A 37-year-old female presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea. Diagnostic imaging with CT cisternography revealed a 7 × 2.5 mm bony defect in the cribriform plate, consistent with an anterior skull base leak. There was no history of recent trauma, although the patient reported a road traffic accident 17 years prior. On preoperative assessment, dark red nail polish was noted, which may interfere with pulse oximetry readings. An alternative site for oxygen saturation monitoring was considered.

Anesthesia was induced with intravenous glycopyrrolate 0.2 mg, midazolam 1 mg, fentanyl 100 micrograms, propofol 150 mg, and atracurium 40 mg. Airway control was secured with a size 7.0 mm endotracheal tube. Anesthesia was maintained with inhalational agents and continuous atracurium infusion at 10 mg/hour.

Additional intraoperative medications included:

• Dexamethasone (Dexona) 8 mg IV
• Dexmedetomidine 30 micrograms IV
• Magnesium sulfate 1 gram IV
• Paracetamol 1 gram IV
• Diclofenac 100 mg rectal suppository

After surgery, neuromuscular blockade was reversed. The endotracheal tube was gently exchanged for an i-gel supraglottic airway to facilitate smooth emergence. Morphine 5 mg was administered intramuscularly for postoperative analgesia.

• CSF rhinorrhea signifies communication between the subarachnoid space and nasal cavity, increasing the risk of ascending meningitis.
• Cribriform plate defects raise the possibility of air embolism, pneumocephalus, and intracranial infections.
• Spontaneous CSF leaks, particularly in middle-aged females, may indicate underlying idiopathic intracranial hypertension (IIH).

References:

Prosser JD, Vender JR, Solares CA. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin North Am. 2011;44(4):857-873. doi:10.1016/j.otc.2011.05.003

Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope.2004;114(2):255-265. doi:10.1097/00005537-200402000-00016

• Avoidance of increased intracranial pressure or nasal pressures during positioning and airway handling.
• Positive pressure ventilation, coughing, or bucking can disrupt surgical repair.
• Goals include a bloodless surgical field, smooth hemodynamics, and protection of the repair during emergence.

Reference:

Fathi AR, Eshtehardi H, Mehdizade A. Cerebrospinal fluid rhinorrhea: diagnosis and management. Med J Islam Repub Iran. 2014;28:69.

• Rule out active infection or elevated ICP.
• Preoperative imaging (CT cisternography) maps the skull base defect.
• Adjust monitoring due to dark red nail polish (use alternate pulse oximeter sites).

Reference:

Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000;110(7):1166-1172. doi:10.1097/00005537-200007000-00023

• Glycopyrrolate 0.2 mg for antisialagogue effect and heart rate control.
• Midazolam 1 mg for anxiolysis and amnesia.
• Fentanyl 100 mcg to blunt airway reflexes.
• Propofol 150 mg for smooth induction and ICP reduction.
• Atracurium 40 mg for neuromuscular relaxation.

Reference:

Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology. 6th ed. McGraw Hill; 2018. Chapter 20, Anesthesia...