Expanded Endonasal Approach to the Clival Recess for Obliteration of a Recurrent Petrous Apex Cephalocele Causing CSF Rhinorrhea: A Technical Case Report and Literature Review

Introduction: Cerebrospinal fluid leak (CSF) rhinorrhea from petrous apex cephaloceles (PAC) are rare and usually treated with open approaches. We describe a case of a symptomatic PAC treated using an expanded endonasal approach (EEA) and a review of previously reported cases.

Methods: Case report and narrative literature review.

Results: The patient was a 27-year-old woman who developed meningitis that became complicated by a PAC. She underwent a middle fossa exploration and repair at age 29. She presented to our clinic at age 33 with recurrent CSF rhinorrhea. She underwent an EEA to the clival angle and petrous apex, where a small bony dehiscence was identified and exposed. A fat graft was used to obliterate the cephalocele’s communication into the sphenoid sinus, and a nasoseptal flap was elevated to reconstruct the floor of the sinus. She was discharged on acetazolamide, but 3 weeks later, she developed recurrent CSF rhinorrhea 3 weeks later and underwent a revision EEA to reinforce her fat packing and revise her nasoseptal flap. Two months later, she experienced an estimated 100cc of CSF rhinorrhea after she bent over while walking, so she underwent a lumbar drain trial, and a ventriculoperitoneal shunt (VPS) when the lumbar drain could not be weaned. She remains asymptomatic 1 month after her VPS placement.

Conclusion : The expanded endonasal approach to the clival recess can provide adequate exposure and favorable visualization to treat CSF rhinorrhea in select cases of petrous apex cephaloceles.