Lingering Issues: Challenges remain in repairing CSF leaks

Kevin C. Welch, MD, assistant professor of otolaryngology–head and neck surgery at Loyola University Medical Center in Maywood, Ill., also emphasized the importance of adequately treating these types of leaks.

“One of the overarching concepts in the management of CSF leaks, primarily spontaneous CSF leaks, is that the surgery fixes only the active leak,” he said. “Medication may be necessary to manage elevated intracranial pressure. In some cases the placement of a shunt is required.” Without these additional treatments, he said, there is a theoretical risk that the underlying condition may cause recurrence or a leak in a new location.

The Frontal Sinus

According to Dr. Welch, CSF leaks that involve the frontal sinus are the most challenging for otolaryngologists to repair, both because of the surgical skill required and due to the inability of current instrumentation to effectively navigate the necessary anatomical regions.

“Reaching frontal sinus CSF leaks can tax the capability of the surgeon as well as the limitations of the current instrumentation,” he said. “However, many frontal sinus CSF leaks can be closed endoscopically or with the assistance of a small frontal sinus trephination.”

“The evidence suggests that for large defects there is an advantage to using arterially based flaps.”
—David W. Kennedy, MD

Antibiotics

The subject of whether or not to use antibiotics in patients with CSF leaks remains controversial because evidence of its benefit in this setting is lacking. According to Dr. Welch, evidence from a number of large studies indicates some benefit in using antibiotics in the setting of traumatic leaks; smaller studies show an incidence of meningitis in up to 29 percent of unrepaired cases of CSF leaks (Rhinology. 2005;43:277-281; Am J Rhinol. 2000;14:257-259).

Despite the inconclusive evidence regarding the necessity of antibiotics, Dr. Welch uses third-generation cephalosporin when repairing CSF leaks because of concerns about meningitis.

The possibility of meningitis in patients with CSF leaks is one reason physicians still prescribe antibiotics, said Dr. Takashima, adding that he and his colleagues typically use a first-generation cephalosporin as a preoperative antibiotic, rather than a broad-based antibiotic. To date, they have not had any patients with infectious complications, Dr. Takashima said.

While acknowledging that some patients with CSF leaks appear to have fewer problems with recurrent meningitis when given a prolonged course of oral antibiotics, Dr. Kennedy does not typically treat his patients with an oral antibiotic. Occasionally, he will use an antibiotic in patients with a history of multiple episodes of meningitis. He emphasized that antibiotics are always used at the time of leak closure.

“Medication may be necessary to manage elevated intracranial pressure.”
—Kevin C. Welch, MD

Intrathecal Fluorescein

Currently, the most sensitive test used to detect a CSF leak is intrathecal fluorescein. According to Dr. Welch, the use of this test is indicated when the site of the leak is unknown or to confirm a leak in an area in which one is suspected. It may also be used to ensure that a leak stops during surgery.