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Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 3  |  Page : 434-436

A novel minimally invasive endoscopic repair in a case of spontaneous CSF rhinorrhea with persistent craniopharyngeal canal


1 Department of Otolaryngology and Head-Neck Surgery, PGIMER, Chandigarh Chandigarh, India
2 Department of Neurosurgery, PGIMER, Chandigarh, India

Date of Web Publication5-Jun-2015

Correspondence Address:
Karan Gupta
Department of Otolaryngology and Head-Neck Surgery, PGIMER, Chandigarh Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.158243

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How to cite this article:
Mohindra S, Gupta K, Mohindra S. A novel minimally invasive endoscopic repair in a case of spontaneous CSF rhinorrhea with persistent craniopharyngeal canal. Neurol India 2015;63:434-6

How to cite this URL:
Mohindra S, Gupta K, Mohindra S. A novel minimally invasive endoscopic repair in a case of spontaneous CSF rhinorrhea with persistent craniopharyngeal canal. Neurol India [serial online] 2015 [cited 2019 Sep 17];63:434-6. Available from: http://www.neurologyindia.com/text.asp?2015/63/3/434/158243


Sir,

Persistent hypophyseal (craniopharyngeal) canal is a rare congenital skull base defect. It extends from the floor of the sella turcica to the nasopharynx and is less than 1.5 mm in diameter. The term craniopharyngeal canal is also used to describe a rarer and much larger bony canal in the same location, which has been referred to as the large craniopharyngeal canal or trans-sphenoidal canal by Currarino et al. [1] Some authors relate its origin to the route of ascent of the Rathke's pouch to the sella turcica;[1],[2],[3],[4] whereas, others propose that it is a vestige of a former vascular channel that develops during the ossification of the sphenoid bone. [4],[5]

A 16-year-old male patient presented with a history of intermittent watery nasal discharge, spontaneous in onset, not associated with headache and anosmia, with no history of trauma. An endoscopic examination with 0˚ rigid nasal endoscope showed a 10 mm × 10 mm opening present in the roof of the nasopharynx in the midline with frank leak of watery fluid seen from the opening. An analysis of the fluid collected from the nasal cavity was positive for β-transferrin, confirming the presence of cerebrospinal fluid (CSF).

The patient underwent a high-definition three-dimensional computed tomography (CT) of the skull base with CT cisternography, which revealed CSF leak from a persistent craniopharyngeal canal. On CT, a bony canal measuring 18 mm in diameter with smooth margins extending from the floor of the sella turcica to the nasopharynx was seen [Figure 1]a-d. No other bony anomaly was noted.
Figure 1: (a) Computed tomographic cisternography axial cut bony window showing the bony canal (18 mm) running through the sphenoid; (b) The coronal image, bone window showing the bony canal (18 mm) connecting the sella with the nasopharynx; (c) The sagittal image showing the bony canal between the sella turcica and the nasopharynx; (d) T1 - weighted sagittal magnetic resonance imaging image showing the normally placed pituitary gland in the sella turcica; (e) The 0˚endoscopic view of the opening of the bony canal on the floor of the sphenoid sinus; and, (f) 0˚endoscopic view of the defect reconstructed with muscle, fat and fascia lata harvested from the thigh

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Magnetic resonance imaging confirmed the findings and ruled out the absence or abnormal position of the pituitary gland.

The patient was taken up for endoscopic repair and reinforcement of the floor of the sphenoid was performed after resecting the attachment of the craniopharyngeal canal from the inter-sphenoid sinus floor. The defect was reconstructed using muscle, fat and fascia harvested from the thigh [Figure 1]e and f. The patient was doing well after 10 months of follow-up [Figure 2].
Figure 2: Post - operative T2 - weighted sagittal magnetic resonance imaging image showing the surgical repair of the craniopharyngeal canal with obliteration of lower end of the canal

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The term "craniopharyngeal canal" or "persistent hypophyseal canal" is generally used to describe a small and vertical midline defect in the skull base that measures <1.5 mm in diameter. Persistent craniopharyngeal canal is a rare entity first described by Landzert et al. in 1868 [6] that has been reported in 5-10% of live births [6] and up to 0.42% of the asymptomatic population.

