Saving One Nostril

Rhinorrhea due to defect in lateral wall of sphenoid sinus is rare. The lateral recess cerebrospinal fluid (CSF) leak is due to excessive pneumatization of the sphenoid sinus involving the base of the pterygoid plate or part of pterygoid plate. Increased intracranial pressure due to various reasons commonly idiopathic intracranial pressure can be associated with lateral recess CSF leak. Such leaks have been managed traditionally earlier through transcranial route.1 Transcranial approach is associated with complications like new onset seizure due to temporal lobe retraction, wound-related complication, and craniotomy defect. However, in recent times endoscopic endonasal approach is most preferred surgical method for the treatment of CSF rhinorrhea irrespective of the site of leak. For the lateral leaks, several endoscopic endonasal approaches have been described. Endoscopic transpterygoid route is the commonly performed approach for lateral recess CSF leak.2 However, the procedure needs detailed anatomical knowledge of that region and the procedure is time consuming. The transpterygoid procedure is associated with paraesthesia of maxillary nerve division due to maxillary nerve manipulation, decreased lacrimation, or changed mucociliary clearance in the maxillary sinus. In this issue, Rai and Dandpat describe a technique of modified ipsilateral endonasal endoscopic transsphenoidal approach to sphenoid sinus lateral recess CSF leak.3 The advantages are minimal manipulation of the nasal cavity, preservation of the maxillary sinus, nil handling of the maxillary division of the trigeminal nerve, and less operative time. The present procedure needs detailed knowledge of the anatomy of vidian canal, origin of the sphenopalatine artery, and availability of the 45 or 70 degrees rigid scope with angled instruments. The management of the raised intracranial pressure with or without CSF diversion is the additional procedure needed for lateral recess CSF leak.