Spontaneous cerebrospinal fluid rhinorrhea in untreated macroprolactinoma--an indication for primary surgical therapy

Medical therapy is usually indicated as first-line treatment for prolactinomas. Surgery is generally reserved as second-line therapy if prolactinomas are non-responsive to dopamine agonists (DA) or DA therapy is not tolerated. Herein, we draw attention to the rare occurrence of spontaneous CSF rhinorrhea in prolactinomas requiring primary surgical therapy. Only 8 cases of confirmed prolactinomas with spontaneous rhinorrhea have been reported in the literature so far.

Two out of 267 surgical cases with pituitary adenomas presented with spontaneous rhinorrhea. Both patients harbored invasive prolactinomas. In both cases, the defect was exposed using a transsphenoidal procedure and was sealed with fascia lata.

Urgent surgical repair of the leak prevented meningitis. In one case, a second operation was required due to recurrent rhinorrhea under postoperative dopamine-agonist therapy of the residual tumor. The clinical course was otherwise uncomplicated.

Certain clinical settings still require primary surgical therapy of prolactinomas. Spontaneous rhinorrhea caused by invasive macroprolactinomas represents a mandatory indication for initial surgery. Early detection and surgical repair of a CSF leak is crucial for a favorable clinical outcome.