Endoscopic Endonasal Transpterygoid Approach to Sphenoid Sinus Lateral Recess Defects
19 January 2019
08 May 2019
21 June 2019 (online)
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.
Keywordsskull base - endoscopic transpterygoid approach - sphenoid sinus lateral recess - cerebrospinal fluid leak - meningoencephalocele
Concept - G.B., M.T.Z., P.C.; Design - G.B., M.T.Z., P.C.; Supervision - G.B., M.T.Z., H.A.E., P.C., D.L.; Resource - E.C., F.R., S.G.; Materials - E.C., F.R., S.G., J.Z., D.L.; Data Collection &/or Processing - E.C., F.R., S.G., J.Z.; Analysis &/or Interpretation - G.B., M.T.Z., H.A.E., D.L., M.B., P.C.; Literature Search - G.B., M.T.Z., M.B., J.Z., P.C.; Writing - G.B., M.T.Z., H.A.E., P.C.; Critical Reviews - G.B., M.T.Z., M.B., P.C.
All authors have read and approved the final version of the article.
GB gratefully acknowledges support from the Turkish ENT Society for support of the Research Fellowship. The authors have no other funding, financial relationships, or conflicts of interest to disclose related to this article.
- 1 Vaezi A, Cardenas E, Pinheiro-Neto C. , et al. Classification of sphenoid sinus pneumatization: relevance for endoscopic skull base surgery. Laryngoscope 2015; 125 (03) 577-581
- 2 Martínez-Capoccioni G, Serramito-García R, Huertas-Pardo B, García-Allut A, Martín-Martín C. Spontaneous cerebrospinal fluid leaks in the anterior skull base: a surgical challenge. J Laryngol Otol 2015; 129 (04) 358-364
- 3 Lai SY, Kennedy DW, Bolger WE. Sphenoid encephaloceles: disease management and identification of lesions within the lateral recess of the sphenoid sinus. Laryngoscope 2002; 112 (10) 1800-1805
- 4 Woodworth BA, Prince A, Chiu AG. , et al. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg 2008; 138 (06) 715-720
- 5 Aggarwal V, Nair P, Shivhare P. , et al. A case of evolving bilateral sphenoidal meningoencephaloceles: case report and review of the literature. World Neurosurg 2017; 100: 708.e11-708.e17
- 6 Landreneau FE, Mickey B, Coimbra C. Surgical treatment of cerebrospinal fluid fistulae involving lateral extension of the sphenoid sinus. Neurosurgery 1998; 42 (05) 1101-1104 , discussion 1104–1105
- 7 Schick B, Brors D, Prescher A. Sternberg's canal--cause of congenital sphenoidal meningocele. Eur Arch Otorhinolaryngol 2000; 257 (08) 430-432
- 8 Kaufman B, Nulsen FE, Weiss MH, Brodkey JS, White RJ, Sykora GF. Acquired spontaneous, nontraumatic normal-pressure cerebrospinal fluid fistulas originating from the middle fossa. Radiology 1977; 122 (02) 379-387
- 9 Cakmak O, Shohet MR, Kern EB. Isolated sphenoid sinus lesions. Am J Rhinol 2000; 14 (01) 13-19
- 10 Mortuaire G, Louis E, Pellerin P. Sphenoidal cerebrospinal fluid rhinorrhea: an original surgical approach. J Craniofac Surg 2004; 15 (03) 458-463
- 11 Donald PJ. Sphenoid marsupialization for chronic sphenoidal sinusitis. Laryngoscope 2000; 110 (08) 1349-1352
- 12 Forer B, Sethi DS. Endoscopic repair of cerebrospinal fluid leaks in the lateral sphenoid sinus recess. J Neurosurg 2010; 112 (02) 444-448
- 13 Fyrmpas G, Konstantinidis I, Selviaridis P, Constantinidis J. Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience. J Laryngol Otol 2014; 128 (09) 797-802
- 14 Tosun F, Carrau RL, Snyderman CH, Kassam A, Celin S, Schaitkin B. Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus. Arch Otolaryngol Head Neck Surg 2003; 129 (05) 576-580
- 15 Janakiram TN, Subramaniam V, Parekh P. Endoscopic endonasal repair of sphenoid sinus cerebrospinal fluid leaks: our experience. Indian J Otolaryngol Head Neck Surg 2015; 67 (04) 412-416
- 16 Ulu MO, Aydin S, Kayhan A. , et al. Surgical management of sphenoid sinus lateral recess cerebrospinal fluid leaks: a single neurosurgical center analysis of endoscopic endonasal minimal transpterygoid approach. World Neurosurg 2018; 118: e473-e482
- 17 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 (02) 345-349
- 18 Castelnuovo P, Pistochini A, Locatelli D. Different surgical approaches to the sellar region: focusing on the “two nostrils four hands technique”. Rhinology 2006; 44 (01) 2-7
- 19 Kasemsiri P, Solares CA, Carrau RL. , et al. Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope 2013; 123 (04) 811-815
