The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2004 The American Laryngological,
Rhinological and Otological Society, Inc.
Nasal Cerebrospinal Fluid Leaks: Critical
Review and Surgical Considerations
Rodney J. Schlosser, MD; William E. Bolger, MD, FACS
Otolaryngologists have assumed a major role in
the evaluation and management of anterior skull
base defects that result in cerebrospinal fluid (CSF)
leaks and meningoencephaloceles. To achieve the
best possible results for patients with CSF leaks, a
thorough understanding of the underlying patho-
physiology and a critical analysis of management
principles and treatment options is essential. Surgi-
cal and medical management of these patients is
highly individualized and depends on a number of
factors, including etiology, anatomic site, patient age,
and underlying intracranial pressure. This review ar-
ticle will highlight the history, physiology, patho-
physiology, diagnosis, surgical techniques, and post-
operative care relevant to nasal CSF leaks and
encephaloceles. Key Words: CSF leak, encephalocele,
endoscopic surgery.
Laryngoscope, 114:255-265, 2004
HISTORY
Surgical repair of cerebrospinal fluid (CSF) leak is
credited to Dandy, who closed a cranionasal fistula using
a frontal craniotomy approach in 1926. A success rate of
60% to 80% was achieved, and the approach soon became
the standard of care. In 1948, Dohlman described the first
extracranial approach. Using a naso-orbital incision, he
closed an anterior skull base defect and CSF leak. Tran-
snasal approaches were subsequently used by Hirsch in
1952, and Vrabec and Hallberg in 1964. Improved instru-
mentation for sinus surgery led to the endoscopic repair of
CSF leaks by Wigand in 1981. Over the past 20 years, the
minimally invasive endoscopic approach has gained wide-
spread acceptance. The diagnostic aspects and surgical
techniques have evolved, leading to higher success rates
(approximately 90%) and lower morbidity than traditional
From the Department of Otolaryngology-Head and Neck Surgery
(R.J.S.), Medical University of South Carolina, Charleston, South Carolina
and the Department of Surgery (Otolaryngology) (W.E.B.), Uniformed Ser-
vices University of the Health Sciences, Bethesda, Maryland, U.S.A.
Editor's Note: This Manuscript was accepted for publication August
27, 2003.
Send Correspondence to Dr. Rodney J. Schlosser, Department of
Otolaryngology-Head and Neck Surgery, 135 Rutledge Ave, Suite 1130,
PO Box 250550, Medical University of South Carolina, Charleston, SC
29425, U.S.A. E-mail: schlossr@musc.edu
Laryngoscope 114: February 2004
STATE OFTHE ART REVIEW
intracranial techniques for most leaks. The endoscopic
approach has become the standard of care.1'2
NORMAL PHYSIOLOGY
Cerebrospinal Fluid Physiology
It is helpful to understand normal CSF physiology
when developing treatment plans for patients with CSF
leaks and meningoencephaloceles. Approximately 70% of
CSF is produced by the choroid plexus located in the lateral,
third, and fourth ventricles. Another 18% is produced by
capillary ultrafiltrate, whereas the final 12% is produced by
the metabolism of water. CSF is formed at a rate of 0.35
mL/minute (20 mL/h or 350-500 mL/day). The total volume
of CSF in an adult is approximately 90 to 150 mL. This cycle
of continual production and absorption results in the total
volume of CSF being turned over three to five times each
day.3
After production in the choroid plexus, CSF flows
primarily from the lateral ventricles through the foramen
of Monroe into the third ventricle. It leaves the third
ventricle through the aqueduct of Sylvius to enter the
fourth ventricle. CSF then exits the fourth ventricle by
way of the foramina of Luschka and the foramen of Ma-
gendie to enter the subarachnoid space around the spinal
cord and cerebral convexities.
CSF absorption occurs along the cerebral convexities
at the arachnoid villi. These villi project into the dural
sinuses and act as one-way valves. To drive CSF through
the villi, a pressure gradient of 1.5 to 7 cm of water is
required. At lower pressure differentials, the villi close
and prevent retrograde flow.
Intracranial Pressure
Normal intracranial pressure (ICP) is approximately
5 to 15 cm of water recorded in the lumbar cistern with the
patient lying down. Moving from lying to sitting can in-
crease CSF pressure measured at the lumbar cistern up to
40 cm of water. This pressure also varies depending on
time of day, patient age, activity level, cardiac cycle, and
respiratory phase. ICP rises approximately 20 to 35 cm of
water during rapid eye movement (REM) sleep when com-
pared with normal daytime measurements. CSF pressure
Schlosser and Bolger: Nasal CSF Leaks
255
also increases at least 4 cm of water during sneezing,
laughing, and Valsalva maneuvers. Increased ICP is de-
fined as sustained pressure over 20 to 30 cm of water or
frequent pressure spikes of this level. Neurologic symp-
toms may develop once pressures reach 15 to 20 cm of
water, and treatment to reduce ICP is generally recom-
mended for patients with mild to moderate elevations,
even in the absence of symptoms.3
Hydrocephalus
Obstruction that occurs within the ventricular sys-
tem, proximal to the outlets of the fourth ventricle, leads
to the formation of noncommunicating hydrocephalus be-
cause the subarachnoid space is separated from the ven-
tricular space. Ventricular dilatation occurs proximal to
the site of obstruction because of the resulting pressure
differential. Communicating hydrocephalus occurs when
the site of obstruction is distal to the ventricular system,
such as at the arachnoid villi. Ventricular dilatation is less
common in this scenario because the ventricular system is
in communication with the subarachnoid space, and no
pressure differential exists between the two. When ele-
vated ICP is present, the weakest anatomic points in the
periphery of the central nervous system occur along the
optic nerve sheath, the cribriform plate, the sellar dia-
phragm, and any other bony dehiscences in the anterior or
middle cranial fossae. These sites can act as potential
release valves for the high pressure. 3
PATHOPHYSIOLOGY
Overview
CSF leaks can be categorized based on etiology, ana-
tomic site, age of patient, or underlying ICP. For this review,
we will discuss leaks based on etiology because this is usu-
ally apparent from the patient's clinical history, then we will
discuss the impact that anatomic location and underlying
ICP have on the surgical repair. CSF leaks occur in a variety
of forms. The size and structure of the bony defect, degree
and nature of the dural disruption, associated ICP differen-
tial, and meningoencephalocele formation vary greatly, de-
pending on the etiology of the CSF leak. Frequently, these
conditions are linked because patients with iatrogenic skull-
base injuries can have relatively large bony defects, but a
large encephalocele may not form if the ICP is normal. In
contrast, spontaneous CSF leaks can have relatively small
bony defects, but elevated ICP contributes to formation of a
Laryngoscope 114: February 2004
256
large encephalocele. All of these factors should be considered
because they influence medical and surgical treatment and
long-term success.
