Spontaneous Temporal Lobe Encephalocele Within the Sphenoid Sinus

Object The cavernous sinus is a small complex structure located at the central base of the skull. Recent extensive use of endoscopy has provided less invasive approaches to the cavernous sinus via endonasal routes, although transcranial routes play an important role in the approach to the cavernous sinus. The aims of this study were to evaluate the feasibility of the purely endoscopic transcranial approach to the cavernous sinus through the supraorbital keyhole and to better understand the distorted anatomy of the cavernous sinus via endoscopy. Methods Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks. Results The endoscopic supraorbital extradural approach was divided into 4 stages: entry into the extradural anterior cranial fossa, exposure of the middle cranial fossa and the periorbita, exposure of the superior cavernous sinus, and exposure of the lateral cavernous sinus. This approach provided superb views of the cavernous sinus structures, especially through the clinoidal (Dolenc) triangle. The lateral wall of the cavernous sinus, including the infratrochlear (Parkinson) triangle and anteromedial (Mullan) triangle, was also clearly demonstrated. Conclusions An endoscopic supraorbital extradural approach offers excellent exposure of the superior and lateral walls of the cavernous sinus with minimal invasiveness via the transcranial route. This approach could be an alternative to the conventional transcranial approach.

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Glial Heterotopia of Sphenoid in Association with a Patent Sternberg's Canal presenting with Meningitis

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/aijoc-7-1-23 ◽

2015 ◽

Vol 7 (1) ◽

pp. 23-25

Author(s):

R Suma ◽

KJ Jeena ◽

VM Pavithran ◽

A Govindan

Keyword(s):

Sphenoid Sinus ◽

Radiological Finding ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Developmental Anomaly ◽

Csf Rhinorrhea ◽

Cranial Fossa ◽

Extended Endoscopic Approach ◽

Glial Heterotopia ◽

Csf Leaks

ABSTRACT Ectopic glial tissue, presenting at various sites of body is a rare embryonic developmental anomaly. Very few cases are reported in adults, most being incidentally detected, revealed only by histopathological findings. One of the rarest locations is the sphenoid sinus. We present here the case of a middle aged female, presenting with spontaneous cerebrospinal fluid (CSF) rhinorrhea and meningitis. With the radiological finding of a soft tissue density in sphenoid sinus with erosion of left temporal skull base, she underwent lateral craniotomy, with excision of the mass and middle cranial fossa floor repair. Histopathology revealed a heterotopic glial tissue. Peroperative finding of a well-defined defect in the lateral wall of an extensively pneumatized sphenoid showed typical features of a patent Sternberg's canal. This case could be a living proof for the existence of this rare developmental anomaly. A persisting Sternberg's canal should be considered as the source of spontaneous CSF leaks with or without lesions in sphenoid sinuses with extensive lateral pneumatization. Most of the cases may be treated with an extended endoscopic approach. Extreme lateral lesions like this would benefit most from a craniotomy approach for proper closure of skullbase defect. Three years after successful surgery, she remains symptom free.

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Middle Cranial Fossa Encephalocele and Cerebrospinal Fluid Leakage: Etiology, Approach, Outcomes

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1688793 ◽

2019 ◽

Vol 81 (03) ◽

pp. 268-274

Author(s):

Beth McNulty ◽

Christopher A. Schutt ◽

Dennis Bojrab ◽

Seilesh Babu

Keyword(s):

