Cerebrospinal fluid (CSF) rhinorrhea is an abnormal communication between the subarachnoid space and the nasal cavity resulting from disruption of the anatomical barriers separating these compartments, including the dura mater, skull base, and sinonasal mucosa [1,2]. It typically presents as clear, watery, unilateral nasal discharge, which may be exacerbated by stooping or performing a Valsalva maneuver. Associated symptoms may include headache, particularly in patients with intracranial hypotension. CSF rhinorrhea may occur following trauma, paranasal sinus or cranial surgery, or spontaneously [2,3]. Spontaneous CSF leaks are particularly associated with middle-aged females and conditions involving elevated intracranial pressure [3]. The cribriform plate of the ethmoid bone represents a vulnerable site for CSF leakage because of its anatomical relationship with the anterior cranial fossa and nasal cavity. Traumatic disruption of the skull base may result in persistent communication between the intracranial and sinonasal compartments [1,2]. Accurate identification of the leak site is essential for appropriate surgical planning. Although clinical examination may occasionally demonstrate an encephalocele or the site of leakage, findings are frequently inconclusive. Biochemical analysis of nasal secretions, particularly beta-2 transferrin testing, is an important diagnostic tool for confirming the presence of CSF [4,5]. High-resolution computed tomography (HRCT) and magnetic resonance imaging (MRI), including cisternographic techniques, assist in identifying skull base defects and demonstrating the communication between the subarachnoid space and nasal cavity [6,7]. The management of CSF rhinorrhea aims to achieve complete and durable separation of the subarachnoid space from the nasal cavity. Persistent leakage carries a risk of ascending intracranial infection, including meningitis, making timely diagnosis and treatment essential [1,8]. Endoscopic endonasal repair has become an established surgical approach because it provides direct visualization of the defect while avoiding the morbidity associated with traditional open procedures [9,10]. Multilayer reconstruction using autologous fat, fascia lata, and vascularized flaps, such as the Hadad nasoseptal flap, provides effective closure and supports satisfactory healing [11,12]. The present case describes the diagnosis and successful endoscopic repair of post-traumatic CSF rhinorrhea arising from a defect in the left cribriform plate, managed using a multilayer reconstruction technique with satisfactory postoperative outcomes.

A 40-year-old female presented to the Department of Otorhinolaryngology with a six-month history of left-sided nasal discharge. The discharge was clear, watery, and non-foul-smelling and was associated with headache. The patient reported a history of facial trauma approximately six months prior to presentation. On clinical examination, a left-sided deviated nasal septum was noted. A sample of the nasal discharge was collected in a sterile container and sent for biochemical analysis. The sample tested positive for beta-2 transferrin, supporting the diagnosis of cerebrospinal fluid (CSF) rhinorrhea. Further radiological evaluation was performed using computed tomography (CT) of the paranasal sinuses with cisternography. Imaging demonstrated a defect in the midportion of the left cribriform plate, adjacent to the medial wall of the left middle ethmoid sinus. The defect measured approximately 0.7 cm in the transverse dimension and 1.4 cm in the anteroposterior dimension. Cisternographic images demonstrated the extension of opacified subarachnoid CSF through the defect in the left cribriform plate into the left nasal cavity, confirming the site of the CSF leak. Based on the clinical presentation, biochemical findings, and radiological evidence, a diagnosis of CSF rhinorrhea secondary to a left cribriform plate defect was established. The patient was subsequently planned for endoscopic endonasal repair of the CSF leak. Surgical Management The patient underwent endoscopic endonasal repair of the CSF leak under general anesthesia. A fascia lata graft and an autologous fat graft were harvested for reconstruction. A Hadad nasoseptal flap was raised to provide vascularized coverage of the repair site. The meningocele was cauterized using bipolar cautery, and the surrounding area was prepared by making the margins raw to facilitate graft adherence. The fat graft was placed over the leak site and secured using fibrin glue. Subsequently, the fascia lata graft was positioned over the fat graft and fixed with fibrin glue. The Hadad flap was then placed over the fascia lata graft to provide vascularized coverage. Surgicel was placed over the reconstructed area and secured using fibrin glue. Gel foam was subsequently applied, followed by nasal packing. The nasal pack was removed on the second postoperative day. Postoperative Course and Follow-up The patient tolerated the procedure well and had an uneventful postoperative course, with no reported postoperative complications. Regular postoperative diagnostic nasal endoscopy was performed during follow-up. Endoscopic examinations at the third and sixth postoperative months demonstrated complete closure of the CSF leak site and satisfactory healing of the reconstructed area. The patient responded well to the surgical intervention, with no evidence of persistent CSF rhinorrhea during the reported follow-up period. Figure 1: Intra operative image of the defect Figure 2: CT Cisterography showing defect Figure 3: Fascia lata graft and fat Figure 4: Fascia lata graft placed over the defect Figure 5: Surgicel kept over the graft Figure 6: Post operative Nasal Endoscopy