Accidental Trauma
Historically, accidental trauma from closed head injury
(CHI) is the most common etiology of CSF leaks, and they
occur in approximately 1% to 3% of all CHI. Traumatic CSF
leaks usually begin within 48 hours, and 95% of them man-
ifest within 3 months of injury.4 Over 70% close with obser-
vation or conservative treatment, such as bedrest or lumbar
drain. Leaks that close without surgical repair are probably
only covered by a thin monolayer of fibrous tissue or regen-
erated nasal mucosa because dura mater does not regener-
ate.5 Although conservative, nonsurgical treatment may be
effective in leak cessation, and it has been associated with a
significant incidence of ascending meningitis (30-40%) in
long-term follow-up. The role for early endoscopic repair is
now being reconsidered as a possible strategy to reduce this
long-term risk of meningitis.
Accidental traumatic CSF leaks represent a hetero-
geneous group of injuries, and highly individualized care
is needed. Patients who suffer blunt head trauma result-
ing in a narrow crack of the skull base with a small dural
tear represent one of the most favorable groups to treat. In
contrast, CHI can also result in multiple or wide cracks
and a broad, multifocal injury (Fig. 1A). Projectile injuries
from bullets, shotgun blasts, or shrapnel may have signif-
icant comminution of the skull base and represent one of
the most difficult groups to treat (Fig. 1B).
Surgical Trauma
The most common surgeries leading to iatrogenic
skull-base defects are functional endoscopic sinus surgery
(FESS) and neurologic surgery. One of the differences
between accidental and surgical trauma may be the size of
the bony defect as well as the degree of dural and associ-
ated brain parenchymal disruption. Although many leaks
from blunt trauma result in fine cracks of the skull base,
iatrogenic defects typically occur during bone resection
and result in bony defects ranging from several millime-
ters to over 2 cm in size.
The two most common sites of skull-base injury as-
sociated with endoscopic sinus surgery are the lateral
lamella of the cribriform plate and the posterior ethmoid
roof near the anterior medial sphenoid wall. Injury to the
Fig. 1. Accidental trauma can result in
a variety of skull-base defects as seen
in these coronal computed tomogra-
phy scans. Blunt trauma (A) may
cause single or multiple cracks, such
as these seen near the right optic
nerve (arrow). Projectile injuries, such
as bullets or shrapnel, can create total
comminution of the skull base (B).
Schlosser and Bolger: Nasal CSF Leaks
Fig. 2. latrogenic trauma, as seen in these coronal computed tomography scans, frequently results in the loss of bone. A common site of injury during
functional endoscopic sinus surgery is the right lateral lamella (arrow in A) when resecting the right middle turbinate. The most common iatrogenic
cerebrospinal fluid leak secondary to neurosurgical procedures occurs during pituitary surgery. This may occur if the approach to the sella is directed too
far anteriorly and superiorly, creating a defect in the planum sphenoidale (arrow near optic nerve in B). This defect encompassed nearly the entire ethmoid
roof because it extended from the optic chiasm to the anterior ethmoid artery.

lateral lamella of the cribriform can occur during an ap- noidal hypophysectomy.6 If tumor or surgical manipula-
proach to the anterior ethmoid or frontal recess or when tion disrupts the sellar diaphragm, a leak can occur. Typ-
resecting the middle turbinate close to the skull base (Fig. ically, a graft of abdominal fat is sufficient to seal the leak,
2A). The bone of the lateral lamella of the cribriform can but a revision surgical procedure and additional grafting
be much thinner than the central and lateral aspect of the measures are required on occasion. A skull-base defect
ethmoid roof and therefore is susceptible to injury. and CSF leak can also occur if the approach to the sphe-
Lateral lamella injuries occur more frequently on the noid is inadvertently directed superiorly (Fig. 2B). Other
patient's right side during endoscopic sinus surgery. Most causes of CSF leak during neurosurgery include craniofa-
surgeons are right handed, and there is a tendency for the cial resection and transcranial approaches to the optic
angle of surgical approach to drift medially, toward the chiasm and cavernous carotid area for tumor or aneurysm.
lateral lamella. Insuring that the patient's head is turned Both accidental and surgical trauma groups usually have
toward the surgeon and therefore is aligned with angle of relatively healthy bone around the defect and normal
the surgical approach can reduce this tendency. If the ICPs, which are favorable factors for a successful repair.
surgeon sits while performing the operation, there are
additional subtle factors to consider. An operating room Tumors
chair that does not elevate sufficiently, an operating room Skull-base tumors can lead to CSF leaks either directly
table that is not fully lowered, and a patient with limited or indirectly. Direct tumor invasion across the anterior skull
range of motion in the neck can subtly change the angle of base can cause large defects with significantly diseased or
surgical approach and predispose the patient to a medial
skull-base injury while the surgeon is operating within
the patient's right nasal cavity.
Iatrogenic posterior ethmoid defects typically occur
in cases where the skull base is thin and the maxillary
sinus is highly pneumatized. The excessive maxillary
pneumatization encroaches medially and superiorly, caus-
ing a corresponding and relative decrease in posterior
ethmoid pneumatization. The height, or superior to infe-
rior dimension of the ethmoid, is reduced. The horizontal
insertion of the middle turbinate, that is, the inferior
aspect of the basal lamella, attaches to the palatine bone
in a relatively greater posterior and superior position.
