Traumatic CSF rhinorrhea associated with COVID-19 testing: a case series and systematic review

This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review.

Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review.

Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1-9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8-18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = - 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful.

This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks.