Nasal encephaloceles: a review of etiology, pathophysiology, clinical presentations, diagnosis, treatment, and complications

Unusual Case of Fetal Meningocele Mimicking Dacryocystocele

Meningocele, a rare subtype of cephalocele, can manifest in various positions and exhibit diverse characteristics. On the other hand, dacryocystocele, also a rare anatomical disorder, typically presents as a cyst located between the nose and the eye. Generally, distinguishing between these 2 lesions is not difficult. The presented case involves a fetus with suspected dacryocystocele, ultimately diagnosed postpartum as meningocele, underscoring the complexities in distinguishing between these conditions. The article details the patient's prenatal examinations, imaging findings, and the subsequent surgical intervention, highlighting the significance of meticulous diagnosis for effective prenatal management. The case illuminates the potential oversight and misdiagnosis challenges associated with atypical cephaloceles, contributing valuable insights for clinicians involved in prenatal diagnosis and management.

Large transethmoidal meningoencephalocele in a neonate involving three discrete defects in lamina cribriform: A case report

Background

Intranasal meningoencephaloceles are rarely encountered in pediatric neurosurgery. The symptoms and clinical features may mimic those of nasal polyps or dermoid cysts. Transethmoidal meningoencephalocele is a rare congenital meningoencephalocele of the anterior skull base with diverse clinical presentation. The appropriate surgical intervention is chosen according to the meningoencephalocele type and location. Radiological examinations such as computed tomography and magnetic resonance imaging are helpful for the differential diagnosis of the encephalocele sac and localization of the cranial bone defect.

Case Description

We are reporting a case of basal meningoencephalocele of the transethmoidal type, which was discovered in a 20-day-old boy presenting with cerebrospinal fluid rhinorrhea, respiratory distress, difficulty in feeding, and meningitis. The preoperative images showed a large herniated intranasal sac with bony discontinuity of the cribriform plate; however, three discrete defects of the cribriform plate with their related discrete herniated sacs were identified intraoperatively. Two staged surgeries were performed in succession: transcranial to separate the sacs from the cranial cavity and seal the anterior fossa floor, followed by transnasal to remove the remnant of the intranasal sacs. Patient symptoms and signs markedly improved after the surgeries.

Conclusion

We highlight the need for urgent intervention at a very young age if the clinical presentation mandates, and also the importance of meticulous intraoperative identification of all bony and dural defects that might be missed in preoperative images to ensure complete repair and prevent recurrence.

Occipital encephalocele: a retrospective analysis and assessment of post-surgical neurodevelopmental outcome

BACKGROUND

Encephalocele represent a group of disorders which is characterised by extracranial herniation of the leptomeninges, brain, and CSF through a structural defect in the cranium. They are usually associated with other intracranial anomalies which may impact the neurological development.

AIM

This study aimed to assess the predictors of neurological development of patients undergone surgical excision of occipital encephalocele.

METHODS

All patients with occipital encephaloceles operated over the last decade (2012-2022). The sac size, presence of hydrocephalous, and associated anomalies were noted. The biopsy of these patients were reviewed and categorised as those which contains mature neural tissue and those without. The neurological outcomes were assessed by social, language, cognitive, and motor milestone and has been stratified into no delay, mild (1 of 4), moderate (2 or 3 of 4), and severe development delay (4 of 4).

RESULTS

Total of 35 patients were included with median age of 10 months (IQR = 5-20 months). Fifteen (42.9%) patients had sac size of ≥ 5 cm, and 23 (65.7%) patients had mature neural tissues on biopsy. The median follow-up period was 6.4 years (IQR = 4.38-10.65) years. Seventeen (49.6%) patients had moderate to severe developmental delay. The sac size of ≥ 5 cm (AOR = 33.5; 95%CI = 3.35-334.8) (p = 0.003) and presence of mature neural content in the sac (AOR = 13.32; 95%CI = 1.1-160.36) (p = 0.041) were associated with significant neurodevelopmental delay.

CONCLUSION

The presence of a large sac of ≥ 5 cm and the presence of mature neural tissues on histopathological specimen of patients with encephalocele point towards the possibility of poor neurological development.

Meningocele in the Parapharyngeal Space: A Case Report and Review of the Literature

The parapharyngeal space has been described as an inverted pyramid shape with the base of the skull and the great cornu of the hyoid bone at the top. Tumors of the parapharyngeal space account for 0.5% of head and neck tumors and a wide range of tumor types can occur in this area, 80% of which are benign, the most common being pleomorphic adenomas of the salivary glands and neurogenic tumors. We present a 39-year-old woman who was hospitalized due to left-sided neck pain with a feeling of blockage in the left ear and hearing loss for 10 months. Imaging showed that the mass was not connected to the cranium and the patient underwent surgical resection via a transoral approach, where the contents of the mass were found to be cerebrospinal fluid, and meningocele in the parapharyngeal space is a rare occurrence. The patient presented mainly with painful symptoms, which were eventually relieved by nerve block therapy.

Nasofrontal encephalocele: A case report with literature and management review

Encephalocele is a rare congenital anomaly characterized by the protrusion of intracranial contents through a defect in the skull base or calvarial. In Southeast Asia, frontoethmoidal encephaloceles are more frequently observed compared to their occurrence in Western countries. Typically, frontoethmoidal encephaloceles present as a visible mass adjacent to the nasal region. In this report, we delineate the case of a 9-year-old boy who presented with a palpable mass on the nasal bridge. Subsequent ultrasound and CT scan evaluations identified a nasofrontal defect with a communicating connection to the intracranial compartment.

Small spheno-ethmoidal meningoencephalocele versus ethmoidal mucocele in spontaneous intracranial hypotension

Background

Meningoencephalocele is defined as an abnormal sac of brain tissue and meninges extending beyond natural skull margins, often leading to cerebrospinal fluid (CSF) leakage. When this condition arises in the spheno-ethmoidal region, the diagnosis becomes more challenging as it can be mistaken for other nasal pathologies, such as mucocele.

Research question

We show in this case report a non-congenital sphenoethmoidal meningoencephalocele causing rhinoliquoral fistula and spontaneous intracranial hypotension.

Results

this 65-year-old woman presented with sporadic rhinoliquorrhoea associated with orthostatic headache, nausea and dizziness. Brain MRI revealed a small lesion of an ethmoidal sinus, which was successfully treated with endoscopic endonasal surgery. Histology confirmed the presence of meningoencephalic tissue positive for S100 protein on immunohistochemistry.

Conclusions

When dealing with lesions of the paranasal sinuses in contact with the anterior skull base, rhinoliquorrhoea presence suggests meningoencephalocele. In dubious cases, a proper workup, including a thorough clinical history and neurological examination, specific imaging, and a direct search of CSF-like markers, is essential to support the differential diagnosis. In such cases, a transnasal endoscopic surgical approach is recommended to obtain a final histological diagnosis and to perform eventual dural plastic surgery.

The Differential Diagnosis of Congenital Developmental Midline Nasal Masses: Histopathological, Clinical, and Radiological Aspects

Developmental midline nasal masses including nasal dermoids (NDs), encephaloceles (EPHCs), and nasal glial heterotopias (NGHs) are a consequence of disrupted embryonal developmental processes in the frontonasal region. Surgery is the only method of treatment in order to prevent local and intracranial inflammatory complications as well as distant deformities of the facial skeleton. Due to their rarity, similar location, and clinical and radiological symptoms, meticulous preoperative differential diagnostics is mandatory. The aim of this thorough literature review was to present and discuss all clinical, histopathological, and radiological aspects of NDs, NGHs, and EPHCs that are crucial for their differential diagnosis.

A non-coding insertional mutation of Grhl2 causes gene over-expression and multiple structural anomalies including cleft palate, spina bifida and encephalocele

Orofacial clefts, including cleft lip and palate (CL/P) and neural tube defects (NTDs) are among the most common congenital anomalies, but knowledge of the genetic basis of these conditions remains incomplete. The extent to which genetic risk factors are shared between CL/P, NTDs and related anomalies is also unclear. While identification of causative genes has largely focused on coding and loss of function mutations, it is hypothesized that regulatory mutations account for a portion of the unidentified heritability. We found that excess expression of Grainyhead-like 2 (Grhl2) causes not only spinal NTDs in Axial defects (Axd) mice but also multiple additional defects affecting the cranial region. These include orofacial clefts comprising midline cleft lip and palate and abnormalities of the craniofacial bones and frontal and/or basal encephalocele, in which brain tissue herniates through the cranium or into the nasal cavity. To investigate the causative mutation in the Grhl2Axd strain, whole genome sequencing identified an approximately 4 kb LTR retrotransposon insertion that disrupts the non-coding regulatory region, lying approximately 300 base pairs upstream of the 5' UTR. This insertion also lies within a predicted long non-coding RNA, oriented on the reverse strand, which like Grhl2 is over-expressed in Axd (Grhl2Axd) homozygous mutant embryos. Initial analysis of the GRHL2 upstream region in individuals with NTDs or cleft palate revealed rare or novel variants in a small number of cases. We hypothesize that mutations affecting the regulation of GRHL2 may contribute to craniofacial anomalies and NTDs in humans.

Salivary gland anlage tumor: Evaluation and management of a rare pediatric condition

BACKGROUND

Neonates and infants are obligatory nasal breathers. Nasal obstruction can therefore be life-threatening and prompt recognition of its cause is critical. Salivary gland anlage tumor (SGAT) is a rare, benign condition that can present with nasal obstruction and respiratory distress within the first weeks of life. Our objective was to outline the clinical presentation, evaluation, and management of SGAT and provide a review of existing literature.

METHODS

A retrospective chart review was performed at a tertiary children's hospital. A comprehensive literature search for SGAT was conducted using Medline, Embase, PubMed, and EBSCO. We present a case from our institution to describe the clinical approach to SGAT.

RESULTS

Forty-one cases of previously reported SGAT, plus our new patient, were included. Patients presented with respiratory distress (30/42, 71.4%), feeding difficulty (14/42, 33.3%) and/or upper airway obstruction (13/42, 31.0%). The majority of tumors were in the nasopharynx (25/42, 59.5%). Surgical excision (36/42, 85.7%) was most commonly performed. Surgical approaches have evolved to include transoral, transpalatal, transnasal endoscopic or a combination of the above. Our patient had a suspected residual/recurrent tumor, later found to be negative on pathology. To date, there have been no reported recurrences.

CONCLUSIONS

SGAT is a rare pediatric condition that is often excluded from the differential diagnosis of nasal obstruction. Clinical evaluation includes flexible nasopharyngoscopy and neuroimaging. Management involves surgical resection, except in cases of spontaneous expulsion. Tissue pathology is required for definitive diagnosis. Tissue biopsy should be performed on follow-up if there is a suspicion for recurrence.

Orbital and periorbital dermoid cysts: a retrospective analysis of 270 lesions

PURPOSE

To report the clinical characteristics and intraoperative findings of periorbital and orbital dermoid cysts and their relationship to location and rupture.

METHODS

Retrospective review of 270 cases with orbital or periorbital dermoid cysts that presented over a period of 11 years. Patients were included if diagnosis of dermoid cyst was made by histopathologic analysis. Clinical characteristics and operative outcomes were recorded and analyzed with Chi-squared analyses or univariate regression. Multivariate binary logistic regression was performed to assess predictors of location and rupture.

RESULTS

Dermoids frequently occurred unilaterally and were more frequently described as mobile (61.5%), followed by fixed (30.8%), and partially fixed (7.7%). Dermoid rigidity was most commonly described as firm (75.5%), followed by cystic, soft, and rubbery. The most common dermoid location was superotemporal (60.4%). On Chi-squared analysis, superotemporal lesions were less likely to have orbital extension than non-superotemporal lesions (OR 0.28, 95% CI: 0.11-0.70, p = .01), less likely to undergo CT (OR 0.16, 95% CI: 0.06-0.41, p < .01) or MRI (OR 0.23, 95% CI: 0.13-0.41, p < .01), more likely to be described as mobile (OR 2.91, 95% CI: 1.32-6.43, p = .01), and less likely to rupture intraoperatively (OR 0.28, 95% CI: 0.11-0.73, p = .01). No variables were associated with rupture in multivariate analysis.

