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OR I G I NAL ART I CLE

Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations Gretchen M. Oakley, MD 1 , Richard R. Orlandi, MD 1 , Bradford A. Woodworth, MD 2 , Pete S. Batra, MD 3 and Jeremiah A. Alt, MD, PhD 1

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 per formed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative manage ment strategies for CSF rhinorrhea. Benefit-harm assess ments, 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 rec ommendations through an iterative process. Results: We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reach ing a highest aggregate grade of evidence of B. The lit erature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair C erebrospinal fluid (CSF) rhinorrhea is an abnormal communication between the subarachnoid space and the sinonasal cavity. It can occur following skull-base trauma, endoscopic sinus surgery (ESS) or neurosurgical procedures, or have a spontaneous etiology. Once a per 1 Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT; 2 Division of Otolaryngology–Head and Neck Surgery, University of Alabama, Birmingham, AL; 3 Department of Otolaryngology–Head and Neck Surgery, Rush University, Chicago, IL Correspondence to: Jeremiah A. Alt, MD, PhD, University of Utah School of Medicine, Division of Otolaryngology–Head and Neck Surgery, 50 North Medical Drive, Room 3C120, Salt Lake City, UT 84132; e-mail: jeremiah.alt@hsc.utah.edu Additional supporting information including summary tables can be found in the online version of this article. Potential conflict of interest: R.R.O. is a consultant for Medtronic. Presented as a poster at ARS Spring Meeting on April 24, 2015, in Boston, MA. Received: 21 May 2015; Revised: 7 July 2015; Accepted: 14 July 2015 DOI: 10.1002/alr.21627 View this article online at wileyonlinelibrary.com.

materials show similar success rates; however, larger de fects may benefit from vascularized gra s. There were no relevant studies to address postoperative activity restric tions. Conclusion: Despite relatively low levels of evidence, rec ommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level stud ies are needed to be er determine optimal clinical man agement approaches. C 2015 ARS-AAOA, LLC. Key Words: CSF leak; CSF rhinorrhea; endoscopic repair; endoscopic skull base repair; perioperative management How to Cite this Article : Oakley GM, Orlandi RR, Woodworth BA, Batra PS, Alt JA. Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol . 2016;6:17–24. sistent leak has been confirmed and localized with the appropriate diagnostic modalities, surgical intervention is indicated due to the risk of meningitis, which has been reported to range from 10% to 37% during conservative management. 1–5 Open intracranial approaches have historically been used for CSF leak repair, but in recent decades these have largely been replaced by endonasal endoscopic approaches, given their high success rate and lower morbidity profile. Com monly utilized endoscopic repair techniques for CSF leak are numerous, including free tissue grafts, vascularized flaps, and tissue sealants, as well as various multilayer com binations of these methods. Studies have shown that vascu larized flaps are superior in the setting of large dural defects or high-flow CSF leaks 6, 7 ; otherwise, implementation of a specific repair technique is directed more by surgeon pref erence than by evidence-based guidance. Perioperative management is believed to play a critical and complementary role in maximizing the success rate of endoscopic CSF leak repair. These strategies include use of perioperative antibiotics, lumbar drainage, and nasal

International Forum of Allergy & Rhinology, Vol. 6, No. 1, January 2016

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