Management Of Cerebrospinal Fluid Rhinorrhea Research Articles

The study of management of cerebrospinal fluid rhinorrhea at tertiary care center

Background: CSF Rhinorrhea is clinically emergency condition in Otorhinolaryngology. Patients were presented with unilateral watery nasal discharge. In the evolving world, CSF leak repair done via endoscopic method. Recurrence is very less with endoscopic repair method of CSF leak. Methods: We took complete history, complete Ear, Nose, Throat and Head and Neck examination, Endoscopic examination of nasal cavity followed by Radiological test in the form of MR Cisternography. Depending upon the site of leak, CSF leak repair done via endoscopic method of overlay and underlay and with the help of fascia, fat, surgical, flap, fibrin glue and cartilage. Results: Total 30 cases analysed where 63.33% & 26.67% patients have defect at cribriform plate & fovea ethmoidal is respectively. 63.33% patients are male, almost all patients are adults. 73.33% are spontaneous & rest are traumatic, 43.33% have circular defect, 36.67% have horizontal defect, 53.33% are treated with fat, surgical, fascia, fibrin glue, 40% are treated with above-mentioned things with flap, 6.67% patients are treated with above-mentioned things with cartilage. Conclusions: Most of CSF leak are spontaneous in nature, most of patients had defect in cribriform plate that too in anterior portion of the plate, almost all patients were adults, more females had defect than males, circular defects are slightly more common than horizontal ones, and most of the patients didn’t need flap or cartilage during surgery.

The Etiology, Diagnosis, and Management of Cerebrospinal Fluid Rhinorrhea: A Tertiary Center Experience.

Introduction The aim of the present study was to describe our institution's nine years of experience in the endoscopic endonasal management of cerebrospinal fluid (CSF) rhinorrhea and to discuss the causes, sites, and outcomes. Methodology The medical records of patients diagnosed with CSF rhinorrhea in King Abdulaziz Medical City-Jeddah (KAMC-J) between 2014 and 2023 were retrospectively reviewed, and all relevant information including body mass index, medical and surgical history, and postoperative outcomes were obtained. Results A total of 20 cases were included in the present study, sixteen (80%) of which were females and four (20%) were males. The mean age of participants was 42.59±13.9 years. Nine cases (45%) were spontaneous CSF rhinorrhea and 11 (55%) were traumatic; within the traumatic group, six cases (54%) were iatrogenic either following previous neurosurgery or functional endoscopic sinus surgery, while the remaining five cases were related to motor vehicle accidents. The mean body mass index for the spontaneous CSF leak was 32 Kg/m2, and 33 Kg/m2 for the traumatic leaks, no statistically significant difference was noted. The cribriform plate was the most common site of leakage (65%). A multilayer surgical technique using facia lata graft with nasoseptal flap was the most common choice for reconstruction with a first-attempt success rate approximating 90%. A recurrence was observed in two patients only. No major complications were reported. The average length of stay was nine days. Conclusion The endoscopic endonasal repair of CSF leak is a safe and reliable procedure and is associated with high success rates and low risk of complications. Therefore, it should be preferred as a first-line treatment for CSF rhinorrhea.

Comparison of two surgical approaches in the management of cerebrospinal fluid rhinorrhea in the lateral recess of sphenoid sinus: A retrospective study.

Cerebrospinal fluid (CSF) leakage from the lateral recess of the sphenoid sinus (LRSS) is usually repaired using endoscopic endonasal approaches, which can be challenging. Various surgical techniques have been developed for the disease. To report our experience with repairing CSF leak from the LRSS via transethmoid sphenoidotomy approach (TESA) and transprelacrimal recess pterygoid root approach (TPLRA), to assess the efficiency of TPLRA by comparing it with TESA. This retrospective study included patients with LRSS CSF rhinorrhea who underwent TESA (n = 10) or TPLRA (n = 5) from January 2011 to December 2020. Demographic characteristics and operation-related parameters were recorded. The mean operation time was 169.5 and 225.0mins in the TESA and TPLRA groups, respectively, with a mean blood loss of 65mL and 68mL, respectively. Histopathological examinations confirmed encephalocele in 11 (73.33%) and 4 (26.67%) cases with meningocele, respectively. CSF rhinorrhea was successfully repaired in the first attempt in both groups during the mean follow-up time of 54months. Postoperative permanent numbness of the cheek was observed in two patients in the TESA group. No cases of lacrimal overflow or subjective dry eye were observed. The TPLRA, which could be an alternative procedure to treat CSF rhinorrhea in the LRSS, provides a straight-line trajectory and effective maneuverability. We also found that CSF rhinorrhea in the LRSS was accompanied by encephalocele or meningocele, with encephalocele presenting more commonly.

Endoscopic endonasal cerebrospinal fluid rhinorrhea repair: a cohort study in Iraq

BackgroundCerebrospinal fluid (CSF) rhinorrhea is a condition where the protective fluid that surrounds the brain finds its way into the nose and sinuses, often appearing as a very watery runny nose. The main surgical approaches for the surgical repair of CSF leaks are intracranial and extracranial. Over the last decade, endoscopic surgery has established itself as the most widely used technique for the repair of CSF fistula. The current study aimed to describe the use of nasal endoscopic technique in the management of cerebrospinal fluid rhinorrhea repair.ResultsResults of our study showed that in addition to CSF leak, 40% of the patients had headache and 17.5% had repeated meningitis. Half of the etiologies for the CSF leak were spontaneous, 35% were congenital, and 15% were traumatic. The more frequent site of leak was left cribriform plate (37.5%). In the majority of patients, 37/40 (92.5%), the type of graft was tensor fascia lata and fat, while in the remaining 3 patients, type of graft was tensor fascia lata and bone, bone and fat, and tensor fascia lata. The repair succeeded in 35 patients giving a success rate of 87.5%.ConclusionIt can be concluded that wide range of age groups from 2–62 years presented as CSF rhinorrhea with female predominance, and there was high success rate of endoscopic CSF rhinorrhea repair with low morbidity.

Management of Cerebrospinal Fluid Rhinorrhea in the Sphenoid Sinus Lateral Recess Through an Endoscopic Endonasal Transpterygoid Approach With Obliteration of the Lateral Recess

Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess is a rare occurrence and poses unique challenges due to limited surgical access for surgical repair. To report our experience of surgical repair of cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess through an endoscopic endonasal transpterygoid approach with obliteration of the lateral recess. To evaluate the efficiency of this surgical procedure. A retrospective study. Twelve cases with cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess were reviewed. Assisted by image-guided navigation, cerebrospinal fluid rhinorrhea was repaired through an endoscopic endonasal transpterygoid approach, with obliteration of the lateral recess. Complications and recurrence were recorded. Medical photographs were used. This surgical approach provided a relatively spacious corridor to dissect the sphenoid sinus lateral recess and do postoperative surveillance. The repair area completely healed in 3 months after surgery. Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess was successfully repaired on the first attempt in all cases (100%). No main complications or recurrence was observed during a mean follow-up time of 40.3 months. The endoscopic endonasal transpterygoid approach gives appropriate access for the treatment of spontaneous cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess. Multilayer reconstruction of a skull base defect with obliteration of the lateral recess is a reliable and simple method.

Management and outcome of treatment modalities of cerebrospinal fluid rhinorrhea

Background Management of cerebrospinal fluid (CSF) rhinorrhea includes either conservative or surgical treatment. The aim of this study is to evaluate the results of management of CSF rhinorrhea in three tertiary care centers in Khartoum state. Patients and methods This was a prospective analysis of 40 consecutive patients who underwent management of CSF rhinorrhea between April 2016 and April 2019. Conservative management consists of a 7–30-day trial of bed rest, head elevation 15–30°, stool softeners, avoidance of straining, and diuretics. All patients were offered conservative treatment except those with meningitis and iatrogenic leak, and patients with tension pneumocephalus were managed surgically from the start. Results A total of 40 patients were included. Spontaneous CSF leak cases were 19 (47.5%), with female to male ratio of 3.75: 1. Posttraumatic CSF leak cases were 16 (40%), with male to female ratio of 2.2: 1. Five (12.5%) patients were iatrogenic, with female to male ratio of 4.0: 1; they were managed? surgically only as well as one patient with history of meningitis. Conservative treatment was successful in 11 (32%) of 34 patients. Surgical treatment was performed for 29 patients, mainly by endoscopic approach in 26 (89.7%) patients, with success rate of 96.1%; osteoplastic flap for two (6.9%) patients, with a success rate of 100%; and intracranial (frontal craniotomy) for one (3.4%) patient, with a success rate of 100%. The success rates following first surgery for patients with posttraumatic, postprocedural, and spontaneous CSF leaks were 100, 100, and 93.3%, respectively. Four patients required second surgery, which was successful in three and failed in one with persistent leak. Conclusion Patients with CSF rhinorrhea were offered conservative treatment initially, except for iatrogenic leaks and past history of meningitis. Failure of conservative management warrants surgical treatment, which has high success rates. Head trauma, technical failures, lack of CSF divergence, and poor management of spontaneous leaks were responsible for recurrence of leak. Decision for surgical repair is appropriate in a teamwork between otorhinolaryngologists and neurosurgeons with attention to surgical approach, operative details, and postoperative care.