CONCLUSION

Superotemporal dermoid cysts are common in the pediatric population, less likely to have orbital extension, undergo imaging, and have intraoperative rupture when compared to other locations in the orbit.

Fetal Occipital Encephalocele: A Case Report

Encephaloceles are considered neural tube defects, but their exact cause is unknown. The outcome is dismal, and essential management and counseling are needed for patients. Two-dimensional and three-dimensional sonography can be used to detect encephaloceles as early as 11 weeks, assist in treatment planning, and improve patient care. This case report presents an occipital encephalocele diagnosed by sonography and followed until delivery.

Surgical Technique and Review of Management of Frontoethmoidal Encephalocoele - A Case Report

The Rationale

Encephalocoele is a herniation of the brain formed during embryonic development, because of the incomplete closure of Neural Tube. It is a rare skull defect and most cases are located in the occipital bone. Frontal encephalocoeles are very rare and they may involve the ethmoid bone, nasal bones and/or the orbits. Surgical repair is complex and usually requires a multidisciplinary approach.

Patient Concerns

We present a case of a 6-month-old baby girl with a congenital frontoethmoidal encephalocoele.

Diagnosis

The diagnosis was made by computed tomography scan that showed a defect on the frontoethmoidal zone.

Treatment

Cranial approach was employed using standard bicoronal access. The malformation was removed and the defect was repaired by using an autologous parietal bone graft, without any complication in the follow-up.

Outcomes and Take-away Lessons

The goal of the surgery is to reconstruct the normal anatomy, to achieve a good cosmetic repair, and to avoid a cerebrospinal fluid leak. A description of the case and the surgical technique is presented with a review of literature.

Repair of Giant Anterior Skull Base Encephalocele Containing Intralesional Eloquent Brain: Technical Note

BACKGROUND

Encephaloceles are herniations of intracranial neural tissue and meninges through defects in the skull. Basal encephaloceles are rare anterior skull base defects incident in 1 in 35,000 live births. Sphenoethmoidal encephaloceles are even more uncommon, with an incidence of 1 in 700,000 live births. Anterior skull base encephaloceles may be life-threatening in infants, presenting as airway obstruction and respiratory compromise. They can also present with cerebrospinal fluid (CSF) rhinorrhea, purulent nasal drainage, or meningitis.

OBJECTIVE

To report a novel technique for repairing a giant sphenoethmoidal encephalocele containing eloquent neural tissue.

METHODS

A 16-mo-old girl presented with progressive airway obstruction from a giant sphenoethmoidal encephalocele that filled her oral cavity. She had multiple congenital anomalies including agenesis of the corpus callosum and cleft lip and palate. Computed tomography showed complete absence of the bony anterior cranial base, and magnetic resonance imaging demonstrated the presence of the pituitary gland and hypothalamus in the hernia sac.

RESULTS

We repaired the encephalocele using a combined microsurgical and endoscopic multidisciplinary approach working through transcranial, transnasal, and transpalatal corridors. The procedure was completed in a single stage, during which the midline cleft lip was also repaired. The child made an excellent neurological and aesthetic recovery with preservation of pituitary and hypothalamic function, without evidence of CSF fistula.

CONCLUSION

The authors describe a novel multidisciplinary technique for treating a giant sphenoethmoidal encephalocele containing eloquent brain. The cleft lip was also repaired at the same time. The ability to work through multiple corridors can enhance the safety and efficacy of an often-treacherous operative endeavor.

An Integrated Approach to the Management of Meningoencephalocoeles

ABSTRACT

Meningoencephalocoeles are congenital herniations of meningeal and cerebral tissues through a cranial defect. They occur most commonly in South-East Asia, and are relatively rare amongst European ancestry populations, with an estimated prevalence of 1/40,000 live births. The treatment of congenital meningoencephalocoeles is primarily surgical and are best managed by dedicated multi-disciplinary craniofacial teams. The authors performed a retrospective case review of all primary meningoencephalocoeles managed in the Oxford University Hospitals NHS Foundation Trust between 1986 and 2012. Twenty-nine cases (13 frontal, 9 occipital, 2 parietal, and 5 basal) were included in this study. The median age at presentation was 11 months (range 0-60 years). Twenty-five cases presented with an external mass; 3 with recurrent meningitis and 1 with otorrhoea. Twenty-six cases underwent surgery, and 17 of these were managed by an integrated approach between 2 or more surgical specialties. Twenty out of 26 operations were performed via a transcranial approach. The authors describe a particularly complex case in order to highlight the challenges associated with management of meningoencephalocoeles, the surgical technique employed, and the importance of a multidisciplinary surgical approach. This is the largest reported case series of meningoencephalocoeles managed in a single hospital in the United Kingdom. Designated craniofacial units with access to multidisciplinary surgical specialties provide a safe and optimal setting for the management of meningoencephalocoeles.

Endoscopic endonasal repair of a temporal lobe meningoencephalocele in the pterygoid fossa: A case report and literature review

Introduction

Meningoceles are defined as herniation of the meninges through a skull base defect. If brain tissue is herniated as well, then it is called meningoencephalocele. The most common locations of meningoceles are the cribriform plate and the lateral recess of the sphenoid sinus, with the most common presentation being CSF leakage. We present a case of temporal lobe meningocele that herniated through a defect in the greater wing of the sphenoid bone to the pterygoid fossa and that was diagnosed incidentally while evaluating the patient for seizures.

Methodology

Case report and literature review.

Conclusion

The endonasal endoscopic approach is a suitable minimally invasive approach for the management of pterygoid fossa lesions, including meningoceles. In this case, the patient had epilepsy with the surgery resulting in the resolution of the seizures.

•

Endonasal approach can be considered as a minimally invasive approach for lesions in the pterygoid fossa.

•

Meningocele are to be considered as a possible etiology for pterygoid fossa masses connected with the middle cranial fossa.

