Cerebrospinal Fluid Rhinorrhea: Diagnosis and Management
Section snippets
Cause
Traumatic leaks are subdivided as surgical (whether planned or unplanned) or nonsurgical (whether blunt or penetrating). Seventy percent to 80% of CSF rhinorrhea is caused by accidental trauma [3]; 2% to 4% of acute head injuries result in CSF rhinorrhea [4].
Nontraumatic CSF rhinorrhea includes high-pressure and normal-pressure leaks. High-pressure CSF rhinorrhea comprises 45% of nontraumatic CSF rhinorrhea, and 84% of these leaks result from tumor obstruction. The remainder is caused by either
Signs and symptoms
The presence of a halo sign on tissue or linens should arouse suspicion of CSF rhinorrhea. Although not generally used now, components of CSF, such as glucose, protein and electrolytes, have been measured. The sensitivity and specificity of these tests remain quite poor [5], [6].
Beta-2 transferrin is highly specific and sensitive in identifying fluid as CSF [7]. Beta-2 transferrin is produced by desialization (carbohydrate-free form) of normal beta-1 transferrin in CSF through cerebral
Localization
Key in management of CSF leakage is localization of the dural defect, which can originate from the anterior, middle, or posterior cranial fossas. The most common site of accidental traumatic fracture seems to be at the cribiform plate where the bone is thick, the area adjacent is thin, and the dura is very adherent [25]. Congenital defects most commonly arise from the superior or lateral walls of the sphenoid sinus or from the cribriform niche adjacent to the middle turbinate vertical
Conservative management
Most CSF leaks resulting from accidental and surgical trauma heal with conservative measures over the course of 7 to 10 days. Less likely to heal spontaneously are leaks in which CSF rhinorrhea develops days or weeks after surgical or accidental trauma, massive leaks that develop immediately after surgery, leaks caused by sustain gunshot wounds, or normal-pressure CSF leaks. CSF fistulae found at the time of endoscopic sinus surgery require repair at the time of initial surgery [4]. Leaks noted
Surgical management
Numerous factors are involved in the surgical management of CSF leaks. These factors include use of a lumbar drain, the approach for repair, the type of graft or flap and its placement, and the use of sealant and nasal packing.
Follow-up
When repair of a defect is near a sinus outflow tract, there is risk that normal sinus drainage will be obstructed. This obstruction may subsequently result in mucocele formation. Postoperative follow-up with CT scanning is appropriate to rule out development of a mucocele when there is concern for obstruction [82]. Meticulous care to ensure that the nonepithelialized surface of the graft is in contact with the intracranial cavity can prevent unplanned outflow obstruction. The risk of
Complications of operative management
According to Hegazy's [46] meta-analysis, repair of a cerebrospinal fistula carries a risk of less than a 1% for meningitis, brain abscess, subdural hematoma, smell disorder, and headache. Senior [48] reports that 2.5% of 522 patients surgically managed for CSF fistula suffered a complication, the most common being meningitis at 1.1%. Spetzler [83] describes a technique for preserving olfaction when an anterior craniofacial approach is required. The cribriform plate, dura, and mucosa are
Prevention of postsurgical cerebrospinal fluid rhinorrhea
Shiley et al [84] analyzed which factors predicted CSF leaks as a complication of transphenoidal removal of pituitary tumors. In contrast to other author's findings [13], [15], size and revision surgery were not significant factors on multivariate analysis. Significant factors did include presence of an intraoperative leak and management of nonadenomatous disease. These patients may warrant more aggressive management to prevent postoperative leaks. A lumbar drain is generally maintained if
Summary
Advances in imaging and endoscopic techniques have improved the ability to diagnose, localize, and treat in a less morbid fashion CSF leaks of the anterior skull base.
An appreciation for the mechanism of leak and of the relationship between CSF production and absorption must be kept in mind when individualizing a repair. Increased CSF pressure caused by overproduction or underabsorption may result in persistence of a leak despite one's best efforts.
Numerous advances in dural replacement grafts
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