International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Cerebrospinal fluid leakage is an important differential diagnosis in long-term runny nose. Nasal cerebrospinal fluid leakage, CSF rhinorrhea, is a rare cause of runny nose but important to keep in mind as a differential diagnosis in patients seeking for long-term problems. CSF rhinorrhea can coexist with IIH, intracranial hypertension that often causes problems such as headaches, tinnitus, and vision loss. The article below from Int Forum Allergy Rhinol, 2020 25 October, shows the results found in an international consensus group. Dimitris Kombogiorgas (MD) is a co-author of the article and works with Likvor CELDA System for this patient group at Hygeia Hospital in Athens, Greece. Listen to him at the upcoming webinar: November 4, 2020 at 14:00. Linked to registration:
Int Forum Allergy Rhinol 2020 Oct 25

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 substitute 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, assessment 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. 

Mr. Dimitris Kombogiorgas  MD, MPhil, MRCSEd, FRCS(SN), CCT UK
Consultant Neurosurgeon
Hygeia Hospital, Athens, Greece

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