•

Surgical resection of encephalomeningocele should be considered for the management of intractable seizures.

Nasal glial heterotopia: A rare interdisciplinary surgical challenge in newborns

Nasal Glioma (NG) represents a rare congenital abnormality of the neonate, which can be associated with skull defects or even a direct communication to the central nervous system. MRI serves valuable information for differentiation from encephalocele, dermoid cyst and congenital hemangioma. Complete resection remains the treatment of choice. We present two cases of NG, which were both suspected during prenatal ultrasound and MRI. In the first case, postnatal MRI showed a transcranial continuity. Mass excision was performed and the defect was covered by a glabellar flap allowing a good cosmetic result. Postnatal MRI excluded a trans-glabellar communication in the second case. After surgical excision, the resulting skin defect was covered with a full thickness skin graft harvested from the right groin. In cases of NGs complete resection and cosmetic appealing results can be achieved and might necessitate a multidisciplinary approach.

Meningitis in the Setting of Frontoethmoidal and Temporal Meningoencephaloceles

This is a patient with multiple meningoencephaloceles which resulted in bacterial meningitis and subsequent status epilepticus. We identify impressive imaging findings demonstrating herniation of the meninges from nasal and bitemporal skull base defects possibly as a result of intracranial hypertension.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Intranasal glial heterotopia in an infant boy

INTRODUCTION

Nasal glial heterotopia is a rare congenital developmental disorder characterized by meningeal epithelium and/or glial components.

CASE PRESENTATION

A 2-month-old boy presented for treatment of a congenital mass in the right nasal cavity near the pharynx. The preoperative diagnosis was congenital intranasal neoplasm. Nasal endoscopic resection of the nasopharyngeal mass was performed under general anesthesia. Histological findings in the resected tissue supported a diagnosis of intranasal glial heterotopia. The surgical outcome was good and no surgical site infection occurred. During 1 year of follow-up, the patient did not exhibit recurrence of heterotopia or related symptoms.

CONCLUSION

Transnasal endoscopic surgery is recommended for patients with intranasal glial heterotopia. Thorough preoperative imaging should be performed before glioma resection. The mass should be differentiated from encephalocele to prevent cerebrospinal fluid leakage and meningitis.

Basal encephalocele: surgical strategy and functional outcomes in the Tokyo experience

OBJECTIVE

The basal encephalocele (BEC) is the rarest form of encephalocele, with an incidence of about 1/35,000 live births. The incidence of its subtype, sphenoidal BEC, is even lower at about 1/700,000 live births. The aim of this study was to propose the optimal surgical approach to repairing BEC, with special attention to the reconstruction of the skull base bone defect.

METHODS

Fourteen consecutive pediatric patients with BEC who underwent surgical repair between March 2004 and March 2020 (10 boys and 4 girls, age 25 days to 7 years, median age 4 months) were enrolled. The follow-up period of the surviving patients ranged from 53 to192 months (mean 119.8 months). The patient demographics, BEC subtypes, preoperative clinical condition, radiographic findings, surgical procedures, and postoperative course were retrospectively analyzed.

RESULTS

There were 4, 8, and 2 cases of sphenoidal BEC, sphenoethmoidal BEC, and ethmoidal BEC, respectively. The size of the bone defect was small in 3 patients, medium in 7, and large in 4 patients. All the patients with sphenoethmoidal and ethmoidal BEC showed associated congenital anomalies other than cleft palate. In total, 25 operations were performed. Two patients underwent multiple operations, whereas the remaining 9 patients received only 1 operation. The transoral transpalatal approach was the initial procedure used in all 14 patients. The transfrontobasal approach was applied as an additional procedure in 2 patients and as part of a 1-stage combined operation in 2 patients. Autograft bone alone was used for skull base reconstruction in 17 early operations. A titanium mesh/plate was used in the remaining 8 operations without any perioperative complications. All BECs were successfully repaired. Three patients died during the clinical course due to causes unrelated to their surgery. All but one of the surviving patients started growth hormone replacement therapy before school age.

CONCLUSIONS

Based on the authors' limited experience, the key to successful BEC repair involves circumferential dissection of the BEC and a firm reconstruction of the skull base bone defect with a titanium plate/mesh. The transoral transpalatal approach is a promising, reliable procedure that may be used in the initial operation. When a cleft palate is absent, transnasal endoscopic repair is recommended. The transfrontobasal approach should be reserved for cases with a huge BEC and other anomalies. Long-term prognosis is apparently favorable in survivors.

Frontoethmoidal Encephalocele Correction Surgery in Benin: A Case Report

INTRODUCTION

Primary encephalocele is a rare deformity that is challenging for the neurosurgeon. It requires a multidisciplinary team for adequate reconstructive surgery.

CASE PRESENTATION

We report the case of a 6-month-old African boy who presented with a frontoethmoidal encephalocele; we present a technical description of the surgical procedure, using no implant.

DISCUSSION/CONCLUSION

The postoperative evolution of the boy was uneventful, with a good clinical result at the follow-up.

Management of anterior fossa cephaloceles

Skull base cephaloceles (SBCs) are defined as herniation of intracranial content through the skull base and are classified based on composition, etiology, and topographic location. Anterior SBCs frequently protrude in the sinonasal cavity, and consequently are at potential risk of infection. Therefore, the current recommendation is to treat SBCs with the primary intent of preventing meningitis, and surgery represents the mainstay of treatment. Anterior SBCs may display a wide spectrum of severity and complexity, and in each case the risks and benefits of surgical approaches are to be carefully weighted based on thorough assessment of symptoms, age, general conditions, location and size of the lesion, as well as expertise of the surgeon. In the last 30 years, the evolution and diffusion of transnasal endoscopic surgery have substantially changed the surgical management of the majority of SBC. In the past, they were treated exclusively with open transcranial approaches that may be burdened by relevant morbidity and risk for severe complications. The transnasal endoscopic corridor now provides easy access to the lesion and different reconstructive strategies using endonasal pedicled flaps, without any external incision, cranioplasty or brain manipulation. However, there are still scenarios in which an exclusive transnasal endoscopic route is contraindicated. The aim of the present review was to provide an overview on the comprehensive management of anterior SBC, with a particular focus on lesions suitable for endoscopic surgery. Furthermore, special aspects of SBC management in children and adults will be highlighted.

