The transnasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhea from the lateral recess of the sphenoid sinus

Abstract Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea from the lateral recess of the sphenoid sinus is surgically challenging. Sternberg’s canal has stirred great controversy as the potential source. The aim of this study was to present our experience with endonasal endoscopic repair, the possible etiopathology, and the outcomes. Study design: This prospective study comprised 10 patients (seven female and three male) with spontaneous CSF rhinorrhea from the lateral recess of the sphenoid sinus, which was not related to trauma, previous surgery, tumors, irradiation, or meningitis. CSF rhinorrhea was confirmed with β2 transferrin test and high resolution CT scan (HRCT) and MRI cisternography. All patients were treated with the endonasal endoscopic conservative retrograde trans-sphenoidal approach. Results: The mean BMI was 35.55 ± 2.84 kg/m2. Elevated intracranial pressure was present in all cases confirmed directly (with a mean intraoperative lumbar drain pressure of 27.5 ± 3.84 cm H2 O), and indirectly [with the presence of primary empty sella (100%), arachnoid pits (30%), and attenuated skull base (40%)]. Osteodural defect was constantly present in the superior wall of the lateral recess, lateral to the foramen rotundum, none above the foramen rotundum or below the vidian canal orifice. The mean follow-up was 46.9 ± 8.26 months. Conclusion: The endonasal endoscopic repair is a safe and effective method. The etiopathology is multifactorial. The management of elevated intracranial pressure is crucial. The potential source is not Sternberg’s canal but persistent cartilaginous vascular channels at the ossification center of the alisphenoid, cartilaginous precursor of the greater wing of the sphenoid bone.