J Neurol Surg B Skull Base 2019; 80(05): 493-499
DOI: 10.1055/s-0038-1676334
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Management of Spontaneous CSF Rhinorrhea: An Institutional Experience

Amit Keshri
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Rajat Jain
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Ravi Shankar Manogaran
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Sanjay Behari
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Deepak Khatri
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Arulalan Mathialagan
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
› Author Affiliations
Further Information

Publication History

19 April 2018

27 October 2018

Publication Date:
05 December 2018 (online)

Abstract

Introduction Cerebrospinal fluid (CSF) rhinorrhea is the leakage of CSF through nasal cavity, due to abnormal communication between the arachnoid membrane and nasal mucosa. Middle-age (fourth to fifth decade) group, female gender, and obesity (body mass index > 40) are the most commonly reported risk-factors for this rare entity. In this study, we present our single center experience of spontaneous CSF rhinorrhea discussing important clinicoradiological aspects in preoperative evaluation and nuances in the endoscopic repair technique.

Material and Methods A retrospective study conducted for 43 spontaneous CSF rhinorrhea patients admitted between Jan 2011 to Jan 2018 at our tertiary care center. All patients underwent endoscopic repair of the defect depending upon their site of leak.

Results Mean age in our study was 36.7 ± 12.3 years (range: 9–62 years). Average BMI in males was found lower (28.7) as compared with females (32).

Most common site of CSF leak was cribriform plate (n = 32, 74.4%) and Planum was found to be the least common site (n = 1, 2.3%) of CSF leak.

Intraoperatively, 23 (53.5%) patients showed high-flow leak. Intrathecal injection of fluorescein dye was used to identify the site of CSF leakage in 15 cases (34.8%). The overall success rate of primary endoscopic repair in our study was 95.3%.

Conclusion Spontaneous CSF rhinorrhea occurs secondary to elevated intracranial pressure, with a predilection for obese females in fourth to fifth decade. Individualized tailored surgical approach depending upon the site, size, and flow-variety of the defect forms the cornerstone of management.

Supplementary File

 
  • References

  • 1 Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 2006; 58 (4, Suppl 2): ONS-246-ONS-256 , ONS-256–ONS-257
  • 2 Lopatin AS, Kapitanov DN, Potapov AA. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg 2003; 129 (08) 859-863
  • 3 Luginbuhl AJ, Campbell PG, Evans J, Rosen M. Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 2010; 120 (05) 876-880
  • 4 Badia L, Loughran S, Lund V. Primary spontaneous cerebrospinal fluid rhinorrhea and obesity. Am J Rhinol 2001; 15 (02) 117-119
  • 5 Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE. Spontaneous cerebrospinal fluid leaks: a variant of benign intracranial hypertension. Ann Otol Rhinol Laryngol 2006; 115 (07) 495-500
  • 6 Sivasankar R, Pant R, Indrajit IK. , et al. Imaging and interventions in idiopathic intracranial hypertension: a pictorial essay. Indian J Radiol Imaging 2015; 25 (04) 439-444
  • 7 Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol 2011; 32 (11) 1986-1993
  • 8 Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147 (02) 196-203
  • 9 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110 (07) 1166-1172
  • 10 Virk JS, Elmiyeh B, Saleh HA. Endoscopic management of cerebrospinal fluid rhinorrhea: the charing cross experience. J Neurol Surg B Skull Base 2013; 74 (02) 61-67
  • 11 Lanza DC, O'Brien DA, Kennedy DW. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope 1996; 106 (9, Pt. 1): 1119-1125
  • 12 Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience. Laryngoscope 2004; 114 (06) 969-974
  • 13 Marton E, Billeci D, Schiesari E, Longatti P. Transnasal endoscopic repair of cerebrospinal fluid fistulas and encephaloceles: surgical indications and complications. Minim Invasive Neurosurg 2005; 48 (03) 175-181
  • 14 Gilat H, Rappaport Z, Yaniv E. Endoscopic transnasal cerebrospinal fluid leak repair: a 10 year experience. Isr Med Assoc J 2011; 13 (10) 597-600
  • 15 McCormack B, Cooper PR, Persky M, Rothstein S. Extracranial repair of cerebrospinal fluid fistulas: technique and results in 37 patients. Neurosurgery 1990; 27 (03) 412-417
  • 16 Ismail AS, Costantino PD, Sen C. Transnasal transsphenoidal endoscopicrepair of CSF leakage using multilayer acellular dermis. Skull Base 2007; 17 (02) 125-132
  • 17 Schuknecht B, Simmen D, Briner HR, Holzmann D. Nontraumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. AJNR Am J Neuroradiol 2008; 29 (03) 542-549
  • 18 Higgins JNP, Cousins C, Owler BK, Sarkies N, Pickard JD. Idiopathic intracranial hypertension: 12 cases treated by venous sinus stenting. J Neurol Neurosurg Psychiatry 2003; 74 (12) 1662-1666
  • 19 Starke RM, Wang T, Ding D. , et al. Endovascular treatment of venous sinus stenosis in idiopathic intracranial hypertension. Complications, Neurological Outcomes, and Radiographic Results ScientificWorldJournal. 2015; 2015: 140408
  • 20 Javadi SA, Samimi H, Naderi F, Shirani M. The use of low- dose intrathecal fluorescein in endoscopic repair of cerebrospinal fluid rhinorrhea. Arch Iran Med 2013; 16 (05) 264-266
  • 21 Seth R, Rajasekaran K, Benninger MS, Batra PS. The utility of intrathecal fluorescein in cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 2010; 143 (05) 626-632
  • 22 Ackerman PD, Spencer DA, Prabhu VC. The efficacy and safety of preoperative lumbar drain placement in anterior skull base surgery. J Neurol Surg Rep 2013; 74 (01) 1-9
  • 23 Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 2005; 115 (02) 205-212
  • 24 Chaaban MR, Illing E, Riley KO, Woodworth BA. Acetazolamide for high intracranial pressure cerebrospinal fluid leaks. Int Forum Allergy Rhinol 2013; 3 (09) 718-721
  • 25 Choi D, Spann R. Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics. Br J Neurosurg 1996; 10 (06) 571-575
  • 26 Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2015; (04) CD004884