Ethmoidal cerebrospinal fluid fistula: a systematic review
DOI:
https://doi.org/10.14409/sigme.2025.4.e0022Keywords:
Trauma, Iatrogenic injury, Complications, Ethmoid bone, Cerebrospinal fluid leakAbstract
Ethmoidal cerebrospinal fluid leak (CSF leak) refers to an abnormal communication between the subarachnoid space and the nasal cavity, allowing direct exposure to the external environment and resulting in a significant risk for serious complications such as meningitis. Multiple etiologies, including traumatic and iatrogenic causes, have been associated with this condition. Diagnosis and management remain challenging for clinicians due to its variable presentation and the lack of standardized treatment protocols. This systematic review aims to describe the main etiologies and therapeutic strategies for ethmoidal CSF leaks. A literature search was conducted in major indexed databases for the period between 2000 to 2023. Seventeen full-text studies were included, all reporting on leak location and surgical techniques. Traumatic causes were the most frequently reported (64%), with transcranial surgical approaches being the predominant treatment modality. Due to heterogeneity in study designs and outcomes, a comparative analysis regarding success rates and complications could not be performed. Despite the increasing adoption of endoscopic techniques, there is still no consensus on standardized therapeutic protocols, and high-quality comparative data are lacking. Further prospective research is needed to establish evidence-based management guidelines
References
Abarca, A., Pardo, J., Lemp, M., & Stott, C. (2010). Reparación endoscópica endonasal de fístulas de líquido cefalorraquídeo no quirúrgicas: experiencia Hospital Clínico Universidad de Chile. Revista de Otorrinolaringología y Cirugía de Cabeza y Cuello, 70(3), 205–214. https://doi.org/10.4067/s0718-48162010000300003
Ahsan Aurangzeb, Ahmed, E., Shahbaz Ali Khan, Ali, A., Adil Ihsan, & Mehmood, S. (2012). Outcome of transcranial repair of traumatic CSF rhinorrhea. PubMed, 24(2), 47–49.
Alobid, I., Enseñat, J., Rioja, E., Enriquez, K., Viscovich, L., de Notaris, M., & Bernal-Sprekelsen, M. (2014). Manejo de las fístulas nasales de líquido cefalorraquídeo según su tamaño. Nuestra experiencia. Acta Otorrinolaringológica Española, 65(3), 162–169. https://doi.org/10.1016/j.otorri.2013.12.003
Basso, A., Acuña, M., Socolovsky, M., Carrizo, A. G., & Funes, P. T. (2023). Neurocirugía. Corpus Libros.
Bernal-Sprekelsen, M., Bleda-Vázquez, C., & Carrau, R. L. (2000). Ascending meningitis secondary to traumatic cerebrospinal fluid leaks. American Journal of Rhinology, 14(4), 257–259. https://doi.org/10.2500/105065800779954473
Bigar, P., et al. (2024). Cisternografía con contraste intratecal para el manejo de las fístulas de LCR. Revista Argentina de Neurocirugía. https://aanc.org.ar/ranc/items/show/387
Brodie, H. A. (1997). Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae: A meta-analysis. Archives of Otolaryngology - Head and Neck Surgery, 123(7), 749–752. https://doi.org/10.1001/archotol.1997.01900070093016
Meco, C., Oberascher, G., Arrer, E., Moser, G., & Albegger, K. (2003). β‐Trace protein test: New guidelines for the reliable diagnosis of cerebrospinal fluid fistula. Otolaryngology, 129(5), 508–517. https://doi.org/10.1016/S0194-5998(03)01448-7
Charry, J. D., Cáceres, J. F., Salazar, A. C., López, L. P., & Solano, J. P. (2019). Trauma craneoencefálico. Revisión de la literatura. Revista Chilena de Neurocirugía, 43(2), 177–182. https://doi.org/10.36593/rev.chil.neurocir.v43i2.82
Crespo Escudero, P., Pérez Sáez, J., Clemente García, A., & Calle Cabanillas, M. I. (2019). Uso de la fluoresceína intratecal para localización de pequeñas fístulas de LCR. Revista ORL, 10(5), 2–19. https://doi.org/10.14201/orl.20629
Eljamel, M. S. (1994). Fractures of the middle third of the face and cerebrospinal fluid rhinorrhoea. British Journal of Neurosurgery, 8(3), 289–293. https://doi.org/10.3109/02688699409029616
Fiore, G., Bertani, G. A., Carrabba, G. G., Guastella, C., Marfia, G., Tariciotti, L., Gribaudi, G. L., Mantovani, G., Di Cristofori, A., & Locatelli, M. (2021). The “Parachute” technique for the endoscopic repair of high-flow anterior skull-base CSF leaks. World Neurosurgery, 151, e880–e887. https://doi.org/10.1016/j.wneu.2021.05.006
Fraser, S., Gardner, P. A., Koutourousiou, M., Kubik, M., Fernandez-Miranda, J. C., Snyderman, C. H., & Wang, E. W. (2018). Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. Journal of Neurosurgery, 128(4), 1066–1071. https://doi.org/10.3171/2016.12.jns1694
Friedman, J. A., Ebersold, M. J., & Quast, L. M. (2001). Post-traumatic cerebrospinal fluid leakage. World Journal of Surgery, 25(8), 1062–1066. https://doi.org/10.1007/s00268-001-0059-7