Cerebrospinal Fluid ◽

Middle Cranial Fossa ◽

Csf Leak ◽

Surgical Approaches ◽

Cerebrospinal Fluid Leakage ◽

Combined Approach ◽

Common Location ◽

Significant Difference ◽

Cranial Fossa ◽

Transmastoid Approach

Objective To compare outcome data for surgical approaches in the management of a middle cranial fossa encephalocele or cerebrospinal fluid (CSF) leak and, secondarily, to evaluate the role of obesity and the etiology of the defect. Design Retrospective Setting Quaternary referral center Participants The study included 73 patients who underwent surgical repair of middle cranial fossa tegmen defects, two of which underwent bilateral repair. Outcome Measures Demographic characteristics, clinical presentation, etiology, imaging, audiometry, surgical findings, method and material for repair, and postoperative course. Results Fifty cases were spontaneous in origin, 2 were iatrogenic, and 23 were because of chronic otitis media. Of the 50, 18 underwent middle fossa craniotomy, 29 underwent a transmastoid approach, and 28 underwent a combined approach for repair. A postoperative CSF leak was seen in five patients: one who had undergone a transmastoid approach and four after a combined approach. There was no significant difference between the three approaches and risk of postoperative CSF fistulae. Two of the CSF fistulae resolved after a lumbar drain, and the remaining three patients required revision surgery. Conclusions Middle cranial fossa tegmen defects are most commonly seen in obese females and are spontaneous in origin. The most common location was the tegmen mastoideum, and these defects were most commonly repaired through the transmastoid approach, with no greater risk of recurrence.

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Glial Heterotopia of Sphenoid in Association with a Patent Sternberg's Canal presenting with Meningitis

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/jp-journals-10003-1160 ◽

2014 ◽

Vol 6 (2) ◽

pp. 81-83

Author(s):

K Ramachandran ◽

R Suma ◽

KJ Jeena ◽

VM Pavithran ◽

A Govindan

Keyword(s):

Sphenoid Sinus ◽

Radiological Finding ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Developmental Anomaly ◽

Csf Rhinorrhea ◽

Cranial Fossa ◽

Extended Endoscopic Approach ◽

Glial Heterotopia ◽

Csf Leaks

ABSTRACT Ectopic glial tissue, presenting at various sites of body is a rare embryonic developmental anomaly. Very few cases are reported in adults, most being incidentally detected, revealed only by histopathological findings. One of the rarest locations is the sphenoid sinus. We present here the case of a middle aged female, presenting with spontaneous cerebrospinal fluid (CSF) rhinorrhea and meningitis. With the radiological finding of a soft tissue density in sphenoid sinus with erosion of left temporal skull base, she underwent lateral craniotomy, with excision of the mass and middle cranial fossa floor repair. Histopathology revealed a heterotopic glial tissue. Peroperative finding of a well-defined defect in the lateral wall of an extensively pneumatized sphenoid showed typical features of a patent Sternberg's canal. This case could be a living proof for the existence of this rare developmental anomaly. A persisting Sternberg's canal should be considered as the source of spontaneous CSF leaks with or without lesions in sphenoid sinuses with extensive lateral pneumatization. Most of the cases may be treated with an extended endoscopic approach. Extreme lateral lesions like this would benefit most from a craniotomy approach for proper closure of skullbase defect. Three years after successful surgery, she remains symptom free. How to cite this article Suma R, Jeena KJ, Pavithran VM, Govindan A, Ramachandran K. Glial Heterotopia of Sphenoid in Association with a Patent Sternberg's Canal presenting with Meningitis. Int J Otorhinolaryngol Clin 2014;6(2):81-83.

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Surgical Approaches to the Cavernous Sinus: A Microsurgical Study

Neurosurgery ◽

10.1227/00006123-199006000-00001 ◽

1990 ◽

Vol 26 (6) ◽

pp. 903-932 ◽

Cited By ~ 226

Author(s):

Tooru Inoue ◽

Albert L. Rhoton ◽

Dan Theele ◽

Margaret E. Barry

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Surgical Approaches ◽

Anterior Clinoid Process ◽

Anatomic Variants ◽

Cranial Fossa ◽

Extradural Approach

Abstract The surgical approaches to the cavernous sinus were examined in 50 adult cadaveric cavernous sinuses using magnification of ×3 to ×40. The following approaches were examined: 1) the superior intradural approach directed through a frontotemporal craniotomy and the roof of the cavernous sinus: 2) the superior intradural approach combined with an extradural approach for removing the anterior clinoid process and unroofing the optic canal and orbit; 3) the superomedial approach directed through a supraorbital craniotomy and subfrontal exposure to the wall of the sinus adjacent to the pituitary gland; 4) the lateral intradural approach directed below the temporal lobe to the lateral wall of the sinus; 5) the lateral extradural approach for exposure of the internal carotid artery in the floor of the middle cranial fossa proximal to the sinus; 6) the combined lateral and inferolateral approach, in which the infratemporal fossa was opened and the full course of the petrous carotid artery and the lateral wall of the sinus were exposed and; 7) the inferomedial approach, in which the medial wall of the sinus was exposed by the transnasal-transsphenoidal route. It was clear that a single approach was not capable of providing access to all parts of the sinus. The intracavernous structures best exposed by each route are reviewed. The osseous relationships in the region were examined in dry skulls. Anatomic variants important in exposing the cavernous sinus are reviewed.