These factors work to result in a "shallow" or small pos-
terior ethmoid cavity and also tend to deflect the angle of
the surgical approach more superiorly. After penetration
of the basal lamella, the surgeon may feel he or she is
comfortably anchored in the anterior and medial aspect of
the posterior ethmoid. The surgeon is soon confronted
with a bony structure that appears to be a septation be-
tween posterior ethmoid cells. However, in this "shallow"
posterior ethmoid, this "cell wall" is actually the skull
base, deceptively positioned in the surgical field.
Fig. 3. Coronal computed tomography of patient with cerebrospinal
CSF leak after neurologic surgery can occur after a fluid leak caused by destruction of the skull base by a pituitary
variety of procedures, but the most common is transsphe- neoplasm.

Laryngoscope 114: February 2004 Schlosser and Bolger: Nasal CSF Leaks
257

missing bone surrounding the defect (Fig. 3). These tumors
can be primary brain or pituitary malignancies that extend
down into the nasal cavity, or, conversely, they may be si-
nonasal primaries that extend intracranially. Therapeutic
treatments for the tumor itself, such as surgery, radiation, or
chemotherapy, can contribute to creating a devascularized
wound bed and skull-base defect that is difficult to repair.
Noncurative treatments that leave persistent tumor may
also compromise CSF leak repair. The one favorable aspect
is that these patients usually have normal ICPs.
Conversely, tumors can indirectly lead to CSF leaks
by obstructing CSF flow, resulting in hydrocephalus. De-
pending on the location of the tumor, this obstruction
causes either communicating or noncommunicating hy-
drocephalus. Success in these cases usually requires treat-
ment of the primary tumor to correct the obstruction or
long-term shunting to divert the high-pressure system.
Repairing the CSF leak without treating the obstructing
lesion may actually worsen the high-pressure condition
because the internal relief valve for the patient's intracra-
nial hypertension is removed.
Congenital
Congenital CSF leaks and encephaloceles are challeng-
ing to treat and, fortunately, are relatively rare. They most
commonly are caused by a developmental skull-base malfor-
mation. These deformities are typically characterized by a
funnel-shaped defect of the bony skull base through which a
meningoencephalocele herniates into the sinonasal cavity.
This may occur in the region of the cribriform plate, and, at
that location, the appearance suggests that a natural open-
ing for an olfactory filae with its accompanying dural sleeve
developed aberrantly (Fig. 4, A and B). Alternatively, large
encephaloceles may also form through a skull-base defect in
Laryngoscope 114: February 2004
258
Fig. 4. Congenital meningoencepha-
loceles are frequently funnel-shaped
defects as seen on coronal computed
tomography (A) and magnetic reso-
nance imagery (B). Surgically, these
funnel-shaped defects (arrows in C)
can make placement of an epidural
bone graft more difficult (D).
the region of the foramen cecum. Patients can have multiple
defects and will require a relatively larger area of repair.
These bony abnormalities can make surgical placement of
epidural grafts difficult because of the misshapen, funnel-
shaped skull base (Fig. 4, C and D). ICPs in this group are
generally normal, with the rare exception being in patients
with congenital hydrocephalus. In these patients with ele-
vated ICPs, CSF leaks and encephaloceles tend to occur at
anatomically weakened sites within the skull base. Similar
to patients with hydrocephalus secondary to an obstructing
tumor, the underlying high-pressure condition should be
treated before definitive repair of the skull-base defect.
Spontaneous
Spontaneous CSF leaks and encephaloceles are inter-
esting and challenging problems. At present, a variety of
clinical conditions have been classified as "spontaneous"
CSF leaks, including leaks associated with tumor, delayed
traumatic leaks, and leaks associated with congenital
skull-base malformation.7'8 We believe CSF leaks that
arise secondary to another condition (tumor, trauma, con-
genital malformation) should be classified and described
as such. We restrict the spontaneous category to patients
with no other discernible etiology for their CSF leak. Im-
portantly, compelling clinical, radiographic, and demo-
graphic data exist to suggest that patients with spontane-
ous CSF leaks represent a distinct clinical entity.9
ICP is an important consideration in understanding
the pathophysiology of spontaneous CSF leaks and ascrib-
ing a logical designation and classification for this condi-
tion. Under the current classification schemes, spontane-
ous CSF leaks and encephaloceles are classified under a
heading of normal ICP.8 Evidence now suggests that ele-
vated ICP is a common clinical finding in patients with
Schlosser and Bolger: Nasal CSF Leaks
spontaneous CSF leaks." Elevated CSF pressures proba-
bly begin with impaired absorption, which leads to in-
creased pulsatile hydrostatic forces exerted at anatomi-
cally weakened sites of the skull base, such as the
cribriform plate or the lateral recess of a hyperpneuma-
tized sphenoid sinus. Eventually, these forces thin the
skull base further to cause a bony defect and dura or brain
tissue to herniate through the defect, forming a meningo-
encephalocele and CSF leak. (Fig. 5).
As previously described, the elevated CSF pressures
seen in this group probably represent a variant of benign
intracranial hypertension (BIH) and accounts for the clin-
ical, radiographic, and surgical picture seen in this group.
Patients are most commonly middle-aged, obese females
with pressure-type headaches, pulsatile tinnitus, and bal-
ance abnormalities in addition to their CSF rhinorrhea.
Radiographically, they often have empty, expanded sellas,
broadly attenuated skull bases, arachnoid pits, and mul-
tiple skull-base defects secondary to chronic hydrostatic
forces. Of all etiologies for CSF leaks, the spontaneous
group is associated with the highest rate (50—100%) of
encephalocele formation, and there are often rather large
meningoencephaloceles herniating through relatively
small bony defects. Spontaneous leaks have the highest
recurrence rate after surgical repair of the leak (25-87%)
compared with less than 10% for most other etiolo-
gies.6,7,10 Unfavorable conditions, such as the elevated
ICP, associated meningoencephaloceles, and a broadly at-
tenuated bony skull base, undoubtedly contribute to this
higher failure rate.
