A leak of cerebrospinal fluid (CSF) can occur from head trauma, after surgeries around the brain, sinuses, ear or skull, and from procedures such as a spinal tap or lumbar puncture. CSF leaks can occur spontaneously as well. Because this fluid that surrounds the brain and spinal cord is under pressure—the body is constantly making new CSF—it will leak until it is stopped by a medical procedure.
Many times, there are no symptoms. But the most common symptom is a watery drainage from the nose (most commonly on one side) or a salty taste from CSF leaking in the back of the throat. Some patients may develop meningitis (infection around the brain) from bacteria that can get from the nose into the brain or go from the nose into the ear, and from there into the brain. If the ear is the source of the CSF leak, the fluid moves behind the ear drum, down the Eustachian tube to the back of the nose (nasopharynx) and into the back of the throat. If the leak accumulates behind the ear drum and a tube is placed in the ear drum, it can lead to a persistent leakage of spinal fluid through the tube.
A CSF leak is a channel for bacteria to get to the brain or spinal cord and cause a life-threatening infection.
There are four main categories of patients who develop CSF leaks:
This is done by performing a scan, most commonly a CT or MRI. Sometimes, these studies have to be performed with contrast agent injected into the cerebral spinal fluid space. This allows the specialist to see where the contrast material leaks. This is more useful for the sinuses than for the ear, where leaks tend to be slower and may not show up in these studies. Another type of study involves the injection of a radionuclide into the cerebral spinal space and an absorbent material is placed at the back of the nose. After a few hours, the absorbent material is removed and tested.
Finally, if fluid can be collected, it is tested for beta-2-transferrin, a protein unique to CSF.
Most sources of CSF leakage around the ear and sinuses can be repaired with minimally invasive approaches using microscopes or endoscopes. Sometimes, a craniotomy (opening of the skull) is performed in conjunction with a neurosurgeon. If the leak occurs immediately after surgery, the treatment of choice is to place a lumbar drain into the spinal fluid space in the lower back, which will slowly remove fluid. The drain is usually in place for three to five days. Reducing the spinal fluid pressure and pressure on the area of the surgery (using packing or a dressing) is often enough to stop a leakage right after surgery.
CSF leaks that persist long after surgery or are spontaneous require surgery to repair the source of the leak.
Treatment for leaks around the ear depend on the location of the leak’s source and the patient's medical status.
View a video of this procedure below. Please note that images in this surgical video may be too graphic for some viewers.
The best treatment for CSF leaks around the sinuses is with an endoscope. The area of the leak may need to be identified by injecting a dye (fluorescin) into the spinal fluid. A special filter is used to see the green color of the leak in the nose. A variety of flaps can be created to plug the leakage spot. Sometimes, a lumbar drain is placed to improve the chances of stopping the leak.
Dr. Hamid Djalilian is one of a few U.S. surgeons with extensive experience treating spontaneous CSF leaks around the ear. He is in the process of publishing the results of nearly a decade of minimally invasive surgical treatments for this condition. Our skull base team also has extensive experience with leaks after surgeries to treat skull-base tumors, which requires tight closure of the spinal fluid spaces to prevent CSF leakage.
To make an appointment with Dr. Hamid Djalilian or Dr. Harrison Lin, our experts in the treatment of CSF leaks around the ear, or with Dr. Naveen Bhandarkar, our expert in the treatment of sinus CSF leaks, please call 714-456-7017 or click here to request an appointment online.