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Risk Factors for the Initial Misdiagnosis of Spontaneous Cerebrospinal Fluid Rhinorrhea
Matthew Y Liu1, Erin M Lopez1, Erik K Weitzel1
1Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, USA.
Objective:
Spontaneous cerebrospinal fluid (CSF) rhinorrhea is commonly misdiagnosed due to overlapping symptomatology with other sinonasal diseases, thus leading to delay in diagnosis and increased risk of meningitis. The objective of this study was to examine the risk factors for the initial misdiagnosis of spontaneous CSF rhinorrhea.
Methods:
A single-institutional retrospective chart review of patients with spontaneous CSF rhinorrhea was performed. Patient characteristics, initial diagnosing provider specialty, and accuracy of radiology reports were compared between subjects initially diagnosed correctly versus those that were not.
Results:
Fifty-seven patients with spontaneous CSF rhinorrhea were included with 61% being initially misdiagnosed with rhinitis, sinusitis, or migraines. Being initially seen by a non-otolaryngology provider was significantly associated with being misdiagnosed (misdiagnosis rate 83%, P < .001, Cramer's V = 0.49). Otolaryngologists had a misdiagnosis rate of 36%. Only 32% of radiology reports correctly identified the skull base defect prior to a positive beta-2 transferrin. However, once the diagnosis of a CSF leak was established, subsequent reads by radiologists were more likely to identify the skull base defect (P < .001). Multivariable logistic regression revealed that initial visit to a non-otolaryngology provider increased the odds of misdiagnosis after adjusting for relevant confounders (P = .035).
Conclusions:
Spontaneous CSF rhinorrhea is commonly initially misdiagnosed by both non-otolaryngology and otolaryngology providers. Moreover, the skull base defect on radiographic imaging is frequently missed by radiologists when the official diagnosis is not established. Further education for all providers on the proper differential diagnosis of sinonasal symptomatology is warranted to expedite the diagnosis of spontaneous CSF rhinorrhea.
Insights
Spontaneous cerebrospinal fluid (CSF) rhinorrhea is often misdiagnosed, especially when patients first see non-otolaryngologists. Early diagnosis is crucial to prevent meningitis, highlighting the need for broader provider education.
Area of Science:
- Neurosurgery
- Otolaryngology
- Radiology
Background:
- Spontaneous cerebrospinal fluid (CSF) rhinorrhea frequently presents with symptoms mimicking common sinonasal conditions.
- Delayed diagnosis of CSF rhinorrhea increases the risk of serious complications, such as meningitis.
Purpose of the Study:
- To investigate risk factors contributing to the initial misdiagnosis of spontaneous CSF rhinorrhea.
- To identify patient and provider characteristics associated with diagnostic delays.
Main Methods:
- Retrospective chart review of patients diagnosed with spontaneous CSF rhinorrhea.
- Comparison of patient demographics, initial provider specialty, and radiology report accuracy between correctly and incorrectly diagnosed groups.
Main Results:
- 61% of patients with spontaneous CSF rhinorrhea were initially misdiagnosed with conditions like rhinitis, sinusitis, or migraines.
- Initial consultation with a non-otolaryngology provider significantly increased the likelihood of misdiagnosis (83% vs. 36% for otolaryngologists).
- Radiology reports often failed to identify the skull base defect initially, but improved after CSF leak diagnosis.
Conclusions:
- Spontaneous CSF rhinorrhea is frequently misdiagnosed by both otolaryngologists and other specialists.
- Radiologists often miss skull base defects on imaging until a CSF leak diagnosis is established.
- Enhanced education for all healthcare providers on sinonasal symptom differentials is essential for timely CSF rhinorrhea diagnosis.
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