CSF rhinorrhea-feasibility of conservative management in children

PurposeTo study the role of conservative management in CSF rhinorrhea in pediatric population.Study designA retrospective study in a tertiary care center.MethodsCases with a diagnosis of CSF rhinorrhea discharged after conservative management but required skull base repair for recurrence of CSF rhinorrhea or meningitis were included in the study between periods 2000 and July 2010.Results12 cases of CSF rhinorrhea managed were treated conservatively, 7 patients again required rehospitalisation for recurrence of CSF rhinorrhea or meningitis. Male:female ratio was 4:1. The age ranged from 3 years to 14 years. Duration of recurrence of the CSF leak or meningitis varied from 6 to 121 months. Presenting symptoms included headache, rhinorrhea, or recurrent meningitis. The time from the initial injury to surgical exploration ranged from 163 to 3650 days. All patients were under regular follow-up and doing well except one had recurrence of the leak 2 months after surgery requiring revision surgery following which the patient had no recurrence.DiscussionThe management of CSF fistulae is still a matter of debate and there will be a risk of recurrent meningitis on conservative management. Most comprehensive study to date indicates there is a 9.8% annual risk of developing meningitis. Duration of recurrence of the CSF leak or meningitis varied from 6 months to 121 months. The overall incidence of meningitis as a result of skull base defect and CSF leak ranges from 9% to 50% with a reported cumulative risk of 85% in 10 years if no repair is performed. As seen in our series CSF repair can resolve with conservative management but there is a risk of intermittent CSF leak or meningitis due to an incompletely healed or tenuous mucosal regeneration which should be addressed surgically. The patients with traumatic CSF leak who were treated with conservative management alone had a 25–29% risk of subsequent meningitis.ConclusionConservative treatment of CSF leaks may lead to recurrent meningitis or leaks, therefore surgical closure of defects at the skull base should be considered treatment of choice to prevent ascending meningitis.