Sphenoid lateral recess cerebrospinal fluid leak [Neurosurgery Wiki]

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=====Sphenoid lateral recess cerebrospinal fluid leak=====

A common area of involvement is a pneumatized lateral recess of the sphenoid (LRS) sinus, where prolonged intracranial pressures lead to arachnoid pits and subsequent development of skull base defects. Even though the LRS is never present at birth, a "congenital" cause of these leaks due to a persistent Sternberg's (lateral craniopharyngeal) canal continues to be erroneously perpetuated in the literature.

They are secondary to erosions from intracranial hypertension and refutes the myth regarding a congenital origin from Sternberg's canal 
((Illing E, Schlosser RJ, Palmer JN, Curé J, Fox N, Woodworth BA. Spontaneous
sphenoid lateral recess cerebrospinal fluid leaks arise from intracranial
hypertension, not Sternberg's canal. Int Forum Allergy Rhinol. 2014 Jan 9. doi:
10.1002/alr.21262. [Epub ahead of print] PubMed PMID: 24407877.)).

A CSF related rhinorrhoea should be suspected in the presence of a unilateral, watery, clear, nonsticky nasal discharge that is commonly associated with a headache. A sphenoid sinus defect may be suspected with fluid gush on forward tilt of head 
((Schick B, Brors D, Prescher A. Sternberg’s canal—cause of congenital spheniodal meningocele. Eur Arch Otorhinolaryngol. 2000;257:430–432. doi: 10.1007/s004050000235.)).

====Surgical Treatment====

===Leaks into sphenoidal sinus===

Lumbar puncture or [[external lumbar drainage]].

If leak persists > 3 days repack sphenoid sinus and pterygoid recesses with fat, muscle cartilage and/or fascia lata.

and continue Lumbar puncture or [[external lumbar drainage]] for 3-5 days.

If leak persists > 5 days lumboperitoneal shunt

===Approaches===
A number of approaches have been described for the lateral recess of the sphenoid sinus. Historically, transcranial approaches have been used for the surgical management of encephaloceles of the lateral recess of the sphenoid sinus
((McCormack B, Cooper PR, Persky M, Rothstein S. Extracranial repair of cerebrospinal fluid fistulas: technique and results in 37 patients. Neurosurgery. 1990;27:412–417. doi: 10.1227/00006123-199009000-00012.))
((Schick B, Brors D, Prescher A. Sternberg’s canal—cause of congenital spheniodal meningocele. Eur Arch Otorhinolaryngol. 2000;257:430–432. doi: 10.1007/s004050000235.))
((Kaufman B, Nulsen FE, Weiss MH, Brodkey JS, White RJ, Sykora GF. Acquired spontaneous, nontraumatic normal pressure cerebrospinal fluid fistulas originating from the middle cranial fossa. Radiology. 1977;122:379–387.)).

Under local anesthesia, a needle is introduced manually through a nostril toward the sella turcica and EDH adhesive or fibrin glue is injected into the sellar cavity or sphenoid sinus, or both. This procedure is simple and safe to perform, acceptable to the patient, and can be done in a short hospital stay 
((Fujii T, Misumi S, Onoda K, Takeda F. Simple management of cerebrospinal fluid
rhinorrhea after pituitary surgery. Surg Neurol. 1986 Oct;26(4):345-8. PubMed
PMID: 2428122.)).