title: Cerebrospinal fluid rhinorrhea: endoscopic repair based on a combined diagnostic approach.
abstract: BACKGROUND
  The treatment of cerebrospinal fluid rhinorrhea has evolved since the first recorded instance of this condition by Willis in 1676. The advancements in radiology and endoscopic nasal surgery have provided ways to solve this potentially dangerous condition. But even now quite a few questions remain unanswered while tackling this difficult clinical situation. Laboratory tests for confirming the presence of cerebrospinal fluid in nasal fluid can yield false positive results and radiological evaluation has never been foolproof when it comes to small leaks and multiple leaks. Also the postoperative recurrence needs to be brought within acceptable limits.
  
  
  OBJECTIVE
  We have tried to evaluate endoscopic repair of CSF rhinorrhea based on a combined diagnostic approach. The methods for diagnosis of CSF rhinorrhea have been reevaluated based on our experience with a view to prevent recurrences and complications.
  
  
  METHODS
  The study group included twenty patients of CSF rhinorrhea who have been treated by endoscopic repair and spans over a period of five years from January 2001 to December 2005. A combination of retrospective and prospective methods of study has been used. Patients have been subjected to laboratory, radiological and dye studies for confirmation and localization of leak. Endoscopic repair of CSF fistula with composite graft and fibrin glue has been performed. Postoperative management included intracranial pressure reducing measures and control of primary condition in cases of spontaneous leak.
  
  
  RESULTS
  Endoscopic repair of CSF rhinorrhea produced a first time success rate of 92%. CT/MR Cisternogram could localize the defect in 85% cases while intrathecal fluorescein aided localization whenever it was used. The use of fibrin glue with composite graft and postoperative intracranial pressure reducing measures could improve the success rate.
  
  
  CONCLUSIONS
  Management of a suspected CSF leak requires a combined diagnostic approach. Endoscopic repair with composite graft and fibrin glue should be the first line of management in cases of CSF rhinorrhea requiring surgical closure. Intracranial pressure reducing measures play an important role in preventing postoperative recurrence.
authors.affiliation: Department of Otorhinolaryngology & Head & Neck Surgery, B J Medical College, Ahmedabad, Gujarat, India.
authors.forename: Neena H
authors.initials: NH
authors.lastname: Bhalodiya
authors.forename: Shawn T
authors.initials: ST
authors.lastname: Joseph
keywords: CSF otorhinorrhea; Cerebrospinal fluid rhinorrhea; Endoscopic repair of CSF leak; Endoscopic skull base surgery; Fluorescein dye; Mondini’s dysplasia