Case Report: Surgical Treatment for Intranasal Meningoencephalocele in a Cat

A 4-month-old cat with epileptic seizures and nasal discharge was presented, and diagnosed with intranasal meningoencephalocele based on the clinical symptoms and findings of CT and MRI. As liquorrhea was suspected, the meningoencephalocele was surgically excised and the postoperative course was favorable. For cribriform plate reconstruction, the autologous tunica vaginalis was used. Rhinorrhea of the cerebrospinal fluid and seizures disappeared after surgery. On CT and MRI at 7 months after surgery, septum formation between the cranial and nasal cavities was confirmed. Currently, no seizures have occurred even though no oral antiepileptic agent was administered. There are few reports of surgical treatment for meningoencephalitis, and there are no reports of reconstruction of the cribriform plate using tunica vaginalis, so we reported the details.

Delayed Cerebrospinal Fluid Rhinorrhea Associated With Ethmoidal Encephalocele After Resection of Remote Meningioma

Diagnosis and treatment of neurosurgical pathology present unique challenges in underserved areas, and many conditions may go undiagnosed, misdiagnosed, or untreated for prolonged periods. The development of an unusual complication, seemingly unrelated to an area of neurosurgical intervention, may be particularly perplexing to non-neurosurgical providers, particularly in areas where neurosurgical procedures have not historically been available. A 44-year-old male presented with a giant meningioma which was successfully resected. A nasal encephalocele was noted preoperatively but was not addressed due to lack of associated symptoms and distance from the tumor. The patient lived on a remote island and was lost to follow-up. He developed delayed cerebral spinal fluid (CSF) rhinorrhea three months after surgery, which was diagnosed and treated by local providers as allergic rhinitis for 11 months until he presented with new-onset seizure. Imaging demonstrated descent of the lateral ventricle into the encephalocele. The encephalocele was amputated and the skull base defect was repaired successfully. The alteration of ventricular anatomy and CSF fluid dynamics following tumor resection appears to have created an environment where a non-traumatic CSF leak could develop where it had previously shown no signs of developing. It may be prudent to treat skull base defects prophylactically to prevent this type of complication, particularly in patients of remote regions where regular follow-up is difficult.

Nasal meningoencephalocele: A retrospective study of clinicopathological features and diagnosis of 16 patients

OBJECTIVE

Nasal meningoencephalocele (encephalocele or cephalocele) is a rare condition with congenital, traumatic, or spontaneous origins. We investigated the clinicopathological characteristics of nasal encephaloceles to improve pathologists' and clinicians' understanding of this disease.

METHODS

Sixteen patients with nasal encephaloceles were enrolled in this retrospective study investigating the condition's clinical and morphological features.

RESULTS

Patients' average age was 37.8 (±20.8) years. The ratio of men to women was 2.2:1, patients' mean age was 47.4 (±11.8) years, and 10/16 patients had spontaneous encephaloceles. All patients with traumatic and spontaneous encephaloceles presented with cerebrospinal fluid leak. In 9/16 patients, the skull defect site occurred on the lateral wall of the sphenoid sinus. Both congenital patients experienced nasal obstruction. Histopathology, herniated tissues were brain and/or meningeal tissue, and the brain tissue was almost mature glial tissue.

CONCLUSION

Nasal meningoencephalocele is a rare condition that can be challenging to diagnose. In patients with recurrent clear nasal discharge or in children with a unilateral nasal mass, a high index of suspicion for encephalocele is essential. In this study, spontaneous cases were most common in adults, and the lateral wall of the sphenoid sinus was the most common location.

Congenital Anterior Skull Base Encephaloceles: Long-Term Outcomes After Transnasal Endoscopic Reconstruction

BACKGROUND

Congenital intranasal encephaloceles (ECs) are rare malformations of the pediatric age, complex to diagnose and treat, above all if associated with genetic syndromes or concomitant dysmorphisms. The aims of the study were to report our experience in managing nasal ECS in children, to evaluate the efficacy and safety of the transnasal endoscopic repair, and to analyze in an overall way the surgical long-term outcomes. Moreover, we sought to contribute to the debate on pathogenesis of ECs, investigating possible related risk factors described in the literature.

METHODS

A retrospective analysis was performed of pediatric nasal ECs managed with a transnasal endoscopic approach at a tertiary referral center through clinical follow-up and telephone survey.

RESULTS

Twenty-three patients with nasal ECs fitted the criteria of the study. Mean age at surgery was 5 years (69 months) and the mean follow-up was 59 months. The clinical presentation is described in detail, with particular emphasis on syndromic cases. Of 23 patients, 17 had an isolated EC, and in 4 patients, a malformation syndrome was associated. EC recurred in 2/23 patients (8.7%) after surgical correction, necessitating a revision procedure. No perioperative complications or long-term sequelae were noted in the entire population.

CONCLUSIONS

Endonasal endoscopic management of congenital ECs is feasible in children, although regular long-term follow-up is essential. Furthermore, the surgical approach does not seem to affect patients' development and quality of life, although more studies and validated questionnaires are needed. No recurrent risk factors were observed able to justify a certain etiologic relation.

Intranasal glial heterotopia in a male infant: A case report

RATIONALE

Nasal glial heterotopia is a rare type of neoplasm consisting of meningothelial and/or neuroglial elements.

PATIENT CONCERNS

A 2-month-old male was evaluated for treatment of a congenital mass in the right nasal cavity near the pharynx.

DIAGNOSES

The patient was preoperatively diagnosed with a congenital intranasal neoplasm.

INTERVENTIONS

Nasal endoscopic resection of the nasopharyngeal mass was performed under general anesthesia. Histological examination of the resected tissue provided a diagnosis of intranasal glial heterotopia.

OUTCOMES

The surgical outcome was good, with no surgical site infection. After 1 year of follow-up, the boy was asymptomatic with no recurrence.

