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Bhuskute GS, Gosal JS, Alsavaf MB, Abouammo MD, Manjila S, Kandregula S, Nayyar AK, Jha DK, Carrau RL, Prevedello DM. Morphometric Comparison of Endoscopic Endonasal Transpterygoid and Precaruncular Contralateral Medial Transorbital Approaches to Sphenoid Sinus Lateral Recess. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01021. [PMID: 38189446 DOI: 10.1227/ons.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/17/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The endoscopic endonasal transpterygoid approach (TPA), minimally invasive compared with the sublabial transmaxillary and transcranial approaches, still accounts for morbidity in benign lateral recess of sphenoid sinus (LRSS) pathologies. Others have suggested an alternative route to the LRSS, the endoscopic contralateral medial transorbital approach (cMTO). However, no quantitative evidence exists to support the clinical application of this approach. This cadaveric study, in a controlled laboratory setting, provides a morphometric comparison of the TPA and cMTO for accessing the LRSS. The study also details the anatomy and technical nuances for optimizing the cMTO corridor. METHODS Ten fresh preinjected human cadaveric specimens (20 sides) were dissected with neuronavigation, completing endoscopic cMTO and TPA on each side. Four parameters-working distance to lateral recess, surgical exposure area, angle of attack (AoA), and surgical freedom-were measured for each approach. Relevant osteological measurements in 10 dried human skulls were recorded. RESULTS The mean distance from the superior margin of the lacrimal sac impression to the inferior margin of the trochlear fossa was 10.29 ± 1.13 mm, and that from the anterior ethmoidal artery foramina to the posterior lacrimal crest was 9.63 ± 1.23 mm. The mean exposure area around the LRSS was significantly higher in TPA (614.09 ± 40.38 mm2) than in cMTO (391.19 ± 59.01 mm2, P = .001). The mean AoA was 9.83° and 10.24° in the cMTO and TPA, respectively, in the craniocaudal direction (P = .529). In the horizontal plane, it was 9.29° and 10.76° (P = .012). There was no significant difference in surgical freedom between the cMTO and TPA (804.61 and 806.05 mm3, respectively; P = .993). CONCLUSION Although comparatively limited exposure area, the cMTO approach has a similar AoA and surgical freedom as TPA and offers better visualization and ergonomic advantages. cMTO provides a feasible, less morbid, multiport technique for benign sphenoid sinus lateral recess pathologies.
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Affiliation(s)
- Govind S Bhuskute
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Moataz D Abouammo
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, Tanta University, Tanta, Egypt
| | - Sunil Manjila
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashish K Nayyar
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Deepak K Jha
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
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Emerson SN, Aversa A, Al-Mefty O. Sealing the Box: Microsurgical Repair of Skull Base Encephaloceles: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e159-e160. [DOI: 10.1227/ons.0000000000000102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022] Open
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Shelesko EV, Chernikova NA, Kravchuk AD, Strunina YV, Okhlopkov VA, Zinkevich DN, Batalov AI, Solozhentseva KD. [Endoscopic endonasal reconstruction of skull base defects in the lateral recess of the sphenoid sinus: evaluation of computed tomograms for planning operations]. Vestn Otorinolaringol 2021; 86:74-81. [PMID: 34964334 DOI: 10.17116/otorino20218606174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Determine the influence of the anatomical features and sizes of the lateral pocket with a defect on the choice of surgical access and the quality of the performed plastics. MATERIAL AND METHODS A retrospective analysis of computed tomograms of 38 patients who underwent surgical treatment at the Burdenko National Medical Research Center for Neurosurgery of the Ministry of Health of Russia about defects of the skull base in the area of the lateral pocket of the sphenoid sinus. The patients were divided into three groups depending on the approach used (the 1st group), the recurrence rate (the 2nd group), and the characteristics of intraoperative visualization of the defect (the 3rd group). RESULTS There were no statistically significant differences in anatomical features in patients who underwent trans-pterygoid and transsphenoidal approaches, as well as in patients of the 2nd group. Patients of the 3rd group (with visualization features) showed statistically significant differences between the distance from the defect to the VR line (p=0.007). In patients with good visualization of the defect using direct optics, this distance was shorter than in patients in whom the defect was visualized with an angled endoscope. No other anatomical differences were noted. CONCLUSIONS The anatomical features of the lateral pocket structure (type of pneumatization, size and volume) did not affect the choice of access to the defect and the frequency of recurrence. When comparing the approaches, it was noted that the trans-pterygoid access, providing direct visualization of defects, minimizes the risk of recurrence in the postoperative period. An objective anatomical indicator for choosing an access to the defects of the lateral pocket can be the distance from the defect to the VR line: at a distance of more than 0.7 cm, it is advisable to perform a trans-pterygoid approach; at a distance of less than 0.7 cm, it is possible to achieve direct visualization of the defect and perform high-quality plastic surgery with a transsphenoidal access.
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Affiliation(s)
- E V Shelesko
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - N A Chernikova
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - A D Kravchuk
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - Yu V Strunina
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - V A Okhlopkov
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - D N Zinkevich
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - A I Batalov
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - K D Solozhentseva
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
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Mukae N, Kuga D, Murakami D, Komune N, Miyamoto Y, Shimogawa T, Sakata A, Shigeto H, Iwaki T, Morioka T, Mizoguchi M. Endonasal endoscopic surgery for temporal lobe epilepsy associated with sphenoidal encephalocele. Surg Neurol Int 2021; 12:379. [PMID: 34513146 PMCID: PMC8422469 DOI: 10.25259/sni_542_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/29/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Temporal lobe epilepsy (TLE) associated with temporal lobe encephalocele is rare, and the precise epileptogenic mechanisms and surgical strategies for such cases are still unknown. Although the previous studies have reported good seizure outcomes following chronic subdural electrode recording through invasive craniotomy, only few studies have reported successful epilepsy surgery through endoscopic endonasal lesionectomy. Case Description: An 18-year-old man developed generalized convulsions at the age of 15 years. Despite treatment with optimal doses of antiepileptic drugs, episodes of speech and reading difficulties were observed 2–3 times per week. Long-term video electroencephalogram (EEG) revealed ictal activities starting from the left anterior temporal region. Magnetic resonance imaging revealed a temporal lobe encephalocele in the left lateral fossa of the sphenoidal sinus (sphenoidal encephalocele). Through the endoscopic endonasal approach, the tip of the encephalocele was exposed. A depth electrode was inserted into the encephalocele, which showed frequent spikes superimposed with high-frequency oscillations (HFOs) suggesting intrinsic epileptogenicity. The encephalocele was resected 8 mm from the tip. Twelve months postoperatively, the patient had no recurrence of seizures on tapering of the medication. Conclusion: TLE associated with sphenoidal encephalocele could be controlled with endoscopic endonasal lesionectomy, after confirming the high epileptogenicity with analysis of HFOs of intraoperative EEG recorded using an intralesional depth electrode.
