Fracture Pattern–Based Risk of CSF Rhinorrhea in Craniofacial Trauma: A Systematic Review

Abstract

Introduction: Traumatic cerebrospinal fluid (CSF) rhinorrhea is an uncommon but clinically significant complication of craniofacial trauma, particularly involving midface and anterior skull base fractures. Disruption of the dura and arachnoid membrane establishes a communication between the subarachnoid space and the nasal cavity, predisposing patients to serious complications such as meningitis and intracranial infections. The risk of CSF leakage varies depending on fracture pattern, severity, and anatomical location, with central midface and skull base injuries demonstrating a higher propensity. However, variability in existing literature necessitates a systematic evaluation of fracture-specific risks.

Objectives: To evaluate the association between craniofacial fracture patterns and the incidence of traumatic CSF rhinorrhea, and to determine high-risk fracture types, management outcomes, and complication profiles.

Methods: This systematic review was conducted in accordance with PRISMA 2020 guidelines. A comprehensive literature search of PubMed and Scopus databases was performed up to January 2025 using relevant keywords and MeSH terms related to CSF rhinorrhea and craniofacial fractures. Studies included retrospective, prospective, cohort, and cross-sectional designs reporting CSF leaks associated with fracture patterns. Case reports, small case series (<10 patients), and non-traumatic CSF leaks were excluded. Data regarding fracture type, incidence of CSF leakage, management strategies, and outcomes were extracted and analyzed. The level of evidence was assessed using the Oxford Centre for Evidence-Based Medicine hierarchy.

Results: Five retrospective studies comprising 3,663 patients were included. The incidence of CSF rhinorrhea ranged from <1% to 30%, varying with fracture location and severity. Fractures involving the anterior skull base, naso-orbito-ethmoid complex, posterior frontal sinus wall, and Le Fort II/III patterns demonstrated the highest risk (5–30%). In contrast, isolated zygomaticomaxillary complex fractures showed minimal association (<1%). Combined fracture patterns significantly increased the likelihood of persistent CSF leaks.

Conclusions: CSF rhinorrhea is strongly associated with central midface and anterior skull base fractures. Early identification of high-risk fracture patterns and timely management are essential to prevent complications. Standardized diagnostic criteria and prospective studies are needed to improve risk stratification and treatment protocols.