Endoscopic Management of Cerebrospinal Fluid Leaks and Encephaloceles

  • Umit Aydin
  • Mustafa Gerek
  • Sergei Karpischenko


Cerebrospinal fluid (CSF) leak results from the breakdown of barriers separating the intracranial space and the paranasal sinuses. CSF rhinorrhea is the leakage of cerebrospinal fluid from the subarachnoid space into the nasal cavity due to defect in the dura, bone, and mucosa. This may be induced by traumatic, iatrogenic, congenital, neoplastic, or inflammatory processes. CSF rhinorrhea may develop directly from the anterior cranial fossa or indirectly through the middle or posterior fossa via the eustachian tube. A CSF leak may be associated with encephalocele, which is the herniation of neural tissue through the skull base. CSF leaks bring the risk of meningeal or intracranial infections, and therefore they should be treated as soon as the diagnosis is made. The surgical management of CSF leak has changed significantly following the introduction of endoscopic sinus surgery in the treatment of rhinosinusitis. Thanks to low morbidity and high success rate, the endoscopic transnasal technique for the repair of CSF rhinorrhea of the anterior cranial base replaces the open intracranial approaches in most cases. Endonasal endoscopic approach is preferred for the repair of CSF leaks, located at the anterior or posterior ethmoid roof and in the sphenoid sinus. CSF leaks, located at the posterior wall of frontal sinuses, can be repaired extradurally with osteoplastic flap approach to the frontal sinus.


Endoscopic management Cerebrospinal fluid (CSF) leak Encephaloceles Endoscopic transnasal technique 


  1. 1.
    Bernal-Sprekelsen M, Alobid I, Mullol J, et al. Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis. Rhinology. 2005;43(4):277–81.PubMedGoogle Scholar
  2. 2.
    Tosun F, Gonul E, Yetiser S, Gerek M. Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea. Minim Invasive Neurosurg. 2005;48(6):355–60.CrossRefGoogle Scholar
  3. 3.
    Kaintz J, Stammberger H. The roof of the anterior ethmoid: a place of least resistance in the skull base. Rhinology. 1990;3:191–9.CrossRefGoogle Scholar
  4. 4.
    Bachmann G, Nekic M, Michel O. Clinical experience with beta-trace protein as a marker for cerebrospinal fluid. Ann Otol Rhinol Laryngol. 2000;109:1099–102.CrossRefGoogle Scholar
  5. 5.
    Ryall RG, Peacock MK, Simpson DA. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. J Neurosurg. 1992;77(5):737–9.CrossRefGoogle Scholar
  6. 6.
    Marshall A, Jones NS, Robertson I. CSF rhinorrhoea: a multidisciplinary approach to minimise patient morbidity. Br J Neurosurg. 2001;15(1):8–13.CrossRefGoogle Scholar
  7. 7.
    Bhalodiya NH, Joseph ST. Cerebrospinal fluid rhinorrhea: Endoscopic repair based on a combined diagnostic approach. Indian J Otolaryngol Head Neck Surg. 2009;61:120–6.CrossRefGoogle Scholar
  8. 8.
    Albadr FB, Alorainy IA. Radiological management of cerebrospinal fluid rhinorrhea. Neurosciences. 2004;9(3):158–64.PubMedGoogle Scholar
  9. 9.
    Zuckerman JD, DelGaudio JM. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair. Am J Rhinol. 2008;22(2):151–4.CrossRefGoogle Scholar
  10. 10.
    Allen MB Jr, El Gammal T, et al. Fistula detection in cerebrospinal fluid leakage. J Neurol Neurosurg Psychiatry. 1972;35:664–8.CrossRefGoogle Scholar
  11. 11.
    Wolman L. The neuropathologic effects resulting from the intrathecal injection of chemical substance. Paraplegia. 1966;4:97–115.PubMedGoogle Scholar
  12. 12.
    Cooper PW, Kassel EE. Computed tomography and cerebrospinal fluid leak. J Otolaryngol. 1982;11(5):319–26.PubMedGoogle Scholar
  13. 13.
    Curnes JT, Vincent LM, Kowalsky RJ, et al. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. Radiology. 1985;154(3):795–9.CrossRefGoogle Scholar
  14. 14.
    Seth R, Rajasekaran K, Benninger MS, et al. The utility of intrathecal fluorescein in cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg. 2010;143(5):626–32.CrossRefGoogle Scholar
  15. 15.
    Dandy WD. Pneumocephalus (intracranial pneumocele or aeroscele). Arch Surg. 1912;12:949–82.CrossRefGoogle Scholar
  16. 16.
    Park J-I, Streslow VV, Friedman WH. Current management of cerebrospinal fluid rhinorrhea. Laryngoscope. 1983;93:1294–300.CrossRefGoogle Scholar
  17. 17.
    Dohlman G. Spontaneous cerebrospinal rhinorrhea. Acta Otolaryngol. 1948;(Suppl 67):20–3.Google Scholar
  18. 18.
    Nasenendoscopie MW. Nachweis, lokalisation und defferential diagnose der nasalen Liquorrhoe. HNO. 1972;20:268–70.Google Scholar
  19. 19.
    Wigand ME. Transnasal ethmoidectomy under endoscopic control. Rhinology. 1981;19:7–15.PubMedGoogle Scholar
  20. 20.
    Stankiewicz JA. Complications in endoscopic ethmoidectomy: an update. Laryngoscope. 1989;99:686–90.PubMedGoogle Scholar
  21. 21.
    Mattox DE, Kennedy DW. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope. 1990;100(8):857–862.CrossRefGoogle Scholar
  22. 22.
    Schnipper D, Spiegel JH. Management of intracranial complications of sinus surgery. Otolaryngol Clin North Am. 2004;37(2):453–72.CrossRefGoogle Scholar
  23. 23.
    Papay FA, Maggiano H, Dominquez S, et al. Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas. Laryngoscope. 1989;99:1195–201.PubMedGoogle Scholar
  24. 24.
    Sierra DH, Nissen AJ, Welch J. The use of fibrin glue in intracranial procedures: preliminary results. Laryngoscope. 1990;100:360–363.CrossRefGoogle Scholar
  25. 25.
    Tosun F, Carrau RL, Snyderman CH, et al. Endonasal Endoscopic Repair Of Cerebrospinal Fluid Leaks Of The Sphenoid Sinus. Arch Otolaryngol Head And Neck Surgery. 2003;129:576–80.CrossRefGoogle Scholar
  26. 26.
    Kerr JT, Felix WK, Chu W, et al. Cerebrospinal fluid rhinorrhoea diagnosis and management. Otolaryngol Clin North Am. 2005;38:597–611.CrossRefGoogle Scholar
  27. 27.
    Mao VH, Keane WM, Atkins JP, et al. Endoscopic repair of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. 2000;122(1):56–60.CrossRefGoogle Scholar
  28. 28.
    Hegazy HM, Currau RL, Snyderman CH, et al. Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis. Laryngoscope. 2000;110:1166–72.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Umit Aydin
    • 1
  • Mustafa Gerek
    • 1
  • Sergei Karpischenko
    • 2
  1. 1.Department of OtorhinolaryngologyUniversity of Health Sciences, Gülhane Medical SchoolAnkaraTurkey
  2. 2.Department of OtorhinolaryngologyPavlov First St. Petersburg State Medical UniversitySaint PetersburgRussia

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