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The transnasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhea from the lateral recess of the sphenoid sinus

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Abstract

Background

Spontaneous cerebrospinal fluid (CSF) rhinorrhea from the lateral recess of the sphenoid sinus is surgically challenging. Sternberg’s canal has stirred great controversy as the potential source. The aim of this study was to present our experience with endonasal endoscopic repair, the possible etiopathology, and the outcomes.

Study design

This prospective study comprised 10 patients (seven female and three male) with spontaneous CSF rhinorrhea from the lateral recess of the sphenoid sinus, which was not related to trauma, previous surgery, tumors, irradiation, or meningitis. CSF rhinorrhea was confirmed with β2 transferrin test and high resolution CT scan (HRCT) and MRI cisternography. All patients were treated with the endonasal endoscopic conservative retrograde trans-sphenoidal approach.

Results

The mean BMI was 35.55 ± 2.84 kg/m2. Elevated intracranial pressure was present in all cases confirmed directly (with a mean intraoperative lumbar drain pressure of 27.5 ± 3.84 cm H2 O), and indirectly [with the presence of primary empty sella (100%), arachnoid pits (30%), and attenuated skull base (40%)].

Osteodural defect was constantly present in the superior wall of the lateral recess, lateral to the foramen rotundum, none above the foramen rotundum or below the vidian canal orifice. The mean follow-up was 46.9 ± 8.26 months.

Conclusion

The endonasal endoscopic repair is a safe and effective method. The etiopathology is multifactorial. The management of elevated intracranial pressure is crucial. The potential source is not Sternberg’s canal but persistent cartilaginous vascular channels at the ossification center of the alisphenoid, cartilaginous precursor of the greater wing of the sphenoid bone.

References

  1. 1

    Forer B, Sethi DS. Endoscopic repair of cerebrospinal fluid leaks in the lateral sphenoid sinus recess. J Neurosurg 2010; 112: 444–448.

    Article  Google Scholar 

  2. 2

    Woodworth BA, Prince A, Chiu AG, Cohen NA, Schlosser RJ, Bolger WE, et al. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg 2008; 138: 715–720.

    Article  Google Scholar 

  3. 3

    Schuknecht B, Simmen D, Briner H, Holzmann D. Non traumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. Am J Neuroradiol 2008; 29: 542–549.

    CAS  Article  Google Scholar 

  4. 4

    Baranano C, Curé J, Palmer J, Woodworth B. Sternberg’s canal: fact or fiction? Am J Rhinol Allergy 2009; 23: 167–171.

    Article  Google Scholar 

  5. 5

    Prosser J, Vender J, Solares C. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin N Am 2011; 44: 857–873.

    Article  Google Scholar 

  6. 6

    Woodworth B, Bolger W, Schlosser R. Nasal cerebrospinal fluid leaks and encephaloceles. Oper Tech Otolaryngol 2006; 17: 111–116.

    Article  Google Scholar 

  7. 7

    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: 1070–1077.

    Article  Google Scholar 

  8. 8

    Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147: 196–203.

    Article  Google Scholar 

  9. 9

    Sternberg M. Ein bisher noch nicht beschriebener Kanal im Keilbein des Menschen. Anat Anz 1888; 3: 784–785. Quoted from: Tomazic et al. [11]

    Google Scholar 

  10. 10

    Castelnuovo P, Dallan L, Pistochini A, Battaglia P, Locatelli D, Bignami M. Endonasal endoscopic repair of Sternberg’s canal cerebrospinal fluid leaks. Laryngoscope 2007; 117: 345–349.

    Article  Google Scholar 

  11. 11

    Tomazic P, Stammberger H. Spontaneous CSF-leaks and meningoencephaloceles in sphenoid sinus by persisting Sternberg’s canal. Rhinology 2009; 47: 369–374.

    PubMed  Google Scholar 

  12. 12

    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: 471–478.

    Article  Google Scholar 

  13. 13

    Izquierdo M, Martin C, Caballero T. Association between cerebrospinal fluid leakage and persistence of Sternberg’s canal: coincidence or cause? Acta Otorrinolaringol Esp 2012; 63: 144–146.

    Article  Google Scholar 

  14. 14

    Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 2005; 115: 205–212.

    Article  Google Scholar 

  15. 15

    Chaaban MR, Illing E, Riley KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation. Laryngoscope 2014; 124: 70–75.

    Article  Google Scholar 

  16. 16

    Banks CA, Palmer JN, Chiu AG, O’Malley BW Jr, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg 2009; 140:826–833.