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Affiliation(s)
- Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Kuga
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Murakami
- Department of Otorhinolaryngology Head and Neck Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noritaka Komune
- Department of Otorhinolaryngology Head and Neck Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Miyamoto
- Department of Otorhinolaryngology Head and Neck Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ayumi Sakata
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroshi Shigeto
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University,Fukuoka, Japan
| | - Toru Iwaki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University,Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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5
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Sreenath SB, Tang DM, Ting JY, Illing EA, Recinos PF, Soni P, Kshettry VR, Cohen-Gadol A, Woodard TD, Sindwani R. Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide. Laryngoscope 2021; 131:2224-2230. [PMID: 34096616 DOI: 10.1002/lary.29672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks. STUDY DESIGN Multi-Institutional, Retrospective Case Series. METHODS Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated. RESULTS Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months. CONCLUSION The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
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Affiliation(s)
| | - Dennis M Tang
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Jonathan Y Ting
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Elisa A Illing
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pranay Soni
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Aaron Cohen-Gadol
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Konar S, Shukla D. Saving One Nostril. J Neurosci Rural Pract 2021; 12:3. [PMID: 33531753 PMCID: PMC7846342 DOI: 10.1055/s-0040-1716809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neuro-Science (NIMHANS), Bangalore, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro-Science (NIMHANS), Bangalore, Karnataka, India
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7
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Rathod R, Virk RS, Nayak G. Plasma Ablation-Assisted Endoscopic Endonasal Transpterygoid Approach to Sphenoid Lateral Recess Cerebrospinal Fluid Leaks: Technique and Outcome. World Neurosurg 2021; 149:e636-e645. [PMID: 33548527 DOI: 10.1016/j.wneu.2021.01.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Management of sphenoid lateral recess (SLR) cerebrospinal fluid (CSF) leaks present a challenge because of the location and requiring complete visualization of the defect for a successful repair. The endoscopic endonasal transpterygoid approach (EETPA) is considered the gold standard in addressing these defects. We lay out our experience in implementing this approach with plasma ablation. METHODS This is a case series of 11 diagnosed patients of SLR CSF leaks who underwent plasma ablation-assisted EETPA repair by a single surgeon between 2011 and 2020 at our institution. Outcomes in terms of surgical field grade on the Wormald 11-point grading scale, postoperative complications, healing on nasal endoscopy and imaging, and surgical success rate were assessed. RESULTS The etiology was spontaneous leak in 10 (90.9%) patients and secondary to temporal lobe abscess and/or meningitis in one (9.09%). Three (27%) patients were previously operated elsewhere by the transsphenoidal route, which we reoperated by this technique. As per Wormald grading, grade 1 field in 3 (27.27%), grade 2 in 6 (54.5%), and grade 3 in 2 cases (18.18%) were noted. Complications occurred in 3 patients (27%) in the form of dry eye (9%), meningitis (9%), and transient CSF rhinorrhea in the immediate postoperative period (9%). Repair sites were well healed on follow-up nasal endoscopy and imaging. The surgical success rate was 100%. CONCLUSIONS Plasma ablation-assisted EETPA allows for a uninostril approach to the SLR, easy accessibility, and better visualization with a bloodless field, which allows appropriate repair, thus minimizing complications and preventing recurrence.
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Affiliation(s)
- Ramya Rathod
- Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh Virk
- Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Gyanaranjan Nayak
- Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Tse GT, Frydman AS, O'Shea MF, Fitt GJ, Weintrob DL, Murphy MA, Fabinyi GC, Bulluss KJ, Cook MJ, Berkovic SF. Anterior temporal encephaloceles: Elusive, important, and rewarding to treat. Epilepsia 2020; 61:2675-2684. [PMID: 33098124 DOI: 10.1111/epi.16729] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the etiology and longitudinal clinical, neuropsychological, psychosocial, and surgical outcome profile of patients with medication refractory epilepsy and temporal encephaloceles with a view to highlight diagnostic clues and management strategies. METHODS The comprehensive epilepsy program databases at two surgical epilepsy centers from January 2000 to October 2018 were reviewed for this observational study, to identify patients with encephaloceles causing temporal lobe epilepsy (TLE) and treated with surgical resection. Their clinical, radiological, neuropsychological, psychiatric, and surgical data were obtained. Body mass index (BMI) data were also reviewed due to possible correlation between idiopathic intracranial hypertension and encephaloceles. RESULTS Thirteen patients (eight female) were identified; only three were recognized on initial magnetic resonance imaging (MRI) report. Temporal encephaloceles were identified on the left in eight patients, on the right in three patients, and bilaterally in two patients. One patient had a strong family history of encephaloceles. The median BMI for patients with seizure onset ≤20 years of age was 22.4, whereas for patients with onset >20 years median BMI was 32.6 (P = .06). Five patients underwent a focal lesionectomy, three patients had limited temporal lobectomy, and five patients had standard anterior temporal lobectomy. Median postoperative follow-up was 5.5 years. All but one patient were free of disabling seizures. Nine of ten neuropsychologically tested patients had no discernable cognitive decline postoperatively. Postoperative psychosocial adjustment features were present in four patients. SIGNIFICANCE Genetic factors and a possible association with idiopathic intracranial hypertension (given female predominance and elevated BMI) may contribute to the causation of temporal lobe encephaloceles. It is notable that a targeted surgical approach in the management of patients with TLE associated with encephaloceles has an excellent long-term clinical and neuropsychological outcome. Subtle encephaloceles should be actively searched for in patients with drug-resistant TLE because they significantly change surgical strategy and prognostication.
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Affiliation(s)
- Gabrielle T Tse
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic., Australia.,Department of Neurology, Austin Health, Heidelberg, Vic., Australia
| | - Aviva S Frydman
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic., Australia
| | - Marie F O'Shea
- Department of Clinical Neuropsychology, Austin Health, Heidelberg, Vic., Australia.,Department of Psychological Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Greg J Fitt
- Department of Radiology, Austin Health, Heidelberg, Vic., Australia
| | - David L Weintrob
- Department of Clinical Neuropsychology, Austin Health, Heidelberg, Vic., Australia.,Department of Psychological Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Michael A Murphy
- Department of Neurosurgery, St. Vincent's Hospital, University of Melbourne, Melbourne, Vic., Australia
| | - Gavin C Fabinyi
- Department of Neurosurgery, Austin Health, Heidelberg, Vic., Australia
| | - Kristian J Bulluss
- Department of Neurosurgery, St. Vincent's Hospital, University of Melbourne, Melbourne, Vic., Australia.,Department of Neurosurgery, Austin Health, Heidelberg, Vic., Australia
| | - Mark J Cook
- Department of Medicine, St. Vincent's Hospital, University of Melbourne, Melbourne, Vic., Australia
| | - Samuel F Berkovic
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic., Australia.,Department of Neurology, Austin Health, Heidelberg, Vic., Australia
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9
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Alves-Belo JT, Mangussi-Gomes J, Truong HQ, Cohen S, Gardner PA, Snyderman CH, Stefko ST, Wang EW, Fernandez-Miranda JC. Lateral Transorbital Versus Endonasal Transpterygoid Approach to the Lateral Recess of the Sphenoid Sinus-A Comparative Anatomic Study. Oper Neurosurg (Hagerstown) 2020; 16:600-606. [PMID: 30107582 DOI: 10.1093/ons/opy211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/09/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The treatment of cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus (LRSS) faces difficulties due to the deep location of the osseous defect. When treated with craniotomies, brain retraction is a concern. The endoscopic endonasal transpterygoid approach (EETA) is a direct and less invasive procedure; however, it may require transection of the vidian nerve (VN). OBJECTIVE To investigate the feasibility of a lateral transorbital approach (LTOA) as an alternative pathway to the LRSS that avoids VN sacrifice. METHODS Six embalmed heads with well-pneumatized LRSS were preselected by inspecting their computed tomography scans. One LTOA and one EETA were performed on 1 side of each specimen. The approaches were compared regarding working distance and neurovascular structures being sacrificed. The working area of the LTOA was also measured. RESULTS The average working distances were 59.9 (±2.94) mm for the LTOA and 76.4 (±3.99) mm for the EETA (P < .001). The LTOA generated a working area with a diameter of 9 to 14 mm. The EETA demanded the sacrifice of VN and the sphenopalatine artery in all specimens to expose the LRSS. No neurovascular structures were found in the trajectory of the LTOA. CONCLUSION The LTOA to the LRSS is feasible, with minimal risk of injuring neurovascular structures. It offers a shorter pathway when compared to the EETA. Although the LTOA provides no options for vascularized flap reconstruction, it allows immediate access to muscle grafts. The LTOA may serve as an alternative to treating cerebrospinal fluid leaks of the LRSS.
