Management of cerebrospinal fluid rhinorrhea: The Medical College of Wisconsin experience

Introduction: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. Methods: A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. Results: Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). Discussion: Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.