TREATMENT OF CSF RHINORRHEA Early cases of post-traumatic CSF rhinorrhoea can be managed by conservative measures such as bed rest, elevating the head of the bed, stool softeners, and avoidance of nose blowing, sneezing and straining. Prophylactic antibiotics can be used to prevent meningitis. Acetazolamide decreases CSF formation. These measures can be combined with lumbar drain if indicated. Surgical repair can be done by the following: 1. Neurosurgical intracranial approach. 2. Extradural approaches such as external ethmoidectomy for cribriform plate and ethmoid area, trans-septal sphenoidal approach for sphenoid and osteoplastic flap approach for frontal sinus leak. 3. Transnasal endoscopic approach. With the advent of endoscopic surgery for nose and sinuses, most of the leaks from the anterior cranial fossa and sphenoid sinus can be managed endoscopically with a success rate of 90% with first attempt. Principles of repair include: (a) Defining the sites of bony areas . It can be (i) Cribriform plate (ii) Lateral lamina close to anterior ethmoid aery (iii) Roof of ethmoid (iv) Frontal sinus leak (v) Sphenoid sinus (b) Preparation of graft site. (c) Underlay grafting of the fascia extradurally followed by placement of mucosa (as a free graft or pedicled flap) (d) If bony defect is larger than 2 cm, it is repaired with cailage (from nasal septum or auricular concha) followed by placement of mucosa. (e) Placement of surgicel and gelfoam fuher strengthens the area. This is followed by a high antibiotic smeared nasal pack. Sometimes fat from the thigh or abdomen is used to plug the defect in place of fascia graft. (f) Lumbar drain if CSF pressure is high. (g) Antibiotics CSF leak from frontal sinus often requires osteoplastic flap, operation and obliteration of the sinus with fat. Ref : ENT textbook by Dhingra 6th edition Pgno : 163-165