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

Abstract

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.