# Situation: A 49-year-old man with acromegaly from a growth hormone–secreting pituitary adenoma undergoes transsphenoidal removal of the tumor. He returns to the surgical ward with nasal packing and an indwelling urinary catheter. On the second postoperative day, after the packing is removed, he reports a steady clear drip from his nose. Which finding MOST supports that the fluid is cerebrospinal fluid (CSF)?

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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 49-year-old man with acromegaly from a growth hormone–secreting pituitary adenoma undergoes transsphenoidal removal of the tumor. He returns to the surgical ward with nasal packing and an indwelling urinary catheter.

On the second postoperative day, after the packing is removed, he reports a steady clear drip from his nose. Which finding MOST supports that the fluid is cerebrospinal fluid (CSF)?

## 보기

1. Thick drainage that forms crusts in the nostril
2. Sneezing with itching of the nose and the eyes
3. Blood-tinged drainage that lessens over the first day
4. A salty taste and a headache worse when sitting up **✔ 정답**

**정답: 4**

## 해설

A CSF leak after transsphenoidal surgery causes clear, watery drainage, a salty taste from postnasal flow, and a positional headache that worsens when upright as CSF pressure falls. The fluid is confirmed by beta-2 transferrin testing of a collected sample.

## 심화 해설

Why option 4 is the answer

After transsphenoidal removal of a pituitary adenoma, the surgical corridor passes through the sphenoid sinus and the sellar floor, immediately beneath the subarachnoid space. Disruption of the arachnoid or the reconstructed skull base can create a direct path for cerebrospinal fluid (CSF) to escape into the nasal cavity. On the second postoperative day, when nasal packing is removed, a persistent clear drip must raise suspicion for a postoperative CSF leak.

A salty taste occurs because CSF, which has a sodium concentration similar to extracellular fluid, flows posteriorly into the pharynx and stimulates the taste receptors for salt. This is a classic bedside clue that the clear fluid is not ordinary nasal mucus. The headache that worsens when sitting up is also highly characteristic: upright posture lowers intracranial CSF pressure further, causing traction on pain-sensitive meningeal structures, while lying flat temporarily restores the CSF cushion and relieves the headache. This positional, low-pressure headache pattern is the opposite of the headache seen with elevated intracranial pressure.

| Finding | Supports CSF leak? | Explanation |
| --- | --- | --- |
| Thick drainage with crusts | No | CSF is thin and watery; thick, crusting secretions suggest mucus or dried blood. |
| Sneezing with nasal and eye itching | No | This points to an allergic or irritant rhinitis, not a dural defect. |
| Blood-tinged drainage that lessens over the first day | No | Expected postoperative serosanguineous drainage that should decrease, not persist as a clear drip. |
| Salty taste and headache worse when upright | Yes | Salty postnasal flow plus a low-pressure positional headache strongly suggests CSF. |

Watch out! A clear nasal drip alone is not diagnostic. The combination of a salty taste and a headache that worsens when sitting up is what makes option 4 the strongest clinical indicator. Key point! Confirmation requires laboratory testing of the collected fluid, most commonly beta-2 transferrin, a protein specific to CSF and perilymph.

Postoperative CSF leak is a serious complication because it creates a portal for bacteria from the nasal cavity to ascend into the meninges, leading to meningitis. In a review of expanded endoscopic endonasal surgeries, postoperative CSF leak was identified as a complication that can lead to meningitis and often requires additional intervention [2]. This is why early recognition at the bedside matters: the nurse who identifies the salty taste and positional headache can alert the surgical team before infection develops.

Management of a confirmed leak may include conservative measures such as bed rest with the head elevated, avoidance of straining, and sometimes a lumbar drain to reduce CSF pressure. If the leak persists, surgical repair may be needed. Reconstruction techniques using vascularized flaps, such as the nasoseptal flap or the posterior pedicle inferior turbinate flap, have been described for recurrent or high-flow leaks after transsphenoidal surgery [3]. In some cases, endoscopic application of sealant with fibrin glue has been used to manage postoperative leaks without reopening the surgical site [4].

From a nursing standpoint, the priority after identifying a suspected CSF leak is to protect the patient from infection and report the finding promptly. The patient should be instructed not to blow the nose, not to cough forcefully, and not to strain during bowel movements, because any increase in nasopharyngeal pressure can worsen the leak or force bacteria through the defect. Monitoring for fever, neck stiffness, photophobia, and altered mental status is essential because these are early signs of meningitis.

The salty taste and upright headache reflect the two core pathophysiologic features of a CSF leak: loss of sodium-rich fluid through the nose and intracranial hypotension from depletion of CSF volume. These features cannot be explained by simple nasal drainage or allergic symptoms, which is why option 4 is the most specific finding among the choices.References (research sources)

- [2]Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery.Research articleIvan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT, Pletcher SD (2015) · DOI: 10.1016/j.jocn.2014.08.009

- [3]Posterior pedicle inferior turbinate flap for recurrent cerebrospinal fluid leak following endoscopic transsphenoidal surgery.Research articleDharanipathy S, Kumar A, Agrawal D (2023) · DOI: 10.1007/s00405-023-08096-5

- [4]The awake endoscope-guided sealant technique with fibrin glue in the treatment of postoperative cerebrospinal fluid leak after extended transsphenoidal surgery: technical note.Research articleCavallo LM, Solari D, Somma T, Savic D, Cappabianca P (2014) · DOI: 10.1016/j.wneu.2013.01.017

## 임상 시나리오

Postoperative CSF Leak RecognitionKey bedside clues after transsphenoidal surgery
After transsphenoidal surgery, a persistent clear watery nasal drip after packing removal should raise suspicion for CSF leak. The fluid is thin and watery, unlike thick mucus or crusting secretions.

A salty taste occurs as CSF flows posteriorly into the pharynx. A headache worse when sitting up and relieved when lying flat reflects low intracranial CSF pressure, a hallmark of CSF leak.

Confirm suspected CSF by testing collected fluid for beta-2 transferrin, a protein nearly unique to CSF. Blood-tinged drainage that lessens over the first day is expected postoperative serosanguineous output, not CSF.

CautionDo not dismiss a clear drip as simple rhinitis. Sneezing with nasal and eye itching suggests allergy, not a dural defect. Early recognition of CSF leak is critical to prevent meningitis.

## 핵심 개념

- **CSF leak** — Escape of cerebrospinal fluid through a dural defect, often presenting as clear watery nasal or ear drainage
- **Transsphenoidal surgery** — Surgical approach through the sphenoid sinus to remove pituitary tumors, creating a potential path for CSF leak
- **Beta-2 transferrin** — Protein found almost exclusively in CSF; used to confirm CSF in suspected leak fluid
- **Low-pressure headache** — Headache that worsens when upright and improves when lying flat due to reduced intracranial CSF volume
- **Acromegaly** — Condition caused by excess growth hormone, often from a pituitary adenoma, leading to enlarged bones and soft tissues

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