Unusual posttraumatic delayed cerebrospinal fluid rhinorrhea due to gunshot wound

Abstract

Delayed posttraumatic cerebrospinal fluid rhinorrhea (CSFr) without meningitis is considered to be relatively rare. However, even years after trauma, recurrence or delayed onset of CSFr and meningitis due to CSFr are possible. In this article, a case of delayed CSFr from the sphenoid sinus without meningitis three years after the transfacial gunshot wound is reported. Plain high-resolution computed tomography sections through the sphenoid sinus showed a bone defect at the roof with CSF-density fluid extending into the sphenoid sinus. Arachnoid membrane herniation into the sphenoid sinus was found and site of CSF fistula confirmed during the surgery. Skull base defect was reconstructed through an endoscopic approach without any complications and the patient was followed up for 12 months without recurrence. The cause, timing, clinical course and location of CSFr make this an apparently unique case. Patients with a skull base defect without CSFr should be closely followed up and may need further evaluation or management due to the possibility of CSFr development. The positive diagnosis of a CSFr raises the matter of choosing the adequate surgical approach for its repair. Endoscopic closure of CSFr is both safe and effective.KeywoRds: Rhinorrhea, Delayed, Posttraumatic, Gunshot wound, Meningitis, Sphenoid sinus ÖZMenenjit olmaksızın geç dönemde gelişen posttravmatik rinore nadir görülen bir durum olmasına rağmen, travmadan sonra yıllar içinde geç dönem rinore ve buna bağlı menenjit gelişmesi mümkündür. Bu makalede, 3 yıl önce yüz bölgesinde ateşli silah yaralanması meydana geldikten sonra, menenjit olmaksızın geç dönemde ortaya çıkan bir rinore olgusu sunulmaktadır. Hastanın yapılan incelemelerinde sfenoid sinüs tavanında kemik defekti ve bu defektten beyin omurilik sıvısı (BOS) kaçışı olduğu gösterilmiştir. Cerrahi sırasında sinüs içerisine araknoid membran herniasyonu izlenmiş olup, defektten BOS kaçağı olduğu da görülmüştür. Kafa tabanındaki defekt endoskopik endonazal transsfenoidal yaklaşım ile hiçbir komplikasyon olmadan tamir edilmiş ve hastanın 12 aylık takiplerinde hiçbir rekürrens izlenmemiştir. Rinorenin nedeni, zamanı, klinik seyri ve lokalizasyonu nedeniyle bu nadir görülen bir olgu olarak kabul edilebilir. Kafa tabanı defekti olan fakat rinore gözlenmeyen hastalar ileride rinore gelişme riski nedeniyle yakın takip edilmelidir. Rinore tanısı kesinleşen hastalarda, cerrahi yaklaşım yolları arasından, endoskopik endonazal yolla yapılan onarım hem efektif hem de güvenli olarak kabul edilmektedir.

Cerebrospinal fluid leak after combat penetrating gunshot wound to the head

“…In other series where the conservative approach and continuous lumbar drain were ineffective, patients underwent surgery [14]. Described cases with manifestation of otorrhea within 48 hours of injury [11], also described cases with later manifestations of otorrhea after craniofacial injury [21].…”

An unusual cause of post traumatic cerebrospinal fluid rhinorrhoea

“…A case of delayed CSF rhinorrhoea, as long as three years after the transfacial gunshot wound, has also been reported. [4] Another case report of an extraordinarily long-term post-traumatic CSF fistula in an adult who presented with frequent clear continuous rhinorrhea and otorrhea for 5 years after basilar skull fracture and later on…”