Leaks into sphenoid sinus

Leaks into sphenoid sinus (including post-transsphenoidal surgery leak).

1. LP BID or CLD: as long as pressure > 150mm H20 or CSF xanthochromia

a) if leak persists > 3 days: repack sphenoid sinus and pterygoid recesses with fat, muscle, cartilage and/or fascia lata (must reconstruct floor of sella, packing alone is inadequate). Some recommend against muscle since it putrefies and shrinks. Continue LP or CLD for 3–5 days post-op

b) if leak persists > 5 days: lumboperitoneal shunt (first R/O obstructive hydrocephalus)

2. more difficult surgical approach: intracranial (intradural) approach to medial aspect of middle cranial fossa

3. consider transnasal sellar injection of fibrin glue under local anesthesia