Otolaryngol Clin N Am

38 (2005) 597–611

Cerebrospinal Fluid Rhinorrhea:

Diagnosis and Management
Julie T. Kerr, MDa, Felix W.K. Chu, MDb,*,
Stephen W. Bayles, MDb
a
Department of Otolaryngology–Head and Neck Surgery, Madigan Army Medical Center,
Tacoma, WA, USA
b
Department of Otolaryngology/Head and Neck Surgery, Virginia Mason Medical Center,
1100 Ninth Avenue, Seattle, WA 98101, USA

Elucidating the cause to a cerebrospinal fluid (CSF) leak is central to its

management. CSF rhinorrhea is commonly classified as (1) traumatic, (2)
nontraumatic, (3) spontaneous, and (4) iatrogenic [1,2]. The diagnostic
localization and management of CSF leak, although challenging, have
improved over the years with the evolution of diagnostic tests and improved
surgical techniques.

Cause
Traumatic leaks are subdivided as surgical (whether planned or
unplanned) or nonsurgical (whether blunt or penetrating). Seventy percent
to 80% of CSF rhinorrhea is caused by accidental trauma [3]; 2% to 4% of
acute head injuries result in CSF rhinorrhea [4].
Nontraumatic CSF rhinorrhea includes high-pressure and normal-
pressure leaks. High-pressure CSF rhinorrhea comprises 45% of non-
traumatic CSF rhinorrhea, and 84% of these leaks result from tumor
obstruction. The remainder is caused by either benign intracranial
hypertension or hydrocephalus. Normal-pressure leaks may result from
bony erosion by tumor, tumor treatment with radiation therapy, arachnoid
granulations, infection, empty sella syndrome, or congenital defects such as
preformed pathways, fistulas, meningoceles, meningoencephaloceles, or
encephaloceles.

* Corresponding author.
E-mail address: [email protected] (F.W.K. Chu).

0030-6665/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2005.03.011 oto.theclinics.com
598 KERR et al

The term spontaneous cerebrospinal fluid leak is controversial. Har-El

[2], Ommaya [3], and Rice [5] categorize spontaneous CSF leaks as
idiopathic or unknown in origin, with the understanding that most, if not
all, eventually have a specific diagnosis.

Signs and symptoms

The presence of a halo sign on tissue or linens should arouse suspicion of
CSF rhinorrhea. Although not generally used now, components of CSF,
such as glucose, protein and electrolytes, have been measured. The
sensitivity and specificity of these tests remain quite poor [5,6].
Beta-2 transferrin is highly specific and sensitive in identifying fluid as
CSF [7]. Beta-2 transferrin is produced by desialization (carbohydrate-free
form) of normal beta-1 transferrin in CSF through cerebral neuraminidase
[8]. It is found only in perilymph, vitreous humor, and CSF. Only 0.5 cm3 of
fluid is required for diagnosis. The test can be performed and completed in
less than 3 hours by immunofixation electrophoresis. Negative testing, how-
ever, does not exclude the diagnosis of CSF leak, particularly if a high mucus
content of the secretions results in difficulty concentrating fluids [9–11].
False-positive results are possible in patients with chronic liver disease,
inborn errors of glycoprotein metabolism, or genetic variants of transferrin
[12]. When these pathologic conditions are suspected, sampling f venous
blood should be sampled for comparison.
Patients with CSF rhinorrhea may complain of a salty taste or even
a sweet taste, because CSF has two thirds the sugar content of blood. A low-
pressure headache may result from an acute or chronic leak. The drainage
may be continuous, may be elicited with Valsalva’s maneuver, or may gush
with change in position because the sphenoid and frontal sinus may act as
reservoirs. Unfortunately, some leaks may be intermittent and not easily
diagnosable.
The most common cause of rhinorrhea from surgical trauma is
transphenoidal management of pituitary tumors (0.5–15%) [13–18]. Seven
percent to 11% of surgeries for acoustic neuromas have been found to result
in CSF rhinorrhea [17,18]. The risk of CSF leak secondary to functional
endoscopic sinus surgery varies from 0.5 to 3% [19,20].
In comparison with accidental trauma, postsurgical traumatic CSF
rhinorrhea may present immediately postoperatively in 50% of patients. The
remainder of leaks ensue 7 days to 1 month later secondary to progressive
maturation and contraction of wounds, devascularization, necrosis of the
soft tissue or bony edges, slow resolution of edema, or increased CSF
pressure [21].
An association has been found between empty sella syndrome,
meningoencephaloceles, and CSF leaks. Patients with an empty sella
commonly present with pressure-type headaches, pulsatile tinnitus, or visual
disturbances. Idiopathic or acquired intracranial hypertension results in
 CEREBROSPINAL FLUID RHINORRHEA 599

