Repairing Lateral Sphenoid Cerebrospinal Fluid Leaks Endoscopically

Cerebrospinalfluid (CSF) leaks in the lateral recess of the sphenoid (LRS) are rare. For cases in which they do occur, however, Brigham and Women’s Hospital offers a minimally invasive, endoscopic alternative to traditional open surgery.

The endoscopic technique was described in a poster presented at April 2018’s Combined Otolaryngology Spring Meeting by Alice Z. Maxfield, MD, a rhinologist in the Brigham’s Department of Otolaryngology-Head and Neck Surgery.

In Endoscopic Management  of Lateral  Sphenoid Cerebrospinal Fluid Leaks, Dr. Maxfield and her colleagues reviewed their experiences with a technique by which radiographic measurements are used to predict endoscopic accessibility for surgical repair of CSF leaks in the LRS.

“CSF leaks from the sphenoid sinus are hard to access and can be difficult to treat with an open surgical procedure,” Dr. Maxfield said. “In addition to issues related to proximity to critical structures, the craniotomy process involves scalp incisions, drilling through the cranial bone, osteotomies and brain retraction—all of which increase morbidity.”

According to Dr. Maxfield, the endoscopic transnasal approach detailed in the poster enables direct exposure to the defect in the sinus, limiting morbidity and allowing patients to recover more quickly.

“We concluded that detailed review of paranasal sinus CT imaging can provide a more quantifiable parameter to guide preoperative decision making,” she said. “As a result, we can improve our ability to counsel our patients and obtain informed consent.”

Dr. Maxfield added that the endoscopic approach is a prime example of how the Brigham can address patient needs in rhinology and anterior skull-based surgery.

“Typically,patients with CSF leaks originating in the LRS visit doctor after doctor trying to find a solution to their problem,” she said. “They are often misdiagnosed as having a stuffy or runny nose, allergies or sinus infection. Once they are accurately diagnosed, they face further obstacles finding treatment because they really need a surgical specialist.”

Sinus specialists, including Dr. Maxfield and her colleague, Regan Bergmark, MD, are positioned to treat uncommon but nevertheless important problems such as LRS CSF leaks.

“This endoscopic technique is a good reflection of our mission to provide the expert,individualized care that improves patients’ lives,” Maxfield said.

Sagittal CT scan demonstrating access through the posterior wall of the maxillary sinus (transpterygoid approach) to the lateral recess of the sphenoid (white arrow). The encephalocele can be seen protruding into the sphenoid sinus.
Sagittal CT scan demonstrating access through the posterior wall of the maxillary sinus (transpterygoid approach) to the lateral recess of the sphenoid (white arrow). The encephalocele can be seen protruding into the sphenoid sinus.

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