Endoscopic management of cerebrospinal fluid leaks

To examine the diagnosis and treatment of patients with cerebrospinal fluid (CSF) rhinorrhea, a cohort of 36 patients treated between 1993 and 2000 were examined to consider the role of imaging and other diagnostic tests such as the presence of beta-transferrin in nasal secretion. The etiology of the condition was considered and was found to be congenital in 7 patients and acquired in 29 patients of which in 15 patients it was traumatic, in 12 patients it occurred spontaneously, and in 2 patients it was associated with Wegener's granulomatosis. Where it was possible to obtain nasal secretion, beta-transferrin proved a highly sensitive and specific test and imaging included computed tomography (CT), CT cisternography, and magnetic resonance imaging (MRI) of which fine detail coronal CT and MRI proved the most helpful. In six patients neither imaging nor beta-transferrin could be used to confirm the diagnosis in which case intrathecal fluorescein was used. Repair was performed endoscopically in all cases with one exception where the defect was felt to be too large for this technique. Middle turbinate mucosa, cartilage, and fascia were the preferred repair materials in the anterior skull base whereas dermalfat was preferentially used in the sphenoid. The overall success rate for an endoscopic approach was 94% although in three cases a second endoscopic procedure was required to produce closure and external approaches were used in two additional patients. The use of a diagnostic algorithm is helpful in both confirming the presence of CSF rhinorrhea and the optimum approach. In the vast majority of cases an endoscopic repair will be successful and it avoids many of the complications associated with craniotomy, particularly in a young population. Therefore, it is our preferred option, although surgeons must be prepared for alternative procedures should these prove necessary.