Risk Factors for the Initial Misdiagnosis of Spontaneous Cerebrospinal Fluid Rhinorrhea

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.