hydrostatic pressure at anatomically weakened sites of the skull. The dura

then herniates into the sella turcica and fills with CSF. This fluid-filled sac
compresses the pituitary gland and results in the radiographic appearance of
an empty sella. The appearance of an empty sella can also occur with
necrosis of a pituitary tumor. These patients have the potential of
developing benign intracranial hypertension, have the highest failure rate
with closure of a CSF leak, and have the greatest likelihood for developing
a meningoencephalocele [22].
Of utmost concern with a CSF leak is the potential for meningitis. There
seems to be a higher risk in cases of CSF rhinorrhea occurring after acci-
dental trauma and in patients whose CSF leak does not close spontaneously.
Mincy’s [5] series of 54 patients with traumatic CSF rhinorrhea demon-
strated that meningitis developed in 11% of patients in whom draining
stopped spontaneously in 7 days, compared with 88% of patients in whom
drainage lasted longer than 7 days. Authors recommend surgical closure of
CSF leaks if drainage has not ceased within 1 to 2 weeks. Surgical closure
earlier than 1 to 2 weeks is unlikely to prevent meningitis.
Immunologically competent individuals presenting with meningitis
should be investigated for CSF fistula [6]. Thirty-five percent of individuals
presenting with recurrent meningitis have a CSF fistula caused by head
trauma. Accidental head trauma and basilar skull fracture can result in
recurrent meningitis any time from 2 months to 21 years after the initial
incident [23].
A dural defect may also result in pneumocephalus. Trauma is the most
common cause of pneumocephalus (74%), followed by tumor, infection,
surgery, and idiopathic causes. Eighty-five percent of these cases heal within
the first week, whether or not they are complicated by meningitis [24]. More
commonly, pneumocephalus results if there is a large dural tear, because air
columns in the frontal or ethmoid sinuses transmit respiratory pressures
with straining, coughing, or sneezing. These tears do not heal spontaneously
and are at higher risk for meningitis; thus, more aggressive surgical man-
agement is warranted [21].

Localization
Key in management of CSF leakage is localization of the dural defect,
which can originate from the anterior, middle, or posterior cranial fossas.
The most common site of accidental traumatic fracture seems to be at the
cribiform plate where the bone is thick, the area adjacent is thin, and
the dura is very adherent [25]. Congenital defects most commonly arise from
the superior or lateral walls of the sphenoid sinus or from the cribriform
niche adjacent to the middle turbinate vertical attachment.
Multiple imaging studies are available to help localize sites of dural
defects. The sensitivities and specificities of these studies vary with patient
population, defect size, operator interpretation, and leak flow rate.
600 KERR et al

High-resolution coronal and axial CT

High-resolution CT is the primary imaging modality for localization of
cranial vault defects. It often is the only test needed for diagnosis [26];
however, it is limited to identifying defects in bone. High-resolution CT scan
in conjunction with an intrathecal fluorescein study accurately localizes
active leaks and supersedes other studies [27]. One- to 2-mm sections in
coronal and axial planes are recommended to evaluate fully all walls of the
sinuses. Partial volume averaging can cause both false-positive and false-
negative findings. Plain CT scans have a 9.5% false-positive identification of
a bony defect in inactive CSF fistulas [28].
CT cisternograms
CT cisternography (CTC) is complementary in both false-positive and
false-negative cases of high-resolution CT imaging. With active leaks, CTC
demonstrates movement of contrast through the defect with a success rate of
85% [29,30].
Weaknesses of this technique include its inability to detect an inactive
leak at the time of study, yielding sensitivities from 48% to 96% [31]. It is
also invasive, cumbersome, and increases exposure to radiation. This
exposure is an important factor in pediatric patients and in patients
requiring multiple imaging studies. CTC is of particular use when the frontal
and sphenoid sinuses act as reservoirs.
Today’s contrast agents include low-osmolarity nonionic substances such
as iohexol and iopamidol. These agents have a low incidence of the side
effects seen with older compounds such as metrizamide [32]. Compounds
such as indigo carmine and Evans blue dye are no longer used because of
their neurotoxicity [29].
Radionuclide cisternograms
Radionuclide cisternography is similar to CTC in that the radiopharma-
ceutical agent, most commonly Technetium 99m, is administered in-
trathecally, followed by gamma camera imaging. It also entails the
endoscopic placement of nasal pledgets. This method is particularly useful
in low-volume or intermittent leaks because, depending on the half-life of
the agent used, the imaging and measurement of uptake can be completed
hours to days (54 hours) after injection of the agent [33].
Radionuclide cisternography, however, has a high number of false-
positive findings (33%) and sensitivities ranging from 62% to 76% [31]. It is
also invasive, has less spatial resolution and localizing ability, and shows less
fine anatomic detail and specificity than CTC [33].
Intrathecal fluorescein
Fluorescein is most commonly used as an adjunct to intraoperative
localization of a skull based defect. The process involves a standard lumbar
 CEREBROSPINAL FLUID RHINORRHEA 601

