CONTEMPORARY MANAGEMENT OF CEREBROSPINAL-FLUID RHINORRHEA

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remai ns controversial. Most studies recommend either an endoscopic or an ex ternal extracranial approach, depending on the surgeon's preference. E ighteen patients with CSF rhinorrhea have been managed at our institut ion since 1990. The causes of the CSF rhinorrhea consisted of function al endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repa ir after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was rep aired during the primary surgery, whereas one patient underwent second ary repair after failure of conservative management of his CSF fistula . Seven patients underwent exploration for spontaneous (:SF rhinorrhea . Four patients had computer tomography scans that showed the leak, an d two patients had cisternography to localize the leak. One patient un derwent magnetic resonance cisternography. Both of these leaks were id entified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mu cosal graft from the septum (7), and a middle turbinate (5). Two patie nts had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent r epair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a secon d repair 8 months after surgery. latrogenic trauma remains the most co mmon cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an e ndoscopic or external approach is used depends on surgical expertise a nd experience.