Occult malformations of the skull base

Giant Cephalocele Case Mimicking Cystic Neoplasia in Skull Base

Petrous apex cephalocel, also called arachnoid cyst or meningocele, is a rare cephalocele caused by protrusion of the posterolateral wall of the Meckel cave to the petrous apex. Increased intracranial pressure is thought to play a role in etiopathogenesis and is generally asymptomatic. Radiologically, they are expansile lesions with the same density or intensity as cerebrospinal fluid and may mimic cystic masses. The diagnosis is made by showing the continuity with Meckel cave on magnetic resonance imaging. No intervention is required in asymptomatic patients; surgical treatment is applied in symptomatics.

A Rare Case of Sphenoid Encephalocoele Presenting with Fifth Cranial Nerve Involvement

A 14-year-old girl presented with chronic headache, recurrent episodes of vomiting, fever, and two episodes of generalized tonic clonic seizure in the past 2 months. Neuroimaging revealed herniation of the brain along with the dura through a defect in the left greater wing of the sphenoid. Left pterional craniotomy was carried out. Herniation of the dural sac along with its contents through the bony defect in the greater sphenoid wing was identified lateral to the V2 nerve passing through the foramen rotundum. The dural defect was repaired. Bony defect was covered with a circular titanium plate. The patient did not have cerebrospinal fluid rhinorrhea postoperatively. At 6-month follow-up, she was asymptomatic.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Excavating Meckel's cave: Cavum-trigeminale-cephaloceles (CTCs)

BACKGROUND AND PURPOSE

Cavum-trigeminale-cephaloceles (CTCs) are rare lesions of Meckel's cave and the petrous apex. Despite distinctive imaging features, they are frequently mistaken for other petrous apex lesions. In contrast to many of these entities, CTCs do--when asymptomatic--not require any invasive work-up or even surgical excision. Since correct diagnosis has profound impact on clinical decision-making, we report on a series of CTCs with distinct imaging features and their important differential diagnoses.

MATERIAL AND METHODS

We report a retrospective series of 5 patients with CTCs and the associated imaging features including the absence of diffusion restriction and solid contrast enhancement as well as their size, anatomical location with regard to adjacent structures and the remodeling or erosion of surrounding bony structures.

RESULTS

Our series contains the largest CTC that has, to the best of our knowledge, been reported so far. It revealed a deep cervical extension and was initially mistaken for a branchial cleft cyst. Furthermore, we show that CTCs can erode or remodel important structures such as canalis nervi hypoglossi, canalis Vidiani, foramen rotundum, ovale, lacerum and spinosum without causing clinical symptoms.

CONCLUSION

In contrast to previous reports in which asymptomatic CTC did not include critical structures such as the foramina rotundum, ovale, lacerum or spinosum or the hypoglossal or Vidian canal, we show that CTCs can be asymptomatic even when eroding or remodeling such clinically important structures. When extending below the skull base, CTCs are a rare differential diagnosis to cystic cervical lesions such as type II branchial cleft cysts.

Petrous apex cephalocoele: contribution of coexisting intracranial pathologies to the aetiopathogenesis

OBJECTIVE

The aim of this study was to show the MRI findings of petrous apex cephalocoele (PAC) and the other intracranial pathologies that coexist with PAC, and to discuss the contribution of the co-existing pathologies to aetiopathogenesis.

METHODS

A retrospective analysis of our imaging archive for the period from January 2012 to October 2013 revealed 13 patients with PAC (12 females and 1 male; age range, 26-69 years). 11 patients underwent MRI examination of the cranium, and 2 patients underwent MRI examination of the sellar region. We evaluated the lesions for content, signal intensity, enhancement, relation to petrous apex and Meckel's cave. Images were also evaluated for coexisting pathologies.

RESULTS

The presenting symptoms included headache, vertigo, cerebrospinal fluid (CSF) leak and trigeminal neuropathy. All patients had PAC. All lesions were located posterolateral to the Meckel's cave and were isointense with CSF signal on all pulse sequences. All lesions were continuous with Meckel's cave. Coexisting pathologies included intracranial aneurysmal dilatation, empty sella, mass in hypophysis, arachnoid cyst, inferior herniation of parahippocampal gyrus and optic nerve sheath CSF distension.