LESSONS

Excision of a nasopharyngeal mass via nasal endoscopy resulted in no recurrence during 1 year of follow-up. Before any surgical treatment for suspected glial heterotopia, the mass should be differentiated clinically and radiologically from an encephalocele to prevent the risk of cerebrospinal fluid leakage and meningitis.

Current management of congenital anterior cranial base encephaloceles

OBJECTIVES

Congenital encephaloceles provide unique diagnostic and reconstructive challenges for the pediatric rhinologist. The objectives of the current study were to evaluate contemporary treatment strategies for congenital encephaloceles focusing on presentation, surgical technique, and outcomes.

METHODS

Multi-institutional retrospective chart review of congenital encephaloceles (2003-2019). Data regarding demographics, presenting symptoms, associated abnormalities, surgical technique, size, location, and complications were collected.

RESULTS

Fourteen patients with 15 congenital encephaloceles were treated using endoscopic techniques (avg 6.0 years, range 2 months-22 years) with mean follow up of 23 months. The majority presented with nasal obstruction (n = 13); only one child had cerebrospinal fluid (CSF) rhinorrhea. Associated anomalies included nasal deformities, congenital hypopituitarism, and Morning Glory syndrome. Average encephalocele size was 2.44 cm (range 0.5-3.6 cm) with mean skull base defect size of 8.6 x 7.7 mm. Locations included the foramen cecum (n = 9), central sphenoid (n = 3), midline anterior cranial fossa (n = 1), orbital plate of frontal bone (n = 1), and ethmoid roof (n = 1). Because of favorable expansion from encephaloceles, it was unnecessary to postpone surgeries to allow nasal cavity growth. Three individuals had prior operations, including surgeries for "nasal polyp" or "adenoid cyst". Two patients had post-operative complications (meningitis and CSF leak) effectively treated with no further sequelae.

CONCLUSIONS

In the current study, congenital encephaloceles in children as young as 2 months were successfully repaired using endoscopic techniques. Endoscopic approaches remain a safe and effective intervention for management of these lesions.

Modification of the Fetal Profile Line to Measure Reversal of Forehead Slope after Early Repair of Frontoethmoidal Encephalocele

Objective  Congenital frontoethmoidal encephaloceles are associated with a shallow sloping forehead. We (1) sought to determine if early repair reverses abnormal forehead slope, and (2) assessed a modification of the fetal profile (FP) line to assess results. Design  Study of two cases. Participants  Newborns with frontoethmoidal encephaloceles repaired prior to the age of 4 months with cranial base bone grafting. Main Outcome Measures  Forehead slope was assessed using a modification of the FP line, defined as the line that passes through the anterior border of the mandible and nasion, on pre and postoperative magnetic resonance imaging (MRI) in the midsagittal plane. A modified FP (mFP) line anterior to the forehead was " - ", while a posterior (normal) mFP line was " + ." The largest distance from the mFP line to the forehead was measured. Results  Both infants underwent bifrontal craniotomy, excision of encephalocele, and repair of cribriform plate defect using full-thickness autologous parietal bone before the age of 4 months. Preoperatively, the mFP line was -20.6 mm in case 1, and -9.8 mm in case 2. In both cases, follow-up MRI showed excellent reversal of forehead slope and normal calvarium development. The mFP line improved to +7.4 (age = 16 months) in case 1, and +7.6 (age = 11 months) in case 2. The parietal bone donor site ossified completely within 3 months in both cases. Conclusion  Early repair with bone grafting can promote normal frontal bone development and improve forehead slope. The mFP line is a useful method to measure degree of forehead slope.

Secondary encephalocele in an adult leading to subdural empyema

Brain abscesses are an uncommon but potentially fatal infection. They can spread directly from an adjacent source or hematogenously from a distant source. Encephaloceles represent a rare form of neural tube defects that can potentially be complicated by the development of meningitis or brain abscess. We report a case of a 63-year-old female who presented with bilateral lower extremity weakness and was ultimately found to have a Streptococcus pneumoniae subdural empyema and an associated frontal lobe encephalocele extending through the left frontal sinus. She was treated with surgical drainage, intravenous antimicrobials, and ultimately surgical repair of the encephalocele. This report highlights a unique presentation of brain abscess. Clinicians should be aware of this potential infectious complication of a neural tube defect.

Non-Midline Frontal Encephalocele Presenting as Disappearing Dermoid

Congenital masses in the lateral brow are most commonly dermoid cysts and can often be excised surgically without additional investigation. These dermoids may rarely develop intracranial extension due to underlying bony erosions and become less prominent over time - a "disappearing dermoid." However, the authors present an unusual alternative case in which an off-midline frontal encephalocele initially presented as a firm irreducible mass but exhibited changing characteristics over time.

Novel mouse model of encephalocele: post-neurulation origin and relationship to open neural tube defects

Encephalocele is a clinically important birth defect that can lead to severe disability in childhood and beyond. The embryonic and early fetal pathogenesis of encephalocele is poorly understood and, although usually classified as a 'neural tube defect', there is conflicting evidence on whether encephalocele results from defective neural tube closure or is a post-neurulation defect. It is also unclear whether encephalocele can result from the same causative factors as anencephaly and open spina bifida, or whether it is aetiologically distinct. This lack of information results largely from the scarce availability of animal models of encephalocele, particularly ones that resemble the commonest, nonsyndromic human defects. Here, we report a novel mouse model of occipito-parietal encephalocele, in which the small GTPase Rac1 is conditionally ablated in the (non-neural) surface ectoderm. Most mutant fetuses have open spina bifida, and some also exhibit exencephaly/anencephaly. However, a proportion of mutant fetuses exhibit brain herniation, affecting the occipito-parietal region and closely resembling encephalocele. The encephalocele phenotype does not result from defective neural tube closure, but rather from a later disruption of the surface ectoderm covering the already closed neural tube, allowing the brain to herniate. The neuroepithelium itself shows no downregulation of Rac1 and appears morphologically normal until late gestation. A large skull defect overlies the region of brain herniation. Our work provides a new genetic model of occipito-parietal encephalocele, particularly resembling nonsyndromic human cases. Although encephalocele has a different, later-arising pathogenesis than open neural tube defects, both can share the same genetic causation.