Challenges and controversies in endoscopic management of cerebrospinal fluid rhinorrhea

Introduction Endoscopic management of cerebrospinal fluid (CSF) rhinorrhea is considered by many as the ideal approach due to its low morbidity and higher closure rate. However, many challenges and controversies are still reported. Objective The aim was to discuss the challenges of endonasal repair of CSF leaks and controversies regarding the use of intrathecal fluorescein (ITF) and the number of graft layers. Materials and methods This retrospective study included 30 patients who had had endoscopic repair for their CSF rhinorrhea in our institute between July 2015 and June 2017. Fifteen (50%) patients were managed using the two-layer repair without ITF injection (group I), while the remaining were managed using three or more graft layers and ITF (group II). Results The study included 30 patients: 17 (57%) women and 13 (43%) men. Their age ranged from 4 to 68 years with mean ± SD = 38 ± 15.86 years. Eighteen cases presented with spontaneous leaks (nine of them had normal CSF pressure). Four (13.3%) cases had defects in the posterior wall of the frontal sinus while other defects involved the fovea ethmoidalis, lateral lamella, and the cribriform plate of the ethmoid. Success rate was equal in both groups (93%). Conclusion Endoscopic management of CSF rhinorrhea has many challenges including repair in the pediatric population and anatomical areas with difficult accessibility, for example, frontal sinus leaks. It requires good endoscopic visualization and endoscopic instrumentation facilities in addition to experienced surgical hands. Double-layer repair and avoidance of ITF show the same success rate as other more time-consuming strategies with life-threatening complications.

Approach to Management of Cerebrospinal Fluid Rhinorrhea: Institutional Based Protocol.

The role of otolaryngologist in the management of CSF rhinorrhea is expanding. It is prudent to evaluate all cases of CSF leak, understand the etiological causes and formalize a working approach to management of such cases to yield better outcome. A retrospective descriptive study of 39 cases of proven CSF rhinorrhea treated at a tertiary care center between January 2014 to August 2019. The data retrieved were analyzed for age, gender, weight, etiology, recurrence of the disease, history of meningitis, nasal or neurosurgical intervention in past, imaging inform of CT and MR cisternography as and when required. This was aimed at understanding the various etiological types of CSF rhinorrhea and work out a management approach. The patients with skullbase tumors who presented with CSF Rhinorrhea were excluded from the study sample. There were 18 cases of spontaneous CSF rhinorrhea and 20 cases of traumatic CSF rhinorrhea. The mean BMI of spontaneous gp was 32.9 ± 2.46kg/m2 while in traumatic group was 25.7 ± 2.94kg/m2 and difference was statistically significant. None of the spontaneous CSF rhinorrhea cases showed features of raised ICP preoperatively either clinically or on imaging except empty sella in 14 of 18 cases. 6 of 18 cases of spontaneous category while 01 of 20 cases in traumatic had recurrence and the recurrence rate was significantly (p < 0.05) higher in spontaneous group. In traumatic group 7 were iatrogenic, 8 were occult traumatic and rest were acute traumatic. 4 of traumatic and 1 spontaneous group had history of meningitis and the incidence was 12.8% in our study group. Early identification and localization of CSF fistula is necessary to reduce morbidity and mortality associated with it. Risk of meningitis is high in CSF rhinorrhea especially in traumatic group. The etiology of CSF rhinorrhea has a bearing on the management and spontaneous CSF rhinorrhea has higher rate of recurrence.