Cerebrospinal fluid rhinorrhea represents a clinically significant condition resulting from an abnormal communication between the intracranial subarachnoid space and the nasal cavity. The condition may occur following trauma and is commonly associated with defects involving the anterior skull base. Persistent CSF leakage is clinically important because of the potential risk of ascending intracranial infection, including meningitis [1,2]. In the present case, the patient developed persistent unilateral watery nasal discharge following facial trauma. The clinical presentation, together with the positive beta-2 transferrin test, supported the diagnosis of CSF rhinorrhea. Beta-2 transferrin testing is widely regarded as a reliable biochemical method for confirming the presence of CSF in nasal secretions [4,5]. Radiological evaluation using CT cisternography demonstrated a defect in the left cribriform plate with communication between the subarachnoid space and the nasal cavity. Accurate localization of the defect is an important component of surgical planning. Previous studies have emphasized the complementary roles of HRCT and MRI-based cisternography in the identification and localization of CSF leaks [6,7]. Endoscopic endonasal repair has become an important treatment modality for CSF rhinorrhea. Systematic reviews and large clinical series have demonstrated high rates of successful closure with relatively low morbidity [8,9,12]. The endoscopic approach allows direct visualization of the skull base defect and facilitates reconstruction using autologous grafts and vascularized tissue. In the present case, a multilayer reconstruction technique was employed using a fat graft, fascia lata graft, and Hadad flap. The fat graft was used to plug the leak, while the fascia lata graft provided additional coverage. The Hadad flap was used as vascularized coverage over the reconstructed area. The use of multilayer reconstruction is supported by clinical studies describing successful repair using combinations of fat, fascia lata, mucosal grafts, and fibrin sealants [10,11]. The Hadad-Bassagasteguy flap provides vascularized tissue for skull base reconstruction and has been described as an important reconstructive option in endoscopic skull base surgery [13,14]. The satisfactory postoperative course and endoscopic findings at the third and sixth months demonstrated successful healing in this patient. Clinical studies have emphasized the importance of follow-up after endoscopic repair to identify persistent or recurrent leakage [9,12,15]. This case emphasizes the importance of recognizing persistent unilateral watery nasal discharge following trauma as a potential manifestation of CSF rhinorrhea. Appropriate biochemical confirmation, radiological localization, and timely surgical management are essential components of effective treatment [3,4,8].

Endoscopic repair is an effective surgical approach for the management of cerebrospinal fluid rhinorrhea associated with skull base defects. In the present case, a defect in the left cribriform plate was successfully repaired using a multilayer reconstruction technique involving a fat graft, fascia lata graft, and Hadad flap. Complete closure of the CSF leak was achieved, and postoperative endoscopic evaluation demonstrated satisfactory healing at the third and sixth months. This case highlights the importance of early diagnosis, accurate localization of the defect, and appropriate surgical intervention in achieving successful outcomes in patients with CSF rhinorrhea.

1. Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope. 2004;114(2):255-65. doi:10.1097/00005537-200402000-00015. 2. Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB. Non-traumatic cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry. 1968;31(3):214-25. doi:10.1136/jnnp.31.3.214. 3. Gonen L, Monteiro E, Klironomos G, Alghonaim Y, Vescan A, Zadeh G, et al. Endoscopic endonasal repair of spontaneous and traumatic cerebrospinal fluid rhinorrhea: a review and local experience. Neurosurg Clin N Am. 2015;26(3):333-48. doi:10.1016/j.nec.2015.03.003. 4. Georgalas C, Oostra A, Ahmed S, Castelnuovo P, Dallan I, van Furth W, et al. International consensus statement: spontaneous cerebrospinal fluid rhinorrhea. Int Forum Allergy Rhinol. 2021;11(4):794-803. doi:10.1002/alr.22704. 5. Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World J Surg. 2001;25(8):1062-6. 6. Yadav YR, Parihar V, Janakiram N, Pande S, Bajaj J, Namdev H. Endoscopic management of cerebrospinal fluid rhinorrhea. Asian J Neurosurg. 2016;11(3):183-93. doi:10.4103/1793-5482.145101. 7. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2016;6(1):8-16. doi:10.1002/alr.21637. 8. Nandapalan V, Watson ID, Swift AC. Beta-2-transferrin and cerebrospinal fluid rhinorrhoea. Clin Otolaryngol Allied Sci. 1996;21(3):259-64. doi:10.1111/j.1365-2273.1996.tb01737.x. 9. Xie M, Zhou K, Kachra S, McHugh T, Sommer DD. Diagnosis and localization of cerebrospinal fluid rhinorrhea: a systematic review. Am J Rhinol Allergy. 2022;36(3):397-406. doi:10.1177/19458924211060918. 10. Oakley GM, Orlandi RR, Woodworth BA, Batra PS, Alt JA. Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2016;6(1):17-24. doi:10.1002/alr.21627. 11. Schlosser RJ, Bolger WE. Endoscopic management of cerebrospinal fluid leaks. Otolaryngol Clin North Am. 2006;39(3):569-83. 12. Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg. 2012;147(2):196-203. doi:10.1177/0194599812451090. 13. Banks CA, Palmer JN, Chiu AG, O'Malley BW Jr, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg. 2009;140(6):826-33. doi:10.1016/j.otohns.2008.12.060. 14. Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000;110(7):1166-72. 15. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882-6. doi:10.1097/01.mlg.0000234933.37779.e4.