PREOPERATIVE ISSUES
To achieve a successful repair, it is imperative that
preoperative studies establish the diagnosis and localize the
Fig. 5. Spontaneous cerebrospinal
fluid (CSF) leaks are associated with
empty or partially empty sella turcica
(arrow in A) as dura and CSF herniate
through the sellar diaphragm com-
pressing the pituitary gland as seen in
this sagittal magnetic resonance im-
age. (B) The bony skull base in these
patients is broadly attenuated as seen
in this coronal computed tomography.
Careful placement of bone grafts into
the epidural space (C) add structural
support in these repairs. This graft
was approximately 2.5 cm long.
Laryngoscope 114: February 2004
site of the leak. Beta-2 transferrin is a protein present only
in CSF, perilymph, and aqueous humor. Testing nasal se-
cretions for /3-2 transferrin represents a much more specific
and sensitive technique compared with previous methods of
testing for glucose, protein, and electrolytes. Only 0.5 mL of
rhinorrhea fluid is needed for testing, but this may be diffi-
cult to obtain in cases of intermittent leaks. False-positives
and false-negatives are unlikely with /3-2 transferrin testing
but can occur.11 Beta-2 transferrin provides an accurate,
noninvasive method to establish the diagnosis of an active
CSF leak, but, unfortunately, it provides little information
on the precise location of the leak.
High-resolution coronal and axial computed tomog-
raphy (CT) is useful in nearly all cases, independent of
leak activity. It provides important bony detail that is
useful in the surgical approach and helps identify and
localize the skull-base defect. Unfortunately, it does not
establish the diagnosis of CSF leak because bony defects
may be present but not be actively leaking CSF.
Radioactive cisternograms require endoscopic place-
ment of intranasal pledgets followed by intrathecal injec-
tion of a radioactive marker. Typical sites for pledget
placement are the anterior cribriform plate, the middle
meatus, and the sphenoethmoidal recess. The pledgets are
removed after several hours, and the amount of radio-
activity on the pledgets is measured. The utility of this
test is with low-volume or intermittent leaks because
the pledgets remain in place for hours and can continuously
collect CSF if a leak is present. Its major weaknesses are an
inability for precise localization of the defect and sensitivities
that can vary from 62% to 76%, with a false-positive rate up
to 33%.7,12,13 Often, the radioactive cisternogram can only
identify the side (right vs. left) of the leak because CSF and
Schlosser and Bolger: Nasal CSF Leaks
259
nasal secretions mix to collect on all the pledgets on a given
side.
CT cisternograms are very helpful tools because they
hold the potential for identifying whether a leak exists
and can give important information on the site of the leak.
A coronal (and axial, if needed) sinus CT is performed
after intrathecal administration of contrast material. It
may be the only test required if it positively identifies
contrast material within a specific paranasal sinus or
meningoencephalocele sac. Its weakness is that it repre-
sents one data point in time and may miss intermittent
leaks; thus, its sensitivity may range from 48% to 96% 12 ' 13
depending on the flow rate and site of the leak. Its greatest
utility is in frontal or sphenoid sinus leaks because these
sinuses act as reservoirs of the contrast material. In sus-
pected frontal or sphenoid leaks, it is essential to obtain
images in an axial plane to properly evaluate the posterior
walls of these sinuses. In the ethmoid and sphenoid roof, it
is essential to obtain images in the coronal plane. In
cribriform plate-olfactory groove defects, contrast mate-
rial can drain into the pharynx and never collect to a
volume substantial enough to be detectable by imaging.
Therefore, the CT cisternogram can be a helpful test,
especially for frontal and sphenoid leaks, but, like other
tests, has shortcomings.
Preoperative intrathecal fluorescein with a thorough
endoscopic examination is useful in establishing the diag-
nosis of CSF leak, but its ability to precisely localize the
leak site may be limited. If a patient has not had previous
sinus surgery, skull-base exposure is limited. On the other
hand, if extensive sinus surgery has been previously per-
formed and there is adequate exposure of the skull base, it
may be very helpful and accurate. Most estimates place
the accuracy around 96%, but there can still be false-
positives and false-negatives. Intraoperatively, when wide
surgical exposure will be obtained, intrathecal fluorescein
is useful in localizing the defect and ensuring a watertight
closure. Depending on the rate of the leak, the rate of CSF
turnover, and the timing of the intrathecal injection, the
fluorescein may be significantly diluted or excreted by the
time of surgery. Use of a blue light filter can improve the
detection of dilute fluorescein.
Caution must be used with intrathecal fluorescein.
We typically use 0.1 mL of 10% fluorescein diluted in 10
mL of the patient's CSF. This dilute fluorescein is slowly
injected over 10 to 15 minutes. We have had no complica-
tions using this technique in more than a decade of expe-
rience. Complications, such as seizures and neurotoxicity,
have been reported when using higher concentrations or
more rapid injections. We provide informed written con-
sent to all of our patients regarding the risks and benefits
of intrathecal fluorescein and its lack of Food and Drug
Administration approval for this use.
Magnetic resonance imaging (MRI) and MR cister-
nography can be used to noninvasively image CSF leaks
and encephaloceles without the need for a lumbar punc-
ture. Some authors use the term MR cisternography to
describe routine MRI studies that rely primarily on T-2
weighted images to highlight CSF;14 however, most re-
ports describe MR cisternography as a recently developed
technique that uses a fast spin-echo sequence with fat
Laryngoscope 114: February 2004
260
suppression and image reversal to highlight CSF fistu-
las. 15 Both techniques are excellent for identifying brain
parenchyma and CSF within meningoencephaloceles.
Their weakness, like many other studies, is that they may
not identify intermittent leaks that are not active at the
time of the study, although some authors have reported
success detecting intermittent or low-flow leaks by these
methods. 13 ' 15 Accuracy has been reported at 89%, with
85% to 92% sensitivity and 100% specificity.14'15
Deciding which preoperative test is needed for a
given patient should be based on the clinical picture and
the precise information needed rather than by following a
rigid algorithm. In addition, the invasiveness of the diag-
nostic test and the risks to the patient should be taken
into account. The reported sensitivity and specificity of
any test should be interpreted with caution because these
statistics are highly dependent on the patient population
studied, size of the defect, flow rate of the leak, and the
individual interpreting the test.
