Cerebrospinal fluid (CSF) rhinorrhea can result from a variety of causes, including traumatic, iatrogenic, and spontaneous events [1]. The presence of CSF rhinorrhea indicates the formation of a pathway between the brain and the external environment via the nasal cavity, posing a risk of infection that necessitates prompt medical attention. Treatment options range from conservative management to immediate surgical intervention. The choice of treatment largely depends on a thorough history to ascertain the cause of the CSF leak. Previous research indicates that while most trauma-induced CSF leaks resolve spontaneously within 7 to 10 days, nontraumatic CSF leaks typically do not improve with conservative management and instead require surgical repair [2,3].

In this case, the patient initially withheld the true cause of the CSF leakage but disclosed during the course of treatment that it had occurred following a faith healing ritual performed by a pseudo-religious group.

A 56-year-old man presented to the emergency room with a sudden onset of drowsiness that began 2 hours before his arrival. Four days prior, the patient had experienced a copious right-sided watery nasal discharge after blowing his nose and was hospitalized at an outside facility with suspected acute sinusitis. On the day of his presentation, he developed a fever and drowsy consciousness. Brain computed tomography (CT) revealed massive pneumocephalus, prompting his transfer to our hospital. Due to the patient’s drowsy state, direct history-taking was not feasible, so we obtained his medical records from the outside hospital. His medical history included hypertension, with no reported history of prior surgery or trauma. Nasal endoscopy performed upon his arrival in the emergency room revealed a septal perforation approximately 2 cm in diameter, located about 0.5 cm posterior to the caudal margin and 1 cm above the nasal floor. Watery discharge was present within the right nasal cavity, but it was not actively leaking (Fig. 1). The Valsalva maneuver did not meaningfully alter the discharge, complicating the differentiation from typical nasal discharge. Paranasal sinus CT showed massive pneumocephalus, a large defect and fracture in the nasal septum, and a 0.4- cm defect in the posterior wall of the right sphenoid sinus. This wall defect was also visible on coronal and sagittal views. Magnetic resonance imaging (MRI) confirmed these findings, with evidence of a CSF leak through the wall defect site (Fig. 2). No other abnormalities or potential causes of the leak were identified on the brain MRI scan (Fig. 3).

The patient was diagnosed with CSF leakage accompanied by septal perforation. Lumbar drainage was performed, followed by a planned repair of the skull base using a trans-septal approach. In the operating room, the previously identified large septal perforation was confirmed. Given the unusual nature of the case, a biopsy was taken from the posterior margin of the perforation. The area of the septal perforation was dissected, and bilateral septal mucosal flaps were elevated. The mucosa on both sides separated without resistance, as if dissection had been previously performed. The septal cartilage was mostly absent, including in the perforated area, and the septal bone was extensively fractured, with a portion of the rostrum also missing. At the orifice of the right sphenoid sinus, mucosal pulsation was observed. A biopsy was taken after the mucosa was removed. Following the removal of all mucosa, endoscopic examination revealed a circular defect of approximately 4 mm on the posterior wall of the right sphenoid sinus, accompanied by CSF leakage (Fig. 4). No other CSF leakage was observed outside this defect. The wall defect was repaired using harvested bone, Megaderm (L&C Bio), Tachosil (Takeda Pharma), and Tissel (Baxter). The reconstruction was completed with a nasoseptal flap, which was smaller than usual due to the septal perforation but sufficient for the repair (Fig. 5). After ensuring the absence of visible leakage, the surgical site was packed with Gelfoam (Pfizer) and Merocel (Medtronic), and the procedure was concluded. Postoperatively, we prescribed intravenous antibiotics, including ceftriaxone 2 g twice daily and both vancomycin 1 g and metronidazole 500 mg three times daily, for 10 days.

Postoperative pathology revealed that the right sphenoid mucosa contained giant cells, as well as acute and chronic inflammation, accompanied by a foreign body reaction. The margin of the left septal perforation exhibited acute inflammation with necrosis. Based on intraoperative findings, we suspected that the CSF leakage was caused by iatrogenic trauma. We planned to obtain a detailed patient history after the patient regained full consciousness. The patient remained hospitalized for 10 days following surgery, during which time his condition stabilized, leading to his subsequent discharge. Upon regaining consciousness and being interviewed, he denied any history of significant surgery or trauma.

At the 2-month postoperative follow-up endoscopy, the size of the septal perforation was unchanged, and the surgical site appeared stable (Fig. 6). During the outpatient visit, the patient revealed that he had participated in faith healing sessions at a religious facility, where a metal rod-like instrument was inserted into his nose repeatedly. This facility had previously been featured on various television programs for causing similar problems.

With recent advancements in endoscopic technology and the growing number of cases employing this surgical approach, understanding endoscopic skull base reconstruction has become essential in rhinology [4,5]. The primary objectives of skull base reconstruction are to: 1) establish a protective barrier to reduce the risk of infection, 2) minimize dead space, and 3) prevent the descent of intracranial contents. Overpacking the defect area should be avoided as it can apply pressure to critical structures, potentially resulting in temporary or permanent cranial nerve palsy. Thus, appropriate initial intervention is vital for the patient’s prognosis, and the procedure should adhere to established principles. Regarding the timing of endoscopic reconstruction, CSF leakage due to trauma often resolves spontaneously within 7–10 days. While observation may be suitable in cases with concurrent trauma, the risk of complications such as meningitis warrants consideration of immediate reconstruction in the absence of other injuries. Similarly, when iatrogenic trauma is identified intraoperatively, prompt surgical intervention becomes imperative [2,6]. Defect reconstruction typically employs a multilayer approach, combining underlay (subdural) and overlay (epidural and beneath the skull base bone) techniques depending on the patient’s condition [6,7]. This may involve using free grafts or pedicled flaps. Free grafts can be autologous tissues, such as mucosa, cartilage, bone, fascia, or fat, or various commercially available materials (e.g., Surgicel, Gelfoam, Tachosil, Duraseal, Hemopatch, Megaderm, etc.). This case details the successful endoscopic reconstruction of a skull base defect following trauma, in line with the principles described above. Notably, the trauma was caused by a faith healing ritual from a pseudo-religious group, an uncommon source of such injuries. Identifying the cause of CSF leakage and formulating an appropriate treatment plan is crucial. However, in cases of indeterminate cause, rapid decision-making based on the patient’s condition is key to optimal recovery. Moreover, since surgical treatment is relatively straightforward and carries minimal morbidity risk, the authors advocate for proactive consideration of surgical intervention.