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Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas
Published on: January 17, 2018
Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide
Satyan B Sreenath1, Dennis M Tang2, Jonathan Y Ting3,4
1Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.
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:
4 Laryngoscope, 131:2224-2230, 2021.
Insights
A simplified endoscopic approach for cerebrospinal fluid (CSF) leaks and meningoencephaloceles in the lateral sphenoid sinus offers a 100% success rate. This modified transpterygoid approach (MTPA) reduces patient morbidity and simplifies surgical access.
Area of Science:
- Neurosurgery
- Otolaryngology
- Skull Base Surgery
Background:
- Cerebrospinal fluid (CSF) leaks and meningoencephaloceles in the lateral sphenoid sinus are challenging surgical problems.
- Traditional transpterygoid approaches pose risks and increase patient morbidity due to extensive dissection of pterygopalatine fossa contents.
Purpose of the Study:
- To evaluate the efficacy and safety of a simplified, endoscopic modified transpterygoid approach (MTPA) for managing lateral sphenoid sinus CSF leaks and meningoencephaloceles.
- To compare the outcomes of MTPA with traditional approaches, focusing on reduced morbidity and simplified surgical access.
Main Methods:
- A multi-institutional retrospective case series of 33 patients who underwent MTPA between 2014 and 2020.
- Evaluation of surgical techniques, skull base reconstruction methods, and postoperative outcomes, including complications and recurrence rates.
Main Results:
- The MTPA achieved a 100% success rate with no recurrent CSF leaks over a 13-month average follow-up.
- Skull base reconstruction utilized various grafts, including mucosal grafts (72.7%) and nasoseptal flaps (12.1%).
- Postoperative complications were uncommon and resolved, including temporary V2 anesthesia (9.7%).
Conclusions:
- The endoscopic MTPA simplifies surgical access to the lateral sphenoid sinus for CSF leaks and meningoencephaloceles.
- This approach effectively manages these conditions with reduced morbidity and without compromising surgical exposure.
- MTPA is a valuable alternative to extensive pterygopalatine fossa dissection for lesions involving the lateral sphenoid sinus.