CONCLUSION

Coexistence with other intracranial pathologies supports the possibility of CSF imbalance and/or intracranial hypertension in the aetiopathogenesis of PAC.

ADVANCES IN KNOWLEDGE

This study examined the contribution of the co-existing intracranial pathologies to the aetiopathogenesis of PAC.

Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience

BACKGROUND

Closure of spontaneous sphenoid sinus cerebrospinal fluid leaks can be challenging because of the relative inaccessibility of the lateral recess and the presence of intracranial hypertension. We present our experience of such cases and highlight factors associated with a successful outcome.

METHODS

Eleven patients with spontaneous, laboratory confirmed, sphenoid sinus cerebrospinal fluid leaks were included. All patients underwent endoscopic closure by either a three-layer technique or fat obliteration.

RESULTS

In all but one patient, the leak was successfully sealed (success rate, 90.9 per cent; mean follow up, 37.1 months). Elevated intracranial pressure was measured in eight patients, two of whom did not exhibit relevant clinical or radiological characteristics. Five patients received diuretics and dietary advice for weight reduction. In one patient with recurrence two weeks after repair, successful revision was performed by additional placement of a ventriculoperitoneal shunt (follow up, 67 months).

CONCLUSION

Long-lasting cerebrospinal fluid fistula sealing in the sphenoid sinus requires stable reconstruction of the defect in three layers or fat obliteration if the anatomy is unfavourable. All patients should be intra- and post-operatively screened for elevated intracranial pressure to identify those who need additional intracranial pressure reduction measures.

Meningoceles in idiopathic intracranial hypertension

OBJECTIVE

MRI abnormalities have been described in patients with increased intracranial pressure (ICP), including in those with idiopathic intracranial hypertension (IIH). Spontaneous CSF-filled outpouchings of the dura (meningoceles) and secondary CSF leaks can occur from elevated ICP in patients with IIH; however, few studies have evaluated these findings. Our objective was to evaluate the frequency of spontaneous intracranial meningoceles among IIH patients and determine their association with visual outcome.

MATERIALS AND METHODS

We performed a retrospective case-control study of consecutive IIH patients between 2000 and 2011 who underwent MRI that included T2-weighted imaging. Demographics, presenting symptoms, CSF opening pressure, and visual outcome were collected for the first and last evaluations. Control subjects included patients without headache or visual complaints who had normal brain MRI results. Stratified analysis was used to control for potential confounding by age, sex, race, and body mass index.

RESULTS

We included 79 IIH patients and 76 control subjects. Meningoceles were found in 11% of IIH patients versus 0% of control subjects (p<0.003). Prominent Meckel caves without frank meningoceles were found in 9% of IIH patients versus 0% of control subjects (p<0.003). Among IIH patients, the presence of meningocele or prominent Meckel caves was not associated with demographics, symptoms, degree of papilledema, CSF opening pressure, visual acuity, or visual field defect severity.

CONCLUSION

Meningoceles are significantly more common in IIH patients than in control subjects and can be considered an additional imaging sign for IIH. Meningoceles are not, however, associated with decreased CSF opening pressure or better visual outcome in IIH.

Petrous apex lesions in the pediatric population

A variety of abnormal imaging findings of the petrous apex are encountered in children. Many petrous apex lesions are identified incidentally while images of the brain or head and neck are being obtained for indications unrelated to the temporal bone. Differential considerations of petrous apex lesions in children include "leave me alone" lesions, infectious or inflammatory lesions, fibro-osseous lesions, neoplasms and neoplasm-like lesions, as well as a few rare miscellaneous conditions. Some lesions are similar to those encountered in adults, and some are unique to children. Langerhans cell histiocytosis (LCH) and primary and metastatic pediatric malignancies such as neuroblastoma, rhabomyosarcoma and Ewing sarcoma are more likely to be encountered in children. Lesions such as petrous apex cholesterol granuloma, cholesteatoma and chondrosarcoma are more common in adults and are rarely a diagnostic consideration in children. We present a comprehensive pictorial review of CT and MRI appearances of pediatric petrous apex lesions.