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Affiliation(s)
- Joao T Alves-Belo
- Surgical Neuroanatomy Lab, UPMC Cen-ter for Cranial Base Surgery, Pittsburgh, Pennsylvania
| | - Joao Mangussi-Gomes
- Surgical Neuroanatomy Lab, UPMC Cen-ter for Cranial Base Surgery, Pittsburgh, Pennsylvania
| | - Huy Q Truong
- Surgical Neuroanatomy Lab, UPMC Cen-ter for Cranial Base Surgery, Pittsburgh, Pennsylvania
| | - Salomon Cohen
- Surgical Neuroanatomy Lab, UPMC Cen-ter for Cranial Base Surgery, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neuro-surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Otolaryngology, Univer-sity of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - S Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric W Wang
- Department of Otolaryngology, Univer-sity of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- Department of Neuro-surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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10
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Wong AK, Wong RH. Minimally Invasive Lateral Paraorbital Approach for Repairing Lateral Recess of the Sphenoid Sinus Spinal Fluid Leak. World Neurosurg 2020; 144:143-147. [PMID: 32891848 DOI: 10.1016/j.wneu.2020.08.202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Andrew K Wong
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ricky H Wong
- Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA.
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11
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Maxfield AZ, Mueller SK, Raquib AR, Sedaghat AR, Bergmark RW, Metson RB, Holbrook EH, Bleier BS, Gray ST. Endoscopic management of lateral sphenoid cerebrospinal fluid leaks: Identifying a radiographic parameter for surgical planning. Laryngoscope Investig Otolaryngol 2020; 5:375-380. [PMID: 32596479 PMCID: PMC7314466 DOI: 10.1002/lio2.412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/20/2020] [Accepted: 05/17/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach. METHODS Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed. RESULTS Twenty-two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively.The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; P = .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm3 ± 0.48, 0.39 cm3 ± 0.40, respectively; P = .04). A LRS volume of 0.400 cm3 or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity. CONCLUSION This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Alice Z Maxfield
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Sarina K Mueller
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
- Department of Otolaryngology, Head and Neck Surgery University of Erlangen-Nuremberg Erlangen Germany
| | - Aaishah R Raquib
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Ahmad R Sedaghat
- Department of Otolaryngology, Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Regan W Bergmark
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA
- Center for Surgery and Public Health Brigham and Women's Hospital Boston Massachusetts USA
- Patient Reported Outcomes, Value and Experience (PROVE) Center Brigham and Women's Hospital Boston Massachusetts USA
| | - Ralph B Metson
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Eric H Holbrook
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Benjamin S Bleier
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
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Wadikhaye R, Yerramneni VK, Yerragunta T, Sharma N. A Rare Case of Sphenoid Encephalocoele Presenting with Fifth Cranial Nerve Involvement. J Pediatr Neurosci 2020; 15:25-28. [PMID: 32435302 PMCID: PMC7227746 DOI: 10.4103/jpn.jpn_8_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 11/18/2019] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Rohit Wadikhaye
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | | | - Thirumal Yerragunta
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Neeraj Sharma
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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13
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Lin BJ, Ju DT, Hsu TH, Chung TT, Liu WH, Hueng DY, Chen YH, Hsia CC, Ma HI, Liu MY, Hung HC, Tang CT. Endoscopic transorbital approach to anterolateral skull base through inferior orbital fissure: a cadaveric study. Acta Neurochir (Wien) 2019; 161:1919-1929. [PMID: 31256277 DOI: 10.1007/s00701-019-03993-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endoscopic transorbital approach (eTOA) has been announced as an alternative minimally invasive surgery to skull base. Owing to the inferior orbital fissure (IOF) connecting the orbit with surrounding pterygopalatine fossa (PPF), infratemporal fossa (ITF), and temporal fossa, the idea of eTOA to anterolateral skull base through IOF is postulated. The aim of this study is to access its practical feasibility. METHODS Anatomical dissections were performed in five human cadaveric heads (10 sides) using 0-degree and 30-degree endoscopes. A stepwise description of eTOA to anterolateral skull base through IOF was documented. The anterosuperior corner of the maxillary sinus in the horizontal plane of the upper edge of zygomatic arch was defined as reference point (RP). The distances between the RP to the foramen rotundum (FR), foramen ovale (FO), and Gasserian ganglion (GG) were measured. The exposed area of anterolateral skull base in the coronal plane of the posterior wall of the maxillary sinus was quantified. RESULTS The surgical procedure consisted of six steps: (1) lateral canthotomy with cantholysis and preseptal lower eyelid approach with periorbita dissection; (2) drilling of the ocular surface of greater sphenoid wing and lateral orbital rim osteotomy; (3) entry into the maxillary sinus and exposure of PPF and ITF; (4) mobilization of infraorbital nerve with drilling of the infratemporal surface of the greater sphenoid wing and pterygoid process; (5) exposure of middle cranial fossa, Meckel's cave, and lateral wall of cavernous sinus; and (6) reconstruction of orbital floor and lateral orbital rim. The distances measured were as follows: RP-FR = 45.0 ± 1.9 mm, RP-FO = 55.7 ± 0.5 mm, and RP-GG = 61.0 ± 1.6 mm. In comparison with the horizontal portion of greater sphenoid wing, the superior and inferior axes of the exposed area were 22.3 ± 2.1 mm and 20.5 ± 1.8 mm, respectively. With reference to the FR, the medial and lateral axes of the exposed area were 11.6 ± 1.1 mm and 15.8 ± 1.6 mm, respectively. CONCLUSIONS The eTOA through IOF can be used as a minimally invasive surgery to access whole anterolateral skull base. It provides a possible resolution to target lesion involving multiple compartments of anterolateral skull base.
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14
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Koerner JC, Sweeney J, Rheeman C, Kenning TJ. Delayed presentation of morning glory disc anomaly and transsphenoidal encephalocele: A management dilemma. Neuroophthalmology 2019; 43:95-101. [PMID: 31312233 DOI: 10.1080/01658107.2018.1479434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/07/2018] [Accepted: 05/17/2018] [Indexed: 01/02/2023] Open
Abstract
Background Morning glory disc anomaly (MGDA) is a rare developmental abnormality of the optic disc that is associated with many other neurological and vascular conditions. Most cases are diagnosed in childhood. Case Report We report a 57-year-old woman who presented to the ophthalmology department for assessment of long-standing poor vision in the left eye and exotropia. Examination showed a left MGDA and bitemporal hemianopsia. These findings prompted magnetic resonance imaging, revealing a transsphenoidal basal meningoencephalocele with herniation of the optic chiasm and inferior hypothalamus into the dural sac. Due to the eloquence of the neurovascular structures it contained, a decision was made not to reduce the meningoencephalocele. Instead, a ventriculoperitoneal shunt was placed. The patient's ophthalmologic examination remained stable over the following year. Conclusion While rare, MGDA can be first diagnosed in late adulthood and a thorough evaluation should be completed to assess for midline cranial defects, vascular abnormalities, and other associated abnormalities. Patients presenting late in life with basal encephalocele, herniation of the optic chiasm, and bitemporal hemianopsia present a management dilemma. In this case, a ventriculoperitoneal shunt was placed with the intention of lowering intracranial pressure to prevent further herniation and reduce the risk of cerebrospinal fluid leak.
