Surgical management of cerebrospinal fluid rhinorrhea factors affecting success

Introduction
Cerebrospinal fluid (CSF) rhinorrhea was defined firstly by Willis in 1676 owing to breakdown of the layers of the meninges, the bone of the skull, the periosteum, and the nasal mucosa. Multiple causes can induce CSF rhinorrhea. These causes may be traumatic (accidental or iatrogenic after endoscopic sinus surgery) or spontaneous. The most common symptom is unilateral rhinorrhea which may be increased by stooping or performing valsalva maneuver. Other manifestations like irritability caused by pneumocephalus can also occur.
Aim
The management of cerebrospinal fluid (CSF) rhinorrhea is challenging. Many factors affect its success and can prevent recurrence or failure. This study aims to investigate the outcome of surgical management for CSF rhinorrhea and the factors associated with it.
Patients and methods
A total of 30 patients were admitted for surgery for nasal CSF fistula. Patients with rhinorrhea with more than 2 weeks of conservative treatment, some patients who underwent open surgery, and others who underwent endoscopic surgery were included in our study. The follow-up was continued for 6–18 months after surgery. Many factors were studied to recognize the causes of recurrence and failure such as intracranial hypertension, site of defect, etiology of leak, size of graft, using of fibrin glue, packing of defect, and type of graft.
Results
Among the included patients, 22 (73.3%) had a history of increased intracranial tension (ICT). The defect was in the cribriform plate in 10 (33.3%) patients, ethmoidal in five (16.7%) patients, sphenoidal in five (16.7%) patients, and in the frontal sinus in two (6.7%) patients. The success of surgery was observed in 20 patients, whereas failure occurred in seven patients, and recurrence occurred in three patients. The most important two factors affecting the outcome are the increased ICT (=0.006) and the size of graft (=0.003).
Conclusion
For successful surgical management of CSF rhinorrhea, increased ICT must be treated thoroughly preoperatively and postoperatively. Furthermore, the size of graft must be large in relation to the size of defect.