Endoscopic cerebrospinal fluid leak repair: how we do it

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Cerebrospinal fluid (CSF) rhinorrhoea is characterized by a defect in the barriers which separate the subarachnoid space from sinonasal tract resulting in the leakage of watery fluid from the nose. Management of CSF rhinorrhoea is by both conservative and/or surgical approach. Transnasal endoscopic method has become the preferred surgical method for the repair of CSF leak because of less complication as compared to the open approach. To evaluate the results of patients who underwent endoscopic repair of CSF rhinorrhoea over a period of 5 years at BJ Medical College, Civil Hospital, Ahmedabad.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 118 patients were included in this retrospective study who underwent CSF leak repair by nasal endoscopy over a period of 5 years between 2011-2016 in the department of ENT at BJ Medical College, Civil Hospital, Ahmedabad. As per review of the records, these patients were diagnosed with CSF leak on the basis of their history, clinical examination, and radiological investigations. Materials used for the repair were fat, fascia lata, fibrin sealant, and/or vascular flap. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Primary surgery was successful in 110 (93%) of cases. In 8 (7%) cases, there was a recurrence of leak which was managed by either conservative management (5 cases, 4%) or by re-exploration (3 cases, 3%).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Transnasal endoscope is an important tool for the evaluation and subsequent treatment of CSF rhinorrhoea. Endoscopic repair of CSF rhinorrhoea is safe, effective, has a low complication rate and has almost completely replaced the open technique.&lt;/p&gt;

Analysis of Various Factors and Techniques to Improve Outcome of Surgical Management of 243 Cases of CSF Rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea occurs when there is a communication between subarachnoid space and sinonasal mucosa due to meningeal, osseous and mucosal defects in the cranial base leading to discharge of CSF from the nose. The risk of developing meningitis after CSF rhinorrhea may vary from 5.6 (Leech and Paterson in Lancet 1:1013-1016, 1973) to 60% (Eljarnel and Foy in Br J Neurosurg 5:275-279, 1991). Hence surgical management of CSF rhinorrhea is highly recommended. Transnasal endoscopic approach first described by Wigand in 1981, has been proven to be the approach of choice in comparison to intracranial and external nasal approach (Jones and Becker in Br Med J 322:122-123, 2001) in most cases. The next defining milestone was the pedicled naso septal vascularized flap described by Hadad et al. (Laryngoscope 116(10):1882-1886, 2006), which could be used to manage large defects. In the present study we assessed 243 cases of CSF rhinorrhea managed by transnasal endoscopic approach. We compared the various factors associated with CSF rhinorrhea and the correlation with the outcome of the surgical treatment. We also analyzed the different sites and techniques of surgical repair and have certain recommendations to improve the surgical outcome. The commonest cause of CSF leak was spontaneous (54.32%) and the commonest site was cribriform plate (43.24%). Patients presented most commonly with watery nasal discharge (82.3%). CT scan with cisternography or MR cisternography is the gold standard to identify the suspected site of leak. Out of 243 patients, 77.77% were operated using free grafts and 22.22% by flap repair. Results are comparable. Hence we would advise simple conservative technique with free grafts to reduce morbidity and shorten the postoperative recovery.

Surgical management of cerebrospinal fluid rhinorrhea factors affecting success

Introduction Cerebrospinal fluid (CSF) rhinorrhea was defined firstly by Willis in 1676 owing to breakdown of the layers of the meninges, the bone of the skull, the periosteum, and the nasal mucosa. Multiple causes can induce CSF rhinorrhea. These causes may be traumatic (accidental or iatrogenic after endoscopic sinus surgery) or spontaneous. The most common symptom is unilateral rhinorrhea which may be increased by stooping or performing valsalva maneuver. Other manifestations like irritability caused by pneumocephalus can also occur. Aim The management of cerebrospinal fluid (CSF) rhinorrhea is challenging. Many factors affect its success and can prevent recurrence or failure. This study aims to investigate the outcome of surgical management for CSF rhinorrhea and the factors associated with it. Patients and methods A total of 30 patients were admitted for surgery for nasal CSF fistula. Patients with rhinorrhea with more than 2 weeks of conservative treatment, some patients who underwent open surgery, and others who underwent endoscopic surgery were included in our study. The follow-up was continued for 6–18 months after surgery. Many factors were studied to recognize the causes of recurrence and failure such as intracranial hypertension, site of defect, etiology of leak, size of graft, using of fibrin glue, packing of defect, and type of graft. Results Among the included patients, 22 (73.3%) had a history of increased intracranial tension (ICT). The defect was in the cribriform plate in 10 (33.3%) patients, ethmoidal in five (16.7%) patients, sphenoidal in five (16.7%) patients, and in the frontal sinus in two (6.7%) patients. The success of surgery was observed in 20 patients, whereas failure occurred in seven patients, and recurrence occurred in three patients. The most important two factors affecting the outcome are the increased ICT (P=0.006) and the size of graft (P=0.003). Conclusion For successful surgical management of CSF rhinorrhea, increased ICT must be treated thoroughly preoperatively and postoperatively. Furthermore, the size of graft must be large in relation to the size of defect.