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Affiliation(s)
- Jagger C Koerner
- Department of Ophthalmology, Albany Medical Center, Albany, NY, USA
| | - Jared Sweeney
- Department of ophthalmology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Charles Rheeman
- Department of Ophthalmology, Albany Medical Center, Albany, NY, USA
| | - Tyler J Kenning
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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15
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Bozkurt G, Turri-Zanoni M, Coden E, Russo F, Elhassan HA, Gallo S, Zocchi J, Bignami M, Locatelli D, Castelnuovo P. Endoscopic Endonasal Transpterygoid Approach to Sphenoid Sinus Lateral Recess Defects. J Neurol Surg B Skull Base 2019; 81:553-561. [PMID: 33134022 DOI: 10.1055/s-0039-1692639] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/08/2019] [Indexed: 12/27/2022] Open
Abstract
Background Lesions affecting sphenoid sinus lateral recess (SSLR) are difficult to visualize and manipulate through the transnasal routes, especially when the sinus is highly pneumatized. External approaches to this area involve extensive surgery and are associated with significant morbidity. The aims of this study are to present our experience with the endoscopic transpterygoid approach as a method for approaching lesions of the SSLR and to evaluate the outcomes of this procedure. Methods Clinical charts of patients who had lesions in the SSLR and who were treated at our institution from September 1998 to June 2018 were retrospectively reviewed. All these patients were managed by the endoscopic endonasal transpterygoid approach. Results Thirty-nine patients were identified. No cerebrospinal fluid leak recurrences were observed during follow-up (range: 1-19.7 years; median: 2.3 years). Hypoesthesia (temporary, 1; persistent, 4) in the region innervated by the maxillary branch of the trigeminal nerve was detected in five (12.8%) patients, while symptoms due to the Vidian nerve damage (dry eye, 3; dry nasal mucosa, 1) were present in four (10%) patients. Conclusions Although the endoscopic endonasal transpterygoid approach is an excellent corridor for dealing with lesions of the SSLR, limited rate of neurologic and lacrimal complications was observed. Potential morbidity of the intervention should be discussed during preoperative counselling.
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Affiliation(s)
- Gülpembe Bozkurt
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Mario Turri-Zanoni
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS & FDRC), University of Insubria, Varese, Italy
| | - Elisa Coden
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Federico Russo
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Hassan Ahmed Elhassan
- Department of Otorhinolaryngology, Lewisham University Hospital, London, United Kingdom
| | - Stefania Gallo
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Jacopo Zocchi
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS & FDRC), University of Insubria, Varese, Italy
| | - Davide Locatelli
- Department of Biotechnology and Life Sciences, Division of Neurosurgery, University of Insubria, Varese, Italy
| | - Paolo Castelnuovo
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS & FDRC), University of Insubria, Varese, Italy
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16
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D'Antonio M, Palacios E, Scheuemann C. CSF Fistula Secondary to Sphenoid Meningoencephalocele. EAR, NOSE & THROAT JOURNAL 2019. [DOI: 10.1177/014556130308201205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Michael D'Antonio
- From the Department of Radiology, Louisiana State University Health Sciences Center, New Orleans
| | - Enrique Palacios
- From the Department of Radiology, Louisiana State University Health Sciences Center, New Orleans
| | - Christian Scheuemann
- From the Department of Radiology, Louisiana State University Health Sciences Center, New Orleans
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17
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Shintoku R, Tosaka M, Shimizu T, Yoshimoto Y. Transcranial and Epidural Approach for Spontaneous Cerebrospinal Fluid Leakage Due to Meningoencephalocele of the Lateral Sphenoid Sinus. Asian J Neurosurg 2018; 13:462-464. [PMID: 29682061 PMCID: PMC5898132 DOI: 10.4103/1793-5482.228579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We experienced a case of sphenoid sinus type meningoencephalocele manifesting as severe cerebrospinal fluid (CSF) rhinorrhea. A 35-year-old man became aware of serous nasal discharge 1 year previously, which had gradually worsened. The nasal discharge was diagnosed as CSF rhinorrhea. Head computed tomography (CT) showed several small depressions in the bone of the left middle cranial fossa, and the largest depression extended through the bone to the lateral sphenoid sinus. Head magnetic resonance imaging revealed that the meningoencephalocele projected to the lateral sphenoid sinus, through this small bone defect of the middle cranial fossa. We performed a combined craniotomy and epidural approach without intradural procedures using neuronavigation. Multiple meningoencephaloceles protruded into small depressions in the middle skull base. The small protrusions not passing through the sphenoid sinus were coagulated. The largest protrusion causing the CSF leakage was identified by neuronavigation. This meningoencephalocele was cut. Both the dural and bone sides were closed with double layers to prevent CSF leakage. The CSF rhinorrhea completely stopped after the surgery. In our case, identification of the leak site was easy with neuronavigation based on bone window CT. The epidural approach also has significant advantages with double layer closure, including both the dural and bone sides. If the site of CSF leakage is outside the foramen rotundum (as with the most common type of lateral sphenoid sinus meningoencephalocele), we recommend the epidural approach using neuronavigation for surgical treatment.
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Affiliation(s)
- Ryosuke Shintoku
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Spontaneous CSF rhinorrhea from the trigeminal canal in an adolescent. Int J Pediatr Otorhinolaryngol 2017; 98:162-165. [PMID: 28583494 DOI: 10.1016/j.ijporl.2017.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/24/2022]
Abstract
We report a case of a seventeen-year old, healthy, non-obese young woman who presented with retro-orbital headaches and metallictasting, left-sided rhinorrhea. Computed tomography revealed a defect along the medial wall of the canal of V2 within a well-pneumatized lateral recess of the left sphenoid sinus. Prior imaging obtained 4 years earlier in the context of nasal trauma showed no such defect - thus lending support for the arachnoid granulation hypothesis of spontaneous CSF leaks from the sphenoid sinus. We perform a literature review and describe a successful repair through an endoscopic transpterygoid approach, which allowed for resolution of symptoms with minimal postoperative morbidity.
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19
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Unusual Association Between Spontaneous Lateral Sphenoid Encephalocele and Chiari Malformation Type I: Endoscopic Repair Through a Transpterygoid Approach. World Neurosurg 2017; 97:759.e17-759.e21. [DOI: 10.1016/j.wneu.2016.09.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 11/17/2022]
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20
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Wong RH, Agazzi S, van Loveren H. "Inverted Gull Wing" Dural Closure and Middle Fossa Floor Reconstruction After Transzygomatic Infratemporal Fossa Approach. World Neurosurg 2016; 89:280-4. [PMID: 26875654 DOI: 10.1016/j.wneu.2016.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ineffective closure of complex skull base approaches leads to wound complications and cerebrospinal fluid (CSF) leak. This can result in protracted hospital stays, additional procedures, delayed postoperative recovery, and increased cost of care. Removal of large middle fossa-infratemporal fossa tumors are particularly problematic as they result in a large dead space with gravity-facilitated CSF leakage into the cavity. In this report we describe the use of a novel technique, the "inverted gull wing" titanium mesh reconstruction. METHODS Attempts to address this problem have focused primarily on closure and the use of myocutaneous flaps. Patients who have had multiple prior treatments are often afflicted with significant tissue attenuation that preclude dural closure or the use of local flaps. Although vascularized free flaps are an effective option in this scenario, they can add significant operative time and often yield suboptimal cosmetic results. We describe the use of the inverted gull wing titanium mesh reconstruction in the closure of 2 patients who underwent complex transzygomatic infratemporal fossa approaches for tumor with dural and sinonasal transgression. RESULTS Postoperatively, there were no pseudomeningoceles, CSF leaks, or technique-related morbidities. CONCLUSIONS The inverted gull wing technique represents a simple, fast, and effective closure for complex transzygomatic infratemporal fossa approaches.
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Affiliation(s)
- Ricky H Wong
- Department of Neurosurgery, NorthShore Neurological Institute, NorthShore University HealthSystem, Evanston, Illinois, USA.
| | - Siviero Agazzi
- Department of Neurosurgery, NorthShore Neurological Institute, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Harry van Loveren
- Department of Neurosurgery, NorthShore Neurological Institute, NorthShore University HealthSystem, Evanston, Illinois, USA
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21
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Zoli M, Farneti P, Ghirelli M, Giulioni M, Frank G, Mazzatenta D, Pasquini E. Meningocele and Meningoencephalocele of the Lateral Wall of Sphenoidal Sinus: The Role of the Endoscopic Endonasal Surgery. World Neurosurg 2015; 87:91-7. [PMID: 26585733 DOI: 10.1016/j.wneu.2015.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 11/01/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. METHODS All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. RESULTS The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26-73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4-167) each patient is in good clinical condition with no further episodes of leaking or seizures. CONCLUSIONS Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.
