Successful repair of CSF leak with a facial translocation approach after two failed endoscopic surgeries

Abstract

Objectives: There has been an increased incidence of cerebrospinal fluid (CSF) leaks associated with greater numbers of sinus and anterior skull base surgeries. The leading causes of CSF leaks are iatrogenic injury and trauma. Over the past 20 years, CSF leak repairs via an endoscopic approach have been reported with success rates ranging from 83%-100%. Failed endoscopic repairs provide a challenge to the clinician. Methods: The case reported here is that of a 38-year-old female, who required nonendoscopic management of her middle cranial base CSF leak, after 2 failed attempts with endoscopic repair. The CSF leak occurred after resection of a pituitary adenoma via a transphenoidal approach. Results: The CSF leak recurred for the third time shortly after the second repair. The defect was then approached via a mini-facial translocation approach. A left lateral rhinotomy incision was made and the left nasal, frontal, and maxillary bones were exposed. After osteotomies were made, the maxillary sinus was rotated laterally exposing the sphenoid sinus. Rongeurs were used to open the sphenoid sinus and direct visualization of the CSF leak in the left lateral aspect of the sphenoid sinus was obtained. The leak was isolated and repaired with fat grafting, fibrin glue, and middle turbinate mucosa by neurosurgery. Conclusion: The patient has had an uneventful recovery with good cosmesis and no recurrence of the CSF leak.