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|NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS
|Year : 2019 | Volume
| Issue : 1 | Page : 71-72
Endoscopic transpterygoid repair of cerebrospinal fluid leaks from lateral recess of sphenoid
Department of Otorhinolaryngology and Skull Base Surgery, Nanavati Superspeciality Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||7-Mar-2019|
Dr. Narayan Jayashankar
Department of Otorhinolaryngology and Skull Base Surgery, Nanavati Superspeciality Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jayashankar N. Endoscopic transpterygoid repair of cerebrospinal fluid leaks from lateral recess of sphenoid. Neurol India 2019;67:71-2
Cerebrospinal fluid (CSF) rhinorrhea was in the past exclusively considered the domain of neurosurgeons and treated through the craniotomy route. The first such neurosurgical repair of CSF leak was performed by Dandy in 1926. Hirsh in 1952 used a transnasal route to repair a sphenoid sinus CSF leak using septal flaps. Harold Hopkins in 1960 developed the rod lens system that dramatically improved visualization, delivered distal illumination, and provided a wider field of visualization. Messerklinger in 1978 used the rod lens system to visualize the lateral nasal wall and study mucociliary transport, thus starting the transnasal endoscopic surgery revolution. Hosemann and Wigand reported on the successful use of endoscopes for transnasal repair of dural defects. Closure of CSF rhinorrhea was then popularized transnasally using endoscopes by several others.,, Endoscopic closure of CSF leaks has now become an accepted and standard practice. At our center, routinely endoscopic repair of CSF leaks is performed except when there is a posttraumatic persistent leak from the frontal sinus, for which a craniotomy is preferred with a multilayered closure including a pericranial flap. Interdisciplinary cooperation between the otorhinolaryngologist and the neurosurgeon is essential to achieve the best outcome with least morbidity.
Sphenoid lateral sinus leaks were considered to be spontaneous and from the Sternberg's canal. Sternberg's canal has been described as a point of incomplete bony fusion during the formation of sphenoid bone, located at the posterior portion of the lateral sphenoid wall, laterally and inferiorly to the maxillary (V2) division of the trigeminal nerve at the foramen rotundum. This closes with connective tissue after development and was considered as a point of least resistance in the lateral wall of sphenoid. However, the presence of Sternberg's canal as the etiological factor has been debated and this subject is extremely controversial. Baranano performed a high-resolution computed tomographic scan in 1000 sphenoid bones and concluded that only one sphenoid bone had a typical location of Sternberg's canal medial to the maxillary (V2) division of trigeminal nerve. However, most CSF leaks from the lateral wall of sphenoid occur lateral to the V2 division of the trigeminal nerve and lateral to the centers of ossification. This is not the typical embryological location of the Sternberg's canal. Hence, the sites of leak in the lateral sphenoid recess are acquired rather than spontaneous. Arachnoid pits are consistently associated with CSF leaks occurring from the lateral sinus of sphenoid, and these pits when associated with intracranial hypertension  are considered as contributory factors for CSF rhinorrhea from this location. It is important to look for features suggestive of intracranial hypertension and arachnoid pits in the lateral wall of sphenoid in the preoperative scans of these subjects., Persistent intracranial hypertension causes these arachnoid pits to create a defect in the lateral sphenoid wall through which arachnoid herniates with the development of a meningocele [Figure 1] or meningoencephalocele. For obtaining a high sensitivity image, a computed tomography (CT) cisternography, magnetic resonance (MR) cisternography, or a combination of both – a high-resolution CT and MR cisternography – in the presence of inactive leaks, is recommended.
|Figure 1: Coronal heavily T2-weighted image reveals a lobulated CSF intensity area extending along the inferomedial margin of the right temporal lobe, herniating through the lateral recess of sphenoid into the sphenoid sinus. This represents a meningocele|
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There have been various reports in literature about CSF leaks occurring from the lateral recess of sphenoid. The transpterygoid approach to the lateral recess of sphenoid to plug the CSF leak has been described in various publications.,, Others have also described associated expansile lesions like meningoencephalocele, mucocoele, tumors, and malignancy. It should be noted that meningoencephaloceles ,, are frequently associated with leaks from lateral recess of the sphenoid. The approach is mainly characterized by a wide maxillary antrostomy upto the posterior wall of maxillary antrum. The posterior wall of maxillary sinus is removed in its medial half to expose the pterygopalatine fossa. The sphenopalatine artery is located just posterior to the crista ethmoidalis and is isolated and clipped. An ethmoidectomy and sphenoidotomy is also performed. The sphenoidotomy opening is widened laterally. Exposure of the lateral recess of sphenoid is limited by the base of pterygoid. The pterygopalatine ganglion and the associated neurovascular structures are retracted and the pterygoid base is drilled out to expose the lateral recess.
The article by Rajasekar G et al., discusses their experience with seven subjects of CSF leak from the lateral recess of sphenoid sinus with different etiologies. Five subjects had features of raised intracranial pressure. They have described the standard endoscopic transpterygoid approach for access to this area. It is noted that they have retracted the pterygopalatine ganglion laterally to drill the base of pterygoid. This step is important to preserve the neurovascular structures in the area and thereby retain a good quality of life in these subjects following the procedure. They have sealed the defect with inlay fat, fascia lata, and cartilage. They have used a pedicled nasoseptal flap in four subjects and a free mucosal graft from the ipsilateral middle turbinate in three subjects. They have outlined their preference for using the pedicled flap in large defects or bilateral defects. This is a perfectly acceptable technique. I personally, however, plug the defect with inlay fat, onlay fascia with the cartilage over it, pushing the fascia into the defect similar to a gasket seal of the defect. The cartilage thus snugly fits the defect like a cork. The pedicled nasoseptal flap from the opposite side is used additionally by me since these leaks are usually associated with raised intracranial pressure and the bone around the defect may be rarefied. The nasoseptal flap covers a broader area than the defect, and thus, in my view, offers protection to the lateral sphenoid wall surrounding the defect. As mentioned in the article by Rajasekar et al., it is very important to deal with the etiology causing the raised intracranial pressure or alternatively use a CSF diversion in these cases of raised ICP. Their excellent technique has also been reflected in their results wherein there has been no recurrence of CSF leak in their series during a mean follow-up of 16.5 months.
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