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Affiliation(s)
- Matteo Zoli
- Center of Pituitary and Endoscopic Skull Base Surgery, Bologna, Italy.
| | - Paolo Farneti
- ENT Department, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | - Marco Giulioni
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Giorgio Frank
- Center of Pituitary and Endoscopic Skull Base Surgery, Bologna, Italy
| | - Diego Mazzatenta
- Center of Pituitary and Endoscopic Skull Base Surgery, Bologna, Italy
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Hammer A, Baer I, Geletneky K, Steiner HH. Cerebrospinal fluid rhinorrhea and seizure caused by temporo-sphenoidal encephalocele. J Korean Neurosurg Soc 2015; 57:298-302. [PMID: 25932300 PMCID: PMC4414777 DOI: 10.3340/jkns.2015.57.4.298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/07/2014] [Accepted: 08/18/2014] [Indexed: 11/27/2022] Open
Abstract
This case report describes the symptoms and clinical course of a 35-year-old female patient who was diagnosed with a temporo-sphenoidal encephalocele. It is characterized by herniation of cerebral tissue of the temporal lobe through a defect of the skull base localized in the middle fossa. At the time of first presentation the patient complained about recurrent nasal discharge of clear fluid which had begun some weeks earlier. She also reported that three months earlier she had for the first time suffered from a generalized seizure. In a first therapeutic attempt an endoscopic endonasal approach to the sphenoid sinus was performed. An attempt to randomly seal the suspicious area failed. After frontotemporal craniotomy, it was possible to localize the encephalocele and the underlying bone defect. The herniated brain tissue was resected and the dural defect was closed with fascia of the temporalis muscle. In summary, the combination of recurrent rhinorrhea and a first-time seizure should alert specialists of otolaryngology, neurology and neurosurgery of a temporo-sphenoidal encephalocele as a possible cause. Treatment is likely to require a neurosurgical approach.
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Affiliation(s)
- Alexander Hammer
- Department of Neurosurgery, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Ingrid Baer
- Institute of Radiology and Neuroradiology, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Karsten Geletneky
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
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23
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Ajlan A, Achrol A, Soudry E, Hwang PH, Harsh G. Spontaneous sphenoid wing meningoencephaloceles with lateral sphenoid sinus extension: the endoscopic transpterygoid approach. J Neurol Surg B Skull Base 2014; 75:314-23. [PMID: 25302142 DOI: 10.1055/s-0034-1372465] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022] Open
Abstract
Spontaneous meningoencephalocele (SME) of the sphenoid wing is a rare cause of cerebrospinal fluid (CSF) leakage. Surgical closure of the fistula is usually required. The approach taken depends on the location of the defect and the extension of the meningoencephalocele. The endoscopic transpterygoid approach may be useful. We prospectively analyzed the three cases of SME of the sphenoid wing with lateral sphenoid sinus extension treated endoscopically at Stanford over the last 3 years with regard to imaging findings, operative technique, and operative morbidity. In our three cases, the extent of pterygopalatine fossa (PPF) exposure undertaken, complete in one and partial in two, depended on the defect site. Follow-up ranged from 17 to 25 months. The fistula was completely closed in all three cases. Extant literature reports a 97% rate of successful closure (N = 65 of 67, with a mean follow-up of 25 months) and no major complications. Endoscopic transpterygoid repair is a useful, safe alternative to traditional approaches for repair of SME of the sphenoid wing. Its feasibility depends on the site of the defect, which can be identified by preoperative imaging. Larger PPF exposure and postoperative lumbar drainage of CSF can be useful and have a low risk of morbidity.
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Affiliation(s)
- Abdulrazag Ajlan
- Department of Neurosurgery, Stanford University, Stanford, California, United States ; Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Achal Achrol
- Department of Neurosurgery, Stanford University, Stanford, California, United States
| | - Ethan Soudry
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Peter H Hwang
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Griffith Harsh
- Department of Neurosurgery, Stanford University, Stanford, California, United States
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Melo NAD, Borges BBP, Magliarelli Filho PA, Godoy MDCL, Pereira LV, Pinna FDR, Voegels RL. Lateral sphenoid sinus recess cerebrospinal fluid leak: a case series. Eur Arch Otorhinolaryngol 2014; 271:2587-94. [PMID: 24748381 DOI: 10.1007/s00405-014-3049-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
Abstract
The lateral recess of the sphenoid sinus is one of the most common sites of meningocele and spontaneous cerebrospinal fluid (CSF) leak. Despite the availability of several techniques for closure of skull base defects occurring in this location, recurrence still poses a major challenge. This report reviews the experience of surgical repair of lateral sphenoid sinus recess CSF leak at a tertiary referral center and provides a brief discussion of this rare lesion. Nine surgeries were performed for six cases of spontaneous lateral sphenoid sinus recess CSF leak (two revisions and one repair of a new defect). Two patients presented with intracranial hypertension (ICH) and four with meningocele or meningoencephalocele. The transpterygoid approach was used in two procedures. A multilayer graft was used in seven cases and a nasoseptal flap in two. Three patients received lumbar or ventricular shunts, and one received acetazolamide for ICH management. Two minor complications were recorded, and the overall surgical success rate was 78 %. We conclude that nasoseptal flaps are a valid option for repair of recurrent CSF leaks, particularly in the lateral sphenoid sinus recess. Furthermore, identification and correction of ICH plays an essential role in the success of treatment in this patient population.
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Schmidt RF, Choudhry OJ, Raviv J, Baredes S, Casiano RR, Eloy JA, Liu JK. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus 2013; 32:E5. [PMID: 22655694 DOI: 10.3171/2012.3.focus1267] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lateral sphenoid encephaloceles of the Sternberg canal are rare entities and usually present with spontaneous CSF rhinorrhea. Traditionally, these were treated via transcranial approaches, which can be challenging given the deep location of these lesions. However, with advancements in endoscopic skull base surgery, including improved surgical exposures, angled endoscopes and instruments, and novel repair techniques, these encephaloceles can be resected and successfully repaired with purely endoscopic endonasal approaches. In this report, the authors review the endoscopic endonasal transpterygoid approach to the lateral recess of the sphenoid sinus for repair of temporal lobe encephaloceles, including an overview of the surgical anatomy from an endoscopic perspective, and describe the technical operative nuances and surgical pearls for these cases. The authors also present 4 new cases of lateral sphenoid recess encephaloceles that were successfully treated using this approach.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey 07101, USA
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Maselli G, Ricci A, Galzio RJ. Endoscope-Assisted Trans-Sphenoidal Approach for Treatment of Sternberg's Canal. J Korean Neurosurg Soc 2012; 52:555-7. [PMID: 23346329 PMCID: PMC3550425 DOI: 10.3340/jkns.2012.52.6.555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 08/10/2012] [Accepted: 12/14/2012] [Indexed: 11/27/2022] Open
Abstract
We report an uncommon case of a 45-year-old woman who presented with spontaneous rhinorrhea. A computed tomography (CT) scan of the head revealed an abnormally large sphenoid sinus associated with a parasellar bony defect (Sternberg's canal) through which magnetic resonance imaging could detect an encephalocele of the right temporal lobe. An endoscope-assisted trans-sphenoidal approach was performed and, with the aid of image guided surgery, reduction of the encephalocele was obtained and followed by surgical repair of the dural and bony defects. The postoperative course was uneventful and the cerebrospinal fluid fistula was closed as confirmed by the postoperative CT scan and by the absence of rhinorrhea. After three years of monitoring the patient remained asymptomatic.