puncture followed by withdrawal of 10 cm3 of CSF, which is then mixed

with 0.2 to 0.25 cm3 of 5% fluorescein (40–60 kg/0.2 cm3; O60 kg/0.25 cm3).
This mixture is injected at a rate of 1 cm3/minute. Thirty minutes is required
for the mixture to diffuse within the CSF. A brilliant yellow fluid leaking in
the nose is visualized in the vicinity of the defect. Use of a blue-light filter
makes the test sensitive to dilutions up to 1 in 10 million [34].
Protocols for appropriate administration have been described, because
side effects can be significant, including lower extremity weakness,
numbness, generalized seizures, opisthotonos, and cranial nerve deficits
[35–37]. If complications do ensue, CSF should be diluted and the head
elevated. Informed consent is required before use.

MRI and MR cisternography

MRI and MR cisternography are noninvasive alternatives to intrathecal
contrast-enhanced high-resolution CT. These modalities are able to distin-
guish inflammatory tissue from meningoencephaloceles but cannot define
bony details, as with CT scanning. T2 images highlight the CSF leak on MRI.
A fast spin echo sequence with fat suppression and image reversal on MR
cisternography highlights the fistula, because CSF appears stark black among
faded surrounding tissues [38]. This study is reported to be 85% to 92%
sensitive and 100% specific [39].
As with CT and radionuclide cisternography, there must be active leakage
at the time of the study; however, serial MR studies can be done without ill
effect. These studies have roughly the same cost as CT cisternography but
are more time efficient and subject patients to less radiation.

Conservative management
Most CSF leaks resulting from accidental and surgical trauma heal with
conservative measures over the course of 7 to 10 days. Less likely to heal
spontaneously are leaks in which CSF rhinorrhea develops days or weeks
after surgical or accidental trauma, massive leaks that develop immediately
after surgery, leaks caused by sustain gunshot wounds, or normal-pressure
CSF leaks. CSF fistulae found at the time of endoscopic sinus surgery
require repair at the time of initial surgery [4]. Leaks noted 5 to 7 days after
surgery may close spontaneously; if there is not resolution in 1 to 2 weeks,
surgery is indicated.
First-line treatment includes bed rest with head elevation, avoidance of
straining activity such as nose blowing, sneezing, and coughing, and the use
of stool softeners.
Antibiotic prophylaxis remains controversial. Most authors avoid
antibiotics to reduce development of resistant organisms [40,41]. Friedman
[42] found the incidence of meningitis after accidental trauma to be 10% in
those treated with antibiotics versus 21% in those not treated. Pappas [6]
602 KERR et al

found that, given the greater incidence of resistant organisms with use of
prophylactic antibiotics, surgical management is the only definitive treat-
ment. If there is gross contamination along a fluid pathway, such as with
a comminuted fracture of the paranasal sinus resulting from acute trauma,
antibiotic prophylaxis does have a role.
A nontraumatic, high-pressure CSF leak caused by increased intracranial
pressure will probably resolve if the intracranial pressure is normalized. The
intracranial pressure can be normalized by use of diuretics such as
acetazolamide or with ventriculoperitoneal shunting. Leaks that do not
resolve with normalization of intracranial pressures warrant surgical
management [43].

Surgical management
Numerous factors are involved in the surgical management of CSF leaks.
These factors include use of a lumbar drain, the approach for repair, the type
of graft or flap and its placement, and the use of sealant and nasal packing.

