Cerebrospinal Fluid Rhinorrhea:

A Review of the Literature

Mark K. Zlab, M.D.
Gary F. Moore, M.D., F.A.C.S.
David T. Daly, M.D.
Anthony J. Yonkers, M.D., F.A.C.S.

Introduction
Cerebrospinal fluid (CSF) rhinorrhea, the leakage of
spinal fluid through the nose, was first described in the
second century AD by Galen who postulated that CSF was
periodically released into the nose by way of the pituitary
and ethmoid regions. For centuries it was accepted that
there was free communication between the brain and the
nose. In 1655 Schneider refuted this concept and in 1826
Miller described a hydrocephalic child with an intermit-
tent nasal discharge of spinal fluid. By the late 1800's, St.
Clair Thompson had compiled a series of patients with
nasal CSF leaks and coined the term rhinorrhea. In these
early series, the leaks were of the non-traumatic type, as
patients with sufficient head injuries to tear the dura rarely
survived long enough to be investigated. Since World
War I, the current classification for CSF rhinorrhea has
been developed .'
CSF rhinorrhea is generally classified as traumatic or
non-traumatic (spontaneous). Traumatic cases are further
subdivided into those incurred during a head injury and
those occurring post-operatively. Spontaneous cases are
divided into high pressure and normal pressure leaks.
cavity may take place across the frontal sinus, the cribiform
plate of the ethmoid, the sphenoid sinus, the sella, or via
the temporal bone to the middle ear and through the
eustachian tube? (Fig. 1).
The phenomenon of delayed traumatic CSF rhinorrhea
is less well understood. One theory is that an osseous
fracture occurs without a dural tear, and in time the same
mechanisms producing a spontaneous rhinorrhea produce
the delayed traumatic CSF rhinorrhea. Other theories
involve the contraction of the traumatic wound ,
devascularization and necrosis of the soft tissue or bony
wound edges, and the resolution of edema associated with
the initial injury.'
Also included in the traumatic group are postsurgical
cases (Fig. 2). These generally follow ethmoid or mastoid
operations. Intracranial operations are also implicated.

Traumatic CSF Rhinorrhea

Traumatic CSF rhinorrhea accounts for approximately
90% of the cases seen, and is a complication of 2% of all
head traumas. Traumatic cases are most common in males
during the third to fifth decades. In most instances the
reasons for the rhinorrhea are obvious, e.g. major head
trauma where the osseous and dural defects are so large
that normal healing without operative intervention is im-
possible. The onset is generally within the first 48 hours
(80%). Ninety-five percent will present within three
months of the accident. The flow of CSF into the nasal
Fig. 1. Schematic representation of potential routes of
leakage of CSF into the nose. These include the frontal
Department of Otolaryngology-Head and Neck Surgery, University sinus, cribiform plate, sphenoid, sella, or by way of the
of Nebraska Medical Center, 600 South 42nd Street, Omaha, NE 68198- petrous temporal bone to the middle ear and through the
1225 eustachian tube. (Adapted from Benvenuti, et al)

