Management of Spontaneous CSF Rhinorrhea: An Institutional Experience

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.

Keywords: CSF rhinorrhea; benign intracranial pressure; cerebrospinal fluid.

Fig. 1

T2 MRI features suggestive of BIH seen in cases of spontaneous CSF leak. ( A ) Empty sella, ( B ) increased CSF spaces around optic nerve, and ( C ) Left transverse sinus stenosis. BIH, benign intracranial hypertension; MRI, magnetic resonance imaging.

Fig. 2

Intraoperative. ( A ) Cutting vertical attachement of middle turbinate and taking it down, ( B ) repair of defect with fat, fascia, and nasoseptal flap with application of surgicel (oxidized cellulose polymer), ( C ) application of tissue glue (two component fibrin sealant) to stablize assembly.

Fig. 3

Endoscopic view showing green dye from right foveal defect after instillation of fluorescein dye.

Fig. 4

Intraoperative. ( A ) Sphenoid encephalocele with high flow leak (communicating with suprasellar cistern), ( B ) arrow shows repair of defect by fat after reduction of defect (bath plug technique), ( C ) application of surgicel (oxidized regenerated cellulose).

Fig. 5

Preoperative CT Cisternography showing sites of csf leak. ( A ) Rt cribriform defect, ( B ) midline defect, ( C ) right sphenoid sinus lateral wall defect. ( D ) sellar defect communicating with suprasellar cistern.