    Article  Google Scholar 

  17. 17

    Bolger WE. Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience. Otolaryngol Head Neck Surg 2005; 133: 20–26.

    Article  Google Scholar 

  18. 18

    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 2006; 16: 207–212.

    Article  Google Scholar 

  19. 19

    Kasemsiri P, Solares CA, Carrau RL, Prosser JD, Prevedello DM, Otto BA, et al. Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope 2013; 123: 811–815.

    Article  Google Scholar 

  20. 20

    Kerr J, Chu F, Bayles S. Cerebrospinal fluid rhinorrhea: diagnosis and management. Otolaryngol Clin North Am 2005; 38: 597–611.

    Article  Google Scholar 

  21. 21

    Dunn CJ, Alaani A, Johnson AP. Study on spontaneous cerebrospinal fluid rhinorrhoea: its aetiology and management. J Laryngol Otol 2005; 119: 12–15.

    CAS  Article  Google Scholar 

  22. 22

    Maira G, Anile C, Mangiola A. Primary empty sella syndrome in a series of 142 patients. J Neurosurg 2005; 103: 831–836.

    Article  Google Scholar 

  23. 23

    Wise SK, Schlosser RJ. Evaluation of spontaneous nasal cerebrospinal fluid leaks. Curr Opin Otolaryngol Head Neck Surg. 2007; 15: 28–34.

    Article  Google Scholar 

  24. 24

    Speck V, Staykov D, Huttner HB, Sauer R, Schwab S, Bardutzky J. Lumbar catheter for monitoring of intracranial pressure in patients with post-hemorrhagic communicating hydrocephalus. Neurocrit Care 2011; 14: 208–215.

    Article  Google Scholar 

  25. 25

    Settecase F, Harnsberger HR, Michel MA, Chapman P, Glastonbury CM. Spontaneous lateral sphenoid cephaloceles: anatomic factors contributing to pathogenesis and proposed classification. Am J Neuroradiol 2014; 35: 784–789.

    CAS  Article  Google Scholar 

  26. 26

    Nemzek WR, Brodie HA, Hecht ST, Chong BW, Babcook CJ, Seibert JA. MR, CT, and plain film imaging of the developing skull base in fetal specimens. Am J Neuroradiol 2000; 21: 1699–1706.

    CAS  PubMed  Google Scholar 

  27. 27

    Pinilla-Arias D, Hinojosa J, Esparza J, Muñoz A. Recurrent meningitis and persistence of craniopharyngeal canal: case report. Neurocirugia (Astur) 2009; 20: 50–53.

    CAS  Article  Google Scholar 

  28. 28

    Aggarwal B, Gupta M, Goyal N. Accessory foramina in the body of sphenoid bone. Bombay Hosp J 2012; 54: 232–235.

    Google Scholar 

  29. 29

    Narasimhan K, Coticchia J. Transsphenoidal encephalocele in a neonate. Ear Nose Throat J 2006; 85: 420, 422

    Article  Google Scholar 

  30. 30

    Cendekiawan T, Wong R, Rabie A. Relationships between cranial base synchondroses and craniofacial development: a review. Open Anat J 2010; 2: 67–75.

    Article  Google Scholar 

  31. 31

    Dharwal K. A sphenoid with multiple developmental variations. Eur J Anat. 16:68–73, 2012.

    Google Scholar 

  32. 32

    Budu V, Mogoant C, Fanuta B, Bulescu I. The anatomical relations of the sphenoid sinus and their implications in sphenoid endoscopic surgery. Rom J Morphol Embryol 2013; 54: 13–16.

    CAS  PubMed  Google Scholar 

  33. 33

    Illing E, Schlosser RJ, James N Palmer JN, Joel Cure J, Fox N, Woodworth BA. Spontaneous sphenoid lateral recess cerebrospinal fluid leaks arise from intracranial hypertension, not Sternberg’s canal. Int Forum Allergy Rhinol 2014; 4: 246–250.

    Article  Google Scholar 

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Correspondence to Mohamed M. El-Sharnouby MD.

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El Tarabishi, M.N., Rabie, H.M., Youssef, T.A. et al. The transnasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhea from the lateral recess of the sphenoid sinus. Egypt J Otolaryngol 32, 13–20 (2016). https://doi.org/10.4103/1012-5574.175797

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Keywords

  • intracranial pressure
  • lateral recess of the sphenoid sinus
  • meningoencephalocele
  • skull base
  • spontaneous cerebrospinal fluid rhinorrhea