Ventriculoperitoneal shunt strategy for cerebrospinal fluid rhinorrhea repair: a case report and review of the literature

We present a 10-year-old boy with a greater than 5-year history of cerebrospinal fluid rhinorrhea. He experienced nine episodes of bacterial meningitis and underwent four surgical repairs, including two endoscopic repairs via the lateral nasal cavity, a craniotomy repair via forehead epidural, and endoscopic repair in combination with a ventriculoperitoneal shunt. The first three surgeries failed, but the fourth was successful, with no recurrence during 2.5 years of follow-up. We suggest that ventriculoperitoneal shunts be considered for refractory recurrent cerebrospinal fluid rhinorrhea, particularly in patients after multiple failures of conventional surgical repair, to reduce intracranial hypertension caused by long-term chronic cerebrospinal fluid compensatory production.

Complications of frontal sinus fractures

Frontal sinus fracture represents 5 to 12% of all maxillofacial fractures. Because of the anatomic position of the frontal sinus and the enormous amount of force required to create a fracture in this area, these injuries are often devastating and associated with other trauma. Associated injuries include skull base, intracranial, ophthalmologic, and maxillofacial. Complications should be categorized to address these four areas as well as the skin-soft tissue envelope, muscle, and bone. Other variables that should be examined are age of the patient, gender, mechanism of injury, fracture pattern, method of repair, and associated injuries. Management of frontal sinus fractures is so controversial that the indications, timing, method of repair, and surveillance remain disputable among several surgical specialties. The one universal truth that is agreed upon is that all patients undergoing reconstructive surgery of the frontal sinus have a lifelong risk for delayed complications. It is hoped that when patients do experience the first symptoms of a complication, they seek immediate medical attention and avoid potentially life-threatening situations and the need for crippling or disfiguring surgery. The best way to facilitate this is through long-term follow-up and routine surveillance.

Unusual presentations of middle fossa encephaloceles: report of two cases

Basal encephaloceles are rare occurrences with occult and often varied presentations. Frequently, the need for surgical treatment is not clear to the patient or the physician, leading to potentially fatal complications. We report the case of a 44-year-old woman with an 8-year history of nonspecific complaints who presented to us with trigeminal neuralgia. Also, an unsual case is presented of a 60-year-old man with bilateral middle fossa encephaloceles who suffered acutely from widespread pneumocephalus acting as a mess lesion. Both are cases of nontraomatic middle fossa encephaloceles, which are of perficular interest due to the age of the patients, their atypical presentations, and the asseciated complications.

How I do it: endoscopic-microscopic anterior skull base reconstruction

Reconstruction of the anterior skull base must be secure and watertight. Failure to achieve this places the patient at risk of the development of cerebral sepsis. We have developed the technique of endonasal duraplasty and have achieved a 90% long-term success rate. In this article we described the key elements of our technique starting with radiographic and fluorescein localization of a skull base defect. The main steps in reconstruction and materials used are detailed, together with modifications of our technique for certain difficult situations and tips for success. Attention is drawn to potential pitfalls that have been identified over 25 years of clinical practice.

Endoscopic repair of a rare basioccipital meningocele associated with recurrent meningitis

Anatomical variants of the basiocciput are uncommon and usually clinically benign. While the majority remain undetected, these anomalies rarely manifest as CSF rhinorrhea or recurrent meningitis associated with meningocele. Compromise of the leptomeninges provides an avenue of ingress for pathological organisms and can lead to recurrent meningitis, necessitating operative repair of the defect to prevent infection. A review of the literature reveals only 3 cases in which a congenital basioccipital defect has been associated with a meningocele requiring surgical repair. The authors present a case of recurrent meningitis in an infant with a congenital basioccipital meningocele treated with a minimally invasive endoscopic technique. At the 2-year follow-up the repair remained successful, with no evidence of recurrence of the meningocele or CSF infection. The literature regarding the etiology and treatment of these lesions was reviewed, with an emphasis on the safety and efficacy of the endoscopic approach. Note that recurrent meningitis in the setting of a skull base defect may indicate the presence of other congenital anomalies that will necessitate multidisciplinary care for a patient's long-term well-being.