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Affiliation(s)
- Giuliano Maselli
- Health Sciences Department and Operative Unit of Neurosurgery, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy
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Almontasheri A, Al-Qahtani B, Aldajani N. Arachnoid pit and extensive sinus pnematization as the cause of spontaneous lateral intrasphenoidal encephalocele. J Clin Imaging Sci 2012; 2:1. [PMID: 22347684 PMCID: PMC3279694 DOI: 10.4103/2156-7514.92363] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 01/09/2012] [Indexed: 11/16/2022] Open
Abstract
Lateral sphenoid encephalocele, especially within the lateral aspect of the sphenoid sinus, when the sphenoid sinus has pneumatized extensively into the pterygoid recess, are considered exceedingly rare. We report a rare case of lateral intrasphenoidal encephalocele with spontaneous cerebral spinal fluid (CSF) rhinorrhea. Computed tomography demonstrated bilateral arachnoid pit, extensive sphenoid sinus pneumatization, and a defect in the superior wall of the left lateral recess of the sphenoid sinus. Magnetic resonance imaging demonstrated anteromedial temporal lobe herniating through the bony defect.
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Affiliation(s)
- Ali Almontasheri
- Department of Radiology, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia
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Bendersky DC, Landriel FA, Ajler PM, Hem SM, Carrizo AG. Sternberg's canal as a cause of encephalocele within the lateral recess of the sphenoid sinus: A report of two cases. Surg Neurol Int 2011; 2:171. [PMID: 22145089 PMCID: PMC3229810 DOI: 10.4103/2152-7806.90034] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/24/2011] [Indexed: 11/17/2022] Open
Abstract
Background: Intrasphenoidal encephaloceles are extremely rare findings. Sternberg's canal is a lateral craniopharyngeal canal resulting from incomplete fusion of the greater wings of the sphenoid bone with the basisphenoid. It acts as a weak spot of the skull base, which may lead to develop a temporal lobe encephalocele protruding into the lateral recess of the sphenoid sinus (SS). Case Description: We present two cases of intrasphenoidal encephalocele due to persistence of the lateral craniopharyngeal canal. The first case presented with cerebrospinal fluid (CSF) rhinorrhea and the second one was referred to the neurosurgical department with CSF rhinorrhea and meningitis. Radiological investigations consisted of computed tomography (CT) scan, CT cisternography and magnetic resonance images in both cases. These imaging studies identified a herniated temporal lobe through a bony defect which communicates the middle cranial fossa with the lateral recess of the SS. Both patients underwent a transcranial repair of the encephalocele because of the previous failure of the endoscopic surgery. There was no complication related to the surgical procedure and no recurrence of CSF leakage occurred 2 and 3 years after surgery, respectively. Conclusion: Encephalocele within the lateral recess of the SS is a rare entity which must be suspected in patients who present with spontaneous CSF rhinorrhea. Congenital intrasphenoidal encephaloceles, which are located medial to the foramen rotundum, seem to be due to persistence of the Sternberg's canal. Transcranial approach is a good option when a transnasal approach had failed previously.
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Affiliation(s)
- Damián C Bendersky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Bachmann-Harildstad G, Kloster R, Bajic R. Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak. Skull Base 2011; 16:207-12. [PMID: 17471320 PMCID: PMC1766457 DOI: 10.1055/s-2006-950389] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE AND IMPORTANCE Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. CLINICAL PRESENTATION A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. INTERVENTION The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. CONCLUSION In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.
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Affiliation(s)
| | - Roar Kloster
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Radoslav Bajic
- Department of Radiology, Division of Neuroradiology, University Hospital of Northern Norway, Tromsø, Norway
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Hofstetter CP, Singh A, Anand VK, Kacker A, Schwartz TH. The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave. J Neurosurg 2010; 113:967-74. [DOI: 10.3171/2009.10.jns09157] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper the authors' goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base.
Methods
Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin.
Results
A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy.
Conclusions
An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.
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Affiliation(s)
| | | | | | | | - Theodore H. Schwartz
- 1Departments of Neurological Surgery,
- 2Otolaryngology, and
- 3Neurology and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
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Prabhu K, Kumbhar KR, Chacko AG. Middle fossa extradural repair of sphenoidal encephaloceles. Br J Neurosurg 2010; 25:124-6. [PMID: 20874451 DOI: 10.3109/02688697.2010.505988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sphenoidal encephaloceles are uncommon but potentially dangerous pathological conditions that present with CSF rhinorrhea. Careful radiological evaluation and localisation of the sphenoid defect are critical in defining the surgical approach. We used the middle fossa extradural approach in two patients with sphenoidal encephaloceles in whom previous endoscopic transnasal repairs had failed.
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Affiliation(s)
- Krishna Prabhu
- Department of Neurosurgery, Christian Medical College, Vellore-632004, Tamil Nadu, India
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32
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Kwon JE, Kim E. Middle fossa approach to a temporosphenoidal encephalocele -technical note-. Neurol Med Chir (Tokyo) 2010; 50:434-8. [PMID: 20505307 DOI: 10.2176/nmc.50.434] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Temporosphenoidal encephalocele (TSE) is a rare entity caused by herniation of the anteromedial temporal lobe into the sphenoid sinus (SS) through a middle fossa (MF) defect. A 45-year-old woman presented with a spontaneous TSE manifesting as a 4-year history of recurrent cerebrospinal fluid rhinorrhea and meningitis. Coronal computed tomography showed a skull defect in the superior wall of the right lateral recess of the SS. This homogeneous intrasphenoidal lesion appeared hypointense on T(1)-weighted magnetic resonance (MR) imaging and hyperintense on T(2)-weighted MR imaging. The patient underwent a frontotemporal craniotomy and extradural MF exploration. The encephalocele was amputated and the temporal base dura primarily sutured and reinforced with fat graft. The MF hole was plugged with temporalis fascia and a calvarial graft layered over the bone defect. Histological examination confirmed meningoencephalocele. Rhinorrhea resolved and the patient remained asymptomatic. Resection of an anteromedial TSE and closure of the craniodural defect in the MF floor via a less invasive extradural skull base approach is effective.
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Affiliation(s)
- Jae Eun Kwon
- Division of Skull Base Surgery, Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Jung-gu, Daegu, Republic of Korea
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Tóth M, Selivanova O, Schaefer S, Mann W. Spontaneous cerebrospinal fluid rhinorrhea: a clinical and anatomical study. Laryngoscope 2010; 120:1724-9. [PMID: 20717949 DOI: 10.1002/lary.20993] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Spontaneous nasal cerebrospinal fluid (CSF) fistula represents a rare clinical entity. The possible etiology and the localization of the rhinorrhea remain an ongoing clinical challenge. The purpose of this study was to evaluate the localization of spontaneous CSF fistula and to correlate it with anatomical studies. STUDY DESIGN Retrospective clinical study, prospective anatomical study. METHODS Twenty-nine patients with spontaneous CSF rhinorrhea were retrospectively studied, 10 males and 19 females. Ages ranged from 10 to 92 years (mean, 50 years). In addition, 48 human skulls from newborns to adults were examined for the postnatal development of the anterior and middle cranial fossa. RESULTS In our study isolated cribriform plate defects were found in four patients. The lateral lamina of the ethmoid bone showed defects in three patients. In nine patients the bony defect could be found in the region of the fovea ethmoidalis. The bony defect between the extra- and intracranial space was found in the lateral recess of the sphenoid sinus in eight patients. Five patients had special sites (e.g., supraorbital recess and frontal recess). CONCLUSIONS This study supports the theory that bony dehiscence in the lateral lamina of the ethmoid bone can be congenital and can also be spontaneously acquired later. The bony dehiscence in the lateral wall of the sphenoid sinus can only develop during pneumatization.
