Abstract
BACKGROUND: CSF leaks are common complications after cerebellopontine angle tumor surgeries, often through the eustachian tube (ET). Repair techniques, including endoscopic endonasal ET obliteration, have failure rates up to 20%. OBSERVATIONS: A 31-year-old male developed CSF rhinorrhea after resection of a left cerebellopontine angle acoustic neuroma. Multiple interventions, including lumbar drainage, craniotomy with fat grafting, and intranasal ET obliteration with N-butyl-2 cyanoacrylate-Lipiodol, failed. The patient later developed recurrent CSF rhinorrhea and pneumocephalus. He underwent endoscopic nasopharyngectomy and pedicled nasoseptal flap (NSF) closure, which successfully resolved the symptoms. At the 1-year follow-up, the patient remained asymptomatic with no recurrence of CSF rhinorrhea or pneumocephalus, and complete mucosal healing was observed. LESSONS: Endoscopic nasopharyngectomy with pedicled NSF closure may be an effective salvage technique for refractory CSF rhinorrhea after multiple failed interventions, including in cases complicated by pneumocephalus. https://thejns.org/doi/10.3171/CASE25269.