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Management of Spontaneous Cerebrospinal Fluid Leaks in the Middle Cranial Fossa and Bone Tegmen Tympani Defect in Patients with Meningitis and Rhinorrhea

Surgical Case Reports ◽

10.31487/j.scr.2020.02.09 ◽

2020 ◽

pp. 1-5

Author(s):

Francesco Paglia ◽

Altamura C.F ◽

D'Angelo L ◽

Francesco Paglia ◽

Marzetti F ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Middle Cranial Fossa ◽

Occurrence Rate ◽

Csf Leak ◽

Surgical Approaches ◽

Csf Rhinorrhea ◽

Tegmen Tympani ◽

Cranial Fossa ◽

Dural Defects ◽

Csf Leaks

The pathogenetic process of spontaneous CerebroSpinal Fluid (CSF) leaks in the middle cranial fossa has not been clearly identified yet. It is related to a tegmen defect associated to the presence of a simultaneous encephalocele or meningoencephalocele. The main complication of a CSF leak is meningitis, whose occurrence rate ranges from 4% to 50% according to different causes and conditions of the leak [1]. Surgical approaches to temporal bone reconstruction include middle cranial fossa (MCF) craniotomy, transmastoid (TM), or a combined (MCF/TM) approach. In our experience, we describe 2 cases of patients who presented with CSF rhinorrhea and meningoencephaloceles correlated with conductive hearing loss and meningitis. The MCF approach is a considerable way to successful repair CSF leaks and encephaloceles due to tegmen tympani and dural defects.

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Variations of sphenoid pneumatization: a CBCT study

Romanian Journal of Rhinology ◽

10.1515/rjr-2015-0013 ◽

2015 ◽

Vol 5 (18) ◽

pp. 107-113

Author(s):

Catalina Craiu ◽

Mihai Sandulescu ◽

Mugurel Constantin Rusu

Keyword(s):

Sphenoid Sinus ◽

Anatomic Variation ◽

Sella Turcica ◽

Middle Cranial Fossa ◽

Maxillary Nerve ◽

Onodi Cell ◽

Cranial Fossa ◽

Left And Right ◽

Air Cells ◽

Case Basis

AbstractBACKGROUND. The pneumatization pattern of the sphenoid sinus seems rather unpredictable, as resulted from previous studies. It is however extremely important for endoscopic approaches to target structures of the middle cranial fossa, such as the pituitary gland.MATERIAL AND METHODS. We aimed at documenting by Cone Beam Computed Tomography (CBCT) the possibilities of anatomic variation of the sphenoid sinus. 25 randomly selected patients were retrospectively analyzed.RESULTS. In 56%, the left and right sphenoidal sinuses were bilaterally symmetrical with respect to the sagittal pneumatization type: four patients had sellar types, one had presellar type and in nine cases the sphenoidal sinuses were reaching posteriorly to the sella turcica. Only in 8% of cases were found conchal types of pneumatization, but they were part of anatomical pictures including Onodi air cells. Such an Onodi cell presented a posterior (sphenoidal) recess reaching posteriorly and superiorly to the pterygopalatine fossa. The recesses of the sphenoid sinus were also documented: anterior or septal, ethmoidal, maxillary, clinoidal and lateral. In 32% was found a lateral recess only engaged between the vidian and maxillary nerve canals.CONCLUSION. It appears that CBCT is a reliable tool for accurate anatomic identification of the sphenoid sinus pneumatization pattern, on a case-by-case basis.