314 Ear, Nose and Throat Journal

 CEREBROSPI NAL FLUID RHINORRHEA: A REVIEW OF THE LITERATURE
Fig. 2. CT scan through cribiform plate demonstrating
defect after removal of an ethmoid sinus/nasal mass. The
patient had postoperative CSF rhinorrhea.
Spontaneous CSF Rhinorrhea 4
Spontaneous CSF rhinorrhea is subdivided into normal
pre ssure and high pressure leaks . Females are more
frequentl y affected (2:1) and pre sent ation is mo st com-
mon in the fourth dec ade. Th e initial leak is frequ entl y
precipitated by cou ghin g, sneezing, or straining. Authors
differ on whether spontaneous leak s have an increased or
decreased incidence of men ingit is. High pre ssure leaks
are due to lon gstanding increases of the intracranial pres-
sure (ICP), and account for45 % of spontaneous leak s. Th e
pathophysiology is that of increased pre ssure in the sub-
arachnoid space which forces CSF through a weak or
potential pathway (generally the cribiform plate ). Eighty -
four percent are precipitated by slow growing tumors,
most commonly pituit ary tumors. In these cases , by the
time a tumor produces a great enou gh change in ICP to
precipitate a leak , there are generally other neurological
signs and abnormalities on skull film s. High pre ssure CSF
rhinorrhea is not due to direct inva sion of the skull base.
Sixteen percent of high pressure leaks are associated with
hydrocephalus. Other abnormalities associated with high
press ure CSF rhinorrhea include Cro uzon 's disease and
Albers -Schonberg disease.
Normal pressure leaks account for 55 % of spontaneous
leak s and are due to the slow ero sion of the skull base
secondary to normal fluctuations in the ICP leadin g to
po int ero sion and CSF rhinorrhea. Ninety perce nt origi-
nate from a con genital or potential path way, such as a
persistent craniopharyn geal canal and nasal encephalocele
or a meningoencephalocele. Other potential pathways
include the olfactory nerve , stalk of the hypophysis or a
Volume 71, Number 7
maldevelopment of the cribiform plat e or diaphragm sell a
(empty sella syndrome). Ten percent are due to direct
ero sion of the skull base by tumor or infec tions. Exampl es
include osteoma s of the frontoethmoids, nasopha ryn geal
angiofibromas, nasoph aryn geal carcinomas, osteol ytic
ero sion s secondary to sinusitis, syphilis and possibl y
mucoceles.
Diagnosis
The diagnosis of CSF rhinorrhea invol ves determining
that the flu id is CSF and identifying the port al of entry into
the nose. Nasal discharge exhibiting a clear ' halo' sur-
rounding a central blood stain after trauma is classically
thought of as CSF. Although this handkerchief test is a
cla ssic example given as ident ifying CSF, it is only a gross
test and produces false positive result s if saliva or tear s are
mixed with the blood/fluid obtained from the nose.
A patient with repe ated attacks of pneumococcal men-
ingitis should be thought of as having a dural tear even if
no nasal drainage is present. Likewise, a finding of
pneumocephalus obligates a work-up to identify the dur al
defect and a treatment of that defect. Th e most common
clinical findings associ ated with CSF rhinorrhea are men-
ingiti s and pneumocephalus.lG luco se determination of
the nasal discharge will assist in identifying the disch arge.
Glucose oxidase papers are unreliable and should not be
used. Quantitative glucose mea surem ents accurately
identify the fluid as CSF if it contains >30 mg/IOO ml
glucose. Many patients describe the drainage as sweet
tasting. Some authors advocate protein ana lysis of the
fluid as more reliable (CSF >45 mg %) than glucose
analy sis.
B2 transferrin (tau transferrin ) analysis has recentl y
gained favor for diagnosing flu id as CSF. The protein is
highly speci fic for human CSF, and is not present in any
other body fluids . Other advantages of this test includ e the
small sample size required «Icc), and the fact that no
special handling or refri geration is required . The samples
can be analyzed by imm unochromatographic assay , gas
chromatography or silver staining.Y
X-ray studies, including tomography , have proven to be
of low yield in identifying fractures or defining the areas
of fluid acc umulation. X-rays may also be misleading if
the dur al tear is distant from the site of the osseous
fracture.
Dye s injected intrathec ally and recovered on nasal
pledgets are of historic interest. Indi go carmine and
meth ylen e blue were used in the 1930 ' s and 1940's, but
abandoned due to complications, primarily neurologic,
315
 ZLAB, MOORE, DALY, YONKERS
and poor localization of the leak.
Fluorescein (1cc of 5% fluorescein injected intrathecally
over 10 minutes) continues to be used diagnostically in
identifying the site ofthe leak, and also intraoperatively to
visually identify the fracture. Transient neurologic com-
plications have been reported.
Pantopaque cistemography does not fill small fistulae
and the contrast media is not water-soluble.
Pneumocephalography provides no contrast within the
tract of the nose and the paranasal sinuses and is uncom-
fortable.
Ornnipaque and Isoview injected intrathecally, in con-
juncture with CT scans, have been found to provide
superior visualization of even small leaks and have a lower
incidence of side effects in our experiences (unpublished
data). Further advantages ofthese contrast media are their
non-ionicity and short half-lives.
Radionuclide cistemography has proved helpful. 1-131
has been widely used, but exposure to high radiation doses
and a high frequency of adverse reactions (up to 24%) has
limited its use. Indium (In-111) is becoming the most
frequently used cistemography radioisotope due to its
short half-life (2.8 days) and lower radiation absorption.
Its primary advantage and disadvantage is its sensitivity.
It is very sensitive and frequently results in overly positive
scans of little localizing benefit. Technetium (Tc-99)
Fig. 3. Recommended placement of nasal pledgets in-
cludes one superiorly near the cribiform plate and ostium
of the sphenoid; one under the middle turbinate near the
ostium of the frontal sinus; and one inferiorly near the
