Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

Abstract

Objective and Importance: Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. Clinical Presentation: A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of b-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. Intervention: The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. Conclusion: In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess

“…We want to stress that the surgical approach should be tailored to the anatomic condition of the patient to control completely the CSF-leak region. We agree with many reports that for achieving a reliable exposure of SSLR, it is not always necessary to remove the pterygoid process completely [15,16,46].…”

Spontaneous Skull Base Meningoencephaloceles and Cerebrospinal Fluid Fistulas

“…On the other hand, the lateral recess of the sphenoid sinus undergoes extensive lateral pneumatization lateral to the foramen rotundum and into the pterygoid process, the greater wing of the sphenoid bone, or both, a process that occurs in as many as 27% of all adults (Fig 6) (8,16,18,24,28,30,38,39). Although formation of a spontaneous CSF fistula in the lateral sphenoid recess has been postulated to result from a persistent lateral craniopharyngeal, or Sternberg, canal (a congenital defect that results from incomplete fusion of the basisphenoid with the greater sphenoid wing and is situated along the course of the internal carotid artery, medial to the superior orbital fissure and foramen rotundum), its location in anatomic studies is inconsistent ( Fig 3).…”

“…Intermittent rhinorrhea may be misdiagnosed as vasomotor rhinitis, allergies, or other conditions (12,39). Dysfunction of herniated or adjacent structures (eg, the pituitary gland and optic chiasm) or, occasionally, epilepsy may be observed (1,43).…”

Abordaje endoscópico transpterigoideo y reparación de base de cráneo tras resección de meningoencefalocele esfenoidal. Nuestra experiencia

“…Solo se han publicado 4 complicaciones intracraneales postoperatorias (3 meningitis, un absceso cerebral) y todas ellas se solucionaron con antibióticos endovenosos y punción lumbar adicional en un caso 8,12,21 . En el caso de una meningitis y en el del absceso cerebral, la vía endoscópica de abordaje fue transetmoidoesfenoidal 8 estando las lesiones situadas en el RLE.…”