Lumbar drain
Controversy surrounds use of a lumbar drain [44–48]. Use of a sub-
arachnoid lumbar drain or serial lumbar punctures is controversial, as well.
If resolution has not occurred after 72 hours in a patient managed
conservatively, draining 150 cm3/day of CSF for 4 additional days before
entertaining surgical options may be beneficial [49]. Lumbar drainage is not
without risk, however. Overdrainage may create a siphon effect with
resultant pneumocephalus. Additional complications include headache,
nausea, vomiting, vocal cord paralysis, occlusion of the posterior cerebral
artery, and lumbar radiculopathy. Hegazy’s [46] meta-analysis documents
that lumbar drainage does not affect success rates. Casiano [44] reports
a 97% success rate in more than 30 patients without use of lumbar drain.
Sixty-seven percent of otolaryngologists use lumbar drainage routinely and
drain for an average of 4 days [48].
Komisar et al [50] recommend drainage if there is suspicion for increased
intracranial pressure. In long-term or congenital leaks, a lumbar drain may
offset the initial rise in intracranial pressure. Suspicion for increased
intracranial pressure is warranted with leak recurrence [51]. Preoperative
intracranial pressure reading will be inaccurate because of the leak, but an
accurate reading can be taken postoperatively.

Surgical approach
Transcranial
Dandy [52], in 1929, was the first to document successful repair of a CSF
leak using an intracranial approach. Success rates ranging from 60% to
 CEREBROSPINAL FLUID RHINORRHEA 603

95% have been reported [53–55]. Spetzler et al [56] experienced a failure rate
of 27% on initial operation and a 10% overall failure rate with multiple
procedures.
Advantages of this approach include improved exposure, ability to
identify multiple defects, and ability to tamponade a leak in a high-pressure
situation. Drawbacks include the inherent increased morbidity, increased
length of hospitalization, and permanent anosmia.

Extracranial
Dohlman [57] was the first to document a successful extracranial repair of
a CSF leak in 1948. Success rates of 86% on initial operation with a 97%
success rate overall have been documented [58,59].
Extracranial repair results in decreased morbidity, no anosmia, improved
endonasal exposure of the sphenoid, parasellar and posterior ethmoids,
cribriform plate, fovea ethmoidalis, and the posterior wall of the frontal
sinus. Inherent to this procedure is a facial scar, risk for facial numbness,
and orbital complications. The procedure can be quite cumbersome. Cere-
bral damage and the lateral extensions of the frontal and sphenoid sinuses
cannot be assessed.

Transnasal
A transnasal approach for closure of CSF rhinorrhea was first described
by Hirsch [60] in 1952. Lehrer and Deutsch [61] improved visualization with
use of the microscope, but visualization of the lateral and superior walls of
the sphenoid sinus is limited. Transnasal approaches risk facial numbness as
well as septal perforation. With use of endoscopes, these approaches are
rarely used today.

Endoscopic
In 1981 Wigand described closure of a cerebrospinal fistula using an
endoscopic approach. Endoscopic intranasal fistula repair is now the
preferred approach, with higher success rates and less morbidity than
intracranial surgical repair [62,63].
Multiple studies have documented high success rates with a wide variety
of grafting materials and adjuncts to closure such as lumbar drain, tissue
sealant, and nasal packing. Regardless of materials used, success rates of
92% to 96% have been documented [38,62,64,65]. Hegazy’s [46] meta-
analysis of 575 cases demonstrates a 90% success rate on first attempt and
a 96% success rate on second attempt.
Generally, a small defect can be closed with an overlay free mucosal graft or
a free fascial graft. The free mucosal grafts can be acquired from the inferior
turbinate or the septum. Fascia can be obtained from the temporalis region or
fascia lata. It is important that, after identification of the bony defect, mucosa
surrounding the perimeter of the defect be removed to stimulate osteogenesis,
thus thickening bone around defect and improving graft incorporation.
604 KERR et al