- 20 Pasquini E, Sciarretta V, Farneti G, Mazzatenta D, Modugno GC, Frank G. Endoscopic treatment of encephaloceles of the lateral wall of the sphenoid sinus. Minim Invasive Neurosurg 2004; 47 (04) 209-213
- 21 Bachmann-Harildstad G, Kloster R, Bajic R. Transpterygoid transsphenoid approach to the lateral extension of the sphenoid sinus to repair a spontaneous CSF leak. Skull Base 2006; 16 (04) 207-212
- 22 Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008; 62 (05) (Suppl. 02) E342-E343 , discussion E343
- 23 Tabaee A, Placantonakis DG, Schwartz TH, Anand VK. Intrathecal fluorescein in endoscopic skull base surgery. Otolaryngol Head Neck Surg 2007; 137 (02) 316-320
- 24 Tomazic PV, Stammberger H. Spontaneous CSF-leaks and meningoencephaloceles in sphenoid sinus by persisting Sternberg's canal. Rhinology 2009; 47 (04) 369-374
- 25 Kwon JE, Kim E. Middle fossa approach to a temporosphenoidal encephalocele -technical note-. Neurol Med Chir (Tokyo) 2010; 50 (05) 434-438
- 26 Gürkanlar D, Akyüz M, Açıkbaş C, Ermol C, Tuncer R. Difficulties in treatment of CSF leakage associated with a temporal meningocele. Acta Neurochir (Wien) 2007; 149 (12) 1239-1242
- 27 Hammer A, Baer I, Geletneky K, Steiner HH. Cerebrospinal fluid rhinorrhea and seizure caused by temporo-sphenoidal encephalocele. J Korean Neurosurg Soc 2015; 57 (04) 298-302
- 28 Alexander NS, Chaaban MR, Riley KO, Woodworth BA. Treatment strategies for lateral sphenoid sinus recess cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg 2012; 138 (05) 471-478
- 29 Spetzler RF, Wilson CB. Management of recurrent CSF rhinorrhea of the middle and posterior fossa. J Neurosurg 1978; 49 (03) 393-397
- 30 Hubbard JL, McDonald TJ, Pearson BW, Laws Jr ER. Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis and surgical management based on the Mayo Clinic experience from 1970 through 1981. Neurosurgery 1985; 16 (03) 314-321
- 31 Bolger WE. Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience. Otolaryngol Head Neck Surg 2005; 133 (01) 20-26
- 32 Marston AP, Van Gompel JJ, Carlson ML, O'Brien EK. A unique case of bilateral recurrent sphenoid sinus cerebrospinal fluid leaks: primary acquired leak within the lateral sphenoid sinus recess, followed by a leak via Sternberg's canal. Ann Otol Rhinol Laryngol 2015; 124 (08) 593-597
- 33 Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009; 119 (01) 19-25
- 34 Kassam AB, Prevedello DM, Carrau RL. , et al. The front door to meckel's cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 2009; 64 (3, Suppl): ons71-ons82 , discussion ons82–ons83
- 35 Jang TY, Kim YH, Shin SH. Long-term effectiveness and safety of endoscopic vidian neurectomy for the treatment of intractable rhinitis. Clin Exp Otorhinolaryngol 2010; 3 (04) 212-216
- 36 Tan G, Ma Y, Li H, Li W, Wang J. Long-term results of bilateral endoscopic vidian neurectomy in the management of moderate to severe persistent allergic rhinitis. Arch Otolaryngol Head Neck Surg 2012; 138 (05) 492-497
- 37 Lin PY, Cheng CY, Wu CC. , et al. Bilateral neurotrophic keratopathy complicating Vidian neurectomy. Am J Ophthalmol 2001; 132 (01) 106-108
- 38 Prevedello DM, Pinheiro-Neto CD, Fernandez-Miranda JC. , et al. Vidian nerve transposition for endoscopic endonasal middle fossa approaches. Neurosurgery 2010; 67 (2, Suppl Operative): 478-484
- 39 Al-Nashar IS, Carrau RL, Herrera A, Snyderman CH. Endoscopic transnasal transpterygopalatine fossa approach to the lateral recess of the sphenoid sinus. Laryngoscope 2004; 114 (03) 528-532
- 40 Schmidt RF, Choudhry OJ, Raviv J. , et al. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus 2012; 32 (06) E5
- 41 El-Tarabishi MN, Fawaz SA, Sabri SM, El-Sharnobi MM, Sweed A. A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess. Eur Arch Otorhinolaryngol 2016; 273 (12) 4305-4314
- 42 Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 2005; 115 (02) 205-212
- 43 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110 (07) 1166-1172
- 44 Sautter NB, Batra PS, Citardi MJ. Endoscopic management of sphenoid sinus cerebrospinal fluid leaks. Ann Otol Rhinol Laryngol 2008; 117 (01) 32-39