Contrasting Surgical Management of CSF Leak from Lateral Recess of Sphenoid Sinus and Its Surgical Outcomes: Our Experience

Management of a pediatric patient with spontaneous cerebrospinal fluid leak in the lateral recess of sphenoid sinus and meningoencephalocele: A case report and literature review

INTRODUCTION AND IMPORTANCE

Spontaneous cerebrospinal fluid (CSF) leak in the lateral recess of the sphenoid (LRS) sinus in a pediatric population is rare and is surgically challenging to repair.

CASE PRESENTATION

We report a case of a 13-year-old girl with hydrocephalus and a ventriculoperitoneal shunt who presented with a two-month history of clear rhinorrhea from the right nostril. Computed tomography (CT) of the head was performed and showed CSF leak through a defect in the lateral recess of the sphenoid sinus. Defect closure was achieved using an endoscopic endonasal approach.

CLINICAL DISCUSSION

CSF leak with meningoencephalocele from the sphenoid sinus is amongst the most difficult cases for repair. Yet the successful rate of repair is as high as 90 % if done endoscopically. Moreover, the location of the defect determines the surgical approach.

CONCLUSION

Spontaneous CSF rhinorrhea from the lateral recess of the sphenoid (LRS) sinus, although rare, requires prompt diagnosis and treatment, as it may lead to significant mortality and morbidity.

Ipsilateral Nasoseptal Flap Pedicle for Transpterygoid Approach: Technical Note

INTRODUCTION

Transpterygoid approach is an expanded endonasal approach (EEA) that allows surgical access to the medial infratemporal fossa, to the skull base area of petrous bone and to the Meckel's cave. During this approach, a sacrifice of sphenopalatine artery is often required, leading to the need of contralateral Hadad-Bassagasteguy flap (HBF) or alternative reconstructive techniques.

MATERIALS AND METHODS

We report a case of spontaneous CSF leak due to a meningo-encephalocele in the left lateral recess of sphenoid sinus, in which an ispilateral nasoseptal flap was harvest and sphenopalatine artery was preserved.

RESULTS

We described the surgical technique adopted to preserve the ipsilateral nasoseptal vascular pedicle during transpterygoid approach and we performed a review of the pertinent literature.

CONCLUSION

Wide exposure of the pterygoid base through transpterygoid approach could be obtained preserving the sphenopalatine artery, allowing skull base reconstruction with ipsilateral nasoseptal flap.

Minimally Invasive Lateral Paraorbital Approach for Repairing Lateral Recess of the Sphenoid Sinus Spinal Fluid Leak

BACKGROUND

Cerebrospinal fluid (CSF) leaks in the lateral recess of the sphenoid sinus (LRSS) are typically spontaneous in nature and require surgical repair. Endoscopic endonasal approaches have become the mainstay of CSF leak repair in the LRSS, though they remain technically challenging and place the vidian nerve (VN) and sphenopalatine artery (SPA) at risk. Here we present a lateral paraorbital approach (LPOA) as a minimally invasive transcranial VN and SPA sparing alternative for LRSS CSF leak repairs.

CASE DESCRIPTION

A 41-year-old African American woman presented with headaches and was found to have a spontaneous CSF leak in the LRSS. A LPOA was used to repair the CSF leak. An incision was made along the frontal process of zygoma (FPZ). Removal of the overhanging portion of the FPZ while sparing the lateral orbital rim and retraction of the temporalis muscle allowed for a tangential approach to the LRSS. A small encephalocele was seen and resected; the defect was identified and repaired with onlay DuraGen (Integra LifeSciences, Princeton, NJ) and Dura Repair (J&J Medical Devices, New Brunswick, NJ). There were no postoperative complications or recurrence of CSF leak.

CONCLUSIONS

The LPOA can be a useful alternative approach to the LRSS for CSF leak repair. The lateral-to-medial approach to defects in this area provides a shorter working distance while avoiding critical neurovascular structures.