1
Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, College of Medicine, Incheon St. Mary’ s Hospital, Incheon, Korea
2
Department of Neurosurgery, The Catholic University of Korea, College of Medicine, Incheon St. Mary’ s Hospital, Incheon, Korea
Hyun-Il Shin
1, Wan-Soo Yoon
2, Jung-Hwan Kim
1, Dong-Hyun Kim
1Endoscopic endonasal transpterygoid approach for repair of a cerebrospinal fluid leak from the lateral extension of the sphenoid
sinus
J Korean Skull Base Society 13권 1호 : 30~34, 2018
종설1 종설2 원저1
증례1 원저2
증례2 증례3 증례4 증례5
Cerebrospinal fluid (CSF) leaks from the middle cranial fossa into the lateral extension of the sphenoid sinus are rare. In the past, the treatment of choice has been closure via a craniotomy.
Only a few cases have been reported; these involved successful treatment using endoscopic surgery with navigation guidance. We treated one patient with a meningoencephalocele and CSF leak located in the lateral extension of the left sphenoid sinus. The CSF leakage site was repaired successfully via an endoscopic endonasal transpterygoid approach. Here we report this case and review the literature.
논문 접수일 : 2018년 5월 21일 논문 완료일 : 2018년 5월 23일
주소 : Department of Otorhinolaryngology-Head and Neck Surgery,
Incheon St. Mary’s Hospital, College of medicine, The Catholic University of Korea, 59 Dongsu-ro, Bupyung-gu, Incheon 21431, Korea
Tel : +82-32-280-5151 Fax : +82-32-280-5556 E-mail : [email protected]
Dong-Hyun Kim
교신저자
Cerebrospinal fluid, Cranial fossa middle, Endoscopy, Sphenoid sinus
Key Words
▒ INTRODUCTION
Cerebrospinal fluid (CSF) leaks from the middle cranial fossa through a lateral extension of the sphenoid are rare and pose a diagnostic and therapeutic challenge. Patients with a CSF leak from the sphenoid sinus present with intermittent rhinorrhea, which can be misdiagnosed as rhinitis and often delays the diagnosis.[1] In such cases, traditional surgical closure of the defect usually involves the transcranial approach.[2, 3]
However, the transcranial approach is more invasive because it requires a craniotomy and retraction of the temporal lobe.
[1] With advances in endoscopic skull base surgery, some instances have been repaired successfully through the endoscopic endonasal approach.[1, 4-9]
We have treated one patient with a meningoencephalocele and CSF leak located in the lateral extension of the sphenoid sinus. The defect site was successfully repaired through the endoscopic endonasal transpterygoid approach with navigation guidance. Here, we present this case and review the literature.
▒ CASE REPORT
A 30-year-old woman complained of intermittent watery rhinorrhea, which was especially aggravated in the prone position or when she bent forward. She had a history of mild head trauma to the left zygomatic area 1 year previously.
She had no other history of trauma or recent sinus disease.
On nasal endoscopy, clear watery fluid was observed in the left side of the nasal cavity. Computed tomography (CT) and magnetic resonance imaging scans of the paranasal sinuses showed a bone defect in the roof of the left lateral sphenoid sinus and a meningoencephalocele arising from the left temporal lobe (Fig. 1, 2).
Septoplasty and abdominal fat harvest were performed under general anesthesia to acquire the necessary nasal septal bone and fat. An endoscopic transpterygoid approach was then performed to resect the meningoencephalocele and to repair the skull base defect. For the transpterygoid approach, a wide maxillary antrostomy and total ethmoidectomy were performed. The posterior maxillary sinus wall mucosa was elevated. The posterior medial aspect of the maxillary sinus was resected to expose and resect the vertical portion of the palatine bone. Dissection was directed from the medial to lateral direction. The posterior wall of the maxillary sinus was removed with a J-curette. The fascial covering was incised, and the underlying adipose tissue was bluntly dissected. The sphenopalatine artery was clipped, transected, and retracted laterally. Fatty tissue was ablated using an Evac 70 coblation device (Arthrocare, Sunnyvale, CA, USA) passing through the pterygopalatine fossa.
After the anterior aspect of the pterygoid process was revealed, a portion of this bone was removed to allow entry
Fig. 1
A B C
Preoperative computed tomography (CT). Axial (A) and coronal (B) CT images show a bony defect (black arrow) of the lateral extension of the left sphenoid sinus roof. The mass (*)
in the lateral extension of the sphenoid sinus was connected to the parenchyma of the temporal lobe. The image did not change after enhancement (C).
to the lateral pterygoid recess of the sphenoid sinus. The meningoencephalocele was observed in the lateral recess of the left sphenoid sinus (Fig. 3). This meningoencephalocele was ablated with bipolar cautery. After resection of the meningoencephalocele, the skull base defect was exposed.