Holoprosencephaly, orofacial cleft, and frontonaso-orbital encephaloceles: Genetic evaluation of a possible new syndrome

Here we report on a Brazilian child who presented semilobar holoprosencephaly, frontonasal encephaloceles and bilateral cleft lip and palate. Malformations also included agenesis of the corpus callosum, abnormal cortical gyres, dilation of the aqueduct, bilateral endolymphatic sac, bilateral cystic cocci-vestibular malformation, and a cribriform defect. The 3D TC craniofacial images showed abnormal frontonasal transition region, with a bone bifurcation, and partial agenesis of nasal bone. The trunk and upper and lower limbs were normal. To our knowledge, this rare association of holoprocensephaly with frontonaso-orbital encephaloceles without limb anomalies has never been reported before. Karyotype was normal. SNP-array showed no copy-number alterations but revealed 25% of regions of homozygosity (ROH) with normal copy number, indicating a high coefficient of inbreeding, which significantly increases the risk for an autosomal recessive disorder. Whole exome sequencing analysis did not reveal any pathogenic or likely pathogenic variants. We discuss the possible influence of two variants of uncertain significance found within the patient's ROHs. First, a missense p.(Gly394Ser) in PCSK9, a gene involved in the regulation of plasma low-density lipoprotein cholesterol. Second, an inframe duplication p.(Ala75_Ala81dup) in SP8, a zinc-finger transcription factor that regulates signaling centers during craniofacial development. Further studies and/or the identification of other patients with a similar phenotype will help elucidate the genetic etiology of this complex case.

Surgical correction of a meningoencephalocele in a thoroughbred filly

OBJECTIVE

To describe the surgical correction of a closed meningoencephalocele in a thoroughbred filly.

STUDY DESIGN

Case report.

ANIMAL

One thoroughbred filly, 1.5 months old at the time of surgery.

METHODS

A meningoencephalocele was identified at birth and diagnosed with radiography and MRI. The abnormal tissue was excised and submitted for histopathology, the dura was closed, and the defect in the skull was corrected with a titanium mesh.

RESULTS

Histopathology confirmed the presence of neural parenchyma consisting of neurons and glial cells. The filly remained without neurologic deficits 7 months after surgery.

CONCLUSION

Surgical correction of a meningoencephalocele was performed and considered successful, with no long-term neurologic deficits postoperatively.

CLINICAL SIGNIFICANCE

Given the paucity of neural tube defect cases in the equine population, no surgical corrective techniques have been reported in the literature. This Case Report describes the first successful surgical treatment of a meningoencephalocele in a horse.

Nasal Framework Osteotomy: An Innovative Approach to Manage an Extremely Long Nose With Meningoencephalocele

Meningoencephlocele is a relatively rare deformity, usually characterized by penetration of brain or meningeal tissues through a defect in skull. This protruding tissue may affect facial structure and subtle to severe facial deformities may appear. Surgical treatments of these deformities are usually done by a team including a neurosurgeon and craniofacial surgeon. The conventional treatments includes several complicated operations to relocate herniating tissues, then correcting malformed facial structure. The nasal framework osteotomy, is an innovative approach that uses transfacial incisions to gain access to herniating tissue. Then, by completing the osteotomy around the nose, the entire nasal structure is lifted and transposed to it is original position. The authors believe that this technique may considerably reduce the complexity and risks of conventional approaches, while aesthetic demands are readily achieved at the same stage.

Sublabial transsphenoidal microsurgical technique to treat congenital transsphenoidal encephalocele: a technical note

Encephalocele is a rare malformation consisting in herniation of cranial contents through a cranial defect. A transsphenoidal location is uncommon, representing 5% of all basal encephaloceles. The surgical treatment of transsphenoidal encephaloceles is challenging. An optimal approach has not yet been determined, and it varies according to the surgical experience. We report the surgical management of a transsphenoidal encephalocele. The encephalocele and the sellar defect were repaired through a sublabial transsphenoidal microsurgical approach (TSM). Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans were crucial for surgical planning. The sublabial transsphenoidal microsurgical approach offered a good and complete exposure of both the sac and the bone defect. Therefore, the congenital defect was successfully repaired with complete resolution of the encephalocele without any surgical or medical complications. Postoperative CT scan and MRI showed the restoration of the bone defect and the recovery of a normal anatomy with herniated structures pushed back into the sella. The described sublabial transsphenoidal microsurgical approach represents a minimally invasive, safe, and effective treatment strategy for transsphenoidal encephalocele.

Choanal Atresia and Other Neonatal Nasal Anomalies

Congenital nasal deformities can cause nasal obstruction with early respiratory distress. Choanal atresia is characterized by no communication between the nasal cavity and nasopharynx. Pyriform aperture stenosis involves more anterior nasal obstruction with limited intranasal space. Nasal masses such as encephaloceles, gliomas, and dermoids are thought to be related through a skull base defect in utero. Imaging with computed tomography and MRI are helpful in distinguishing lesions and identifying intracranial communication. Nasolacrimal duct cysts can get infected and cause obstruction. Nasal septal deviation can be corrected at bedside if detected early. Evaluation and treatment are discussed with all these entities.

Nasal Glioma: A Rare Cause of Congenital Inner Canthal Swelling

Nasal glioma, encephalocele, and ectopic brain are rare congenital anomalies. The terminology applied to these entities has been historically confusing. In many cases, the terms overlap and may be employed synonymously although some authors emphasize their differences. The authors describe herein a child with an inner canthal mass of brain-like tissue that they interpret as nasal glioma, a variety of encephalocele that has lost its connection to the intracranial contents. This research was conducted in conformity with the Helsinki Declaration and Health Insurance Portability and Accountability Act regulations.

