International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Christos Georgalas; Amanda Oostra; Shahzada Ahmed; Paolo Castelnuovo; Iacopo Dallan; Wouter van Furth; Richard J Harvey; Philippe Herman; Dimitrios Kombogiorgas; Davide Locatelli; Cem Meco; Jim N Palmer; Otavio Piltcher; Anshul M Sama; Hesham Saleh; Raj Sindwani; Thibaut Van Zele; Bradford A Woodworth

doi:10.1002/alr.22704

International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Int Forum Allergy Rhinol. 2021 Apr;11(4):794-803. doi: 10.1002/alr.22704. Epub 2020 Oct 25.

Authors

Christos Georgalas^{1

2}, Amanda Oostra³, Shahzada Ahmed⁴, Paolo Castelnuovo⁵, Iacopo Dallan⁶, Wouter van Furth⁷, Richard J Harvey⁸, Philippe Herman⁹, Dimitrios Kombogiorgas¹⁰, Davide Locatelli¹¹, Cem Meco^{12

13}, Jim N Palmer¹⁴, Otavio Piltcher¹⁵, Anshul M Sama¹⁶, Hesham Saleh^{17

18}, Raj Sindwani¹⁹, Thibaut Van Zele²⁰, Bradford A Woodworth²¹

Affiliations

¹ Endoscopic Skull Base Centre Athens, Hygeia Hospital, Erythrou Stavrou 4, Maroussi, Athens, 15123, Greece.
² Medical School, University of Nicosia, 93 Agiou Nikolaou Street, Engomi, Nicosia, 2408, Cyprus.
³ Department of Neurosurgery, Evangelismos University Hospital Athens, Athens, Greece.
⁴ Department of ENT and Skull Base Surgery, Birmingham Hospital, Birmingham, UK.
⁵ Department of Otorhinolaryngology, University of Insubria, Varese, Italy.
⁶ Department of Otolaryngology - Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
⁷ Department of Neurosurgery, Leiden University Medical Center (LUMC), Leiden, Netherlands.
⁸ Sydney ENT clinic, Sydney, Australia.
⁹ Department of Otolaryngology, Hôpital Lariboisière, Paris, France.
¹⁰ Department of Neurosurgery, Hygeia Hospital, Athens, Greece.
¹¹ Neurosurgical Clinic, Insubria University, ASST Settelaghi, Varese, Italy.
¹² Department of ORL-HNS, Ankara University Medical School, Ankara, Turkey.
¹³ Department of ORL-HNS, Salzburg Paracelsus Medical University, Salzburg, Austria.
¹⁴ Otorhinolaryngology-Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
¹⁵ ENT Department, Hospital de Clinicas de Porto Alegre - UFRGS, Brazil.
¹⁶ ENT Surgeon, Spire Nottingham Hospital, Nottingham, UK.
¹⁷ Department of Otolaryngology - Head and Neck Surgery, Charing Cross Hospital, London, UK.
¹⁸ ENT Surgery, Imperial College, London, UK.
¹⁹ ENT Cleveland Clinic, Cleveland, OH.
²⁰ Department of Otorhinolaryngology, UZ Ghent University Hospital, Gent, Belgium.
²¹ Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, AL.

PMID: 33099888
DOI: 10.1002/alr.22704

Abstract

Background: The association between spontaneous cerebrospinal fluid (CSF) leak/rhinorrhea and idiopathic intracranial hypertension (IIH) has been increasingly recognized over the last years. However, considerable variability of opinion regarding the assessment, investigations, and management of patients with spontaneous CSF rhinorrhea remains.

Methods: A consensus group was formed from experts from Europe, Asia, Australia, South and North America. Following literature review and open discussions with members of the panel, a set of 61 statements was produced. A modified Delphi method was used to refine expert opinion with 3 rounds of questionnaires and a consensus group meeting in Santo-Rhino meeting in September 2019.

Results: Fifty statements (82% of total) on spontaneous CSF leak and IIH reached consensus. In 38 of 50 statements, the median response was 7 (strongly agree) and in the 12 remaining statements the median response was 6 (agree). Eleven statements were excluded because they did not reach consensus and one new statement was added during SantoRhino meeting. The final statements refer to patient history and clinical examination ("History taking should include presence of headache, tinnitus and visual defects"), investigations (role of Thin Slice Computed Tomography and CISS/FLAIR sequences in Magnetic Resonance Imaging), principles of management (watchful waiting or measures to reduce ICP are supplementary but cannot subsitute surgical closure), surgical technique, intraoperative, early postoperative and long term management.

Conclusion: We present fifty consensus statements on the diagnosis, investigation, and management of spontaneous CSF rhinorrhea based on the currently available evidence and expert opinion. Although by no means comprehensive and final, we believe they can contribute to the standardization of clinical practice. Early diagnosis, prompt surgical closure of the defect, assesment for and treatment of potentially co-existing idiopathic intracranial hypertension in a comprehensive multidisciplinary approach are essential in order to successfully manage spontaneous CSF rhinorrhea, reduce associated morbidity and prevent recurrence.

Keywords: IIH; consensus article |; idiopathic intracranial hypertension; rhinorrhea; spontaneous CSF leak.

Publication types

Practice Guideline
Review

MeSH terms

Cerebrospinal Fluid Leak
Cerebrospinal Fluid Rhinorrhea* / diagnosis
Cerebrospinal Fluid Rhinorrhea* / surgery
Humans
Intracranial Hypertension*
Pseudotumor Cerebri*
Rhinorrhea