Cerebrospinal fluid (CSF) rhinorrhoea is due to breach in arachnoid membrane, duramater, bony skull base, periosteum, and the nasal mucosa1. It is divided into traumatic and non-traumatic. Non-traumatic causes include spontaneous csf rhinorrhoea , congenital causes , and leaks due to intracranial or skull base tumours 2. Csf leak due to trauma is more common, and is divided into iatrogenic (secondary to anterior skull base surgery and endoscopic sinus surgery ESS) and non-iatrogenic skull base trauma.
Only 1-2% of ESS presents as CSF rhinorrhoea as a post operative complication 3. Most common clinical presentation of CSF leak is clear, unilateral rhinorrhoea, which is exacerbated on bending over or performing a Valsalva maneuver 4. Headache if present should raise suspicion of raised ICP or intracranial pathology 5.
CSF markers like Beta-2 transferrin, Beta -2 tracer protein which are sensitive and specific marker are useful in making diagnosis6.Traumatic CSF leak usually stops with conservative treatment and bed rest but if CSF leak is not resolved than it needs a surgical solution. There has been a significant evolution in repair of CSF Rhinorrhoea over the past 30 years. Previously craniotomy was done for repair, which had a variable success rate and relatively high morbidity 5. Wigand in 1981 described the first endoscopic csf leak repair 1981, Since then literature reports various case series that describe different endoscopic methods and materials for repair, with success rates varying between 70% and 100%, with a average around 90% 7.
Spontaneous. CSF Rhinorrhoea is mainly prevalent in middle-aged female having high BMI (fatty,40,female)Spontaneous CSF leaks have signs of raised ICP and can be categorized in low flow and high flow leaks. Causes of spontaneous csf leak are benign intracranial hypertension presenting as headache, vision loss, pulse synchronus tinnitus, photopsia, eye pain pappiloedema , normal neurological exam. Drugs toxicity of vit a, tetracycline, ocp, steroids are also found to be associated with spontaneous csf rhinorrhoea.Few Systemic conditionslike hypothyroidism, CRF are also found associated with spontaneous csf rhinorrhoea. Anatomical defects like Presence of sternberg canal cause leak from lateral wall of sphenoid.
Various radiological features associated with spontaneous csf rhinorrhoea pointing towards benign intracranial hypertension(seen on T2 MRI) are empty sella, peri optic nerve csf leak, tortuity of optic nerve, bilateral venous sinus stenosis- lateral segments of the transverse sinuses, no evidence of current or remote thrombosis.In this study we are sharing our experience in managing Spontaneous CSF leak and the very unique pattern in Radiology and intra-operative findings and individualized approach towards each case. CSF diversion for initial few days in select cases and using vascularized flaps is very useful in getting results close to 96 percent.