On the other hand, the disadvantages include anosmia, retraction-related brain injury and longer hospital stay. Another advantage is that it is possible to repair the leakage site even if the ICP is high due to severe brain injury. The advantage of intracranial approach is that the operation field is widely exposed, hence, it is convenient to repair multiple defect of CSF leakage. In general, if the leakage site is involved in the anterior fossa, then the anterior fossa craniotomy is carried out via bicoronal incision while the subtemporal craniotomy is considered in the CSF leakage of middle fossa. The indications of intracranial repair of CSF leakage are as follows: 1) accompanied craniofacial injuries 2) a large bone defect which cannot be solved by the endoscopic repair method only and 3) in a situation where the leaking fistula site is not obvious via endoscopic examination. Early detection of CSF leak will be critical for the patient in order to prevent possible bacterial meningitis and intracranial abscess formation. High-pressure type is a symptom in which headache continues to increase and relived when CSF was drained out. The headache could be classified as a high pressure type and low pressure type. Most patients of the CSF leakage complained of headache. There may also be a ‘Reservoir sign’ in which the CSF goes out when taking a head up position in the lying position. Patients may experience a salty taste or may have ear fullness or hearing loss. Furthermore, other otolaryngeal diseases must be differentiated such as allergic rhinitis or vasomotor rhinitis prior to the diagnosis of CSF leak. The clear and non-mucoid fluid drainage from nose and ear can be presented with mixed nature of bleeding, however, this can be further tested for a ‘double-ring’ or ‘halo’ sign on a filter paper. 14) If the patient is alert, a complaint of the salty postnasal drip is presented. The most common clinical symptom is the leak of clear and watery drainage from the nose and ear with a positional dependency. The decision of whether to observe or to surgically intervene is most likely to be dependent on the cause, site of leak, and timing of the leak. Thus, early detection of CSF leaks is important as it determines the outcome of the patient. 12) The traditional treatment involves intravenous antibiotics treatment as well as primary repair of dural defect if the definite injury is suspected. Except the cases with spontaneous diseases, traumatic CSF leak can be potentially detrimental with various complications such as bacterial meningitis if not self-resolved. 22 28) The risk of meningitis from the traumatic CSF leak can present with high morbidity and even mortality depending on the cause and site of CSF leak. Post-traumatic CSF leaks are seen 1% to 3% of all closed traumatic brain injuries (TBI) in adults and 80% to 90% of all the causes of CSF leaks in adult patients are due to head injuries. After severe craniomaxillofacial trauma, the destruction of the meningeal structure may lead to the CSF leak from the subarachnoid space. It is produced at choroid plexus and a total volume of 140 mL are actively circulating and turned over daily. Cerebrospinal fluid (CSF) is a physiologic fluid for protecting brain and maintaining intracranial pressure (ICP).
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