Spontaneous Cerebrospinal Fluid Leak in a Transgender Man
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A transgender man in his 20s presented with 9 months of right-sided rhinorrhea. He reported spontaneous onset of clear, salty nasal drainage without history of trauma. The patient also reported postural headaches. He had a history of chronic sinusitis with nasal polyposis and had undergone bilateral endoscopic sinus surgery 6 months prior, but rhinorrhea preceded surgery. The patient’s medical history was significant for taking testosterone cypionate intramuscular injections, 200 mg, bimonthly for 6 years. He had undergone previous subcutaneous mastectomy for gender confirmation. The patient denied any history of meningitis. Examination showed brisk right rhinorrhea when leaning forward.

Results of beta-2 transferrin assay for cerbrospinal fluid (CSF) were positive, and (CT) scans showed a defect in the middle fossa lateral to the right foramen rotundum in a hyperpneumatized sphenoid sinus, with extensive mottling of the skull base bilaterally including ovoid bony defects from arachnoid pits and aberrant granulations consistent with idiopathic intracranial hypertension (IIH).

The patient underwent expanded endonasal surgery by otolaryngology and neurosurgery specialists for CSF leak repair. A lumbar drain was placed. A transpterygoid approach was performed to allow straight-line access to the skull base defect. The vidian nerve was transected for access, whereas the maxillary nerve was preserved. An encephalocele with active CSF leak was identified and reduced with bipolar electrocautery. The bony defect measured 4 mm, with unhealthy and irregular surrounding bone.

The CSF leak was repaired with inlay collagen dural substitute, septal cartilage inlay graft, and free mucosal onlay graft harvested from the nasal floor. The lumbar drain was removed on postoperative day 2, and the patient was discharged on postoperative day 3 with a prescription for 1 month of acetazolamide, 500 mg, twice daily. At 8-month follow-up the patient had no evidence of CSF leak. He declined repeat lumbar puncture for measuring CSF opening pressure.

Source: https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2770567?widget=personalizedcontent&previousarticle=0
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