oriface of the eustachian tube. (Adapted from Duckert, et al)
316
labeled albumin injected intrathecally in conjunction with
serial scans has proved helpful, but the short half-life
requires a fairly free flowing leak for visualization.
Intrathecal metrizamide in conjunction with CT scans
are helpful in anatomically localizing active CSF leaks.
The scans can be performed in the 'head-up' position
(conservative management positioning) yet smaller fistu-
lae can be demonstrated by employing Valsalva maneu-
vers. Metrizamide has the added advantage of being
relatively free of neurotoxicities.V
Care must be taken with all scans involving nasal
pledgets to: 1) avoid saturation and contamination of
neighboring pads, 2) avoid contamination while removing
the pledgets and 3) avoid using too large a number of
pledgets where their locations cannot be accurately en-
sured . Current recommendations include using three
pledgets in each nasal passage to identify all possible
routes of leakage; one superiorly in the region of the
cribiform plate and sphenoid sinus ostium; one under each
middle turbinate near the frontal sinus ostium; and one
inferiorly adjacent to each eustachian tube orifice 7 (Fig. 3).
Management of CSF Rhinorrhea
Once the diagnosis ofCSF rhinorrhea is made, manage-
ment can be medical or surgical.
Medical Management
Medical management is advocated, if possible, to allow
the body's reparative processes a reasonable chance to
heal itself without the possible detrimental effects of
surgical exploration. Patients should be kept in the 'head-
up' position. Coughing, sneezing, nose blowing and
straining should be avoided. Laxatives are given , fluids
are restricted and some centers advocate steroid and di-
uretics use (both are probably minimally effective). Pro-
phylactic antibiotic use is controversial; many groups
advocate use only for patients with complications or open
skull fractures with gross contamination. In the presence
of increased ICP the most effective way to decrease the
ICP is by repeat lumbar taps by way of an indwelling
lumbar subarachnoid catheter or continuous removal of
fluid by way of an indwelling catheter attached to low
intermittent suction. Medical management is advocated
for mild to moderate closed head injury, LeFort II frac-
tures (with disruption of the nasoethmoid complex) and
for postsurgical CSF rhinorrhea (short-term).
Surgical Management
Surgical management is reserved for open wounds,
Ear, Nose and Throat Journal
 CEREBROSPINAL FLUID RHINORRHEA: A REVIEW OF THE LITERATURE
intracranial hemorrhages, pneumoc ephalus, delayed on-
set leaks, spontaneous leaks, and leaks not responding to
conservative management.
The intracranial approach employs uni- or bilateral
frontal bone flaps. Advantages to this technique include
direct visualization, the simultaneous inspection and re-
pair of adjacent cortex, and a better chance of tamponading
a leak precipitated by increased ICP. Drawbacks to the
intracranial approach include increased morbidity , longer
operation and hospitalization and the increased risk of
developing anosmia.
Extracranial repair of CSF rhinorrhea is associated with
decreased morbidity, decreased incidence of anosmia, and
superiorexposure of the sphenoid , parasellar and posterior
ethmoid regions . Limitations of this approach include an
inability to examine underlying cortex, lack of success at
repairing high pressure leaks, and poor visualization of
frontal or sphenoid sinuses with prominent lateral exten-
sions.
Current thought is that unless there is a coexisting
indication for intracranial exploration, the most appropri-
ate initial approach for CSF rhinorrhea is by an extracra-
nial rhinological repair. Extracranial approaches includes
the frontal osteoplastic sinusotomy (brow incision) to
repair a posterior wall frontal sinus fracture. Sublabial
transseptal sphenoidotomy is the approach of choice for
sphenoid repair unless ethmoid involvement is also impli-
cated, in which case an external or transnasal
ethmoidectomy is preferable. A lateral rhinotomy inci-
sion (curved nasoorbital exposure) provides adequate
exposure for repair of fractures of the ethmoid labyrinth or
cribiform plate. In all of the above cases the sinus must be
obliterated with muscle or fat after a fascial patch has been
secured over the defect.' The introduction of fibrin glue to
aid in securing fascial patches to the defect has been a
promising advance and appears to decrea se the incidence
of recurrence. " In all cases the nose should be packed
postoperatively and systemic antibiotics employed in the
immediate post-op period . Some groups advocate antibi-
otic impregnation of the nasal packing and reserving the
use of systemic antibiotics for patients with postoperative
infections .
In conclusion, the majority of cases of CSF rhinorrhea
are traumatic and present in the first three months. Spon-
taneous leaks imply an underlying abnormality which
must be identified prior to treatment. Diagnosis and
identification of the site of the leak is often inaccurate,
even with meticulous care given to placing and removing
the nasal pledgets. Once the leak is identified, medical or
Volume 71, Number 7
surgical treatment may be attempted. Recurrent leaks are
common and serial operative procedures have been re-
ported to stop even small leaks."
Summary
CSF rhinorrhea may be spontaneous or traumatic, the
majority of cases being traumatic and presenting within
the first three months . Spontaneous leaks imply an under-
lying abnormality which must be identified prior to treat-
ment. Diagnosis and identification of the site of the leak
is often inaccurate, even with meticulous care given to
placing and removing the nasal pledgets. Once the leak is
identified , medical or surgical treatment may be attempted.
Recurrent leaks are common and serial operative proce-
dures have been reported to stop even small leaks.
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4. Shu gar JMA , Som PM, Eisman W, et al. Non-traumatic cere-
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