Larger defects at risk for a secondary encephalocele or small defects with

elevated intracranial pressure are treated more appropriately with a bone
graft placed in an underlay fashion within the epidural space and a fascial
graft to provide a watertight seal placed in an overlay fashion. Septal bone
may prove difficult to sculpt. Septal cartilage may prove thick, and it tends
to fracture easily.
When neither material is available, cranial bone is another alternative
[66]. In this process, the defect is identified and exposed, mucosa is removed
several millimeters circumferentially, and any encephalocele is reduced with
electrocautery. The dura is then elevated from the skull base, thus defining
the epidural space. Cranial bone is harvested over the mastoid cortex.
Temporalis fascia is harvested as well. A diamond burr is used to sculpt and
shape the cranial bone graft, which is placed within the epidural space.
Fascia is placed extracranially. This placement may be followed by use of
a sealant or collagen packing such as Gelfoam.
Composite grafts of turbinate bone and mucosa also have been used as
an overlay graft. Additional materials used include pedicled mucosal or
mucochondral flaps, abdominal fat, muscle, dermal allograft [67], and exog-
enous materials such as Vicryl mesh [68] and hydroxyapatite.
Hydroxyapatite has both osteoconductive and osseointegrative proper-
ties and is the most commonly used alloplastic material. Issues with chronic
granulation tissue, inflammation and infection, and prolonged healing time
have arisen [69].
A bathplug technique has been described with fat obtained from the
lobule of the ear or the abdomen. It is superior to the underlay technique
when there is a defect in the cribriform plate, where dissection of dura off the
cranial base can prove challenging because of the presence of olfactory fibers
passing through the dura, or when the bone is thin and fractured so that it
will not support a bony graft [70].
The authors have used variations of this technique, dubbed the ‘‘cuff
link’’ repair, to repair sellar and clival defects successfully. This technique
uses a double layer of lyophilized dura or fascia to sandwich the dural
defect, taking advantage of the hydrostatic CSF pressure to seal the defect
and stop the leak.
Animal studies have documented the key features required for
appropriate closure of an anterior cranial vault bony dehiscence with
a graft. If the defect is more than 1 cm wide, the underlay technique with
bone or cartilage is preferred to prevent herniation of cerebral tissue.
Defects smaller than 1 cm can be closed adequately with soft tissue in an
overlay technique alone. One can expect a 20% postoperative reduction in
size of a free mucosal graft, with shrinkage beginning within the first few
days [71].
Iatrogenic cranial-based defects created after excision of anterior skull
base tumors pose a different challenge to the head and neck surgeon. Access
osteotomies have enabled resection of tumors that used to be inoperable.
 CEREBROSPINAL FLUID RHINORRHEA 605

Several types of flaps have been studied, including anteriorly based

pericranial flaps, bipedicled galeal flaps, radial forearm fascial/fasciocuta-
neous flaps, rectus abdominis flaps, and the latissimus dorsi flaps [72,73].
Historically, nonvascularized grafts such as pericranium, temporalis fascia,
fascia lata, muscle and fat, allograft or synthetic dura, or surgical cellulose
mesh were used. These grafts, however, carried high risks of necrosis,
postoperative CSF leaks, and infection. Today, dural closure is best
accomplished by autografts such as fascia lata or temporalis fascia.
Lyophilized cadaver dura and bovine pericardium are alloplasts that may
also be used. These grafts are further supported by local or free vascularized
tissue. This technique has reduced the morbidity and mortality previously
encountered in reconstruction of the anterior cranial base [74–79]. The
ability to transfer large composites of tissue from distant sites has allowed
massive defects to be handled with greater ease. Because they are not
confined by the orientation of a local pedicle, free flaps maybe oriented more
appropriately to obliterate dead space adequately and augment coverage.
Free vascularized muscle tends to seal dural closures better than fat.
Fasciocutaneous flaps may be quite beneficial, relying on fascial character-
istics as dural replacement and relining the floor of the anterior cranial vault
when space is limited so that large, bulky muscle flaps cannot fit the space
without increasing pressure on the brain.

Sealant
Fibrin, created by a combination of fibrinogen, thrombin, and calcium
cofactor, is the most commonly used sealant today. Tisseel is a fibrin sealant
that includes components of autologous cryoprecipitate from single-donor
plasma, bovine thrombin, and an antifibrinolytic agent that yields a more
stable clot. This fibrin sealant provides a temporary watertight closure and
creates an additional barrier to CSF leakage during wound healing and
fibrosis.

Packing
Packing materials can be either absorbable or nonabsorbable. Whether
packing is used and which type is used is the surgeon’s choice. Senior et al
[48] reported that 86% of rhinologists use packing to repair CSF leaks.
Hegazy’s [46] meta-analysis reported that 60% of patients were packed
postoperatively. No study to date has determined a difference in outcome
with use of packing.

Special considerations
Spontaneous encephaloceles have a higher rate of treatment failure [80]. In
these cases, cranial bone graft may be more successful, because intracranial
pressure is likely to be elevated whether the defect is small or large. Bone graft
606 KERR et al

can prevent reherniation. These patients may require ventriculoperitoneal

shunts or other means to lower intracranial hypertension.
A dehiscence in the sphenoid sinus may be treated by either an overlay or
underlay graft technique, but obliteration with abdominal fat is a commonly
used technique. There is risk for mucocele formation, however. A frontal
sinus defect may warrant an osteoplastic approach for repair.
Most pediatric cases can be managed conservatively. Only 0.25% of head
traumas in children result in a CSF leak. Although earlier authors have
recommended 3 weeks of conservative management, Jones et al [81] recom-
mend repair at 7 days if the leak has not healed with conservative measures
because of the inherent risk of meningitis. Jones also found that the use of
prophylactic antibiotics did not affect the incidence of meningitis.

