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Oakley et al.

packing, as well as postoperative bed rest, activity restric tions, continuous positive airway pressure (CPAP) use, and air travel. However, the benefits, harm, and appropriate duration of these strategies remains unclear in the litera ture. Our purpose was to perform an iterative evidence-based review on perioperative management strategies that are commonly used and provide evidence-based recommenda tions where available. Materials and methods The methodology described by Rudmik and Smith 8 for the development of an evidence-based review with recommen dations was followed for preparation of this article. Five endoscopic repair techniques and 8 perioperative manage ment strategies commonly used in the setting of CSF leak were selected for inclusion in the analysis: prophylactic antibiotics, lumbar drainage, endoscopic repair with fat grafts, bone grafts, allografts, and free mucosa grafts vs vascularized grafts, glues and sealants, nasal packing, post operative bed rest, the resumption of CPAP usage, duration of activity restrictions, air travel, and postoperative medi cations. A systematic review of the literature was performed us ing PubMed, EMBASE, and Cochrane Review Databases from 1990 through September 2014 using the terms “cere brospinal fluid “ and/or “cerebrospinal fluid rhinorrhea” in combination with each of the 13 endoscopic repair and pe rioperative management strategies. This resulted in a total of 719 abstracts, which were evaluated for relevance. The exclusion criteria applied were language other than English, non-human studies, nonrhinologic leak, and case reports. The remainder of the studies were included for evaluation and graded for level of evidence using reported research methodology. 9 After analysis of each article, summary tables were de veloped, as well as an aggregate grade of evidence, benefit harm assessments, and value judgment for each strategy that had more than 1 included study. When the available lit erature was sufficient, recommendations were made based on published evidence. The literature was reviewed and the initial manuscript was prepared by 3 authors (G.M.O., J.A.A., and R.R.O.). Additional authors were then asked to critically evaluate the recommendations based on their review of the literature (B.W. and P.B.) per the protocol for the above mentioned online iterative process.

meningitis or local infection during conservative manage ment or following endoscopic repair. However, this strat egy carries the risk of selecting for resistant bacteria, which may potentially result in meningitis. As a result, their rou tine use in CSF leaks has been questioned. Ten studies were identified following database search that met inclusion cri teria and assessed the efficacy of antibiotics in this setting (see Aggregate grade of evidence below). Eftekhar et al. 1 randomized 109 patients with traumatic pneumocephalus to 5 days of prophylactic ceftriaxone or no antibiotics and examined the risk of meningitis as the outcome measure. The results showed that the overall rate of meningitis did not differ (18.9%with antibiotics, 21.5% without antibiotics; p = 0.74). Four meta-analyses demon strate conflicting results. A 1997 meta-analysis by Brodie 13 included 324 subjects with basilar skull fractures and found a lower rate of meningitis associated with prophylactic antibiotic use. However, 3 larger meta-analyses have all shown the opposite. Rathore 14 in 1991 (n = 848), Villalo bos et al. 15 in 1998 (n = 1241), and Ratilal et al. 16 in 2011 (n = 2376) found that antibiotic prophylaxis did not impact the rate of meningitis. In addition to possibly selecting for resistant organisms, antibiotics confer the risk of allergic reactions and in many cases substantial cost with intravenous delivery. The pre ponderance of the evidence appears to favor avoiding the routine use of prophylactic antibiotics with CSF leaks. The use of antibiotics intraoperatively and postoperatively for CSF leak closure surgery has not been examined and therefore no evidence-based recommendation can be made (Supporting material 1). Aggregate grade of evidence: B (Level 1: 3 studies; Level 3: 4 studies; Level 4: 3 studies) Benefit: Based on first principles; may reduce risk of menin gitis in immediate post-traumatic or perioperative period. Harm: May select for microbial resistance in the individual and more broadly at a population level, drug allergies. Cost: Moderate (cost varies). Benefits-harm assessment: No benefit in traumatic leaks, unknown benefit in perioperative leaks, moderate poten tial harm. Value judgments: Meningitis has serious sequelae. Recommendation level: Option. Intervention: Use of prophylactic antibiotics for CSF leaks. Lumbar drainage Lumbar drains are sometimes used in an effort to mini mize increased intracranial pressure during the immediate postoperative period that could cause displacement of the skull-base repair. Placement of an indwelling catheter in the intrathecal space has significant risks, including menin gitis, persistent CSF leak from the dural puncture, pneu mocephalus, brain herniation, and death. Cost is another consideration, in that there is evidence demonstrating the potential for lumbar drains to increase the length of hospi tal stay.

Results Prophylactic antibiotics

The rate of meningitis either preoperatively or during con servative management for posttraumatic CSF leak is re ported to range from 10% to 37%. 1–5 The postopera tive meningitis risk following transnasal skull-base surgery ranges from 0.3% to 7%. 4,10–12 Prophylactic antibiotics are often used for CSF leaks in an effort to decrease the risk of

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

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