Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base

Abstract

Objectives/Hypothesis Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail. Study Design Retrospective case series. Methods The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis. Results Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground‐glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground‐glass opacities on imaging resolved in all six cases. Conclusions Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment. Level of Evidence 4 Laryngoscope, 131:462–466, 2021

Aspiration of Cerebrospinal Fluid Rhinorrhea as a Cause of Non-resolving Pneumonia

“…Lung lesions are considered to be secondary to the chronic aspiration of leaked CSF (6). Supporting this view, a chest CT scan shows airway-centered ground glass opacities with or without bronchial wall thickening and a tendency of lower lobe predominance (2,5,6). In our patients, the upper lung zone was also involved.…”

An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report

“…Zada et al first reported a case about chronic aspiration-induced pneumonitis caused by spontaneous ethmoid sinus meningocele with CSF rhinorrhea, and indicated that increased diagnostic complexity associated with pulmonary complications led to unnecessary intervention and treatment delays [ 7 ]. CSF rhinorrhea can be considered as a cause of chronic pneumonitis despite the lack of direct evidence [ 8 ]. A controlled clinical trial has shown that sinonasal secretions can be transferred to the lungs whether in patients with cystic fibrosis or healthy subjects [ 9 ].…”

A Case of Aspiration Pneumonia Caused by Cerebrospinal Fluid Leaks Associated with Delayed Identification of Iatrogenic Skull Base Injury during Endoscopic Sinus Surgery

“…Interestingly, the chest CT showed imaging findings similar to those of aspiration pneumonia in bedridden patients who are always in a supine position. It was recently reported that spontaneous CSF leaks can cause chronic aspiration pneumonitis [ 4 , 5 ]. The pathology in this case may have had the same mechanism.…”