Study of Etiology, Outcome and Limitations of Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

Study of Etiology, Outcome and Limitations of Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

Preoperative topical intranasal fluorescein in diagnosis of cerebrospinal fluid rhinorrhea

Background and Objectives: The preoperative diagnosis of cerebrospinal fluid (CSF) leak site is necessary for the management of CSF rhinorrhea. At present, intrathecal fluorescein is a common approach for it; however, regarding drawbacks, its value is limited. This study aimed at examining the effects of topical intranasal fluorescein (TINF) on the preoperative diagnosis of CSF rhinorrhea and intraoperative localization of CSF fistula. Patients and Methods: In this cross-sectional study, 32 consecutive patients with CSF rhinorrhea were recruited. Topical intranasal 10% fluorescein was placed in common sites of leakage, the middle turbinate meatus, the roof of the ethmoid plate, and sphenoethmoidal recesses. Change of the color of fluorescein indicated the presence of CSF, and thus, the site of the fistula could be outlined. The accuracy rates of diagnosis of leak site identified by TINF were compared with those by available imaging modalities, CSF analysis, intraoperative findings, and follow-up. Results: The cause of the leak was traumatic in 22 patients and nontraumatic in 10 patients. Preoperative accuracy rate of the location of CSF fistula was estimated 58.3% by available imaging study. The preoperative diagnosis rate of CSF rhinorrhea and the CSF fistula site localization rate by TINF were both 100%. No recurrence was found during the follow-up for 2–12 months. No complication had been reported. Conclusions: Preoperative TINF is an easy, quick, sensitive, safe, and accurate tool in localization of the site of the CSF fistulas and can be considered as a viable noninvasive alternative to the intrathecal fluorescein technique for preoperative diagnosis of CSF rhinorrhea.

Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre.

SUMMARYThe aim of this study was to elucidate the risk factors for cerebrospinal fluid (CSF) rhinorrhoea following transsphenoidal surgery and discuss its prevention and treatments. We retrospectively reviewed 474 consecutive cases of pituitary adenoma treated with 485 transsphenoidal surgical procedures from January 2008 to December 2011 in our department. We analysed the incidence of intra- and post-operative CSF leakage and outcomes of various repair strategies. Intra-operative CSF leakage was encountered in 85 cases (17.9%), and post-operative CSF rhinorrhoea in 13 cases (2.7%). Seven of the 13 patients with post-operative CSF rhinorrhoea did not experience intra-operative CSF leakage; three of these patients had adrenocorticotropic hormone-secreting adenomas. Of the remaining 6 patients with both intra- and post-operative CSF leakage, 2 were treated for giant invasive prolactinomas, and 2 had previously undergone transsphenoidal surgery. In eight patients, the leak was resolved by lumbar puncture, lumbar external drainage, resting in a semi-reclining position, or other conservative treatment. Two CSF leaks were repaired with gelatine foam and fibrin glue using a transsphenoidal approach, and two with autologous fat graft and sellar floor reconstruction using a transnasal endoscopic approach. After undergoing two transnasal endoscopic repairs, one patient with post-operative CSF rhinorrhoea was successfully treated by further lumbar subarachnoid drainage. In conclusion, procedures using gelatine foam, fibrin glue and autologous fat graft are common and effective techniques for the management of CSF rhinorrhoea after transsphenoidal surgery. When a CSF leak is detected during transsphenoidal surgery, thorough sellar reconstruction and long-term follow-up are necessary.

Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea.

