2026 Poster Presentations
P228: IATROGENIC ANTERIOR SKULL BASE CSF LEAKS COMPLICATED BY CENTRAL NERVOUS SYSTEM INFECTIONS AND NEUROVASCULAR SEQUELAE: TWO COMPLEX CASES REQUIRING TAILORED ENDOSCOPIC REPAIR BY JOINT ENT AND NEUROSURGERY COLLABORATION
Ghanaym AlMazrouei, MBBS; Maryam AlZubaidi, MD; Aisha AlMazrouei, MBBS; Tarek Rayan, MD; Hilal Omar, MD; Tamer Bayoumi, MD; SSMC
Functional endoscopic sinus surgery and skull base surgery have revolutionized the management of sinonasal and anterior skull base pathology. Despite advancements, iatrogenic CSF leaks remain rare but potentially devastating, with reported rates of 0.2–0.8%. Anterior skull base defects, particularly at the cribriform plate and fovea ethmoidalis, create direct communication between the sinonasal tract and intracranial compartment, predisposing patients to CNS infections and neurovascular sequelae. While the Hadad Bassagasteguy flap is the gold standard for extensive leaks, surgical planning is more complex when this flap is unavailable or when systemic complications preclude immediate intervention.
We present two cases of iatrogenic anterior skull base CSF leaks following endoscopic sinonasal surgery in outside facilities, each complicated by distinct CNS sequelae: meningitis with superior sagittal sinus thrombosis and multifocal infarction in one, and ventriculitis with drug induced hepatitis in the other. Collectively, these cases highlight the critical role of early recognition, multidisciplinary collaboration, and tailored reconstructive strategies when conventional options are not feasible.
Case 1: A 41 year old man underwent FESS with bilateral polypectomy, concha bullosa resection, and septoplasty. Within weeks, he developed fever, headache, and altered mental status, progressing to meningitis. MRI demonstrated multifocal ischemic and hemorrhagic infarcts involving both hemispheres and cerebellum, with superior sagittal sinus thrombosis. CT and MRI revealed a cribriform plate defect with herniated brain tissue into the nasal cavity. He was stabilized with intravenous antibiotics. Once infection resolved, he underwent delayed endoscopic repair. Due to extensive septal loss precluding nasoseptal flap harvest, a multilayer closure was fashioned with fascia lata graft, bone buttress, fibrin glue, and a vascularized inferior turbinate flap. Postoperative imaging confirmed graft integrity. The patient recovered to GCS 15 with mild imbalance requiring rehabilitation, but no recurrent CSF leak.
Case 2: A 33 year old woman underwent septoplasty and ethmoidectomy. She developed clear rhinorrhea and was admitted with fever, headache, and vomiting. MRI demonstrated ventriculitis with FLAIR/DWI changes and mild ventriculomegaly. Cultures were negative, but empiric meningitic dose meropenem was initiated. Her clinical status improved, but she developed severe drug induced hepatitis. Subsequent CT and MRI revealed a left fovea ethmoidalis cribriform defect with a 16 mm ethmoid meningoencephalocele. She underwent endoscopic multilayer repair with fascia lata inlay and onlay grafts, autologous fat buttress, fibrin sealant, and repositioned nasoseptal flap supported by lumbar drainage. Postoperative imaging confirmed closure. At follow up, she remained neurologically intact, without CSF leak, with normalized liver function and seizure free with a normal EEG.
Results: Both patients achieved definitive closure without recurrent CSF rhinorrhea. These cases highlight the systemic and neurological complications arising from CSF leaks, as well as the importance of adaptability in reconstructive technique when the nasoseptal flap is unavailable or non feasible.
Conclusion: Iatrogenic anterior skull base CSF leaks can manifest with severe complications. Successful management requires prompt recognition, radiological imaging, and ideally, a multidisciplinary ENT and neurosurgery approach. Both cases show that with coordinated care and tailored planning, even the most complex sequelae of skull base CSF leaks can be managed with favorable outcomes.