Narizan ARİFFİN, Teoh Jian WOEİ, Balwant Singh GENDEH

Spontaneous pseudomeningocele of sphenoid sinus or sphenoid mucocele?: A diagnosis dilemma

A pseudomeningocele is an abnormal collection of cerebrospinal fluid (CSF) that communicates with the CSF space around the brain or spinal cord. We describe a rare case of spontaneous non-traumatic pseudomeningocele in a 28 year-old gentleman who presented with delayed puberty associated with headache. Computed tomography revealed an expansile mass over bilateral sphenoid sinuses. Magnetic resonance imaging supported the diagnosis of sphenoid mucocele. A transnasal transphenoidal endoscopic sphenoidotomy was performed. Intraoperatively, despite an anatomical puncture through the sphenoid ostium, alarmingly, the opening leaked out CSF. A dehiscent was identified with a dural opening. This was repaired with multilayer technique. Clinical improvement was observed post-operatively. The case reported here is unusual as they presented on imaging as a fluid collection in sphenoid sinus simulating a mucocoele, but were filled with CSF and represent pseudomeningocele. Surgeons should be alert to the presence of pseudomeningocele as they can mimic a mucocele or nasal polyp.

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1. Smith DK, El-Sayed I, Pafundi E, Dolan RW. Presentation and treatment of a posttraumatic pseudomeningocele of the superior orbit. Am J Otolaryngol 2000; 21: 219-221.

2. Mehendale NH, Samy RN, Roland PS. Management of pseudomeningocele following neurotologic procedures. Otolaryngol Head Neck Surg 2004; 131: 253-262.

3. Goel A, Desai KI, Nadkarni TD, Muzumdar DP. An unusual post-traumatic occipitocervical pseudomeningocele: case report. Surg Neurol. 2001; 56: 62-65.

4. Mahapatra AK, Tandon PN. Post-traumatic intradiploic pseudomeningocele in children. Acta Neurochir (Wien) 1989; 100: 120-126.

5. Kaufman B, Nulsen FE, Weiss MH, et al. Acquired spontaneous, nontraumatic normalpressure cerebrospinal fluid fistulas originating from the middle fossa. Radiology 1977; 122: 379- 387.

6. D'Almeida AC, King RB. Intradiploic cerebrospinal fluid fistula. Report of two cases. J Neurosurg 1981; 54: 84-88.

7. Menku A, Koc RK, Tucer B, Akdemir H. Is skull fracture necessary for developing an intradiploic pseudomeningocele as a complication of head injury in adulthood? Acta Neurochir (Wien) 2004; 146: 623.

8. Zweig JL, Carrau RL, Celin SE, et al. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success. Otolaryngology Head Neck Surg 2000; 123: 195-201.

9. Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110: 1166-1172.

10. Hughes RGM, Jones NS, Robertson IJA. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: The Nottingham experience. Journal of Laryngology and Otology 1997; 111: 125-128.

11. Snyderman CH, Kassam AB, Carrau R, Mintz A. Endoscopic Reconstruction of Cranial Base Defects following Endonasal Skull Base Surgery. Skull Base 2007; 17: 73-78.

12. Gendeh BS, Mazita A, Selladurai BM, et al. Endonasal endoscopic repair of anterior skull base fistulas: The Kuala Lumpur experience Journal of Laryngology and Otology 2005; 119: 866-874.

13. Gendeh BS, Wormald PJ, Forer M, Goh BS, Misisran K. Endoscopic repair of spontaneous cerebro-spinal fluid rhinorrhea: A repair of 3cases. Medical Journal of Malaysia 2002; 57: 503- 508.