Diagnosis and Treatment of Cerebrospinal Fluid Rhinorrhea Following Accidental Traumatic Anterior Skull Base Fractures

Mateo Ziu, M.D.; Jennifer Gentry Savage, M.D.; David F. Jimenez, M.D.

Disclosures

Neurosurg Focus. 2012;32(6):e3 

In This Article

Abstract and Introduction

Abstract

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.

Introduction

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition that still presents a major challenge in terms of its diagnosis and management. It is estimated that meningitis develops in approximately 10%–25% of patients with this disorder, and 10% of them die as a result. Approximately 80% of all cases of CSF rhinorrhea are caused by head injuries that are associated with cranial fractures.[118] The estimated incidence of basilar skull fracture from nonpenetrating head trauma varies between 7% and 15.8% of all skull fractures, with associated CSF leakage occurring in 10%–30% of these patients.[95,118] The leak can occur wherever the dura mater is lacerated during injury and there is a communication between the intracranial and nasal cavities.

Despite many advances, it is still difficult to critically interpret the literature with regard to the optimal management of CSF leakage following craniomaxillofacial trauma. Most published articles, while documenting the efficacy of endoscopic surgery to repair CSF leaks, have failed to separate patients into distinct etiological groups when reporting outcome. In addition, no authors have consistently analyzed the success of nonsurgical treatment modalities, such as bed rest and CSF diversion, and still little is known about the incidence and natural history of this disease entity, the need for antibiotics, and the surgical indications for and timing of intervention.[10]

Furthermore, the issues related to CSF leak caused by traumatic injury are complex and multiple. Having conducted a thorough review of existing literature, we discuss here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant to traumatic anterior skull base injuries and attempt to identify areas in which further research is needed.

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