“Sealing the Gap” : CSF Leakage Demystified-A Comprehensive Analysis of our Experience in CSF Rhinorrhea Management

Abstract

CSF (Cerebro Spinal Fluid) rhinorrhoea occurs when the fluid leaks from subarachnoid space into the nasal cavity. The study aims to find out the prevalence and demographic distribution of CSF leak and to describe the site of the CSF leak along with the management. We did a prospective study on 180 patients admitted with head injury in neurosurgery department, along with the patients who came to ENT department with unilateral nasal discharge during the time period from March 2017 to March 2021. A total of 36 cases of CSF leak were obtained during the time period. The etiology in 18 cases was head injury & the other 18 cases were either due to infectious or nontraumatic causes. In our study, 26(72.22%) patients were aged less than 50 years. Incidence was more among males compared to females. The most common etiology was head injury - 18(50%) patients followed by the spontaneous leak- 16 (44.44%) patients with the most common site as the cribriform plate. Endoscopic repair using a hadad flap was done in most of the patients. Trauma due to head injury is the most common etiology in CSF rhinorrhea with more number of patients aged less than 50 years. Most of the leaks can be repaired successfully with the use of endoscope with excellent illumination & localizing the exact site of the leak.

Introduction

Cerebralspinal fluid (CSF) leak is an prominent complication of traumatic head injury, and most leaks occur immediately after the injury or within subsequent days or weeks [1]. This occurs when an abnormal path is inadvertently created due to a defect in the dura, cribriform plate, or the frontal, ethmoidal and sphenoid sinuses [2].

CSF Rhinorrhea can be divided into traumatic and non-traumatic. The traumatic group can be divided into accidental (80%) & iatrogenic (16%). The non-traumatic group less than 4% includes idiopathic (spontaneous), neoplasms, congenital defects and infections [3].

Otolaryngology procedures such as septoplasty and endoscopic surgery carry a well-documented risk of CSF rhinorrhea and are potentially life-threatening [4]. Hence otolaryngologists should be aware of the proper surgical technique to avoid postoperative CSF leakage.

Diagnosis is mainly based on high-resolution computed tomography (CT). Usually CSF rhinorrhea following head injury, conservative treatment is initially given & surgery is planned if medical treatment fails [5].

Therefore, achieving a better patient outcome, early detection of CSF leaks is crucial. The decision whether to observe or to surgically intervene depends on the cause, site, timing of the leak [6]. In this article, we put forth our experience with CSF rhinorrhea in our center in South India.

Objectives

1. To study the prevalence of CSF leak in head injury patients.

2. To study the incidence and distribution of cases according to age, sex, and etiology.

3. To study the definitive site of the CSF leak along with the management.

Materials and Methods

Study Design

A Prospective study was done between March 2017- March 2021 in a tertiary care hospital.

Study Population

Patients attending neurosurgery and Otolaryngology out patient department were included. During the time period, 180 patients who were admitted with head injuries in neurosurgery department was evaluated, along with the patients who came to ENT department with unilateral nasal discharge.

Study Conduct

HRCT and MRI were performed in all patients.

Figures 1, 2 and 3. Tables 1 and 2.

Fig. 1.

T2 weighted MRI showing defect in the sphenoid

Fig. 2.

CT showing defect in the cribriform plate

Fig. 3.

Showing defect in the cribriform plate

Table 1.

The following table shows age wise distribution of 180 cases with head injury

1)AGE WISE STRATIFICATION OF HEAD INJURY PATIENTS WITH CSF LEAK (N = 180)
AGE GROUPS	CSF LEAK		TOTAL
	YES	NO
≤ 30	6	61	67
31–40	7	27	34
41–50	2	22	24
51–60	3	21	24
> 60		31	31
TOTAL	18	162	180

Table 2.

The following table shows 36 cases of CSF rhinorrhoea

		NUMBER	PERCENTAGE (%)
1) AGE	a) <50YEARS	26	72.22
	b) >50 YEARS	10	27.77
2) SEX	a) MALE	20	55.55
	b) FEMALE	16	44.44
3) ETIOLOGY	a) TRAUMA (TOTAL): -HEAD INJURY(HI)	18 18	50 50
	b) NON TRAUMATIC - SPONTANEOUS(S) - INFECTIOUS(I)	16 2	44 6
4) SITE				RIGHT	LEFT
	a)CRIBRIFORM PLATE	21	58.33	16	5
	b) SPHENOID	6	16.66
	c)FOVEA ETHMOID	4	11.11	3	1
	d) FRONTAL SINUS	2	5.55	1	1
	e) MULTIPLE SITES	3	8.35
5)MANAGEMNT		NUMBER	PERCENTAGE	TRAUMA	NON TRAUMA
	a)CONSERVATIVE	12	33.33	8(HI)	4(S)
	b)OPEN CRANIOTOMY	5	13.88	5(HI)
	c)ENDOSCOPIC REPAIR	19	52.77	5(HI)	12(S) + 2(I)
6)FLAPS USED		HADAD FLAP	MIDDLE TURBINATE FLAP	FREE FLAP	MULTILAYER FLAP
	- CRIBRIFORM PLATE	8	2
	- SPHENOID			2	3
	- FRONTAL SINUS				1
	- FOVEA ETHMOID	2		1

Discussion

Conservative treatment includes bed rest, head-end elevation of more than 30 degrees, laxatives, antibiotics, avoidance of straining, nose blowing, Valsalva maneuvers, the use of straws etc. [6]. Most CSF leaks close within 7 to 10 days, can wait up to 6 weeks [7, 8]. Diuretics like acetazolamide reduce CSF production and hence CSF pressure, and thus may help in treating CSF rhinorrhea [9].

Among 180 patients who were admitted with head injury, 18 patients (50%).

presented with CSF rhinorrhea whereas in the remaining 18 patients CSF leak was due to non-traumatic causes, which is similar to the study by Mathias et al. study where 56% of cases were due to traumatic causes [10].

In our study, in a total of 36 cases, around 72% of the patients were less than 50 years of age. Sarkar et al. reported the same with ages ranging between 28 and 54 years [3]. In our study, the most common site of CSF leak was found to be in the cribriform plate (58.33%) which is comparable to the study conducted by Sharma et al. (60%) [11].

In our study, 33.33% of patients were managed conservatively, with antibiotics for 3 weeks, laxatives for 2 weeks and acetazolamide 250 mg twice daily for 1 month, followed by once daily for 15 days, and then every alternate day for 3–6 months. In our study, Lumbar drainage was placed in 2 patients preoperatively and in 2 patients it was inserted immediately after surgery.

Open craniotomy was done in 13.88% and 52.77% of patients were managed by endoscopic repair with the most common flap being the Hadad flap. A study done by Vender et al. states that endoscopic closure of leaks or defects at the skull base should be considered as the treatment of choice due to the high degree of success rate(90%), easy access, precision, and accuracy [2]. While open techniques still have their role.

Conclusion

The present prospective study concludes that the most common cause of CSF rhinorrhea is trauma with a larger number of patients under 50 years and a male preponderance. In our study, the most common site of CSF rhinorrhea was identified in the cribriform plate. Most of the leaks can be successfully repaired with the use of endoscope, thus reducing morbidity and mortality rates. The success reported here results from a detailed preoperative evaluation including endoscopic identification of the exact site of leaks, imaging methods, assessment of the defect size and closure with the appropriate graft, and proper post-operative care.

Funding

No external funding has been received.

Data Availability

Data transparency has been maintained.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Approval

Appropriate ethical clearance has been obtained from the institute.

Consent for Publication

Appropriate consent for publication taken.