Cerebrospinal Fluid Leak following Balloon Sinuplasty of Sphenoid Sinus: A Case Report and Review of the Literature

Objective To present a case of cerebrospinal fluid (CSF) leak following sphenoid balloon sinuplasty and to perform a review of the literature on complications following balloon sinuplasty.

Study Design Case report and systematic review of the literature.

Results We report a case of a 51-year-old woman transferred to us for management of CSF rhinorrhea following balloon-assisted sphenoidotomy. The patient was suspected to have CSF rhinorrhea 2 days following the initial procedure after complaining of intermittent headaches, nausea, and vomiting. CT head imaging in an emergency room revealed significant pneumocephalus. She was placed on bedrest and conservative management. Failing resolution of her CSF leak, she was then transferred to our tertiary care hospital 10 days postoperatively. CT imaging was suspicious for a breach in the mid-planum sphenoidale just anterior to the sella. The entire skull base was found to be very thin, with bony dehiscences of bilateral optic and internal carotid canals. Intraoperatively, the breach site was found to be a high pressure, high-volume leak through a 2-mm mucosalized fistula. The site of injury was inferomedial to and within 5 mm of a dehiscent carotid artery. An endoscopic transsphenoidal exposure was performed. The leak was repaired using a pedicled vascularized nasal septal flap. Successful repair and resolution of rhinorrhea and pneumocephalus were noted postoperatively. A systematic literature review was conducted using search terms, “complication,” “balloon sinuplasty,” and “adverse events.” Two distinct large cohort studies reported only one case of postoperative periorbital swelling that resolved spontaneously. Only two publications reported complications following balloon sinuplasty—one ethmoid CSF leak and one medial orbital wall fracture. A publication querying the OpenFDA database, however, found 114 reported adverse events associated with balloon-assisted sinus surgery. These comprised four deaths and two unclassified events. There were also 17 cases of skull base injury with15 CSF leaks. Orbital injury was the most common complication with 13 patients requiring lateral canthotomy and 3 medial orbital wall decompressions. CSF leak was significantly associated with frontal surgery and sphenoid surgery.

Conclusion Balloon-assisted sinus procedures appear to have high safety and low complication rates in the published literature. The FDA database enumerates orbital and CSF leak complications, but complication rates cannot be gauged from this source. We present the first published case of CSF rhinorrhea following sphenoid balloon sinuplasty. Our report suggests that the risk of CSF leak may be higher in patients with thin skull base. While balloon-assisted surgery is largely a safe technique with low reported rates of complications, otolaryngologists and skull base surgeons should be aware of potential intracranial and orbital complications. Delayed recognition or repair of CSF leaks may result in severe morbidity and mortality from pneumocephalus and intracranial infection.