Frontoethmoidal encephalocele in a cat

Case summary

An 11-month-old female neutered domestic shorthair cat presented for further investigation of a 1 month history of generalised tonic–clonic seizures. Physical examination revealed microphthalmia of the left eye and right-sided hemiparesis. MRI of the brain and cranial neck was performed using a 1.5-Tesla system. MRI revealed a left frontoethmoidal encephalocele and microphthalmia of the left eye. Conservative treatment with antiepileptic medication was elected. The cat was managed on phenobarbitone and levetiracetam. Seizures have remained well controlled 12 months post-diagnosis.

Relevance and novel information

This is the first known case report of a frontoethmoidal encephalocele in a cat. This case was presented to increase clinical awareness of this congenital malformation and as a differential diagnosis for any young cat that presents with seizures.

Diagnosis and Surgical Management of Congenital Intranasal Teratoma in a Newborn: A Rare Case Report

Teratomas are the most common germ cell tumors of childhood. Head and neck teratomas, however, account for less than five percent of all teratomas. Considered rare at an incidence of 1 in 20,000 to 40,000 live births, they may occur in the cervical region, nasopharynx, brain, orbit, or oropharynx. Teratoma presenting as an isolated intranasal mass is extremely rare. In this report, we describe a case of a mature teratoma arising from the roof of the nasal cavity presenting as an isolated intranasal mass, the first of its kind from our literature review. The tumor was resected endoscopically with no recurrence detected.

Frontoethmoidal encephalocele. Report of a case

Encephaloceles are uncommon in western countries and most cases are located in the occipital bone. Frontal encephaloceles may involve the ethmoid bone, nasal bones and/or the orbits. Surgical repair is complex and usually requires a multidisciplinary approach. The goal of the surgery is to reconstruct the normal anatomy, to achieve a good cosmetic repair and to avoid a cerebrospinal fluid leak. We present a case of a patient with a large congenital frontoethmoidal encephalocele. Autologous calvarian bone grafts were used to repair of encephalocele defect and for the reconstruction of the frontonasal area. The defect closure and the cosmetic result were satisfactory, and the only complication detected was the infection of a previously performed ventriculoperitoneal shunt. A description of the technique and a review of the literature are presented.

Multimaterial 3D printing preoperative planning for frontoethmoidal meningoencephalocele surgery

INTRODUCTION

Surgical correction of frontoethmoidal meningoencephalocele, although rare, is still challenging to neurosurgeons and plastic reconstructive surgeons. It is fundamental to establish reliable and safe surgical techniques. The twenty-first century has brought great advances in medical technology, and the 3D models can mimic the correct tridimensional anatomical relation of a tissue organ or body part. They allow both tactile and spatial understanding of the lesion and organ involved. The 3D printing technology allows the preparation for specific surgery ahead of time, planning the surgical approach and developing plans to deal with uncommon and high-risk intraoperative scenarios.

CASE PRESENTATION

The present report describes a case of frontoethmoidal encephalocele, (nasofrontal subtype) of a 19-month-old girl, whose surgical correction was planned using 3D printing modeling.

CONCLUSION

The 3D model allowed a detailed discussion of the aspects of the surgical approach by having tissues of different consistencies and resistances, and also predicting with millimetric precision the bilateral orbitotomy measurements. Moreover, it was a fundamental and valuable factor in the multidisciplinary preoperative discussion. This approach allowed reducing the time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. 3D models can be very helpful tools in planning complex craniofacial operative procedures.

Repair of Frontoethmoidal Encephalocele in the Philippines: An Account of 30 Cases Between 2008-2013

BACKGROUND

Frontoethmoidal encephalocele is a congenital abnormality of the anterior skull base involving herniation of cranial contents through a midline skull defect. Patency of the foramen cecum, along with other multifactorial variables, contributes to the development of frontoethmoidal encephaloceles. Because of limited resources, financial constraints, and lack of surgical expertise, repair of frontoethmoidal encephaloceles is limited in developing countries.

METHODS

Between 2008 and 2013 an interdisciplinary team composed of neurosurgeons, craniofacial surgeons, otolaryngologists, plastic surgeons, and nursing personnel, conducted surgical mission trips to Davao City in Mindanao, Philippines. All patients underwent a combined extracranial/intracranial surgical approach, performed in tandem by a neurosurgeon and a craniofacial surgeon, to detach and remove the encephalocele. This procedure was followed by reconstruction of the craniofacial defects.

RESULTS

A total of 30 cases of frontoethmoidal encephalocele were repaired between 2008 and 2013 (20 male; 10 female). The average age at operation was 8.7 years, with 7 patients older than 17 years. Of the 3 subtypes, the following breakdown was observed in patients: 18 nasoethmoidal; 9 nasofrontal; and 3 naso-orbital. Several patients showed concurrent including enlarged ventricles, arachnoid cysts (both unilateral and bilateral), and gliotic changes, as well as orbit and bulbus oculi (globe) deformities. There were no operative-associated mortalities or neurologic deficits, infections, or hydrocephalus on follow-up during subsequent trips.

CONCLUSIONS

Despite the limitations of performing advanced surgery in a developing country, the combined interdisciplinary surgical approach has offered effective treatment to improve physical appearance and psychological well-being in afflicted patients.

Endonasal management of pediatric congenital transsphenoidal encephaloceles: nuances of a modified reconstruction technique. Technical note and report of 3 cases

OBJECTIVE Congenital transsphenoidal encephaloceles are rare malformations, and their surgical treatment remains challenging. This paper reports 3 cases of transsphenoidal encephalocele in 8- to 24-month-old infants, who presented mainly with airway obstruction, respiratory distress, and failure to thrive. METHODS The authors discuss the surgical management of these lesions via a minimally invasive endoscopic endonasal approach, as compared with the traditional transcranial and transpalatal approaches. A unique endonasal management algorithm for these lesions is outlined. The lesions were repaired with no resection of the encephalocele sac, and the cranial base defects were reconstructed with titanium mesh plates and vascular nasoseptal flaps. RESULTS Reduction of the encephalocele and reconstruction of the skull base was successfully accomplished in all 3 cases, with favorable results. CONCLUSIONS The described endonasal management algorithm for congenital transsphenoidal encephaloceles is a safe, viable alternative to traditional transcranial and transpalatal approaches, and avoids much of the morbidity associated with these open techniques.