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Affiliation(s)
- Miklós Tóth
- Department of Otorhinolaryngology, Johannes Gutenberg University Medical School, Mainz, Germany.
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34
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Arai A, Mizukawa K, Nishihara M, Fujita A, Hosoda K, Kohmura E. Spontaneous cerebrospinal fluid rhinorrhea associated with a far lateral temporal encephalocele--case report. Neurol Med Chir (Tokyo) 2010; 50:243-5. [PMID: 20339278 DOI: 10.2176/nmc.50.243] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 35-year-old female complained of right-sided watery nasal discharge persisting for 2 weeks. Neuroimaging investigations revealed a defect in the lateral side of middle cranial fossa, temporal lobe encephalocele protruding into the lateral extension of the sphenoid sinus, and cerebrospinal fluid (CSF) collection on the right side of the sphenoid sinus. The transcranial approach was performed for resection of the encephalocele and obliteration of the cranial base defect anterolateral to the foramen spinosum with transcranial multilayered closure of the defect using autologous fat, cranial bone graft, and vascularized split temporal muscle. At 1-year follow up, the CSF rhinorrhea had not recurred. Transcranial multilayered closure of the defect is safe and reliable, particularly for large CSF fistula at the far lateral sphenoid sinus.
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Affiliation(s)
- Atsushi Arai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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35
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Tabaee A, Anand VK, Cappabianca P, Stamm A, Esposito F, Schwartz TH. Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg 2010; 112:1070-7. [PMID: 19698044 DOI: 10.3171/2009.7.jns0842] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Spontaneous meningoencephaloceles of the lateral sphenoid sinus are rare lesions that are hypothesized to result from persistence of the lateral craniopharyngeal canal. Prior reports of the management of this lesion have been limited by its relative rarity. The objective of this paper is to report the theoretical etiology, surgical technique, and outcomes in patients undergoing endoscopic repair of spontaneous meningoencephalocele of the sphenoid sinus. METHODS The authors conducted a retrospective review of a multiinstitutional series of 13 cases involving patients who underwent endoscopic repair of spontaneous meningoencephalocele of the lateral sphenoid sinus. The surgical technique and pathophysiological considerations are discussed. RESULTS The clinical manifestations included CSF rhinorrhea (85%), chronic headache (77%), and a history of meningitis (15%). The endoscopic approaches to the lateral sphenoid sinus were transnasal (39%), transpterygoid (23%), and transethmoid (39%). Two patients (8%) had postoperative CSF leaks, one of which closed spontaneously and one of which required revision endoscopic closure. All patients were free of leak at most recent follow-up. One patient experienced postoperative meningitis in the early postoperative period. CONCLUSIONS Endoscopic endonasal closure is an effective modality in the treatment of spontaneous meningoencephaloceles of the lateral sphenoid sinus. If the sphenoid sinus has extensive lateral pneumatization, adequate exposure may require a transpterygoid approach.
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Affiliation(s)
- Abtin Tabaee
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, New York, USA.
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Kamat AA, Bhattacharyya D, Carroll TA. Brain sag as a cause of postoperative neurological deterioration following anterior cranial fossa floor repair for post traumatic cerebrospinal fluid rhinorrhoea. Br J Neurosurg 2009; 21:303-6. [PMID: 17612925 DOI: 10.1080/02688690701365788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A patient with posttraumatic CSF rhinorrhoea underwent a transcranial anterior skull base repair, with a lumbar drain being inserted at induction of anaesthesia. Postoperative neurological deterioration occurred due to brain sag. Following treatment, there was significant recovery albeit in a slow and steady fashion. Patients with brain sag as a result of lumbar drain insertion can make a good recovery, despite an initial presentation with signs of severe brainstem compression, which could easily be misinterpreted as having a poor prognosis. Absence of an initial dramatic response to treatment does not necessarily imply poor outcome in the long term.
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Affiliation(s)
- A A Kamat
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, South Yorkshire, UK.
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38
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Abstract
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.
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Abstract
Cerebrospinal fluid fistula secondary to head trauma is a potentially dangerous problem and precise localization and radical treatment is mandatory. The diagnostic technique is either computed tomography cisternography or MR cisternography. For evaluating the safety of diagnostic modalities and efficacy of treatment especially in terms of surgery, animal studies demonstrating traumatic cerebrospinal fistula model are indispensable not only for neurosurgeons but also for neuroradiologists. The authors in this paper describe a traumatic cerebrospinal fistula in an animal model using rabbits. The cerebrospinal fluid leakage was demonstrated successfully in all eight rabbits and was verified by computed tomography cisternography. The results led us to conclude that rabbit model of traumatic cerebrospinal fluid fistula is safe and has low mortality and morbidity rates. Further studies including larger number of animals should be considered in order to verify safety more accurately.
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40
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Akyuz M, Arslan G, Gurkanlar D, Tuncer R. CSF Rhinorrhea from a Transclival Meningocele: A Case Report. J Neuroimaging 2008; 18:191-3. [DOI: 10.1111/j.1552-6569.2007.00187.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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41
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Gürkanlar D, Akyuz M, Acikbas C, Ermol C, Tuncer R. Difficulties in treatment of CSF leakage associated with a temporal meningocele. Acta Neurochir (Wien) 2007; 149:1239-42. [PMID: 17943225 DOI: 10.1007/s00701-007-1273-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 07/23/2007] [Indexed: 11/29/2022]
Abstract
Temporal meningocele is a rarely encountered pathology. It is caused by communication between the subarachnoid space of the middle fossa and lateral extension of the sphenoid sinus. Cerebrospinal fluid (CSF) pressures and the hydrostatic pulsatile forces may lead to the development of pitholes on the middle fossa at the sites of arachnoid villi with herniation of dura/arachnoid or brain tissue into the sinus. We describe an adult patient who presented with spontaneous CSF rhinorrhea due to a temporal meningocele. She was first operated on transsphenoidally, but the CSF rhinorrea did not cessate, therefore she was operated transcranially five days after the first operation. There has been no CSF rhinorrhea for three and a half years. Transcranial temporal encephalocele repairment is more effective than transsphenoidal surgery. Recurrent CSF leaks can occur due to both the increased CSF pressure and the insufficient operation technique.
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Affiliation(s)
- D Gürkanlar
- Department of Neurosurgery, Akdeniz University School of Medicine, Antalya, Turkey.
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42
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Pasqualetto L, La Tessa G, De Bellis L, Paonessa A, Iannaccone G, De Bellis M, Sirabella G. CT-Cisternography in Post-Surgical CSF Rhinorrhea. Neuroradiol J 2007; 20:642-5. [DOI: 10.1177/197140090702000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 08/01/2007] [Indexed: 11/16/2022] Open
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is a dangerous problem. CSF rhinorrhea implies an abnormal communication between the subarachnoid space and the nasal cavity, with subsequent leakage of CSF through the anterior nasal apertures. requiring surgical repair. Imaging techniques have evolved from conventional cranial radiography to polytomography, thin-section computed tomography (CT) and intrathecal water-soluble iodinated contrast agent-enhanced CT cisternography. We present two cases of post-surgical CSF rhinorrhea in which the best diagnostic findings were obtained by CT cisternography.
