Американский Научный Журнал THE CASE OF BILATERAL DEFECTS OF THE LATERAL RECESSES OF THE SPHENOID SINUS (4-10)

Spontaneous defects of the lateral recess of the sphenoid sinus are results from incomplete fusion of the greater sphenoid wing bone with the basisphenoid. This anomaly is known as the lateral craniopharyngeal canal or the Sternberg's canal. However, the exact mechanisms of the formation of defects in the lateral recess are still poorly understood and cause much controversy. The progressive erosion of the skull base in patients with increased intracranial pressure and well pneumatized sphenoid sinus may result in focal areas of dehiscence and herniation of intracranial contents. In this article, we present a rare case of the development of bilateral meningocele of the lateral recess of the sphenoid sinus with a recurrent bilateral cerebrospinal fluid leak. A 38 old female patient presented to our clinic with rhinorrhea when the head was tilted forward. A computer cisternography scan of the sinuses showed that the patient has bilateral meningoencephalocele of the lateral recesses of the sphenoid sinus. The operation “Endoscopic endonasal plasty of complex skull base defects in the lateral recesses of the sphenoid sinus on the left and right under the control of the Medtronic fusion navigation system” was performed. In the postoperative period, no complaints. The patient was discharged on day 6 after surgery. Скачать в формате PDF
4 American Scientific Journal № ( 36) / 2020
МЕДИЦИНА И СТОМАТОЛОГИЯ

THE CASE OF BILATERA L DEFECTS OF THE LAT ERAL RECESSES OF THE SPH ENOID SINUS

Shelesko E.V., Fomichev D.V.,
Chernikova N.A., Zinkevich D.N.
Federal State Autonomous Institution
“N.N. Burdenko National Scientific and Practical Center for Neurosurgery”
of the Ministry of Healthcare of the Russian Fede ration,
4-Tverskaya -Yamskaya Str. 16, Moscow, Russia, 125047
Director - A.A. Potapov

Abstract . Spontaneous defects of the lateral recess of the sphenoid sinus are results fr om incomplete fusion
of the greater sphenoid wing bone with the basisphenoid. This anomaly is known as the lateral craniopharyngeal
canal or the Sternberg's canal. However, the exact mechanisms of the formation of defects in the lateral recess are
still po orly understood and cause much controversy. The progressive erosion of the skull b ase in patients with
increased intracranial pressure and well pneumatized sphenoid sinus may result in focal areas of dehiscence and
herniation of intracranial contents. In t his article, we present a rare case of the development of bilateral
meningocele of the lateral recess of the sphenoid sinus with a recurrent bilateral cerebrospinal fluid leak. A 38 old
female patient presented to our clinic with rhinorrhea when the head w as tilted forward. A computer cisternography
scan of the sinuses showed that the p atient has bilateral meningoencephalocele of the lateral recesses of the
sphenoid sinus. The operation “Endoscopic endonasal plasty of complex skull base defects in the later al recesses
of the sphenoid sinus on the left and right under the control of the M edtronic fusion navigation system” was
performed. In the postoperative period, no complaints. The patient was discharged on day 6 after surgery.
Key words : Cerebrospinal fluid leak, meningoencephalocele, sphenoid sinus, sternberg’s canal, endoscopic,
trans pterygoid approach, skull base

Введение .
Spontaneous defects of the lateral recess of the
sphenoid sinus are results from incomplete fusion of the
greater sphenoid wing bone with the basisphenoid. [1 -
3]. This anomaly is known as the lateral
craniopharyngeal canal or the Sternberg's can al. [4].
Ho wever, the exact mechanisms of the formation of
defects in the lateral recess are still poorly understood
and cause much controversy. Many authors argue that
meningocele and cerebrospinal fluid of this localization
occurs as a result of increase d intracran ial pressure,
hyperpneumatization of the sphenoid sinus and obesity
[5-6].
The most common symptom in this pathology is
nasal liquorrhea, which is manifested by cerebrospinal
leak from the nasal cavity when the head is tilted. Other
manifestati ons of the disease include headache,
recurrent meningitis, coughing at night. [7 -9].
Preoperative CT cystornography imaging for bony
detail and MR imaging for soft tissue detail is critical
for assessing pathology of the skull base. In some cases,
when per forming com puted tomography of the brain, it
is possible to detect meningocele as an accidental find
[10 -12]
Meningocele and cerebrospinal fluid leak from the
lateral recess can lead to potentially fatal
complications, such as meningitis, brain abscess or
pneumocepha lus. Therefore, some authors recommend
surgical treatment, even in cases where there is no
evidence of cerebrospinal fluid leak or there was no
history of meningitis. [13 -14].
Transcranial approach to the treatment of nasal
CSF leak is graduall y becoming less preferable due to
its difficulty, possibility of trauma and a high risk of
damaging the vital structures. Nowadays the choice
falls on the transsphenoidal, transethmoidal and
transpterygoid approaches in endoscopic endonasal
surgeries on th e sphenoid sinus
The choice of the approach depends on the
surgeon’s experience, availability of the necessary
tools, anatomical features of the patient and the location
of the defect of sphenoid sinus [15, 16].
In this article, we present a rare case of the
develo pment of bilateral meningocele of the lateral
recess of the sphenoid sinus with a recurrent bilateral
cerebrospinal fluid leak.
Описание клинического случая .
A 38 old female patient presented to Institution
“N.N. Burdenko National Scientific and Practical
Center for Neurosurgery” with rhinorrhea when the
head was tilted forward.
Life history: Childhood infections, obesity of the
first degree. Craniocerebral injuries and allergic
reactions are denied
Medical history: One year ago, the patient began
to notic e the flow of clear fluid from the lef nasal
passage, which periodically spontaneously ceased, then
again recurred. She was treated at the place of residence
with a diagnosis of allergic rhinitis without effect. After
6 months, the patient turned to the Novo sibirsk
Regional Hospital, where cerebrospinal leak was
suspected and computerized cisternography was
performed. After that, on t he left, the discharge
stopped, but appeared on the right. A computer
cisternography scan of the sinuses showed that the
patien t has bilateral meningoencephalocele of the
lateral recesses of the sphenoid sinus. The patient was
sent to Institution “N.N. Bur denko National Scientific
and Practical Center for Neurosurgery” for further
treatment.

