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September 10, 2020

Spontaneous Cerebrospinal Fluid Leak in a Transgender Man: Is Testosterone Therapy a Risk Factor?

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Summit Medical Group, Florham Park, New Jersey
  • 2Department of Otolaryngology–Head and Neck Surgery, Saint Barnabas Medical Center, Livingston, New Jersey
  • 3Atlantic NeuroSurgical Specialists, Sparta, New Jersey
JAMA Otolaryngol Head Neck Surg. Published online September 10, 2020. doi:10.1001/jamaoto.2020.2394

A transgender man in his 20s presented with 9 months of right-sided rhinorrhea. He reported spontaneous onset of clear, salty nasal drainage without history of trauma. The patient also reported postural headaches but denied vision loss. He had a history of chronic sinusitis with nasal polyposis and had undergone bilateral endoscopic sinus surgery 6 months prior, but rhinorrhea preceded surgery. The patient’s medical history was significant for taking testosterone cypionate intramuscular injections, 200 mg, bimonthly for 6 years. He had undergone previous subcutaneous mastectomy for gender confirmation. The patient denied any history of meningitis. Examination showed brisk right rhinorrhea when leaning forward. Results of β2 transferrin assay for cerbrospinal fluid (CSF) were positive, and computed tomographic (CT) scans showed a defect in the middle fossa lateral to the right foramen rotundum in a hyperpneumatized sphenoid sinus, with extensive mottling of the skull base bilaterally including ovoid bony defects from arachnoid pits and aberrant granulations (Figure 1) consistent with idiopathic intracranial hypertension (IIH).