SURGICAL TECHNIQUE
General Principles
The surgical approach and repair technique used de-
pend on numerous factors previously mentioned, such as
the etiology of the leak, associated ICPs, encephalocele
formation, and the site and type of defect. Historically, the
success rate for traditional neurosurgical repair through
craniotomy is generally accepted as approximately 70% to
80%.1,10 With advanced endoscopic and extracranial tech-
niques, otolaryngologists can now close most CSF leaks
with greater than 90% success and avoid the morbidity of
a craniotomy. A variety of approaches are used to access
the various areas of the skull base. The basic principles of
endoscopic repair of skull-base defects and CSF leaks cen-
ter on positive identification of the leak site, meticulous
preparation of the recipient bed, and accurate placement
of an appropriate graft material. The subsequent discus-
sion of surgical approaches is based on the anatomic re-
gion of the skull base.
Ethmoid Roof and Cribriform Area
Generally, leaks in the cribriform plate and ethmoid
roof are treated with a standard transnasal endoscopic
approach. Topical decongestion with oxymetazoline
(0.05%) followed by a lateral nasal wall injection with 1%
lidocaine with 1:100,000 epinephrine promotes hemosta-
sis during surgery. The nose is then irrigated with a 600
mg/100 mL solution of clindamycin to decrease bacteria
within the surgical field and reduce the potential for in-
tracranial seeding from the operative field. All cameras
and light cables are gas sterilized the evening before sur-
gery to achieve a level of sterility on the surgical field
similar to that of a formal neurosurgical procedure. With
this consideration, we operate from the television monitor
using the endoscopic camera to avoid contamination of the
surgical field from the endoscope eyepiece after it touches
the surgeon's skin or glasses. We also perform a surgical
scrub and antimicrobial preparation of the face and donor
site. A complete endoscopic ethmoidectomy and maxillary
antrostomy are usually needed to provide adequate expo-
Schlosser and Bolger: Nasal CSF Leaks
 sure of the skull-base defect and leak. Frontal sinusoto-
mies, sphenoidotomies, and middle-superior turbinecto-
mies are performed if additional exposure is needed.
Sinuses adjacent to the CSF leak site may need to be
opened to prevent postoperative obstruction secondary to
scarring or packing. For example, frontal sinusotomies
and sphenoidotomies are often required even though the
leak may be in the ethmoid roof or cribriform. This proac-
tively prevents the formation of iatrogenic mucoceles in
the surrounding sinuses and minimizes "collateral dam-
age." Positive identification of the defect may be accom-
plished by direct inspection, but intrathecal fluorescein
can be very helpful in precisely identifying small leaks
and demonstrating small meningoencephaloceles.
The recipient bed is prepared by removing several
millimeters of mucosa surrounding the bony defect to
widely expose the site. Exocrine mucus glands within si-
nus mucosa will continue to make mucus and may sepa-
rate the graft from the recipient bed if it is not removed;
thus, it is critical to thoroughly remove the mucosa to
expose the underlying bone. A diamond burr or curette
can be used to lightly abrade the recipient bed bone and
stimulate osteoneogenesis.
Once the recipient site is prepared, any encephaloce-
les are ablated or reduced using bipolar cautery. Standard
bipolar cautery devices have rigid straight shafts that
cannot be bent to access all areas of the skull base. Mal-
leable, commercially available suction monopolar cautery
devices can be shaped to reach difficult areas in the ante-
rior and lateral skull base and can be used selectively
within the ethmoid cavity. We specifically avoid the use of
monopolar cautery near or adjacent to the lamina papy-
racea or optic nerve region.
As the encephalocele is progressively ablated, metic-
ulous hemostasis is required. This is especially important
when treating the encephalocele base to avoid the poten-
tially devastating complication of intracranial hemor-
rhage. This complication could occur if the encephalocele
was sharply resected and the base retracted intracrani-
ally. Precise application of electrocautery to the stalk or
base helps prevent intracranial bleeding. Even small
amounts of oozing from capillaries should be considered
significant given the hemostatic stresses of extubation
and postoperative vomiting and the closed confines of the
cranial cavity after repair. Once the encephalocele base is
reduced, if a lumbar drain has been placed preoperatively,
the drain is then opened, and CSF is diverted away from
the graft site and into the collection bag. Removing ap-
proximately 10 to 15 mL and then positioning the collec-
tion bag to establish a rate of flow of 5 to 10 mL/hour will
allow the encephalocele base to be reduced intracranially,
facilitating intracranial graft placement.
The repair is performed by gently elevating the dura
above the bony skull-base defect and then using bone
grafts in an underlay fashion in the epidural space. An
otologic elevator is helpful in dissecting the dura and
defining the epidural space. When bone grafts are used,
great care in graft design and placement is needed. In
some patients, such as those with spontaneous leaks, the
entire skull base is attenuated and can easily fracture,
creating an even larger defect. These defects often have
Laryngoscope 114: February 2004
complex three-dimensional configurations, requiring pre-
cise shaping of the bone graft (Fig. 5, A and B). Once the
bone graft is of satisfactory size and shape, it is soaked in
clindamycin solution to decrease the risk of intracranial
seeding of bacteria. The graft is then carefully placed in
the epidural space to close the bony defect. After position-
ing the bone graft (if used), temporalis fascia is placed in
an overlay fashion. In contrast with the fascia grafts used
for tympanoplasties, our grafts are intentionally kept
thick to decrease the chance of having a small hole de-
velop. Multiple layers of absorbable packing follow the
fascia graft.
