What are complications of cerebrospinal fluid (CSF) rhinorrhea?

Answer

Meningitis is the most feared and severe complication of a CSF leak. Bacterial meningitis is typically due to Streptococcus pneumoniae and Haemophilus influenzae. The risk of meningitis during the first 3 weeks after trauma is estimated to be 10%. The rate increases to 40% in nontraumatic CSF rhinorrhea.

Some studies have reported that conservative management using bed rest and lumbar drains is associated with a high incidence of ascending meningitis. Thus, prompt surgical closure of a CSF leak is advocated by some authors. Meningitis caused by a persistent CSF leak is associated with a high mortality rate.

Only a small percentage (< 1%) of patients develop new meningitis after surgical closure. Not all cases of postoperative meningitis are due to the aforementioned bacteria. Some patients may develop aseptic meningitis due to meningeal irritation as a result of manipulation during surgical repair.

The surgical mortality rate is 1-3% for intracranial procedures and is negligible for external procedures. Anosmia is the main contributor to morbidity for intracranial approaches, occurring in 20-25% of the cases.

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

Dodson EE, Gross CW, Swerdloff JL, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Otolaryngol Head Neck Surg. 1994 Nov. 111(5):600-5. [Medline].
Hegazy HM, Carrau RL, Snyderman CH, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000 Jul. 110(7):1166-72. [Medline].
Lee TJ, Huang CC, Chuang CC, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. Laryngoscope. 2004 Aug. 114(8):1475-81. [Medline].
Lopatin AS, Kapitanov DN, Potapov AA. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg. 2003 Aug. 129(8):859-63. [Medline].
Marshall AH, Jones NS, Robertson IJ. CSF rhinorrhoea: the place of endoscopic sinus surgery. Br J Neurosurg. 2001 Feb. 15(1):8-12. [Medline].
Ryall RG, Peacock MK, Simpson DA. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. J Neurosurg. 1992 Nov. 77(5):737-9. [Medline].
Marchiano E, Carniol ET, Guzman DE, Raikundalia MD, Baredes S, Eloy JA. An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010. J Neurol Surg B Skull Base. 2017 Feb. 78 (1):18-23. [Medline]. [Full Text].
Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. Laryngoscope Investig Otolaryngol. 2017 Oct. 2 (5):215-24. [Medline]. [Full Text].
Fleischman GM, Ambrose EC, Rawal RB, et al. Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. Laryngoscope. 2014 Nov. 124 (11):2645-50. [Medline]. [Full Text].
Lieberman SM, Chen S, Jethanamest D, Casiano RR. Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects. Am J Rhinol Allergy. 2015 Jan-Feb. 29 (1):77-81. [Medline].
Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. Ann Emerg Med. 1993 Apr. 22(4):718-20. [Medline].
Ray BS, Bergland RM. Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure. J Neurosurg. 1969 Apr. 30(4):399-405. [Medline].
Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2016 Jan. 6 (1):8-16. [Medline].
Byrne JV, Ingram CE, MacVicar D, et al. Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry. 1990 Dec. 53(12):1072-5. [Medline].
Eljamel MS, Pidgeon CN, Toland J, et al. MRI cisternography, and the localization of CSF fistulae. Br J Neurosurg. 1994. 8(4):433-7. [Medline].
Albu S, Florian IS, Bolboaca SD. The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea. Clin Neurol Neurosurg. 2016 Mar. 142:43-7. [Medline].
Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015 Apr 28. 4:CD004884. [Medline].
Gosal JS, Gurmey T, Kursa GK, Salunke P, Gupta SK. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. Neurol India. 2015 Mar-Apr. 63 (2):197-201. [Medline].
Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. Outcomes of endoscopic repair of cerebrospinal fluid rhinorrhea without lumbar drains. Am J Rhinol Allergy. 2016 Nov 1. 30 (6):424-9. [Medline].
Elmorsy SM, Khafagy YW. Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: a review of 31 cases. Ear Nose Throat J. 2014 Jun. 93(6):E14-9. [Medline].
Kreatsoulas DC, Shah VS, Otto BA, Carrau RL, Prevedello DM, Hardesty DA. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. J Neurosurg. 2020 Feb 28. 1-7. [Medline].
Lemonnier LA, Tessema B, Kuperan AB, et al. Managing cerebrospinal fluid rhinorrhea after lateral skull base surgery via endoscopic endonasal eustachian tube closure. Am J Rhinol Allergy. 2015 May. 29 (3):207-10. [Medline].
Makary CA, Zalzal HG, Ramadan J, Ramadan HH. Endoscopic endonasal CSF rhinorrhea repair in children: Systematic review with meta-analysis. Int J Pediatr Otorhinolaryngol. 2020 Apr 10. 134:110044. [Medline].
Cappabianca P, Cavallo LM, Esposito F, et al. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery. 2002 Dec. 51(6):1365-71; discussion 1371-2. [Medline].
Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Neurosurgery. 2010 Sep. 67(3 Suppl Operative):ons150-8; discussion ons158. [Medline].
DeConde AS, Suh JD, Ramakrishnan VR. Treatment of cerebrospinal fluid rhinorrhea. Curr Opin Otolaryngol Head Neck Surg. 2015 Feb. 23 (1):59-64. [Medline].
Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Laryngoscope. 2017 Sep. 127 (9):2011-6. [Medline].
Adams AS, Francis DO, Russell PT. Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea. Int Forum Allergy Rhinol. 2016 Nov. 6 (11):1126-30. [Medline].

Media Gallery

An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus.
After intrathecal fluorescein is administered, an exposed frontal recess encephalocele is seen.
A defect in the skull base is measured with a sterile ruler.
A small cribriform plate encephalocele is observed only after removing the middle turbinate.
Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. (Defect measured approximately 7mm.)
Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele.
This image represents an endoscopic view with a 70-degree telescope through the left frontal recess. A large defect is noted, and the meningocele has been resected. Repair of the leak can be performed with an underlay fascia graft and an anterior-based pedicled mucosa flap.
Triplanar images of a patient with a left lateral recess meningoencephalocele. The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa.

of 8

Author

Kevin C Welch, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, The Feinberg School of Medicine

Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa;Proforma;Neosoma<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .

Additional Contributors

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

James Stankiewicz, MD Professor, Chair, Program Director, Department of Otolaryngology-Head and Neck Surgery, Loyola University Chicago School of Medicine

James Stankiewicz, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Nadieska Caballero, MD Fellow in Rhinology and Skull Base Surgery, Sinus and Nasal Institute of Florida

Nadieska Caballero, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society

Disclosure: Nothing to disclose.

Acknowledgements

Joseph M Scianna, MD Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Scianna is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society

Disclosure: Nothing to disclose.

Srinivas Mukkamala, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center

Disclosure: Nothing to disclose.

What are complications of cerebrospinal fluid (CSF) rhinorrhea?

Related Questions:

References

Tables

Contributor Information and Disclosures