The patient came to the clinic 17-May-2010 complaining of massive CSF leak from the left nostril for 2 months with failed conservative treatment. The patient suffered blunt injury to the forehead three months ago with direct injury to the forehead.

CT-scan of the brain with frontal and axial cuts with bone window thin cuts performed 24-April-2010 showing filling of the ethmoid sinus in the left side with small bony defect 10 mm lateral to the crista Galli with fluid filling the ethmoid sinus under the bony defect and down to the left maxillary sinus.

On examination the patient is neurologically free with preservation of olfaction.

Bifrontal skin flap was created and reflected to the nose. Using 2 small burr holes a bony flap was was created symmetrical to the midline , violating during that the frontal sinus. Careful extradural dissection of the left orbital roof. The crista Galli was seen and the ethmoidal bony defect was identified with the dural defect was also seen. There was only one bony defect 4X4 mm rounded in shape with smooth edges. The dura near the olfactory bulb was not violated to avoid traction injury to the olfactory bulb. A small piece of muscle was impacted to the bony defect in hourglass shape. The dural defects were repaired using Nylon 6 zero. Using artificial dura and Glubran the bony and dural defects were also sealed to provide more security, so as not to miss micro defects.

Routine closure of the wound.

Smooth postoperative recovery with no CSF leak coming from the nose.

The ethmoid sinuses are tiny bony structures and minor injury can cause fractures of these bones. Growing fracture of the bone could be the detrimental factor in the appearance of such complication.

In no way this repair can be achieved through trans-nasal approach. Only subfrontal approach can give the confidence of identifying and taking the appropriate measures to prevent CSF leak.