Cerebrospinal Fluid Leakage in Endoscopic Sinus Surgery: Prevention and Management

Cerebrospinal fluid (CSF) leak remains one of the most serious complications of endoscopic sinus surgery (ESS). Although rare, its consequences may include meningitis, pneumocephalus, intracranial abscess, and long-term neurological morbidity. This expanded manuscript presents a comprehensive academic review of preventive strategies, surgical techniques, anatomical considerations, and postoperative management regarding CSF leaks in ESS. Among the critical intraoperative hazards, catastrophic orbital hemorrhage and CSF leak represent the two complications most universally dreaded by rhinologic surgeons. Both events underscore the necessity of meticulous preoperative planning, high-resolution CT evaluation, and disciplined intranasal dissection that respects natural boundaries. Although the majority of ESS procedures proceed uneventfully, even small breaches in the skull base may lead to CSF rhinorrhea, with potential sequelae including meningitis, intracranial abscess, pneumocephalus, prolonged hospitalization, and the need for revision surgery. Early intraoperative recognition—such as identifying clear pulsatile fluid, the reservoir sign, or sudden visualization of dura—is essential, as timely repair can prevent both acute morbidity and delayed complications.The purpose of this work is to provide surgeons with a clear, structured framework to minimize risk and to optimize outcomes through evidence-based repair protocols.