Follow-up
When repair of a defect is near a sinus outflow tract, there is risk that
normal sinus drainage will be obstructed. This obstruction may sub-
sequently result in mucocele formation. Postoperative follow-up with CT
scanning is appropriate to rule out development of a mucocele when there is
concern for obstruction [82]. Meticulous care to ensure that the non-
epithelialized surface of the graft is in contact with the intracranial cavity
can prevent unplanned outflow obstruction. The risk of obstruction is
unavoidable, however, when the leak approximates an outflow tract.

Complications of operative management

According to Hegazy’s [46] meta-analysis, repair of a cerebrospinal fistula
carries a risk of less than a 1% for meningitis, brain abscess, subdural
hematoma, smell disorder, and headache. Senior [48] reports that 2.5% of
522 patients surgically managed for CSF fistula suffered a complication, the
most common being meningitis at 1.1%. Spetzler [83] describes a technique
for preserving olfaction when an anterior craniofacial approach is required.
The cribriform plate, dura, and mucosa are removed en bloc to preserve
olfaction.

Prevention of postsurgical cerebrospinal fluid rhinorrhea

Shiley et al [84] analyzed which factors predicted CSF leaks as
a complication of transphenoidal removal of pituitary tumors. In contrast
to other author’s findings [13,15], size and revision surgery were not
significant factors on multivariate analysis. Significant factors did include
presence of an intraoperative leak and management of nonadenomatous
disease. These patients may warrant more aggressive management to
prevent postoperative leaks. A lumbar drain is generally maintained if there
 CEREBROSPINAL FLUID RHINORRHEA 607

is an intraoperative CSF leak. Various techniques and materials exist for

closure of the sella and sphenoid after removal of a pituitary lesion;
however, no studies have compared results using these techniques and
materials. Cappabianca et al [85] found that patients with microadenoma or
macroadenoma without suprasellar extension or with incompletely removed
extension could be managed without closure or packing of sella. The sella
should be packed with intradural or extradural closure of the sellar floor if
there is intraoperative prolapse of the suprasellar cistern toward the sellar
floor, bleeding from medial wall cavernous sinus, or injury to the carotid
artery. Closure of both the sella and the sphenoid sinus is warranted when
there is an intraoperative CSF leak or removal of a paninvasive macro-
adenoma. Closure in this case comprises a first layer of autologous or
synthetic dura intradurally, a second layer of autologous fat or resorbable
substance placed within the sella, then autologous or synthetic dura placed
extradurally followed by fibrin glue applied to the sellar floor, and, finally,
packing of the sphenoid. The materials used to rebuild the sella include
alumina ceramic plates, silicone plate, stainless steel plate, titanium, dura
patch, and polyester-silicone dural substitute.
It is generally agreed that a CSF leak identified intraoperatively during
a transphenoidal resection, functional endoscopic sinus surgery, or cranial-
based resection should be repaired at that time [62]. Some authors note
a trend for complications of a CSF leak to occur more often when a right-
handed surgeon operates on the right nare, during ethmoidectomy, and
when operating on severe polyposis [86]. Awareness that a CSF leak can
arise during from a blow of the osteotome against bony septum and
perpendicular plate of ethmoid or from use of the bony septum as a fulcrum
can help prevent a CSF leak from occurring.

Summary
Advances in imaging and endoscopic techniques have improved the
ability to diagnose, localize, and treat in a less morbid fashion CSF leaks of
the anterior skull base.
An appreciation for the mechanism of leak and of the relationship
between CSF production and absorption must be kept in mind when
individualizing a repair. Increased CSF pressure caused by overproduction
or underabsorption may result in persistence of a leak despite one’s best
efforts.
Numerous advances in dural replacement grafts and tissue sealants have
improved the ability to achieve watertight closure of the cranial vault.
Microvascular techniques have allowed larger defects previously not
reconstructable to be handled with relative ease by trained personnel. With
expanded reconstructive techniques, the ability to handle larger disease
processes of the skull base continues to expand.
608 KERR et al

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