Endoscopic repair of anterior skull-base defects has become the gold standard for management of cerebrospinal fluid (CSF) rhinorrhea. Both improved techniques and adjuvant therapies have led to accepted success rates of greater than 90%. As management has evolved, shorter hospitalizations have been required and the goal of this study is to analyze the outcomes of patients repaired on an outpatient basis vs those managed as inpatients postoperatively. Patients undergoing endoscopic repair of CSF rhinorrhea between 2004 and 2014 were identified by review of medical records. Demographic and clinical data were collected and compared between patients having surgery with and without postoperative admission. Patients managed with lumbar drains were not included. Statistical analyses were preformed to determine if any differences in patient demographics and outcomes existed. A total of 86 patients were identified; 39 of 86 patients (45.3%) underwent outpatient surgery; 47 patients were admitted postoperatively with a mean hospital stay of 1.66 days with a median and mode of 1 day. No statistically significant differences were found between leak location, etiology, rates of recurrence, or complications. The outpatient group was found to have a greater proportion of small defects <1 cm2 (p = 0.003). Repair technique was also significantly different between groups (p = 0.001). Endoscopic management of CSF rhinorrhea is a safe method of treatment with reliable success rates. Our retrospective analysis revealed comparable outcomes in patients treated with and without postoperative hospital admission, and supports the idea that outpatient management may be reasonable in certain patients, especially those with defects <1 cm2 .

Endoscopic management of cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.

Management of cerebrospinal fluid rhinorrhea: an evidence‐based review with recommendations

Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions. Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.

Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.

Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches.

Management of Craniofacial Polytrauma Complicated by Cerebrospinal Rhinorrhea

Objective: The aim of the investigation was to reveal the characteristics of the management of penetrating craniofacial injury against the background of polytrauma, and develop the algorithm of preoperative examination and treatment of concomitant craniofacial polytrauma complicated by cerebrospinal fluid rhinorrhea based on the use of modern neuroimaging techniques. Material and Methods: A total of 637 patients with major concomitant injuries underwent treatment in Nizhny Novgorod Regional Trauma Center from 2010 to 2012. Overall 85 patients (13.34%) had concomitant cerebral and facial skeleton injuries, among them there were 62 (9.7%) cases with cerebrospinal fluid rhinorrhea revealed on admission. Results: Concomitant injury of brain and bones of the facial skeleton in polytrauma was found in 13.3% of patients with polytrauma;9.7% cases were found to have penetrating craniofacial injuries. Relying on the experience obtained, we suggested the algorithm of preoperative assessment and planning of surgical management of craniofacial injury complicated by cerebrospinal fluid rhinorrhea using modern neuroimaging techniques based on the assessment of a patient's condition. Conclusions: The use of the algorithm in everyday practice in patients with penetrating craniofacial injury and polytrauma enables to improve the diagnosis and objectify the time optimal for surgical management of cerebrospinal fluid rhinorrhea, reduce the lethality up to 8%, and the morbidity of inflammatory complications up to 4.8%.

Endoscopic management of CSF rhinorrhea.

Transnasal endoscopic repair has become the treatment of choice for most anterior cranial and all sphenoid sinus breaches. The aim of this paper is to evaluate the results of endoscopic management of cerebrospinal fluid (CSF) rhinorrhea in a tertiary care center in South India. A retrospective analysis of 40 consecutive patients who underwent endoscopic repair of CSF rhinorrhea between 2010 and 2013 was performed. Endoscopic procedure consisted of defining the defect and removal of mucosa for 3-4 mm surrounding it. Repair was done using septal cartilage (for defects involving sphenoid sinus where sinus was packed with fat), fascia lata, oxidized cellulose, and fibrin sealant. Lumbar drain was placed for 2-4 days in selected cases. A lumbar-peritoneal shunt was inserted in patients with spontaneous CSF rhinorrhea and high opening lumbar CSF pressure. Spontaneous CSF leaks were more common in middle-aged females, whereas posttraumatic CSF leaks were common in young adult males. The success rates following first surgery for patients with posttraumatic, spontaneous, and postprocedural CSF leaks were 85.7, 81.8, and 75%, respectively, which improved to 95.7, 100, and 100% following second procedure, respectively. Technical failures, poor graft uptake because of radiation therapy, location of leak in the lateral sphenoid recess, lumbar peritoneal shunt malfunction, and poor healing of skull base fractures were responsible for recurrence of leak. Team work between neurosurgeons and otorhinolaryngologists with attention to identification of site of leak, preparation of graft bed, securing the graft in place, and postoperative care is critical to achieve a high level of success for endoscopic repair of CSF rhinorrhea.