Cerebrospinal Fluid Nasal Fistula of the Lateral Sphenoid Recess, Associated with Idiopathic Intracranial Hypertension and Primary Empty Sella Syndrome

Case Presentation

Austin J Otolaryngol. 2017; 4(2): 1093.

Cerebrospinal Fluid Nasal Fistula of the Lateral Sphenoid Recess, Associated with Idiopathic Intracranial Hypertension and Primary Empty Sella Syndrome

Vargas-Aguayo AM* and Sanchez-Castro GF

Department of Otorhinolaryngology, Centro Médico ABC, Mexico

*Corresponding author: Alejandro Martín Vargas Aguayo, Department of Otorhinolaryngology, Centro Médico ABC, Mexico

Received: June 19, 2017; Accepted: August 09, 2017; Published: August 16, 2017

Abstract

Current treatment of nasal Cerebrospinal Fluid (CSF) leaks, are preferable realized by endoscopic approach, and several techniques describe a high success rate when it comes to defect closure. However when associated with high intracranial pressure, the success rate decreases importantly without the establishment of a complete treatment. Up to 45% of the spontaneouslyappearing fistulas can be associated to an elevation in intracranial pressure. A prompt and adequate recognize of the clinical and radiological findings, such as meningoceles, empty sella syndrome, etc., represent a great impact on the prognosis. Complementary measures include long term medical treatment to decrease the production of CSF and weight loss. A 40 years old female patient with high body mass index, presented with symptoms of nasal CSF leak, diagnosis was made with biochemical parameters and radiological studies to determinate a bony defect on left sphenoidal lateral recess wall. The leak was successfully sealed in a multilayer fashion with complementary treatment.

Keywords: Cerebrospinal fluid leak; Spontaneous; Transanal endoscopic surgical procedures; Idiopathic intracranial hypertension

Introduction

The importance of recognizing the etiology of a disease, directly affects the prognosis of the patient. At present, when it comes to Cerebrospinal Fluid (CSF) nasal fistulas, there has been an ideological change concerning its cause. The current consensus establishes that many CSF nasal fistulas that appear “spontaneously” are associated with idiopathic intracranial hypertension and with empty sella syndrome, which comes up on imaging. The handling of this disease must be directed towards reestablishing normal physiology, in order to have a higher success rate. We will now present a case with that has the above mentioned characteristics, but with difficult endoscopic access to close the fistula (lateral sphenoid recess).

Clinical Case

40-year-old female patient, with spontaneous onset of rhinorrhea, accompanied by an intermittent pulsing headache that had been going on for 4 months and that had increased some 3 weeks before, after the patient took a 7-hour flight. The rinorrhea was constant, but was more evident when the Valsalva maneuvers were performed.

Physical exploration revealed slightly elevated arterial pressure, 130/90mm of Hg, a body weight of 84kg, a height of 1.67cm, with a body mass index of 30.1kg/m2. The nasal endoscopy identified a very moist nasal mucosa in the left nostril. Noticeable leak when the head was inclined, turbinates appeared to be normal. Both tympanic membranes showed no reaction to light, the oropharynx showed evidence of post-nasal hyaline discharge.

The rhinorrhea liquid was collected to make a cytochemical that was compatible with CSF, since Beta-2 Transferrin was not available.

In the computerized tomography of the nose and paranasal sinuses, a highly pneumatized sphenoid was observed with what appeared to be something with the density of soft tissue on it; a bone defect in the left lateral sphenoid recess, around the optical carotid recess, was also identified (Figures 1, 2). The T2 magnetic resonance of the skull gave evidence of a hyperintense signal coming from the shpenoid’s interior, strongly suggesting the presence of cerebrospinal fluid (Figure 3). Empty sella syndrome, which showed arachnoid herniation through the sellar diaphragm, also showed up in the T1 sequence, compressing the pituitary gland in the characteristic image of the anchor shape (Figure 4).