CSF Rhinorrhea

Flora^1*, Subathra Devi. M², Maha Lakshmi³

¹Assistant Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator , Kauvery Hospital, Cantonment., Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery Hospital, Cantonment., Trichy, Tamil Nadu

*Correspondence

Abstract

Cerebrospinal fluid (CSF) rhinorrhoea is the leakage of cerebrospinal fluid through the nose due to a defect in the skull base and dura mater. It may occur following trauma, surgery, congenital abnormalities, or spontaneously. Early recognition is essential because untreated CSF rhinorrhoea increases the risk of serious complications such as meningitis, brain abscess, and pneumocephalus. Nurses play a vital role in the early identification of symptoms, ongoing neurological assessment, infection prevention, patient education, and postoperative care. This article reviews the causes, clinical features, diagnostic methods, treatment options, and evidence-based nursing management of a 31-year male patient, who came with C/O CSF rhinorrhoeas

Key words: Cerebrospinal fluid (CSF); Rhinorrhoea; Meningitis

Introduction

Cerebrospinal fluid (CSF) rhinorrhoea is the abnormal leakage of cerebrospinal fluid through the nasal cavity due to a defect in the skull base and the surrounding meningeal layers. Although relatively uncommon, it is a clinically significant condition because it creates direct communication between the intra cranial cavity and the external environment, increasing the risk of life-threatening infections such as meningitis. CSF rhinorrhoea may result from traumatic injuries, skull base fractures, neuro surgical procedures, tumors, congenital defects, or spontaneous causes associated with elevated intracranial pressure. Patients typically present with clear, watery nasal discharge that is often unilateral and increases with bending forward, coughing, or straining.

Case presentation

A patient presented with history of old RTA with severe head injury, bilateral frontal parietal depressed skull fracture, bilateral ZMC fracture, frontal, nasal & zygoma fracture, bilateral temporal contusion – right thin frontal SDH (07.04.2026 to 15.04.2026), S/P open reduction and internal fixation for bilateral ZMC fracture on 09.04.2026: who came with complaints of CSF rhinorrhoea – right side on 24.04.2026.

Social History: Nil

Allergies: Nil , Co- morbidities= Nil

Past Medical History: Nil

Past Surgical history

Open reduction and internal fixation for bilateral ZMC fracture on 09.04.2026,
BI coronal craniotomy and anterior skull base repair, cranialization of frontal sinus, vascularized flap placement and mesh fixation on 01.05.2026

Physical Examination

Temp	101°F,
PR	72/min
BP	110/70 mmHg
SpO2	98% in room air
CVS	S1S2 (+)
RS	BAE (+)
P/A	Soft
CNS: GCS	E4 V5 M6
Moving all four limbs

Relevant Investigation

Multislice CT scan Cisternogram – Report (20.05.2026)

Multiple facial bone fracture with postoperative changes with internal fixation in situ with large bony defect in the floor of anterior cranial fossa on left side directly communicating with ethmoid air cells.
To consider CSF rhinorrhoea due to bony defect in the anterior cranial fossa on the left side near the mid-line.

Relevant Investigations

1	Procalcitonin	0.13 ng/mL
2	Glucose (POCT)	114 mg/dL
3	Glucose (POCT)	117 mg/dL
4	CSF - Protein	36.06 mg/dL
5	CSF - Sugar	52 mg/dL
6	CSF Total WBC	2 Cells/Cumm
7	Total WBC Count	13920 Cells/Cumm
8	Platelet Count	322000 cells/µl
9	C Reactive Protein (CRP)	56.0 mg/L

Diagnosis

Medical and Surgical Management

Consultant, ENT advised Endoscopic CSF leak repair after neuro clearance.

After getting anaesthetist’s fitness and informed consent he underwent Endoscopic trans nasal CSF leak repair under GA + LP drain done under General anesthesia on 23.05.2026, sample sent for analysis. Post procedure uneventful. Serial CSF monitoring was done in the post-operative period which was within normal limits. Graded sitting and then ambulation done. He was treated with anticonvulsants, antibiotics, analgesic, PPI and other supportive measures.

LP drain removed and skin defect closed with skin clips. Clip removed, Tolerated oral diet, self-voiding. He improves symptomatically, no CSF or discharge from nose and no fever.

Outcome

Dental surgeon opinion obtained for malocclusion and advised no malocclusion and oral care.. Post operatively, during bed rest no CSF leak, afebrile, headache decreased.

Physio: graded sittings were started up to 90 degree, no CSF leak confirmed. After ambulation was started, no CSF leak was confirmed.. Dressing changes and operating wounds healthy, Flap relaxed. Tolerated oral diet, self-voiding

Nursing Management

Nursing care focuses on preventing infection, monitoring neurological status, minimizing cerebrospinal fluid leakage, and promoting patient recovery.

Assessment

Monitored vital signs and neurological status regularly.
Assessed the characteristics of nasal discharge (clear, watery, unilateral, continuous or intermittent).
Observed for signs of meningitis such as fever, neck stiffness, severe headache, altered mental status, or photophobia.
Monitored for increased intracranial pressure, including changes in level of consciousness, vomiting, or pupillary abnormalities.
Maintained the head of the bed elevated at 30–45 degrees unless contraindicated.
Instructed the patient to avoid coughing, sneezing, nose blowing, bending forward, heavy lifting, and straining during bowel movements, administered stool softeners as prescribed to prevent straining

Infection Prevention

Performed strict hand hygiene and maintained aseptic technique during all procedures.
Avoided inserting nasogastric tubes or nasal suction unless specifically ordered.

Medication Management

Administered prescribed analgesics, antibiotics, or other medications as ordered.
Ensured adequate pain control while avoiding excessive sedation that may mask neurological changes.

Postoperative Care

Monitored the surgical site for bleeding or recurrent CSF leakage.
Neurological assessments hourly monitored
Observed for complications such as meningitis, recurrent leak, or increased intracranial pressure.

Patient and Family Education

Explained the condition, treatment plan, and importance of adhering to activity restrictions.
Teached the patient and attendant to report persistent clear nasal discharge, fever, severe headache, or changes in vision or consciousness immediately.

Discharge medications

S.No	Drug Name	Strength
1	T. Pan	40 mg
2	T. Para	1 g
3	T. Gardenal	60 mg
4	T. Topirol	25 mg
5	T. Zerodal	100 Mg
6	T. Diamox	250 mg
7	T. Silodal	8 mg
8	Syp. Cremaffin plus	15 mL

Discussion

The patient had persistent CSF leakage through the nose, requiring repeated monitoring, ENT evaluation, lumbar puncture/drain and further CSF leak repair. This resulted in prolonged treatment, restricted mobility and discomfort to the patient. However, after the final procedure, the patient improved, with no further nasal discharge or fever, and was able to eat and walk normally

Conclusion

CSF rhinorrhea is a potentially serious condition that requires early recognition and prompt management to prevent complications such as meningitis and other intracranial infections. Accurate assessment, timely diagnosis, and appropriate medical or surgical treatment are essential for successful outcomes. Nurses play a pivotal role in identifying early signs of CSF leakage, monitoring neurological status, implementing infection prevention measures, providing postoperative care, and educating patients and their families. A multidisciplinary approach combined with evidence-based nursing practice can reduce complications, promote healing, and improve patient safety and quality of care. Continuous nursing vigilance and patient education remain fundamental to achieving optimal clinical outcomes.

CSF Rhinorrhea

CSF Rhinorrhea

Flora1*, Subathra Devi. M2, Maha Lakshmi3

Nightingale Journals

Flora^1*, Subathra Devi. M², Maha Lakshmi³