Sphenoid Region
Defects in the central sphenoid can be approached
through the endoscopic transethmoid approach by per-
forming a wide sphenoidotomy. Repair principles are sim-
ilar to those for ethmoid roof leaks. A traditional midline
transeptal approach may also provide excellent access to
perisellar leaks. The sinus mucosa immediately surround-
ing the defect is elevated and removed. The remainder of
the sphenoid sinus mucosa is left in place. It is doubtful
that removal of all sinus mucosa from the sphenoid is
consistently possible, and the likelihood of subsequent
mucocele formation after complete sphenoid obliteration
is high. In addition, stripping mucosa from the lateral
sphenoid wall presents unnecessary risk should the ca-
rotid or optic nerve be clinically dehiscent. We prefer to
precisely localize and repair the skull-base defect. The
graft material is then placed on the prepared recipient
bed. Abdominal fat may be used as the primary graft
material, or, preferably, a piece of fascia can be placed
directly over the defect, and abdominal fat can serve a
secondary supportive function. In this case, the abdominal
fat acts as biologic packing to hold the fascia in place. Fat
that does not become supported by blood vessel in-growth
involutes within weeks and is readily cleared from the
sinus, often without any debridement. This permits the
sinus to remain patent and functional and minimizes risk
of mucocele formation.
Defects located in the lateral recess of the sphenoid
sinus are difficult to access by the midline transeptal or
endoscopic transethmoidal approaches and may require
an endoscopic transpterygoid approach.16 After a total
ethmoidectomy, wide sphenoidotomy and wide maxillary
antrostomy are performed, the posterior wall of the max-
illary sinus is removed, and the pterygopalatine fossa is
entered. The internal maxillary artery and its branches
are identified, moved inferiorly, or clipped and divided to
expose the deeper areas of the pterygopalatine fossa. Cra-
nial nerve V2, the vidian nerve, and the sphenopalatine
ganglion are dissected free and preserved if possible. The
anterior wall of the sphenoid sinus that has pneumatized
the pterygoid plates is drilled away to gain access to the
lateral recess of the sphenoid sinus. This provides the
necessary exposure to then reduce any encephalocele and
repair the skull-base defect using bone or fascia grafts as
described previously.
Schlosser and Bolger: Nasal CSF Leaks
261
Frontal Sinus
An external extracranial approach using a tradi-
tional osteoplastic flap and ipsilateral frontal sinus oblit-
eration is recommended for defects in the frontal sinus.
The defect is exposed, and any encephalocele is reduced.
All mucosa is removed from the frontal sinus, followed by
meticulous drilling with a diamond burr to remove muco-
sal remnants. Abdominal fat is used to obliterate the sinus
after placing underlay bone and overlay fascia grafts to
close the skull-base defect as described above. Defects
within relatively small frontal sinuses may require a bi-
lateral obliteration.
Leaks that are particularly difficult to repair are
those that extend to the isthmus of the frontal sinus
outflow tract. It is this site where the skull base transi-
tions from the horizontal (axial) orientation of the ethmoid
roof-cribriform plate to the vertical (coronal) orientation
of the posterior table. This area is at the limit of an
external osteoplastic approach from above and an endo-
scopic approach from below. A combined approach may be
needed (Fig. 6).
Intracranial Approach
Although otorhinolaryngologists are now able to suc-
cessfully access all areas of the anterior and central skull
Laryngoscope 114: February 2004
262
base, there are still limitations to extracranial ap-
proaches, and certain cases are more amenable to neuro-
surgical repair by way of craniotomy. These may include
patients with multiple, comminuted defects, broadly at-
tenuated or badly deformed skull bases, tumors with in-
tracranial extension, large bilateral defects in an anosmic
patient, and high-pressure leaks requiring CSF diversion
procedures.
Grafts Materials and Selection
Multiple varieties of grafting materials and place-
ment techniques have been described, and most have been
very successful. The specific graft material chosen de-
pends on the size and location of defect, the anatomic
character of the defect and recipient bed, and presence of
elevated CSF pressure. Each skull-base defect, meningo-
encephalocele, and leak is unique, and, therefore, an al-
gorithmic approach is not optimal. In general, a mucosa or
fascia-free graft, placed in an overlay fashion, may be
sufficient for a fine crack in the skull base or a small defect
with normal CSF pressure. Spontaneous closure has even
been reported, but in addition to the immediate goal of
leak cessation, the long-term risk of ascending meningitis
must be considered. In large skull-base defects or small
defects with elevated CSF pressure, such as spontaneous
Fig. 6. Coronal computed tomogra-
phy demonstrates a traumatic skull-
base defect extending from the pos-
terior table of the right frontal sinus (A)
down into the ethmoid roof (B). This
patient required both an external os-
teoplastic approach and an endo-
scopic approach to repair the entire
length of the defect. Triplanar imaging
demonstrates the length and location
of the defect (C). A fascia overlay graft
was placed through the frontal recess
and covered the length of the defect
and was followed by unilateral frontal
sinus obliteration with abdominal fat.
Schlosser and Bolger: Nasal CSF Leaks
CSF leaks, an epidural space bone graft and extracranial
fascial graft may be advantageous, especially in consider-
ation of long-term results and lifelong prevention of de-
layed ascending meningitis.
Experimental evidence demonstrates that a free graft
guides wound healing by acting as a scaffold.17 Free grafts
are adherent to bone at 1 week and are replaced by fibrous
connective tissue at 3 weeks, with some degree of postoper-
ative contracture. We generally recommend a multilayer
closure, when possible, that includes a bone graft placed in
an underlay fashion in the epidural space followed by a
fascia graft placed in overlay fashion intranasally against
exposed bone around the defect. This type of repair provides
both structural support from the bone graft in the epidural
space and watertight closure from the fascia. It reconstructs
both the bone and the soft-tissue aspect of the defect, ad-
dressing the short-term goal of CSF leak cessation and the
long-term goals of preventing encephalocele or CSF leak
recurrence or ascending meningitis.
An added theoretic benefit is the baffling effect of the
bone graft and its positive effect on fascial graft healing,
especially in the immediate postoperative period. Without
a bone graft, the brain parenchyma and reduced enceph-
alocele will tend to push back through the defect with
Valsalva or cough. This can possibly elevate the fascial
graft from the recipient bed and disrupt the fine network
of fibrous in-growth and angiogenesis needed for optimal
wound healing and graft closure. An epidural space bone
graft prevents the extrusion of the reduced encephalocele
with cough or Valsalva, thereby allowing the fascia graft
to remain sealed to the recipient bed.