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Endoscopic Endonasal Transethmoidal Transcribriform Transfovea Ethmoidalis Approach to the Anterior Cranial Fossa and Skull Base

Neurosurgery ◽

10.1227/01.neu.0000368395.82329.c4 ◽

2010 ◽

Vol 66 (5) ◽

pp. 883-892 ◽

Cited By ~ 66

Author(s):

Jeffrey P. Greenfield ◽

Vijay K. Anand ◽

Ashutosh Kacker ◽

Michael J. Seibert ◽

Ameet Singh ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Sphenoid Sinus ◽

Malignant Tumors ◽

Anterior Skull Base ◽

Anterior Cranial Fossa ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Lumbar Drainage ◽

Cranial Fossa

Abstract OBJECTIVE The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach. METHODS An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis. RESULTS Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors. CONCLUSION The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

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Extensions of the Sphenoid Sinus

Neurosurgery ◽

10.1227/01.neu.0000367619.24800.b1 ◽

2010 ◽

Vol 66 (4) ◽

pp. 797-816 ◽

Cited By ~ 90

Author(s):

Jian Wang ◽

Sharatchandra Bidari ◽

Kohei Inoue ◽

Hong Yang ◽

Albert Rhoton

Keyword(s):

Computed Tomography ◽

Sphenoid Sinus ◽

Middle Cranial Fossa ◽

Cranial Base ◽

Sellar Region ◽

Computed Tomography Images ◽

Suprasellar Region ◽

Cranial Fossa ◽

Minimally Invasive Access ◽

Selection Of

Abstract OBJECTIVE The transsphenoidal approach has been extended in recent years from tumors of the sellar region to lesions involving other areas bordering the sphenoid sinus including the cavernous sinus, Meckel's cave, middle cranial fossa, planum sphenoidal, suprasellar region, and clivus. The goal of this study was to examine various pneumatized extensions of the sphenoid sinus that may facilitate extended approaches directed through the sinus. METHODS The sphenoid sinus and its surrounding structures were examined in 18 cadaver heads, and the results were correlated with the findings from 100 computed tomography images of the sinus. The sellar type of the sphenoid sinus in which the pneumatization extended beyond the anterior sellar wall was further classified according to the various extensions of the sinus. METHODS The sphenoid sinus and its surrounding structures were examined in 18 cadaver heads, and the results were correlated with the findings from 100 computed tomography images of the sinus. The sellar type of the sphenoid sinus in which the pneumatization extended beyond the anterior sellar wall was further classified according to the various extensions of the sinus. RESULTS The sellar type of the sphenoid sinus was classified into the following 6 basic types based on the direction of pneumatization: sphenoid body, lateral, clival, lesser wing, anterior, and combined. The recesses and prominences, formed by pneumatization of the sinus, act as “windows” opening from the sinus in different areas of the cranial base and may facilitate minimally invasive access to lesions in the corresponding areas. CONCLUSION The variations in the extensions of pneumatization of the sphenoid sinus may facilitate entry into areas bordering the sphenoid sinus and play a role in the selection of a surgical approach to lesions bordering the sinus.

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Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1304 ◽

2017 ◽

Vol 10 (1) ◽

pp. 42-44

Author(s):

Satyawati Mohindra ◽

Sandeep Mohindra ◽

Kiran Joshi ◽

Harsimrat S Sodhi

Keyword(s):

Magnetic Resonance ◽

Sphenoid Sinus ◽

Lateral Wall ◽

Csf Leak ◽

Nasal Discharge ◽

Transnasal Approach ◽

Csf Rhinorrhea ◽

Repeat Magnetic Resonance Imaging ◽

Computed Tomographic ◽

General Physical

ABSTRACT Objective To report a rare case of delayed spontaneous cerebrospinal fluid (CSF) leak through clival region in the sphenoid sinus. Case report A 35-year-old female presented to our outdoor clinic with watery right nasal discharge for past 2 months, which increased on bending forward. Her medical history, general physical and neurological examinations were unremarkable. High-resolution computed tomographic scan and magnetic resonance cisternography were performed and suggestive of defect in right cribriform plate and right sphenoid sinus. Endoscopic repair was done but same symptoms occurred after 1 month. Repeat magnetic resonance imaging showed fistula in the lateral wall of right sphenoid sinus. Revision endoscopic transnasal CSF rhinorrhea repair was done. Lumbar subarachnoid drain was left in place for 5 days. No recurrence was noted at 12-week follow-up. Conclusion Endoscopic transnasal approach is the best modality of treatment for midline skull base defects. Delayed leaks can present from previously weak areas and all the doubtful areas must be examined during surgery. How to cite this article Mohindra S, Mohindra S, Joshi K, Sodhi HS. Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair. Clin Rhinol An Int J 2017;10(1):42-44.

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