Spontaneous cerebrospinal fluid rhinorrhea: results from a management algorithm integrating intracranial pressure assessment and endoscopic endonasal repair

Abstract Background Spontaneous cerebrospinal fluid (CSF) rhinorrhea has emerged as a distinct clinical entity closely linked to idiopathic intracranial hypertension (IIH). The absence of a clear traumatic etiology frequently results in delayed recognition and exposes patients to potentially life-threatening complications, particularly meningitis. Endoscopic endonasal repair is now widely regarded as the gold standard for management; nevertheless, optimal surgical strategies remain debated, especially in the context of persistently elevated intracranial pressure. Growing evidence suggests that failure to identify and address underlying pressure abnormalities may predispose recurrence. Therefore, adopting a protocol-based approach that combines meticulous skull base reconstruction with systematic evaluation of intracranial pressure may be essential for achieving durable repair and improving patient outcomes. Results This study included 17 females (85%) and 3 males (15%), with a mean age of 41.75 ± 6.88 years and mean BMI of 35.35 ± 2.56 kg/m 2 . The most common defect sites were the cribriform plate of ethmoid (55%), Ethmoid sinus (25%), sphenoid sinus (20%). Radiological evidence of empty sella was found in 15 patients (75%), and 8 patients had transverse sinus stenosis (TSS) (40%). Intraoperative CSF opening pressure through lumbar puncture (LP) exceeded 20 cmH 2 O in 13 patients (65%) from which 9 underwent lumboperitoneal shunt and 4 underwent ventriculoperitoneal shunt, CSF diversion was not required in 7 patients (35%). Defect size was 5 mm in 8 patients (40%). Onlay closure alone was used in 12 patients (60%), and combined onlay-underlay closure in 8 (40%). The overall success rate, defined as complete stoppage of CSF leak throughout follow-up period, was 90% (18/20). Two patients (10%) developed recurrent CSF leak. Postoperative complications occurred in 2 patients (10%) (epistaxis in 1 and tension pneumocephalus in 1), with no mortality. The median hospital stay was 2 days. Conclusion Endoscopic endonasal multilayer skull base reconstruction provides a high success rate in the management of spontaneous CSF rhinorrhea when combined with careful defect repair and attention to intracranial pressure status.