Images in Clinical Medicine

Cerebrospinal Fluid Leak

Theo Diekman, M.D., Ph.D., and Bram Mees, M.D.

N Engl J Med 2009; 361:e26October 1, 2009

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Article

Video

Leak of Clear Fluid from the Right Nostril upon Bending Forward.

A 50-year-old postmenopausal woman with asthma and allergic rhinitis presented with a 6-month history of unilateral rhinorrhea. When she woke in the mornings, she noticed a stain (halo) on her pillow. Rhinorrhea was precipitated by coughing and sneezing. She reported no headaches, weight change, galactorrhea, or visual disturbance. When she bent forward (e.g., when putting on her shoes), drops of clear fluid fell from her right nostril (see video). The fluid contained β₂-transferrin, a finding consistent with the presence of cerebrospinal fluid (CSF).

Radiography of the sinuses revealed an enlarged sella turcica (Panel A, arrow), and a computed tomographic scan showed an air–fluid (presumably CSF) level in the right sphenoid sinus (Panel B, arrow). Magnetic resonance imaging revealed a pituitary macroadenoma measuring 17 by 12 mm, with an enlarged adenohypophysis (Panel C, arrow) with a cystic component (Panel C, arrowhead) and a normal neurohypophysis, which we suspect eroded the posterior wall of the sphenoid sinus, leading to a direct connection with the CSF. Endoscopic transnasal transsphenoidal adenomectomy, sealing of the dura with an autologous abdominal-fat graft, and drainage of the lumbar CSF did not stop the rhinorrhea. A second transnasal exploration, with repair of a CSF leak in the lamina cribrosa, did stop the rhinorrhea. One year after surgery, she is doing well and has no signs of pituitary dysfunction.

Theo Diekman, M.D., Ph.D.
Bram Mees, M.D.
Deventer Hospital, Deventer, the Netherlands

This article (10.1056/NEJMicm0708178) was updated on April 6, 2011, at NEJM.org.