Surgery MCQs Q27

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SURGERY • NEUROSURGERY

A 28-year-old man presents after a minor head injury with clear watery discharge from the nose. The fluid increases on bending forward. There is suspicion of CSF rhinorrhea.

What is the appropriate initial management?

A Plain X-ray and nasal packing

B Immediate surgery

C Nasal packing only

D Antibiotics and observation

E Analgesia

The diagnosis is Traumatic CSF Rhinorrhea. Initial management is always conservative as most leaks resolve spontaneously.

Decoding the Stem

1

CLUE "Clear nasal discharge + post-trauma"

DIAGNOSIS CSF Rhinorrhea (likely cribriform plate fracture).

2

CLUE "Increases on bending forward"

TEST The Reservoir Sign – pathognomonic for CSF leak.

Explanation

D. Antibiotics and observation: ✅ Correct. Most traumatic CSF leaks (85%) resolve spontaneously within 7–10 days with head elevation and avoidance of straining. While prophylactic antibiotics are controversial, they are often a preferred exam option for initial care.

A & C. Nasal packing: ❌ Contraindicated. Packing increases intracranial pressure and significantly raises the risk of ascending infection (meningitis).

B. Immediate surgery: Incorrect. Surgery is only indicated if the leak persists beyond 7–10 days or if there is recurrent meningitis.

E. Analgesia: Incorrect. While appropriate for pain, it is not the primary "initial management" for a potential CSF leak.

🧠 CSF Leak Summary

Feature	Clinical Correlation
Confirmation	β-2 Transferrin (Most Specific)
Positioning	Head End Elevation (30-40°)
Surgery Time	Persistent leak > 7–10 days
Contraindication	Nasal Packing

Integrated Clinical Questions

1. What is the most specific biochemical test for identifying fluid as CSF?

Answer: β-2 transferrin assay (only found in CSF, perilymph, and aqueous humor).

2. What is the most common site of fracture leading to CSF rhinorrhea?

Answer: Cribriform plate of the ethmoid bone.

3. When is surgical intervention indicated for a post-traumatic CSF leak?

Answer: If the leak is persistent (>7–10 days) or if the patient experiences recurrent meningitis.

4. What position advice should be given to the patient during observation?

Answer: Strict bed rest with head elevation (30–40 degrees) to reduce CSF pressure at the site of the leak.

5. What is the major potential complication of untreated or improperly managed CSF rhinorrhea?

Answer: Bacterial Meningitis (most commonly caused by S. pneumoniae).

⚡ Exam Pearls

• Traumatic CSF Leak: Conservative management (90% success rate).
• Meningitis: The most feared complication. Prophylactic antibiotics are standard in most exam vignettes.
• Reservoir Sign: Sudden gush of fluid on bending forward is a classic finding.

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