Septal vomer bone was placed above the defect site to prevent recurrence. A DuraGen dural onlay repair graft (Integra Life Sciences Corp., Plainsboro, NJ, USA) was applied to the defect site. A TachoSil (Baxter Healthcare Corp., Village, CA, USA) fibrin sealant patch was applied over the DuraGen graft. Fibrin glue was used to seal around the TachoSil patch. The lateral aspect of the sphenoid was then packed with abdominal fat.
Two-thirds of the anterior portion of the left middle turbinate was partially resected and rotated laterally to cover the defect.
The construct was supported by Gelfoam and nasal packing.
Postoperatively, the patient was neurologically intact and
showed no evidence of CSF leakage (Fig. 4). She complained of dryness of the left eye after surgery, but this symptom resolved spontaneously 3 months later. The reconstruction site had healed well by the 9-month follow-up.
▒ DISCUSSION
Pneumatization of the sphenoid sinus is variable and can involve a portion or the entire body of the sphenoid bone and its processes. This sometimes occurs in the pterygoid process and the greater wing of sphenoid,[4] but lateral sphenoid meningoencephaloceles are rare.[5] Some occur spontaneously, but most are secondary and can be caused by trauma, iatrogenic injury, or skull base erosion caused by inflammatory or neoplastic processes.[5, 6] The treatment options for this rare defect depend on the direction and size
Fig. 3
A B C D
Intraoperative images guided by the navigation system. Coronal (A), sagittal (B), axial (C), and overview (D) images show the meningoencephalocele in the lateral portion of the left sphenoid sinus. The point at which the bold and thin blue lines meet in each figure indicates the tip of the wand of the navigation system, which was located at the meningoencephalocele in the lateral portion of the left sphenoid sinus. Bold blue lines indicate the overall vector direction of the navigation.
Fig. 2
A B C
Preoperative magnetic resonance imaging shows a mass (*) with iso signal intensity similar to that of the brain on T1-weighted imaging (WI) (A) and iso- to slightly high signal
intensity on T2-WI (B) in the lateral portion of left sphenoid sinus. The image did not change after enhancement (C).
of the meningoencephalocele and the exact location of the bone defect. Surgical repair is more often successful for secondary meningoencephaloceles than for spontaneous meningoencephaloceles.[6] Our case was considered as secondary because of the patient’ s history of head trauma.
Traditionally, meningoencephaloceles are treated through the microsurgical transsphenoidal approach, frontotemporal-anterior middle cranial fossa approach, transmaxillary approach, or an external transethmoidal sphenoidotomy.[4, 5, 7] In most patients without lateral extension of the sphenoid sinus, this can be done via the transnasal or paranasal route using an endoscope or microscope.[1] The problems with the traditional approach are the limited visibility and maneuverability because of the obstructing nasal speculum,[7] risk of complications associated with brain retraction or facial incisions and osteotomy, and oblique surgical orientation, which can increase the risk of injury to the lateral wall and its vital neurovascular structures.[4, 5]
The endoscopic endonasal transpterygoid approach is a newer procedure. The advantage of this approach is its ability to offer a better visualization for repairing CSF leaks in the lateral recesses of the sphenoid sinus, which increase the surgical maneuverability without increasing the risk of complications associated with brain retraction or facial osteotomy.[4] The use of angled endoscopes and instruments is more helpful for visualizing and accessing the lateral sphenoid sinus.
Initial reports of treating these lesions transnasally
suggested a higher failure rate.[3, 7] The poor outcomes were the result of inadequate visualization of defects in the walls of the lateral recess of the sphenoid sinus. Whether it is better to approach the defects by opening the sphenoid ostium more by sufficient drilling (transnasal-transsphenoidal or transseptal-transsphenoidal approach) or by an endoscopic endonasal transpterygoid approach was discussed with the neurosurgeon. Considering that recent reports[7-9]
recommend the endoscopic endonasal transpterygoid approach to treat these lateral lesions, we decided to use the endoscopic endonasal transpterygoid approach in this case. In this case, the endoscopic endonasal transpterygoid approach was found to facilitate the operative field of view of the lesion in the lateral recess of the sphenoid sinus. However, the endoscopic transpterygoid approach to the lateral sphenoid has potential complications including bleeding and inadvertent central nervous system injury. A reduction in tear secretion from manipulation or resection of the sphenopalatine ganglia was a concern in this case.[7] Our patient complained of eye dryness after surgery, but the symptom resolved spontaneously within 3 months. Effective treatment requires proper surgical technique, an experienced surgeon who is familiar with the vascular elements, and a thorough knowledge of the anatomy of the surrounding structures. In selected cases, this approach enables the otolaryngologist or neurosurgeon to treat lesions of the lateral extension of the sphenoid sinus using an endoscopic technique.[4, 7]
Fig. 4
Postoperative computed tomography (CT) at 10 weeks after surgery. Axial (A) and coronal (B) CT show the reconstruction (black arrow) of the bony defect of the lateral extension of the left sphenoid sinus roof.
A B
