The patient came to the clinic 21-April-2013 complaining of CSF leak from the right nostril for 1 month, which stopped the last week. The patient had right otitis media 2 years ago and was treated accordingly then underwent surgical correction for septal deviation 12 months ago.

MRI of the brain done 11-April-2013 showing massive sinusitis with polyps of both maxillary sinuses with deformity of the right olfactory groove and disappearance of the right substacia cribrosa and CSF pocket extending down to the nasal septum right side. CT-scan also showing the wide bone defect at the mentioned area.

On examination: The patient has anosmia both sides. No meningeal signs. Otherwise neurologically free.

Bifrontal approach with reflection of the bone flap to the right ear. The dura was opened parallel to the inferior border of the craniotomy. The dura was dissected around the huge bone defect in the area of the right  olfactory bulb and planum sphenoidale. The brain substance was extruding to the bone defect, for what resection of the herniated material was coagulated and bisected. The dural defect was identified at the bony defect site and using Lyodura, the dural defect was water-tightly closed. sometimes intradural and other time extradural. A small bone harvested from the cranium was used to fill the bone defect. A piece of muscle was used over the bone graft. and Surgicele was put under the Lyodura.

Routine closure of the wound. Smooth postoperative recovery. The patient sent to the ICU for 24 hour observation.

The patient was discharged in 14-June-2013 and he progressed at home tonic-clonic convulsion with secondary generalization with a direct trauma to the craniotomy site. He was admitted to Shmaisani hospital and CT-scan of the brain was done immediately showed normal brain structures and the bony alignments are acceptable. Daily evacuation of bloody exudate about 40 ml was evacuated from under the flap and he was discharged 21-June-2013 to keep in Tegretol CR 400 twice daily and Epanutin 100 mg three times a day.

The cause of the CSF leak is mostly a growing fracture of the substacia cribrosa after performed septal deviation correction. The bone at this area is very thin and minimal trauma cold lead to fracture.

The bone defect is large enough, that it can be sealed only by surgical means.