When faced with small bony defects, we do not at-
tempt to place fascia or fat plugs into the epidural space
for several reasons. One concern is that this technique
could enlarge the bony borders of the defect. There may
also be difficulty interpreting the resulting soft-tissue sig-
nal on subsequent postoperative imaging studies in these
patients. Finally, placement of an epidural soft-tissue
graft and its subsequent herniation back through the bony
defect could potentially act as a stent to prevent osteoneo-
genesis and closure across the bony defect. We prefer to
prepare the graft site as described above, paying particu-
lar attention to gently scraping or drilling the bone sur-
rounding the defect with the thought of stimulating os-
teoanagenesis. We then place a thick temporalis fascia
graft over the bony defect, both to seal the defect and act
as scaffolding for fibrous in-growth.
In addition to bone and fascia grafts, a number of
authors use free mucosal grafts. Septal mucosa provides
the advantages over middle turbinate mucosa of being
thicker and allowing for a larger graft to be harvested if
needed. When harvesting a septal graft, it is easiest to
make the posterior septal incisions first, followed by the
inferior, then superior, cuts. This allows the surgeon to
work in a posterior to anterior and inferior to superior
direction and avoids the problem of having blood drain
down into the operative field. Inferior turbinate mucosal
grafts are relatively thick, and a significant portion can be
harvested while still leaving a mucosalized functioning
turbinate remnant. Unfortunately, the amount of graft
material available is less than that from the septum.
Laryngoscope 114: February 2004
Composite grafts using turbinate bone and mucosa pro-
vide a two-layer closure, but both layers are placed simul-
taneously in an overlay fashion and do not have the sta-
bility of an epidural graft. In addition, it is difficult to
sculpt the bony portion of a composite graft to precisely fit
the skull-base defect while it is still attached to its muco-
sal covering.
Tissue Adhesives
A variety of tissue adhesives have been anecdotally
reported for CSF leak repairs, but no scientific clinical
studies have been conducted. One experimental study us-
ing a mouse model did show an apparent advantage to
using fibrin sealant with a free muscle graft.18 If tissue
adhesives are used, they must be applied very conserva-
tively because a thick layer of adhesive may actually pre-
vent the graft material from coming into contact with the
wound bed.
Packing
Degradable packing such as Gelfoam, Surgicel, and
Avitene have all been used with success; however, there is
no proven scientific advantage to any one product. Gelfilm
or Silastic sheeting used between multiple layers of pack-
ing may prevent the inadvertent removal or movement of
all the layers of packing and possible disruption of the
graft during the early postoperative period.
PERIOPERATIVE ISSUES
Lumbar Drain
In appropriate cases, a lumbar drain is placed before
the induction of general anesthesia. This is best done with
the patient awake and in a sitting position to fill the
lumbar cistern with CSF. The lumbar cistern then dilates,
and CSF pressure can be increased up to 40 cm of water,
thus making it easier to find the subarachnoid space and
place the drain. Patients with long-term CSF leaks can
have a relative depletion of CSF, and it can be difficult to
identify the subarachnoid space and withdraw CSF or
place the lumbar drain if this is done while the patient is
in the decubitus position.
Once the spinal needle is in the intrathecal space,
fluorescein (0.1 mL of 10% solution diluted in 10 mL of
CSF) is slowly injected through the needle over 10 min-
utes. This can aid in precise identification of the bony
skull-base defect and associated CSF leak and help con-
firm a watertight repair at the end of the procedure. We
have not noted any complications from fluorescein in over
10 years of experience when used as outlined above. Com-
plications are usually related to higher concentrations,
more rapid injections, or suboccipital punctures. 19 After
fluorescein instillation is complete, the lumbar catheter is
inserted, secured, and clamped for the initial portion of
the procedure. It may be difficult to inject fluorescein
through the lumbar catheter, and, therefore, we prefer to
inject it through the spinal needle before catheter inser-
tion. Later in the surgical procedure, after the skull-base
defect is exposed and preparations for bone graft place-
ment are being made, 10 to 15 mL of CSF is removed over
15 minutes to aid in reduction of the cauterized encepha-
Schlosser and Bolger: Nasal CSF Leaks
263
locele base. After graft placement, the lumbar drain is
then kept open, and 5 to 10 mL per hour is drained for the
remainder of the procedure and for the initial postopera-
tive period. Diligent care of the lumbar drain is required
during the immediate postoperative period. The tempta-
tion to clamp the drain during patient extubation or trans-
port should be resisted. This is precisely when the greatest
risk exists for ICP elevation caused by coughing, Valsalva
maneuvers, and patient movement that would be trans-
mitted against the graft. The height of the drain is ad-
justed to keep the drainage between 5 and 10 mL of CSF
per hour. If the drain is too low, excessive CSF can be
removed, leading to brain-stem herniation. Conversely, if
the drain height is too high, air may flow retrograde into
the intrathecal space and lead to pneumocephalus. Nurs-
ing staff must understand that the rate of drainage is to be
adjusted by changing the height of the drain, not by rapid
drainage and interval clamping.
The lumbar drain is most important during the first
24 hours after surgery. During this period, it is especially
useful in avoiding large spikes in ICP should the patient
cough or strain during extubation or transport or have
nausea and vomiting during the immediate postoperative
period. Keeping the drain in longer than 24 to 48 hours
probably does not provide any significant advantage to the
repair. The tensile strength of the repair probably in-
creases very little during the first week because this is
when imbibition occurs. There is very little fibrosis be-
cause this phase of wound healing takes place several
weeks later. The majority of the structural support of the
repair rests on any underlay graft placed in the epidural
space and on intranasal packing compressing the ex-
tracranial fascia or mucosa graft against the recipient bed.
For most repairs, we remove the lumbar drain after 24 to
48 hours, depending on the condition of the patient.
Positive Pressure Ventilation
Positive pressure ventilation in patients with a CSF
leak carries the risk of pneumocephalus. Fatal cases have
been reported from patients blowing their nose 20 or, after
pneumotoscopy,21 in the presence of patent cranial fistu-
las. To decrease this risk, our anesthesiologists perform
rapid sequence intubation and minimize masking the pa-
tient and use positive pressure ventilation. On extubation,
we also try to avoid positive pressure, but the presence of
a multilayer closure and nasal packing should minimize the
risk postoperatively.