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Affiliation(s)
| | | | | | | | - G. Iannaccone
- Department of Neurosurgery, Santa Maria di Loreto Nuovo Hospital; Naples Italy
| | - M. De Bellis
- Department of Neurosurgery, Santa Maria di Loreto Nuovo Hospital; Naples Italy
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Jagannathan J, Okonkwo DO, Prevedello DM, Kanter AS, Laws ER. Arachnoid diverticula associated with anterior cranial base tumors: technical case report. Neurosurgery 2007; 61:E172-3; discussion E173. [PMID: 17621009 DOI: 10.1227/01.neu.0000279741.38178.2d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Cerebrospinal fluid (CSF) diverticula are uncommonly associated with anterior cranial base tumors. When they occur, they often complicate the surgical management of these tumors via a transsphenoidal approach. This report examines the effectiveness of transsphenoidal surgery in the treatment of these rare entities. METHODS We performed a review of four sellar and parasellar tumors (three pituitary adenomas and one chordoma) that contained an arachnoid diverticulum communicating with the intracranial subarachnoid space. RESULTS One of these tumors (a prolactinoma) was successfully treated medically and regressed dramatically in size; the remaining three were treated by transsphenoidal resection. In all of the operative cases, the tumor was successfully resected with no endocrinological or neurological deficit. An intraoperative CSF leak was encountered in each operative case and was treated by packing the sella with an abdominal fat graft. One patient returned to the operating room for a CSF leak repair. No instances of infection, meningitis, or other major complications occurred. Sellar and parasellar tumors associated with arachnoid diverticula can be successfully treated using transsphenoidal surgery. CONCLUSION Preoperative anatomic localization of the CSF diverticulum, as well as anticipatory planning for an intraoperative CSF leak are essential. Whenever possible, it is probably wise to preserve the arachnoidocele rather than to rupture it intentionally, obliterating the dead space within the sella in either situation.
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Affiliation(s)
- Jay Jagannathan
- Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA.
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Castelnuovo P, Dallan I, Pistochini A, Battaglia P, Locatelli D, Bignami M. Endonasal endoscopic repair of Sternberg's canal cerebrospinal fluid leaks. Laryngoscope 2007; 117:345-9. [PMID: 17277632 DOI: 10.1097/01.mlg.0000251452.90657.3a] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Management of cerebrospinal fluid leaks or encephaloceles of Sternberg's canal is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of the study was to assess the real effectiveness of an endoscopic endonasal approach for treating cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus. STUDY DESIGN The authors conducted a retrospective evaluation. METHODS Clinical charts of patients with cerebrospinal fluid leaks and/or encephaloceles of Sternberg's canal treated at our institution were retrospectively reviewed. All these patients were managed with an endonasal endoscopic procedure. RESULTS Fifteen patients (9 female and 6 male) were included in this study. Nine patients underwent a transethmoidal-pterygoidal-sphenoidal approach with a multilayer reconstructive technique. No cerebrospinal fluid leak recurrences were observed during follow up (mean follow up 37.6 +/- 21.7 standard deviation months) CONCLUSIONS The transethmoidal-pterygoidal-sphenoidal approach provides a wide, safe, and direct route to the lateral recess of the sphenoid sinus. Multilayered reconstruction of the skull base defects must be considered the first option for this kind of lesion.
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Affiliation(s)
- Paolo Castelnuovo
- Department of Otorhinolaryngology, University of Insubria, Varese, Azienda Ospedaliero Universitaria Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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Abstract
BACKGROUND Pneumatization of the sphenoid sinus occasionally includes an extensive lateral recess creating an area beneath the temporal lobe that is relatively inaccessible to surgical intervention. Pathology in this anatomic location presents special surgical and therapeutic challenges. Recently, several authors have described the endoscopic transpterygopalatine fossa approach to this anatomic region. This approach is associated with minimal morbidity while providing direct endoscopic surgical access for managing a variety of disease processes in this region. METHODS This study presents eight cases requiring this approach or a modification of this approach. Six patients presented with temporal lobe meningoencephaloceles with cerebrospinal fluid rhinorrhea. Each case was managed successfully through this surgical approach. RESULTS One patient experienced transient postoperative palatal anesthesia due to injury to the greater palatine nerve and another complained of ipsilateral dry eye postoperatively. Two other patients had neoplasms (inverting papilloma and chondrosarcoma), which were successfully addressed through this technique. There were no postoperative complications in these patients. CONCLUSION We have previously described the relationships of neural and vascular structures in this anatomic region. This article will review these relationships as they pertain to this surgical approach and will discuss the indications, techniques, and surgical outcomes in this series of patients. This approach is a valuable addition to the endoscopic armamentarium of the experienced endoscopic surgeon.
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Affiliation(s)
- Thomas A Tami
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0528, USA
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Blaivie C, Lequeux T, Kampouridis S, Louryan S, Saussez S. Congenital transsphenoidal meningocele: case report and review of the literature. Am J Otolaryngol 2006; 27:422-4. [PMID: 17084229 DOI: 10.1016/j.amjoto.2006.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Indexed: 10/24/2022]
Abstract
Intrasphenoidal meningoencephalocele is a rare clinical entity. Its origin can be congenital, traumatic, tumoral, or spontaneous. Presenting as cerebrospinal fluid fistula with rhinorrhea, the diagnosis and treatment of this uncommon disease is a real challenge for the otorhinolaryngologist. We report a case of sphenoidal meningocele treated using an endoscopic procedure and review the literature regarding its congenital origin.
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Affiliation(s)
- Catherine Blaivie
- Department of Otorhinolaryngology, Head and Neck Surgery, CHU Saint-Pierre, Brussels, Belgium
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Woodworth BA, Bolger WE, Schlosser RJ. Nasal cerebrospinal fluid leaks and encephaloceles. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.otot.2006.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bikmaz K, Cosar M, Iplikcioglu AC, Dinc C, Hatiboglu MA. Spontaneous cerebrospinal fluid rhinorrhoea due to temporosphenoidal encephalocele. J Clin Neurosci 2006; 12:827-9. [PMID: 16169229 DOI: 10.1016/j.jocn.2004.09.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 09/22/2004] [Indexed: 10/25/2022]
Abstract
A 57-year old man was referred to our hospital with spontaneous cerebrospinal fluid (CSF) rhinorrhoea of 6 years duration. He had an episode of meningitis 2 months previously. CT cisternography and cranial MRI revealed a defect in the lateral wall of the sphenoid sinus, with an anteromedial temporosphenoidal encephalocele. Surgery was performed transcranially through a pterional approach. The temporal encephalocele was amputated, the sphenoid sinus obliterated and the dural defect repaired. Lumbar drainage was used for 5 days after surgery. Spontaneous CSF rhinorrhoea is only infrequently due to temporal encephalocele. Anteromedial temporosphenoidal encephaloceles are the least common type of temporal encephalocele, with only 12 reported in the literature.
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Affiliation(s)
- Kerem Bikmaz
- Social Security Okmeydani Training Hospital, Istanbul, Turkey
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Bolger WE. Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience. Otolaryngol Head Neck Surg 2005; 133:20-6. [PMID: 16025047 DOI: 10.1016/j.otohns.2005.03.063] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pathology within a lateral recess of a widely pneumatized sphenoid sinus is difficult to access with the use of traditional open and current endoscopic surgical approaches. A new surgical procedure, the endoscopic transpterygoid approach, directly accesses this region. A clinical experience over several year with this approach is reported as well as a refined and updated description of the technique. SETTING Tertiary care center. METHODS Retrospective review of medical records of patients treated with the endoscopic transpterygoid approach to the lateral sphenoid recess. RESULTS An endoscopic transpterygoid approach was performed in 9 patients, 6 to resect a middle fossa meningoencephalocele and repair the CSF leak and associated skull base defect, 2 for possible invasive fungal sinusitis, and 1 to marsupialize a symptomatic epidermoid cyst. Patients tolerated the approach well and no significant complications occurred. CONCLUSIONS AND SIGNIFICANCE In selected cases, the endoscopic transpterygoid approach enables the otolaryngologist to meet modern demands to treat conditions in the lateral sphenoid using minimally invasive techniques that are well-tolerated by patients. The surgical approach and the initial experience described herein is presented in the hopes that it can aid fellow otolaryngologists to help patients with challenging conditions in this region of the body.
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Affiliation(s)
- William E Bolger
- Division of Otolaryngology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
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