To the Editor:
The article by Thakur et al, “Commentary: Maximilian Sternberg (1863-1934): The Man Behind Sternberg's Canal and His Contribution to the Modern-Day Skull Base Anatomy and Neuroscience—Historical Vignette,”1 states the persistence of congenital Sternberg’s canal predisposes patients to spontaneous lateral cerebrospinal fluid (CSF) leaks.2 The suggestion that congenital persistence of Sternberg's canal is associated with lateral sphenoid recess CSF leaks is invalid and unsupported by prior literature.
The article misidentifies the location of the Sternberg canal (as seen in their Figure 2C), which could explain the authors’ misattribution of its existence to lateral sphenoid CSF leaks (Figure).1,3 While Thakur et al1 accurately describe the embryological formation of the canal, they fail to consider its trajectory occurs medial to the superior orbital fissure. This relationship is notable since the vast majority of lateral sphenoid CSF leaks occur lateral to the infraorbital nerve and foramen rotundum, which nullifies the proposed statement that lateral sphenoid CSF leaks occur due to persistent Sternberg's canal.4
Lateral sphenoid CSF leaks most often develop due to chronic pressure erosion from persistently elevated intracranial hypertension rather than a congenital etiology. Illing et al5 evaluated 77 patients with lateral sphenoid CSF leaks and identified that 96% of patients displayed signs of intracranial hypertension on radiological imaging (ie, empty sella, attenuation of the skull base) and 95% had objective evidence of elevated open postsurgical lumbar drain or ventriculostomy pressure. Idiopathic intracranial hypertension (IIH) has a complex pathophysiology that often requires a multidisciplinary approach for treatment that includes weight loss, pharmacotherapy, and surgical interventions.6-10
In conclusion, we suggest the authors of the manuscript reconsider the claim that Sternberg's canal is significantly associated with lateral sphenoid CSF leaks. There is overwhelming evidence contradicting this premise, and we feel it should be eliminated from the literature.
This study did not receive any funding or financial support.
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Dr Woodworth is a consultant for Cook Medical, Baxter, and Smith and Nephew. Dr Grayson serves on the advisory board for GlaxoSmithKline Plc.
1. Thakur JD, Manzi B, Savardekar AR, Singh MP, Menger R, Nanda A. Commentary: Maximilian Sternberg (1863-1934): the man behind Sternberg's canal and his contribution to the modern-day skull base anatomy and neuroscience—historical vignette. Neurosurgery. 2018;83(3):E120-E124.
2. Aaron G, Doyle J, Vaphiades MS, Riley KO, Woodworth BA. Increased intracranial pressure in spontaneous CSF leak patients is not associated with papilledema. Otolaryngol Head Neck Surg. 2014;151(6):1061-1066.
3. van Gilse PHG. Investigations on the development of the sphenoidal sinus. J Laryngol Otol. 1926;41(3):137-144.
4. Baranano CF, Cure J, Palmer JN, Woodworth BA. Sternberg's canal: fact or fiction?Am J Rhinol Allergy. 2009;23(2):167-171.
5. Illing E, Schlosser RJ, Palmer JN, Cure J, Fox N, Woodworth BA. Spontaneous sphenoid lateral recess cerebrospinal fluid leaks arise from intracranial hypertension, not Sternberg's canal. Int Forum Allergy Rhinol. 2014;4(3):246-250.
6. Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Laryngoscope. 2017;127(9):2011-2016.
7. McCormick JP, Tilak A, Lampkin HB, et al. An expedited intracranial pressure monitoring protocol following spontaneous CSF leak repair. Laryngoscope. 2021;131(2):E408-E412.
8. Chaaban MR, Illing E, Riley KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation. Laryngoscope. 2014;124(1):70-75.
9. Chaaban MR, Illing E, Riley KO, Woodworth BA. Acetazolamide for high intracranial pressure cerebrospinal fluid leaks. Int Forum Allergy Rhinol. 2013;3(9):718-721.
10. Woodworth BA, Prince A, Chiu AG, et al. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg. 2008;138(6):715-720.
We would like to acknowledge the editors of the Journal of Laryngology and Otology for their assistance in providing Figure for the manuscript from their original article “Investigations on the Development of the Sphenoidal Sinus.”