Antibiotics
We do not use long-term prophylactic antibiotics in
patients recently diagnosed with CSF leaks but believe
that perioperative antibiotics are warranted. During sur-
gery, tissue grafts are placed through the contaminated or
colonized nasal cavity to rest against brain tissue at the
cranial base defect. In our opinion, risks of intracranial
infection outweigh the risks of prophylactic perioperative
antibiotics. We generally use intravenous ceftriaxone be-
cause of its CSF penetration. Trimethoprim-sulfa or levo-
floxacin are other alternatives that afford a degree of
blood-brain barrier penetration and can be helpful in pa-
tients with cephalosporin allergies. In addition, we irri-
Laryngoscope 114: February 2004
264
gate the sinonasal cavity with clindamycin solution dur-
ing the procedure in an attempt to minimize bacterial
contamination and seeding of graft material.
POSTOPERATIVE ISSUES
Activity
All patients are kept at strict bedrest while lumbar
drains are in place. After the lumbar drain is removed,
patients gradually resume ambulation. Patients are in-
structed on movement techniques to avoid breath holding
and Valsalva maneuvers and are encouraged to continu-
ously inhale or exhale when changing position. We encour-
age light activity for 6 weeks after surgery
Bed Position and Lumbar Drain Management
Alterations in bed position will alter the CSF pressure
at the graft site. When the patient is lying perfectly flat, the
ICP is roughly equivalent at all points from the lumbar
cistern to the skull base. As the head of bed is raised, CSF
pressure at the anterior skull base decreases, whereas the
pressure in the lumbar cistern increases proportionally.
Brain parenchyma may also help to maintain the position of
epidural grafts when the patient is raised to the sitting
position. We keep patients slightly elevated at 15 degrees
while the lumbar drain is in place and dictate a specific bed
position rather than specify a range of bed positions such as
"head of bed at 15 to 30 degrees." When given a range, the
patient or nursing staff may make repeated adjustments of
the bed, leading to changes in CSF pressure at the lumbar
cistern and to difficulty in adjusting the height of the lumbar
drain to maintain proper drainage rate. Over-drainage of
CSF is a real concern in this setting. Once the drain is
removed, we allow approximately 4 hours for the lumbar
drain catheter site to seal. Thereafter, we gradually elevate
the head of bed to 30 degrees to decrease the CSF pressure at
the skull-base defect repair site. If patients do well and do
not exhibit any signs of a spinal headache, we then advance
them to a sitting position and light activity. Patients that
experience spinal headaches and are thought to have persis-
tent CSF drainage from the dural puncture site of lumbar
drain are treated with a blood patch in consultation with our
anesthesia service. An additional consideration is obtaining
an ICP measurement in a patient with suspected ICP eleva-
tion, which may be important for future management
decisions.
In this patient population, after 24 to 36 hours of drain-
age, we first clamp the drain, maintain the patient at strict
bedrest, and wait approximately 4 to 6 hours to insure that
CSF production has been restored at normal volume. The
head of bed is then lowered to a flat position, the flow is
diverted by way of a three-way stopcock to a properly zeroed
pressure transducer, and a pressure reading is taken. A
Queckenstedt's test is useful in confirming that the pressure
recorded through the lumbar catheter accurately reflects
ICP. This is performed by manually obstructing both inter-
nal jugular veins simultaneously. This maneuver increases
ICP approximately to 10 to 30 cm of water within 5 to 10
seconds and should be reflected in the CSF pressure read-
ings and waveforms seen on the transducer. If an appropri-
ate response is not seen with a Queckenstedt's test, the CSF
Schlosser and Bolger: Nasal CSF Leaks
pressure reading may be falsely dampened from catheter
obstruction or obstruction to CSF pressure transmission be-
tween the lumbar cistern and the intracranial cavity. After
obtaining the necessary information on CSF pressures, the
lumbar drain is removed, and the management plan detailed
above is resumed.
Acetazolamide
Acetazolamide is a diuretic that can decrease CSF
production up to 48%.22 We have recently begun to use it
in cases where elevated ICP plays a role. It has reduced
ICP in several of our patients with spontaneous leak and
improved their symptoms of pulsatile tinnitus and
pressure-type headaches. We generally recommend either
dosing two times a day with the 500 mg sustained release
form or providing only an evening dose. Theoretically, this
approach will maximize the effects of the drug during
REM sleep when ICPs peak. The optimal timing, dosing,
and long-term benefits of this approach have not been
proven, but it may reduce the risk of developing subse-
quent skull-base defects in patients with elevated CSF
pressures. We periodically monitor electrolytes in any pa-
tient placed on long-term diuretic therapy.
Endoscopic Care
Patients are seen every 1 to 2 weeks postoperatively.
Very conservative endoscopic debridement is performed to
maintain patency of the dependent sinuses surrounding
the repair to avoid stasis of secretions and bacterial infec-
tions. The area of the packing and graft are specifically
avoided to allow adequate healing. By 6 weeks postoper-
atively, most patients have returned to relatively normal
activity levels, and little packing remains.
Continuous Positive Airway Pressure
We have repaired several patients with obstructive
sleep apnea who use continuous positive airway pressure
(CPAP). We restrict the use of CPAP during the immedi-
ate postoperative period to avoid the risk of pneumocepha-
lus from positive pressure ventilation. All of our patients
have been able to safely resume using their CPAP 4 to 6
weeks after surgery. Unfortunately, limiting use of CPAP
may lead to hypoxic nocturnal episodes that lead to ele-
vation of ICP and pressure at the graft site. The decision
to resume CPAP must be individualized for each patient
on the basis of the degree of apnea and the potential risks
and benefits of the positive pressure. Further study of this
subgroup of patients is needed.
SUMMARY
The role of the otolaryngologist in diagnosing and
treating CSF leaks of the anterior and central skull base
continues to expand. A comprehensive understanding of
the physiology, pathology, diagnosis, and treatment ap-
proaches is crucial to the proper treatment of this wide
variety of skull-base defects.
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