Chronic Cerebrospinal Fluid Rhinorrhea Managed with Endoscopic and Open Approaches

Introduction: Anterior cranial fossa skull base defects, encephaloceles, and cerebrospinal fluid (CSF) rhinorrhea are related to several underlying pathologies, including untreated pseudotumor cerebri/increased intracranial pressure, congenital lesions, chronic infections, trauma, and iatrogenic injury. Unfortunately, patients may experience a delay in diagnosis and treatment due to unfamiliarity with the disease process within the medical community. This problem is exacerbated in underserved communities. Untreated CSF rhinorrhea exposes the patient to risks of seizures, meningitis, intracerebral abscess, headaches, and intracranial hypotension. We present a case of chronic CSF rhinorrhea treated at our institution with open and endoscopic endonasal approaches. Prolonged untreated drainage may complicate management and is the best addressed by a multidisciplinary otolaryngology and neurosurgery skull base team.

Case Report: A 58-year-old morbidly obese female with a history of endoscopic sinus surgery at an outside institution (ESS) 10 years prior presented to clinic with daily CSF rhinorrhea since surgery. The patient described an iatrogenic skull base injury at the time of initial surgery. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed a left 1-cm anterior fossa skull base defect with frontal encephalocele, encephalomalacia, and minimal contrast enhancement. A lumbar drain was placed and intrathecal fluorescein was administered. The patient underwent an endoscopic endonasal repair during which dystrophic calcification, likely representing attempted repair with the middle turbinate, was identified over the defect. The encephalocele was transected and the defect was repaired with abdominal fat, a tensor fascia lata bilayer button, and a nasoseptal flap. On postoperative day 5, the patient developed an elevated white count, confusion, and fever. CT and MRI were consistent with left inferior frontal cerebritis. The patient was taken for a bifrontal craniotomy. The endoscopic repair was found to be intact, the inflamed parenchyma was resected, and the dura was closed with a pericranial graft. The patient is neurologically intact at 6 months with complete resolution of CSF rhinorrhea.

Conclusion: We routinely address anterior skull base pathology via the endoscopic route in our practice; however, this patient represents an extreme example of untreated chronic CSF rhinorrhea. The endoscopic closure of the defect likely eliminated the drainage route for the chronically infected/ inflamed frontal lobe, thereby exacerbating an underlying cerebritis. Open transcranial management remains an important part of the armamentarium when addressing similar pathology. Treatment by a multidisciplinary skull base team improves patient outcomes by providing all modalities within one institution.

Publication History

Article published online:
12 February 2021