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Images in Neurology
August 2009

Cerebrospinal Fluid Rhinorrhea With Spontaneous Sphenoid Sinus Fistula

Arch Neurol. 2009;66(8):1038. doi:10.1001/archneurol.2009.145

A 48-year-old man presented with a 1.5-year history of rhinorrhea, which increased on tilting the head forward or backward. There was no history of trauma, meningitis, or other relevant disease. No further neurological symptoms were reported and the physical examination results were unremarkable. The nasal secretion was positive for cerebrospinal fluid (CSF)–specific β2-transferrin. A cranial computed tomographic scan revealed an extensively pneumatized sphenoid sinus with a bony defect of the right sinus (Figure 1A). A magnetic resonance image revealed a fluid-filled cyst protruding into the right sphenoid sinus (Figure 1B). Hence, the patient was diagnosed with a spontaneous sphenoid sinus fistula. Closure of the fistula was attempted via an endonasal endoscopic approach. Intraoperatively, a submucosal collection of CSF was exposed at the back of the sinus after intrathecal administration of 5% sodium fluorescein (Figure 2A). The CSF leaked along the sheath of the internal carotid artery into the nasopharynx, where it oozed from small defects in the mucous membrane on performing the Valsalva maneuver (Figure 2B). The defect was closed with DuraSeal (Confluent Surgical, Waltham, Massachusetts). Three months postoperatively, the patient remains free of symptoms.