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Table of Contents    
NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 73

Endonasal transpterygoid approach for lateral sphenoid recess cerebrospinal fluid leaks: Technical aspects


Department of Neurosurgery, Yashoda Hospital, Secunderabad, Telangana, India

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Anandh Balasubramaniam
Department of Neurosurgery, Yashoda Hospital, Alexander Road, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.253591

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How to cite this article:
Balasubramaniam A. Endonasal transpterygoid approach for lateral sphenoid recess cerebrospinal fluid leaks: Technical aspects. Neurol India 2019;67:73

How to cite this URL:
Balasubramaniam A. Endonasal transpterygoid approach for lateral sphenoid recess cerebrospinal fluid leaks: Technical aspects. Neurol India [serial online] 2019 [cited 2019 Mar 18];67:73. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/73/253591




Rajasekar et al., have elegantly shown good outcomes with endonasal transpterygoid approach for lateral sphenoid recess cerebrospinal fluid (CSF) leaks. They have rightfully brought attention to the associated raised intracranial pressure (ICP) that also needs treatment.[1]

With the evolution of endoscopic endonasal skull base techniques, rapid advances have been made in approaching difficult skull base areas in a minimally invasive way, limiting the morbidity of intracranial approaches. The transpterygoid approach to the lateral sphenoidal recess not only avoids a craniotomy but also provides a panaromic view and an increased freedom of maneuverability for excecuting a multilayered reconstruction for the defects, critical for the success of CSF leak repairs.[2]

However, certain points need to be emphasized on the technical aspects of the approach. While addressing the sphenopalatine artery, it needs to be kept in mind that coagulation of the artery will render the posterior naso septal flap avascular on the same side. If the flap is planned for use in reconstruction, it has to be used as a free flap or the opposite side flap can be harvested.[2] Neurological complications have been reported, including parenchymal hemorrhage, seizure, hemipalatal hypesthesia and dry eyes secondary to the encephalocele repairs, and pterygopalatine ganglion and maxillary nerve injuries.[3]

All lateral recess leaks may not need the transpterygoid approaches. Depending on the need of access during the surgery, the extent of lateral exposure can be modified/limited as needed, keeping in mind the structures at risk. This could also reduce the surgical time and avoid unnecessary risk ofcomplications in many cases.[4]

Patients with spontaneous CSF leak tend to have more chances of raised ICP than their counterparts who have sustained a traumatic injury. The failures of the repair procedure too are high in the spontaneous group, if raised ICP features are not looked for and corrected. Correcting the CSF pressure alone with CSF shunting may worsen the risk of meningitis and is not advised without repairing the defect. It is recommended to attend to the raised pressure with CSF diversion/mass removal along with the repair of the CSF leak in patients who have signs of raised ICP at the time of the leak.[5]

In patients who do not have any signs of raised pressure at the time of leak, the authors' suggestion of following up the patients with measurement of CSF pressure at 3 weeks seems reasonable.



 
 » References Top

1.
Rajasekar G, Nair P, Abraham M, Felix V, Karthikayan A. Cerebrospinal fluid rhinorrhea from the lateral recess of sphenoid sinus: More to it than meets the eye. Neurol India 2019;67:201-6.  Back to cited text no. 1
  [Full text]  
2.
Schmidt RF, Choudhry OJ, Raviv J, Baredes S, Casiano RR, Eloy JA, et al. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus 2012;32:E5.  Back to cited text no. 2
    
3.
Caballero N, Welch K, Lininge L. Complications associated with a transpterygoid approach to meningoencephalocele repair. J Neurol Surg B 2012;73-A121.  Back to cited text no. 3
    
4.
Turner JH, Dubin M, Quinones-Hinojosa A, Boahene DO. Repair of CSF leaks in the lateral recess of the sphenoid sinus transsphenoid vs. transpterygoid approach. Laryngoscope 2011;121(Suppl. 4). Available from: https://jhu.pure.elsevier.com/en/publications/repair­of-csf-leaks-in-the-lateral-recess-of-the-sphenoid-sinus-t-6. [Last accessed on 2019 Oct 02].  Back to cited text no. 4
    
5.
Pérez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2013;33:330-7.  Back to cited text no. 5
    




 

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