Cerebrospinal fluid leak with recurrent meningitis following tonsillectomy

The authors report an unusual case of bilateral large petrous apex cephaloceles in a 14-year-old boy with a history of recurrent meningitis. Although these lesions are rare and usually asymptomatic, surgical correction is recommended if they are associated with a persistent CSF leak. In this patient, the extensive bilateral cranial defects were not adequately treated by an intracranial approach alone. Repair of a defect in the posterior pharyngeal wall, the site of a prior tonsillectomy, ultimately resulted in repair of the CSF fistula.

Endoscopic endonasal management of encephaloceles in children: an eight-year experience

OBJECTIVE

Skull base encephaloceles are difficult to diagnose and to treat. Traditionally, they are approached externally via craniotomic routes. Endoscopic management of skull base defects is the standard treatment in adults. Our aim is to evaluate the efficacy and safety of endoscopic endonasal repair of basal encephaloceles in the paediatric population.

METHODS

Retrospective evaluation of paediatric encephaloceles managed endoscopically at a tertiary referral centre.

RESULTS

Eleven subjects fitted the criteria of the study. Mean age at surgery was 6.1+/-4.6 SD years, while mean follow-up was 46.5+/-28 SD months. Most of the defects were located in the anterior cranial fossa. All patients were managed successfully with no complications.

CONCLUSIONS

Endonasal endoscopic management of congenital encephaloceles is feasible in paediatric patients. Meticulous pre-op neuroimaging is of paramount importance when dealing with such cases.

Recurrent meningitis secondary to isolated C3 deficiency

A 5-year-old child presented with the second episode of meningitis when we started investigating her to find a cause for recurrent episode of meningitis. During this she suffered from a third attack after which she was diagnosed as having isolated C(3) deficiency. She was put on penicillin prophylaxis and vaccinated against encapsulated bacteria, after which she is now doing well.

Spontaneous encephaloceles of the temporal lobe

Encephaloceles are pathological herniations of brain parenchyma through congenital or acquired osseus-dural defects of the skull base or cranial vault. Although encephaloceles are known as rare conditions, several surgical reports and clinical series focusing on spontaneous encephaloceles of the temporal lobe may be found in the otological, maxillofacial, radiological, and neurosurgical literature. A variety of symptoms such as occult or symptomatic CSF fistulas, recurrent meningitis, middle ear effusions or infections, conductive hearing loss, and medically intractable epilepsy have been described in patients harboring spontaneous encephaloceles of middle cranial fossa origin. Both open procedures and endoscopic techniques have been advocated for the treatment of such conditions. The authors discuss the pathogenesis, diagnostic assessment, and therapeutic management of spontaneous temporal lobe encephaloceles. Although diagnosis and treatment may differ on a case-by-case basis, review of the available literature suggests that spontaneous encephaloceles of middle cranial fossa origin are a more common pathology than previously believed. In particular, spontaneous cases of posteroinferior encephaloceles involving the tegmen tympani and the middle ear have been very well described in the medical literature.

Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis

Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.

Petrous apex cephalocele and empty sella: Is there any relation?

OBJECTIVE

To document the presence of incidental petrous apex cephalocele (PAC) in association with empty sella in a group of patients and propose an etiologic/pathologic relation between the two lesions.

MATERIALS AND METHODS

Retrospective review of our imaging archive for the period from October 2001 to October 2006 revealed five patients with PAC (four females and one male; age range, 25-60 years; mean, 47 years). All patients underwent enhanced MR examination of the skull base and four of them underwent CT examination. Lesions were evaluated for size, content, signal intensity, enhancement, and relation to Meckel's cave and petrous apex. Images were also evaluated for the presence of empty sella.

RESULTS

The presenting symptoms in all patients were not attributable to PAC. None of the patients had symptoms related to the trigeminal nerve or history of CSF leak. Four patients had bilateral PAC and one had left PAC (total nine lesions). The lesions ranged from 6 mm to 15 mm (mean 9 mm) in the maximum diameter. All lesions were centered posterolateral to Meckel's cave and had low attenuation on CT with sharply demarcated margins. No lesion reached the inner ear structures, internal auditory canal, or mastoid air cells. On MR imaging, all lesions demonstrated CSF signal intensity that is continuous with that of the Meckel's cave. Only the periphery of the lesions demonstrated mild enhancement. All patients had empty sella. One patient had small arachnoid cysts in the middle cranial fossa, bilaterally.

