Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide

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.

Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes

“…Several small series of ipsilateral NSFs from a transpterygoid approach have been published, with largely successful reconstruction outcomes, though the existing reports are limited to repairs of encephaloceles and CSF leaks in the sphenoid sinus. [1][2][3][9][10][11] Our study builds on the existing body of literature by validating the use of NSFs from an ipsilateral transpterygoid approach in expanded endonasal approaches for more extensive tumors of the skull base. The technique shown here demonstrates that the strategies from prior descriptions are also key to achieving successful reconstruction outcomes in expanded endonasal cases: wide decompression of the sphenopalatine foramen and PPF contents, and release of the key neurovascular attachment points of the PPF.…”

“…Currently, there is limited data regarding reconstructive outcomes of ipsilateral NSFs from a transpterygoid approach, with existing series pertaining to encephalocele or cerebrospinal fluid (CSF) leak repair. [1][2][3] There are currently only case reports with limited flap outcome data from expanded endonasal skull base cases, where wider exposures and longer cases may impose additional risks and challenges to pedicle management. 4 Here, we report our reconstructive outcomes in expanded endonasal skull base cases that utilize ipsilateral NSFs during a transpterygoid technique with SPA preservation.…”

Sealing the Box: Microsurgical Repair of Skull Base Encephaloceles: 2-Dimensional Operative Video

“…5 Standard transsphenoidal approaches provide limited visualization of certain areas, 6 and failure to obtain a durable repair is not uncommon. 2,7-9 Notwithstanding the good results reported with endoscopic repairs and the increased popularity of this approach, 10-14 additional pterygoid and pterygopalatine fossa dissection may be required, with concomitant risk of vidian or maxillary nerve dysfunction and postoperative dry eye. 10,15 This is particularly relevant with laterally located encephaloceles.…”