Role of the Anesthesiologist

In this chapter, we will discuss some of the challenges that anesthesiologists face during CSF rhinorrhea correction surgery. Prophylactic antibiotic therapy is recommended to reduce the incidence of meningitis and toxic shock syndrome, both of which have an elevated morbidity and mortality rate. Chronic idiopathic intracranial hypertension (IIH) may be the cause of a CSF leak and its early management after the correction should be included in the treatment plan, either through behavioral changes (weight loss), pharmacological management (acetazolamide), or surgical treatment (shunting). Obesity (frequently related to IIH) creates specific challenges for the anesthesiologist involving airway management and ventilation, for which a backup plan must be ready before the start of induction, should the need arise. The diagnosis of obstructive sleep apnea requires careful management after surgery since the use of continuous positive airway pressure must be avoided for at least 7 days. Intraoperative induced hypotension is not recommended. A median arterial pressure of 65-70 mmHg or higher should be targeted to ensure adequate cerebral perfusion pressure and blood flow. Valsalva maneuver can help identify the leak during the early stages of the procedure, but it can displace the recent reconstruction, cause bleeding and hematoma formation, and create an unexpected pneumocephalus through a vacuum effect. During the emergence period after the end of surgery, the anesthesiologist should minimize coughing, hypertension, hypoxia, and hypercapnia, which can lead to hemorrhage, cerebral edema, and elevated ICP. The postoperative care for the first 2-3 h after extubating the patient should be closely monitored, when any hemodynamic and neurological changes will be detected and treated early. Prevention of pain, nausea, and vomiting should be standard for every patient. After this period, once the patient is fully awake, he can be discharged to the floor. Intensive care unit should be reserved for patients with severe comorbidities that require close monitoring and for cases with intraoperative complications, rather than adopted as a standard of care for every case.