CONCLUSION

PAC and empty sella are similar mechanically in terms of CSF extension and erosion into petrous apex and sella, respectively. Both conditions are seen predominantly in females and have been reported in association with CSF leak, which raises a possibility of etiologic/pathologic relation between the two.

Invasive Cerebrospinal Fluid Cysts and Cephaloceles of the Petrous Apex

OBJECTIVE

To describe the presentation, diagnostic evaluation, and surgical management of petrous apex cerebrospinal fluid (CSF) cysts and cephaloceles.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Six patients with symptomatic CSF cysts or cephaloceles.

INTERVENTION(S)

All patients underwent operative intervention.

MAIN OUTCOME MEASURE(S)

Presentation, imaging characteristics, operative findings, surgical approach, resolution of symptoms, and complications.

RESULTS

Six patients presented with various neurotologic symptoms including vertigo, otalgia, diplopia, meningitis, hearing loss, and retroorbital headaches. Four lesions were centered within the anterior petrous apex and were classified as a cephalocele originating from Meckel's cave. The remaining two lesions were arachnoid cysts that involved the posterior petrous apex. Cysts and cephaloceles both demonstrated bone erosion on computed tomography and were hyperintense on T2-weighted magnetic resonance imaging and isointense or hypointense on T1-weighted magnetic resonance imaging. A variety of surgical approaches was used to treat these lesions. Preoperative symptoms were improved in five of six cases. One patient developed a postoperative CSF leak that resolved with conservative measures.

CONCLUSION

Petrous apex CSF cysts and cephaloceles may present with a variety of neurotologic symptoms. Imaging often helps narrow the differential diagnosis, but these lesions can still be confused with other erosive skull base lesions such as cholesterol granulomas, epidermoids, or tumors. Optimal treatment of symptomatic posterior petrous apex CSF cysts is marsupialization via a posterior fossa approach (i.e., retrosigmoid or retrolabyrinthine). A middle fossa approach with obliteration of the anterior petrous apex may be used to treat symptomatic CSF cephaloceles arising from Meckel's cave.

Endoscopic endonasal approaches to anterior skull base defects in pediatric patients

INTRODUCTION

We studied 12 pediatric patients with congenital or acquired anterior skull base defects. All subjects underwent surgery owing to progressive symptoms. The endoscopic endonasal approach is a new method in the treatment of this pathology in children.

MATERIALS AND METHODS

Twelve children had surgery to correct anterior skull base defects: seven patients with a spontaneous anterior basal meningoencephalocele and five with posttraumatic cerebrospinal fluid (CSF) leakage. The defects were repaired using the endoscopic endonasal approach, which combined with the fluorescein diagnostic test, detects the exact location of the skull base defect. Different closure techniques were used to obtain a permanent graft, depending on the type, location, and size of the defect. An intraoperative fluorescein test confirmed the absence of CSF leakage after surgery.

RESULTS

The follow-up period ranged from 3 to 72 months. Symptoms resolved in all patients after surgery and none of them experienced complications or recurrence of CSF leakage. Postoperative magnetic resonance scans showed that the defect had successfully been repaired in all patients.

DISCUSSION

The surgical treatment of skull base defects in children reduces life-threatening risks, which include infections, CSF leaks, and enlargement or trauma of the sac. The endoscopic technique minimizes surgical scars and has little impact on brain tissue. The endoscopic endonasal approach to the anterior skull base helps to preserve the physiology of the nose and sinuses and reduces the impact on the still developing splanchnocranium in pediatric patients. It ensures a definitive repair of the defect and requires a very short inpatient period.

Basilar meningitis associated with ethmoid and sphenoid cephaloceles

Nontuberculous causes of basilar meningitis are rare. This study presents the case of a male who developed fever and meningitis caused by Streptococcus pneumoniae. He developed multiple cranial nerve palsies and imaging findings consistent with basilar meningitis and ventriculitis. Computed tomographic scans of the floor of the anterior fossa were performed after the detection of a cephalocele on magnetic resonance imaging. This imaging revealed a defect in the cribiform plate and fovea ethmoidalis with a large nasoethmoidal cephalocele. There was a second separate defect and cephalocele involving the middle cranial fossa. The association of basilar meningitis with an atypical organism should lead to a careful search for disruption in the floor of the anterior or middle cranial fossa.

