title: Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.
abstract: BACKGROUND
  Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance.
  
  
  METHODS
  A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process.
  
  
  RESULTS
  We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions.
  
  
  CONCLUSIONS
  Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Gretchen M
authors.initials: GM
authors.lastname: Oakley
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Richard R
authors.initials: RR
authors.lastname: Orlandi
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, University of Alabama, Birmingham, AL.
authors.forename: Bradford A
authors.initials: BA
authors.lastname: Woodworth
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Rush University, Chicago, IL.
authors.forename: Pete S
authors.initials: PS
authors.lastname: Batra
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Jeremiah A
authors.initials: JA
authors.lastname: Alt
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002559:Cerebrospinal Fluid Rhinorrhea / Q000628:therapy*; D003131:Combined Modality Therapy; D004322:Drainage / Q000379:methods; D004724:Endoscopy / Q000379:methods; D006801:Humans; D019990:Perioperative Care; D019651:Plastic Surgery Procedures / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: CSF leak; CSF rhinorrhea; endoscopic repair; endoscopic skull base repair; perioperative management