An Unprecedented Complication in Pharyngeal Flap Surgery: Cerebrospinal Fluid Leakage

Velopharyngeal insufficiency (VPI) arises from inadequate closure of the velopharyngeal unit, resulting in hypernasality. The primary approach for treating severe VPI is surgical intervention, most commonly through pharyngeal flap procedures. Although the pharyngeal flap has been considered the gold standard for the correction of VPI, recent studies have raised concerns about its safety, particularly due to significant complication rates. The pharyngeal flap is elevated above prevertebral fascia, which is anatomically proximate to both the clivus and the internal carotid artery. Various midline anomalies may coexist in patients presenting with isolated cleft palate and syndromic features, such as the case described here. We present the case of an 18-year-old female with atypical craniofacial features who underwent a pharyngeal flap procedure for VPI. Intraoperatively, cerebrospinal fluid (CSF) leakage was encountered but successfully managed with purse-string sutures. Postoperative imaging revealed pneumocephalus without active CSF leakage. Clinically, no postoperative CSF leakage was detected. The patient was discharged after antibiotics and showed significant speech improvement, with no neurological complications. This case highlights challenges and critical management strategies for complex craniofacial anatomy in pharyngeal flap surgery. In selected patient populations, preoperative computed tomography or magnetic resonance cisternography can help mitigate the risk of complications such as CSF leakage or injury to the internal carotid artery during the elevation of pharyngeal flap. A review of the existing literature did not reveal any previously published reports documenting this rare complication of CSF leakage. Level of Evidence: Level 5 case report.