The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea

Abstract 

Background

The CSF rhinorrhea is a kind of common clinical disease. The preoperative diagnosis and intraoperative localization of CSF fistulas are critical to treatment of CSF rhinorrhea. At present, intrathecal fluorescein regarding endoscopic transnasal cerebrospinal leakage repair is a common method for localization of the fistula; however, it has some disadvantages because it needs a specific endoscope, and the trauma from lumbar puncture as well as the potential complications of intrathecal fluorescein, as a result, widely limited its clinical use. Topical intranasal fluorescein can avoid the above-mentioned shortcoming. The aim of this work was to describe the use of topical fluorescein in the intraoperative localization of CSF fistulas and to screen its use in preoperative diagnosis of CSF rhinorrhea.

Methods

Fifteen patients with CSF rhinorrhea were treated with an endoscopic endonasal technique. Topical intranasal 5% fluorescein for preoperative diagnosis and intraoperative localization of the site of the leak was placed in middle turbinate meatus, the roof of the ethmoid plate, and sphenoethmoidal recesses. A change in the color of the fluorescein from brown to green fluorescence denoted the presence of CSF, and the site of the leak could be traced. The accuracy rate of diagnosis and leak site identification was made by comparison with glucose analysis, intraoperative findings, and follow-up.

Results

The cause of the leak was accidental trauma in 5 patients and spontaneous in 10 patients. The preoperative use of fluorescein-soaked cotton was 100% accurate in diagnosing CSF rhinorrhea. The intraoperative use of topical intranasal fluorescein was also 100% accurate in locating the site of the CSF fistula when compared with the surgical findings. It had achieved 100% success rate in sealing the CSF fistulas in our 15 patients with no recurrence detected during the follow-up period (mean, 2-24 months). No complications have been reported.

Conclusion

In the presence of a clinically diagnosed CSF leakage and location of the leakage fistula, topical fluorescein is a very easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas. It should be considered as a viable noninvasive alternative to intrathecal fluorescein.

Abbreviations: CSF, The cerebrospinal fluid, CT, computed tomography, FDA, Food and Drug Administration, MRI, magnetic resonance imaging

Keywords: Fluorescein, Cerebrospinal fluid leakage, Rhinorrhea, Endoscope, Surgery