Gómez Hermosilla, O., Alarcón Peralta, L., & Ortiz Bogado, J. (2013). Abordaje endoscópico endonasal de fístulas de líquido cefalorraquídeo: nuestra experiencia. Cirugía Paraguaya, 37(2), 17–21. http://scielo.iics.una.py/scielo.php?script=sci_arttext&pid=S2307-04202013000200005
Hirayama, A., Komatsu, F., Hotta, K., Imai, M., Oda, S., Shimoda, M., & Matsumae, M. (2016). Endoscopic endonasal repair of cerebrospinal fluid leakage caused by a rare traumatic clival fracture. Neurologia Medico-Chirurgica, 56(2), 81–84. https://doi.org/10.2176/nmc.cr.2015-0152
Jaume, A., Salle, F., Devita, A., Martínez, F., & Sgarbi, N. (2015). Fístula de líquido cefalorraquídeo postraumática: propuesta de algoritmo diagnóstico y terapéutico. Archivos de Medicina Interna, 37(1), 47–52. http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-423X2015000100009
Jones, V., Virgin, F., Riley, K., & Woodworth, B. A. (2012). Changing paradigms in frontal sinus cerebrospinal fluid leak repair. International Forum of Allergy & Rhinology, 2(3), 227–232. https://doi.org/10.1002/alr.21019
Lanza, D. C., O’Brien, D. P., & Kennedy, D. N. (1996). Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. The Laryngoscope, 106(9), 1119–1125. https://doi.org/10.1097/00005537-199609000-00015
Liao, K.-H., et al. (2016). Risk of death in patients with post-traumatic cerebrospinal fluid leakage—Analysis of 1773 cases. Journal of the Chinese Medical Association, 79(2), 58–64. https://doi.org/10.1016/j.jcma.2015.10.002
Liezel Ulloque Caamaño, et al. (2023). Fístula nasal de líquido cefalorraquídeo post-traumática. Revista Argentina de Neurocirugía, 37(2). https://doi.org/10.59156/revista.v37i02.495
Machín, M., et al. (2014). Fístula de líquido cefalorraquídeo: una rara complicación secundaria a una miasis naso-etmoidal. Revista Chilena de Neurocirugía, 40, 122–124. https://www.neurocirugiachile.org/pdfrevista/v40_n2_2014/ortiz_p122_v40n2_2014.pdf
Martínez-Ruiz-Coello, M. del M., et al. (2022). Fístula de líquido cefalorraquídeo traumática tras test PCR nasal. Revista ORL, 13(1), e27908. https://doi.org/10.14201/orl.27908
Piek, J. (2000). Surgical treatment of complex traumatic frontobasal lesions: Experience in 74 patients. Neurosurgical Focus, 9(1), 1–6. https://doi.org/10.3171/foc.2000.9.1.2
Ramón Moreno-Luna, et al. (2022). Utilidad de los colgajos e injertos endonasales en cirugía endoscópica nasosinusal. Acta Otorrinolaringológica Española, 73(5), 323–335. https://doi.org/10.1016/j.otorri.2021.02.005
Rocchi, G., et al. (2005). Severe craniofacial fractures with CSF fistula: Indications for repair. Surgical Neurology, 63(6), 559–563. https://doi.org/10.1016/j.surneu.2004.07.047
Rouvière, H., & Delmas, A. (2005). Anatomía humana: Descriptiva, topográfica y funcional (11.ª ed., Vol. 1). Masson.
Samsara López Hernández, et al. (2024). Spontaneous CSF fistula and idiopathic intracranial hypertension. Neurocirugía (English Edition), 35(2), 57–63. https://doi.org/10.1016/j.neucie.2023.02.002
Sánchez, J. A., Velázquez, A. M., & Santana, H. V. (2012). Manejo integral de fístulas de líquido cefalorraquídeo.
Schlosser, R. J., & Bolger, W. E. (2004). Nasal cerebrospinal fluid leaks: Critical review and surgical considerations. The Laryngoscope, 114(2), 255–265. https://doi.org/10.1097/00005537-200402000-00015
Scholsem, M., et al. (2008). Management of anterior cranial base fractures with CSF fistulae. Neurosurgery, 62(2), 463–471. https://doi.org/10.1227/01.neu.0000316014.97926.82
Sherif, C., et al. (2011). Algorithm for CSF leak associated with anterior skull base fractures. Neurosurgical Review, 35(2), 227–238. https://doi.org/10.1007/s10143-011-0352-3
Shi, J.-B., et al. (2010). Frontal sinus CSF leaks: Repair in 15 patients. ORL, 72(1), 56–62. https://doi.org/10.1159/000275675
Umana, G. E., et al. (2022). Cerebrospinal fluid leaks after anterior skull base trauma: A systematic review. World Neurosurgery, 157, 193–206.e2. https://doi.org/10.1016/j.wneu.2021.10.065
Yilmazlar, S., et al. (2005). CSF leakage complicating skull base fractures: Analysis of 81 cases. Neurosurgical Review, 29(1), 64–71. https://doi.org/10.1007/s10143-005-0396-3
Zhang, F., et al. (2021). Treatment of traumatic CSF rhinorrhea via extended extradural anterior skull base approach. Chinese Journal of Traumatology. https://doi.org/10.1016/j.cjtee.2021.06.002
Zlab, M. K., et al. (1992). Cerebrospinal fluid rhinorrhea: A review. Ear, Nose & Throat Journal, 71(7), 314–317. https://doi.org/10.1177/014556139207100707
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Laura Soledad Degiorgio, Luis Eloy Morales, Guillermo Daniel Román
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