During the embryological development of the sphenoid bone, the channel is described as being located at the junction of the basi-pre-sphenoid and the basi-post-sphenoid. [2],[5],[7] It closes at the end of the 10 th week of embryological development. [7]

The most frequent symptoms are related to pituitary malfunction due to compression of the gland [3],[6] or to unintended hypophysectomy after adenoidectomy (that was being carried out to alleviate the respiratory distress). [2]

The literature describes the treatment of this malformation in the same context as the management of trans-sphenoidal encephaloceles. Most of the authors agree for the need of surgical repair in the cases showing rhinorrhea, recurrent meningitis or respiratory distress due to the presence of a pharyngeal mass. [8],[9],[10] Historically, the surgical approach included two different options, trans-cranial and trans-oral-trans-palatal routes. The trans-cranial route allows a good repositioning of the herniated tissue and the closure of the bony defect with a periosteal flap with or without frontal bone fragment. [10] It has been associated with morbidity in up to 70% and mortality up to 50% of patients, [8],[9],[10] mainly due to unintended hypophysectomy during herniated tissue resection, or due to CSF leakage. The trans-oral-trans-palatal approach, a minimally invasive procedure, allows the closure of the defect and the repair of the mucosal plane. But, it requires some kind of relaxation of the dural sac by fenestration or by CSF diversion. [8],[9] The main risks associated with this approach are infection, CSF leakage and the lack of identification of the herniated tissue. [8],[9],[10]

We report a novel minimally invasive endoscopic surgical technique of reconstruction and obliteration of the craniopharyngeal canal. The canal attachment is first resected from the inter-sphenoid floor and separated from the sphenoidal walls, and the defect obliterated by a triple-layer reconstruction consisting of muscle, fat and fascia.

 
  References Top

1.
Currarino G, Maravilla KR, Salyer KE. Transsphenoidal canal (large craniopharyngeal canal) and its pathologic implications. AJNR Am J Neuroradiol 1985;6:39-43.  Back to cited text no. 1
    
2.
Hughes ML, Carty AT, White FE. Persistent hypophyseal (craniopharyngeal) canal. Br J Radiol 1999;72:204-6.  Back to cited text no. 2
    
3.
Ekinci G, Kilic T, Baltacioglu F, Elmaci I, Altun E, Pamir MN, et al. Transsphenoidal (large craniopharyngeal) canal associated with a normally functioning pituitary gland and nasopharyngeal extension, hyperprolactinemia, and hypothalamic hamartoma. Am J Roentgenol 2003;180:76-7.  Back to cited text no. 3
    
4.
Lopatin AS, Kapitanov DN, Potapov AA. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg 2003;129:859-63.  Back to cited text no. 4
    
5.
Madeline LA, Elster AD. Postnatal development of the central skull base: Normal variants. Radiology 1995;196:757-63.  Back to cited text no. 5
    
6.
Meder JF, Melanson D, Ethier R. Persistent craniopharyngeal canal. Apropos of 3 radiologic studies. J Neuroradiol 1983;10:265-74.  Back to cited text no. 6
    
7.
Madeline LA, Elster AD. Suture closure in the human chondrocranium: CT assessment. Radiology 1995;196:747-56.  Back to cited text no. 7
    
8.
Kai Y, Nagahiro S, Yoshioka S, Ushio Y. Application of the skull base technique to the repair of transsphenoidal meningoencephaloceles. Pediatr Neurosurg 1996;25:54-6.  Back to cited text no. 8
    
9.
Kennedy EM, Gruber DP, Billmire DA, Crone KR. Transpalatal approach for the extracranial surgical repair of transsphenoidal cephaloceles in children. J Neurosurg1997;87:677-81.  Back to cited text no. 9
    
10.
Lewin ML. Sphenoethmoidal cephalocele with cleft palate: Transpalatal versus transcranial repair. Report of two cases. J Neurosurg 1983;58:924-31.  Back to cited text no. 10
    


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