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Objectives: The annual risk of meningitis in unrepaired fistulas is widely quoted to be approximately 10% per annum. Our aim was to review our experience with cerebrospinal fluid (CSF) leaks and to calculate the overall risk and the annual incidence of meningitis, and to correlate our findings with the causation and the effect of operative intervention in a subgroup of patients who had a history of meningitis., Methods: We prospectively collected data on all patients referred with a CSF leak to our tertiary referral center over a 12-year period between 1994 and 2006. We had a follow-up rate of 91%., Results: One hundred eleven patients had a proven leak on endoscopy, beta-2 transferrin, imaging, and/or fluorescein lumbar puncture. The accumulated duration of an active CSF leak in the cohort was 190 years. The total number of episodes of meningitis was 57 in 21 patients, giving an overall risk of developing meningitis of 19%, with an overall incidence of 0.3 episodes per year. There was a progressive reduction in the incidence of meningitis with time, and most episodes occurred within the first year following the onset of the CSF leak. However, the risk persisted as long as the CSF leak was active., Conclusions: The overall risk of meningitis in patients with persistent CSF rhinorrhea was 19%. The annual incidence of meningitis was 0.3 episodes per year, with most episodes occurring within the first year following the onset of the leak. Endoscopic closure is the treatment of choice in most CSF leaks; if successful, it reduces the risk of meningitis.

Introduction: Although endoscopic closure is now the treatment of choice in the majority of patients with sinonasal cerebrospinal fluid (CSF) leaks, there is a recurrence rate of up to 10% in most series., Objectives: Our aim was to review our experience in the management of CSF leaks and in particular the cause of recurrent leaks., Methods: We prospectively collected data on all cases referred as a suspected CSF leak to us, a tertiary referral center, over a 10 year period between 1994 and 2004., Results: The 121 patients referred with an apparent CSF leak had a mean age of 51 (range 2-87) years. Fifty-three percent were male, and 47% were female. In 24 cases, investigations revealed that there was in fact no CSF leak, and in 17 posttraumatic cases, the leak ceased spontaneously. Twenty-nine patients had a spontaneous CSF leak. Of the 80 cases surgically repaired, 72 had an endoscopic approach, with a success rate of 90%, increasing to 97% after a second procedure and 99% by a third procedure. Eight patients with a posterior wall frontal sinus leak underwent an external frontal sinus procedure. There were 8 failures, and 6 occurred in the 13 patients with a spontaneous leak and evidence of raised intracranial pressure (ICP)., Conclusions: In conclusion, our endoscopic repair rate for sinonasal CSF leaks are good and compare well with the standards in the literature. Raised ICP is the most common reason for recurrent CSF leak after repair. Patients with a spontaneous CSF leak and evidence of raised ICP had a 46% failure rate. When consenting such patients for surgery, they must be informed of the lower success rate and that they may need additional procedures, including shunting.

Multiple congenital dehiscence of the skull base is rare and can give rise to spontaneous CSF rhinorrhoea. A search of the world literature revealed only five reports of CSF leak with more than one concomitant skull base defect. When treating a patient with spontaneous CSF rhinorrhoea the possibility of its originating from the middle ear and eustachian tube should be considered. An intrathecal injection of fluorescein is useful in establishing the site of a CSF leak especially when a computed tomography scan (CT) or magnetic resonance image (MRI) has not localized the site. We discuss a case of a 72-year-old lady presenting with CSF rhinorrhoea, who had an anterior skull base defect localized with the help of intrathecal fluorescein and repaired surgically. Subsequent to this she had a further episode of CSF rhinorrhoea that originated from a middle-ear meningocele that was then repaired.

Cerebrospinal fluid (CSF) rhinorrhoea has been managed by both neurosurgeons and otorhinolaryngologists, with neurosurgeons often choosing an intracranial approach and otorhinolaryngologists an extracranial approach. Recently, transnasal endoscopic techniques have been introduced that significantly reduce the morbidity of surgical repair when compared with previous techniques. The sense of smell was preserved in all patients who underwent an endoscopic repair of their CSF leak where it was present preoperatively. The results of transnasal endoscopic repair now make it the treatment of choice for most anterior cranial and sphenoid CSF leaks, with the exception of defects in posterior wall of the frontal sinus or defects larger than 5 cm. It is vital that a diagnosis of a CSF leak is confirmed by immunofixation of beta 2 transferrin as unilateral rhinorrhoea can masquerade as a CSF leak. We illustrate our experience with 78 patients who were referred with a diagnosis of CSF rhinorrhoea.

Before contemplating surgery for cerebrospinal fluid (CSF) rhinorrhoea it is vital that the correct diagnosis is established. This can be done using immunofixation of beta-2-transferrin, that is nearly always positive in cases of CSF rhinorrhoea. Fluorescein lumbar puncture is useful in establishing the exact site of a leak and also in confirming the absence of a leak where the clinical suspicion is high but the beta-2-transferrin is negative. High resolution computed tomography (CT) scanning is a useful radiological investigation for identifying a bony defect. We present nine patients who presented with clear rhinorrhoea that was clinically highly suggestive of a CSF leak. Three of these patients had undergone previous craniotomies for presumed CSF rhinorrhoea. The diagnosis of CSF rhinorrhoea was excluded in all patients using beta-2-transferrin with or without fluorescein lumbar puncture. The authors believe that measurement of beta-2-transferrin should be mandatory before surgery for CSF rhinorrhoea.

The diagnosis of cerebrospinal fluid (CSF) rhinorrhoea should be established beyond reasonable doubt before surgical intervention is embarked upon. It is important not to miss the diagnosis in view of the real potential complication of meningitis if it is left untreated. We describe a management algorithm which centers around the selective use of nasal endoscopy, immunofixation of beta2 transferrin, high resolution coronal CT scans, and fluorescein lumbar puncture. This management strategy is illustrated with 36 cases. We have developed a minimally invasive endoscopic technique to repair CSF leaks, and in 30 patients we had a success rate of 93% after one procedure.

The use of intrathecal injections of fluorescein has a role in the diagnosis and management of cerebrospinal fluid leaks using endoscopic techniques. The Polymedic 'pencil point' needle has a lower incidence of headache after dural puncture than standard bevelled needles. We describe a safe method of introducing fluorescein into the thecal space.

We present an unusual case of generalized erosion of the skull base. We have not found a similar case reported in the world literature. The presenting symptom was spontaneous cerebrospinal fluid (CSF) rhinorrhoea which arose from a bony defect associated with herniation of the right temporal lobe into the sphenoid sinus. We discuss the management of such a case including imaging of the skull base and the endoscopic repair of the bony defect.

The conventional neurosurgical management of cerebrospinal fluid (CSF) rhinorrhoea has been by intracranial access. Otorhinolaryngologists have undertaken extracranial approaches where access has been possible, and more recently an endoscopic approach has been advocated. We report 17 patients with confirmed CSF rhinorrhoea treated with endoscopic techniques between 1993 and 1996. Follow-up ranged from four to 32 months and showed an overall closure rate of 16 out of 17 patients with no complications. No patient undergoing primary endoscopic repair developed anosmia. The use of fluorescein helped localize the site of the CSF leak in four patients in whom the computed tomography (CT) scan had not identified the site of the defect. We conclude that the endoscope is a valuable tool in the evaluation and subsequent treatment of CSF rhinorrhoea. Where the skull base defect is accessible to the endoscope, we propose that an endoscopic approach should be considered as the preferred method.