients are due to head injuries. After severe craniomaxillofacial trauma, the destruction of the meningeal structure may lead to the CSF leak from the subarachnoid space. It is produced at choroid plexus and a total volume of 140 mL are actively circulating and turned over daily. Cerebrospinal fluid (CSF) is a physiologic fluid for protecting brain and maintaining intracranial pressure (ICP).
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