Recurrent meningitis associated with a petrous apex cephalocele

We present the case of a 6-year-old girl with recurrent bacterial meningitis and cerebrospinal fluid (CSF) rhinorrhea associated with a petrous apex cephalocele (PAC). We diagnosed her by means of three-dimensional computed tomography (CT) and heavily T2-weighted magnetic resonance imaging (MRI). Petrous apex cephaloceles are usually an asymptomatic incidental finding in adults; however, they should be considered as a possible cause of CSF rhinorrhea, otorrhea, and recurrent meningitis in children.

Intrasphenoidal encephalocele associated with cerebrospinal fluid fistula and subdural hematomas: technical case report

OBJECTIVE AND IMPORTANCE

Intrasphenoidal encephalocele is a rare clinical entity that is often complicated by rhinorrhea, recurrent meningitis, and headache, but in no case has the association of rhinorrhea with subdural hematomas been described. A surgical procedure to stop persistent cerebrospinal fluid leakage is reported.

CLINICAL PRESENTATION

A 59-year-old man sought care for intractable rhinoliquorrhea of 6 months' duration. Cranial computed tomographic and magnetic resonance imaging scans revealed a basal posterior frontal bony defect and an evocative image suggesting intrasphenoidal encephalocele.

INTERVENTION

A transnasal transsphenoidal surgical procedure was performed; the encephalocele was removed, and the sphenoid sinus was filled with an inflatable pouch made of synthetic dura mater containing abdominal fat. Postoperative reduction of the rhinoliquorrhea, but not its total disappearance, was observed. Total disappearance was achieved only after endonasal, transmucosal inflation of the pouch with human fibrin glue. One of the subdural hematomas disappeared spontaneously, and the other was treated by a surgical procedure.

CONCLUSION

The possible role of the presented technique in the treatment of cerebrospinal fluid leakage is discussed.

Bacterial meningitis secondary to a transethmoidal encephalocele presenting to the emergency department

We present the case of a patient seen in the Emergency Department (ED) at the height of enteroviral meningitis season with the chief complaint of the worst headache of his life. He was subsequently found to have pneumococcal meningitis as the result of an encephalocele located within the left ethmoid sinus. The key features of the patient's past medical history, the steps to diagnosis, and a discussion of this exceedingly rare entity are detailed.

Advances in the management of CSF rhinorrhoea

Cerebrospinal fluid fistulae are under-diagnosed, difficult to locate and often clinically silent. They are potentially lethal and carry a long-term cumulative risk of meningitis. They should be fully investigated and treated aggressively. Current endoscopic techniques combined with intrathecal fluorescein dye enable most defects to be located and sealed with minimal morbidity.

Recurrent bacterial meningitis: report of two cases from Riyadh, Saudi Arabia

We report two cases of recurrent bacterial meningitis after head injury in two Saudi boys. The brain CT scan showed bony defects in both despite normal otolaryngeal clinical findings. One child remained well after surgical repair but the other was lost to follow-up.

A Le Fort I osteotomy approach to lateral sphenoid sinus encephalocoeles

Meningo-encephalocoeles of the skull base may present as spontaneous cerebrospinal fluid rhinorrhoea or acute meningitis. Previous approaches to midline skull base lesions have been either intracranial, via a craniotomy, or by transfacial or endoscopic extracranial approaches. This paper presents an alternative approach to lateral sphenoid sinus encephalocoeles through a Le Fort I osteotomy approach.

Idiopathic diffuse erosion of the skull base presenting as cerebrospinal fluid rhinorrhoea

We present an unusual case of generalized erosion of the skull base. We have not found a similar case reported in the world literature. The presenting symptom was spontaneous cerebrospinal fluid (CSF) rhinorrhoea which arose from a bony defect associated with herniation of the right temporal lobe into the sphenoid sinus. We discuss the management of such a case including imaging of the skull base and the endoscopic repair of the bony defect.