63.13 When CSF leaks from the patient’s nose or ears

This is the result of a fracture of the base of a patient’s skull, which puts his arachnoid space in communication with his nose or ears. If you are not sure if the fluid is CSF, or merely nasal discharge, test some fresh fluid for glucose with a urine test strip. Only CSF contains glucose. Mop his nose or ears clean, but don’t plug them. Don’t lumbar puncture him, because this will lower his CSF pressure, and may assist organisms to enter his meninges.

LEAKING CSF FOLLOWING A HEAD INJURY

If the patient’s airway and level of consciousness permit, lower his CSF pressure in the wound by nursing him sitting up.

ANTIBIOTICS Give him co-trimoxazole 960 mg 8–12 hourly, or sulphadimidine 2 g initially followed by 1 g 6 hourly. Also give him chloramphenicol 50 mg/kg/24 hrs in 6 hourly doses. NOSE A leak of CSF from a patient’s nose is much more common than a leak from his ears, and rarely lasts more than a few days. Note which nostril the CSF escapes from. Don’t let him blow his nose, because this may blow bacteria through the crack in his skull into his meninges.

If CSF leaks from his nose for more than 10 days, refer him for repair of his dura.

EARS A leak from the ears is less significant than a leak from the nose. If CSF leaks from a patient’s ears for more than 3 days, he is probably bleeding intracranially and needs burr holes.