Results of Conservative Management of CSF Rhinorrhea in Post Traumatic Patients

Objectives: We aimed to see the results of conservative management of CSF rhinorrhea in post-traumatic patients. Material and Methods: An observational study was conducted on 50 patients for 3 months from 1 st November 2021 to 31 th Jan 2022. Patients presented to neurosurgery unit II, PINS. All patients had a history of road traffic accidents (RTA). Results: The age range was 10 – 50 years. The mean age was 25 years. All patients were managed conservatively for one week. We advised complete bed rest to all patients for 2 weeks. Head ends of all patients were slightly inclined from 15 – 30 degrees to reduce pressure in basal cisterns. We gave acetazolamide, mannitol, antibiotics, and anti-epileptic medication to all patients. CSF rhinorrhea in our 43 (86%) patients was stopped completely. In our 5 (10%) patients, CSF rhinorrhea was cured completely after doing a lumbar puncture with drainage of CSF and with the placement of a lumbar drain at a rate of 10 ml per hour. In our 2 (4%) patients, CSF rhinorrhea was not cured. We have to do surgery either by trans cranial or endoscopic repair of CSF rhinorrhea. Conclusion: CSF rhinorrhea is best cured by conservative management except in 4% of cases.


INTRODUCTION
CSF rhinorrhea can cause meningitis in 10 percent of cases per year. There are many causes of CSF rhinorrhea. It can be caused by trauma to the skull base, osteomyelitis, congenital anomalies, and destructive lesions. CSF rhinorrhea can occur through a defect in a cribriform plate or ethmoid sinus and posterior wall of frontal sinus to nasolacrimal duct. It can also occur in middle cranial fossa fractures via sphenoid sinus or Eustachian tube. Severe head and neck trauma cause skull base fractures and CSF rhinorrhea. Spinal fluid leakage from the nose can lead to fulminant meningitis. [1][2][3] CT with or without intrathecal contrast is used to localize the site of the leak. There is no need to do CT cisternography and radionuclide cisternography when clinical and imaging findings are matched. [4][5][6][7] Beta-2 transferrin is found in the CSF but not present in the blood, nasal mucus, or tears. Detection of glucose in CSF in nasal and ear discharge is used to confirm the presence of CSF. [8][9][10][11][12] Most cases of CSF rhinorrhea resolve within a week. Surgical closure of leaks or defects at the skull base should be done to prevent leaks so that delayed bacterial meningitis may not occur. 13 Medical management consists of one week trial of bed rest with the head of the bed elevated at approximately 15 -30° to reduce the CSF pressure at the basal cisterns. Patients having CSF rhinorrhea must avoid coughing, sneezing, nose-blowing, constipation, and heavy lifting. Prophylactic antibiotics may be given to patients. [14][15][16] We can place a subarachnoid lumbar drain for continuous drainage of approximately 5 -10 mL of CSF per hour. [17][18][19]

Study Design
An observational study was conducted on 50 patients for 3 months from 1 st November 2021 to 31 st Jan. 2022 at Punjab Institute of Neuroscience (PINS), Lahore.

Inclusion Criteria
Patients having a history of trauma, age range 10 -50 years, GCS above 13/15, and patients having co-morbidities were included in the study.

Exclusion Criteria
Patients having GCS below 13/15, ages above 50 years and less than 10 years, and patients having spontaneous CSFrhinorrhea were excluded from the study.

Data Collection and Analysis
Patients' data were entered on preformed Performa for collection. SPSS version 22 was used for data analysis.

Management Technique
In 50 patients, we did conservative management of the CSF rhinorrhea for 2 weeks to see that either it is resolved by conservative management or not. We included only post-traumatic patients. We used lumbar puncture and lumbar drainage to help resolve the CSFrhinorrhea in those cases which are not resolved by mannitol, acetazolamide, etc.

Age Incidence
The age range was 10 -50 years and the mean was 30 years.

Outcome and Complications
A good outcome was observed in 86% of patients. Complications were reported in 10% of cases (Table 1). Meningitis was reported in 6% of cases, headache in 2% of cases, and seizures occurred in 2% of cases (Table 2).

DISCUSSION
Our patients were in the range of 10 -50 years and with a mean age of 30 years. In our study, 30 (60%) patients were male and 20 (40%) patients were female. All patients had CSF rhinorrhea regardless of etiology. We planned for conservative management of all patients. For the first week, we did head elevation gradually from 15 -30 degrees to reduce pressure in basal cisterns. We gave ceftriaxone, amoxicillin, metronidazole and acetazolamide to all (100%) patients. Our 5(10%) patients had pneumocephalus. In these patients, we improved hydration status, gave antibiotics, and antiepileptic drugs, and gave oxygen for 2 days. Our 3 (6%) had wounds over the skull on presentation after a road traffic accident. We did the cleaning, debridement, and then antiseptic dressing of the wound until the wound heals. We gave mannitol to our 45 (90%) patients on presentation.
Our patients had diabetes mellitus, hypertension, chronic kidney disease, ischemic heart disease, etc. Our patients had a history of altered state of consciousness, multiple episodes of vomiting, fits, and headaches.
In the second week, in those patients who were not improved after conservative management, we did a lumbar puncture for CSF drainage and also placed a lumbar drain. In 4 (8%) patients we placed a lumbar drain and in 1 (2%) patient we did a lumbar puncture and drained CSF. After doing these management measures, 2 (4%) patients did not cure. In these patients, we performed a CT scan with FESS protocol and an MRI brain with CSF rhinorrhea protocol. These 2 (4%) patients were prepared for surgery either by transcranial or endoscopic approach.
All patients' baseline and bleeding profiles were monitored. In all patients, CT brain plain was performed before the operation. In all patients, comorbidities were dealt with after consulting with the medical department.
In our study, the main complications were headaches, meningitis, and seizures. Meningitis occurred in 3 (6%) patients. Seizures occurred in 1 (2%) patient. Headache occurred in 1 (2%) patient. We did complete a CSF examination to rule out infection. All 3 (6%) patients had bacterial meningitis. We gave vancomycin and meropenem to treat the infection and all 3 (6%) patients recovered from meningitis. For headaches, we have pain killers and for seizures gave sodium valproic acid.
Patients were given antibiotics, antiepileptics, pain killers, mannitol, acetazolamide, and antiemetic. The follow-up period was 14 days through OPD. According to Ratilal et al. antibiotics prophylaxis should be given to prevent meningitis. 20 DeConde et al. described the management of CSF rhinorrhea. 21

Limitations
Patients come from remote areas in PINS. So, they present late and there is less compliance with treatment in the community.

CONCLUSION
In our study, 96% of cases of CSF rhinorrhea are resolved by conservative management. Most cases of CSF rhinorrhea are resolved by conservative management.
Conservative management has the advantages of good outcomes, lesser hospital stays, and fewer complications as compared to surgery.