American Scientific Journal № ( 36) / 2020 5

Objective data on admission: satisfact ory
condition. Somatically and neurologically preserved.
ENT -examination: signs of nasal liquorrhea on the
right are noted. Exami nation by a ophthalmologist:
there were no signs of congestive optic discs, there
were no oculomotor symptoms. The CT of the br ain for
the navigation system shows destructive changes in the
lateral recesses of the sphenoid sinus on the left and
right, with the presence of meningocele in them. The
ventricular system is not enlarged. Convex
subarachnoid spaces are not expanded [5, 6 ]. The
median structures are not biased. Basal tanks are traced
(figure 1). Клинические анализы крови, мочи,
ликвора в норме.

Figure 1 CT (frontal projection). Bilateral defects of the lateral recess of the sphenoid sinus
(indicated by arrows). The line s connect the round foramen and the channel of the Vidiev nerve.

Clinical diagnosis: Complex skull base defects.
Spontaneous relapsing nasal liquorrhea. Bilateral
defects of the lateral recesses of the sphenoid sinus.
Course of treatment: under general anesthesia, the
operation “Endoscopic endonasal plasty of complex
skull base defects in the lateral recesses of the sphenoid
sinus on the left and right under the control of the
Medtronic fusion navigation system” was performed.
Lumbar puncture was performed during the operation.
At the same time, cerebrospinal fluid pressure was
increased and amounted to 200 mm. water pillar. A
lumbar drain was inserted before surgery.
During the operation, the Medtronic fusion
navigation system was used. Two -sided transpterygoid
approach was performed. This method is commenced
with the processus uncinatus, resection and the highest
possible poste rior expansion of the maxillary sinus
ostium. After that basal plate of the middle turbinate is
perforated, and the cells of ethmoid sinus are widely
opened. This is followed by expanding the opening of
the sphenoid sinus and removing posterior wall of the
maxillary sinus with clipping or coagulating a.
Sphenopalatina and its branches. During the final stage
of the procedure , an anterior wall of the sphenoid sinus
is gradually removed, since it actually serves as the
posterior wall of the sphenopalatine fos sa, which
allows a possibility for a better view of the lateral
sections of the sinus with 00 endoscope and for
manipulat ion with straight tools. As a result of a
thorough anatomical dissection in the fossa itself,
standard transethmoidal sphenotomy, and r esection of
the winged process of the sphenoid bone, an access
route to the lateral sections of sphenoid sinus is formed,
which is restricted downwards by a mobilized
maxillary artery and which is divided into two parts by
the nerve structures of the sphen opalatine fossa -
pterygopalatine ganglion and the Vidian nerve. During
the procedure, the vessels are coagulated and the
nervous structures are moved laterally, this way
anterior wall of the sphenopalatine fossa becomes
exposed, making it possible to remov e it with the drill
and subsequently to localize CSF fistula.
After ensuring an access to the problematic
location, in c ase meningocele was detected it was
removed, further step was identifying the skull base
defect and carrying out reconstruction using f ascia lata,
bone of the nasal septum and mucoperiosteum attached
to the nasal septum fixed by fibrin -thrombin glue
“Evice l”. (figure 2 а-d, рис 3 а,b)

6 American Scientific Journal № ( 36) / 2020
Figure 2 a -d Approach to the lateral recess of the sphenoid sinus on the left. (Intraoperative photo) .
A - uncovered cells of the ethmoid labyrinth, sphenoid sinus, maxillary sinus, b - lateral extension of the
sphenoid sinus, c – plastic of the defect of autobone and fascia lata, d - a nanoseptal flap over the defect
(ethmoid - cells of the the ethmoid labyrinth, maxillaris - maxillary sinus, sph - sphenoid sinus, * -
meningoencephalocele, Co - middle turbinate, fascia lata – fascia lata, os - bone, ns flap - nasoseptal flap)

Figure 3 a -b Approach to the lateral recess of the sphenoid sinus on the ri ght. (Intraoperative photo).
A - lateral extension of the sphenoid sinus, b – plastic of the defect of fascia la ta
(sph - sphenoid sinus, * - meningoencephalocele, fascia lata – fascia lata)

In the postoperative period, the patient's condition
is satisfac tory. No sensory impairment on the face,
lacrimation, or other access complications were noted.
Examination by op hthalmologist: there were no signs

American Scientific Journal № ( 36) / 2020 7

of congestive optic discs, there were no oculomotor
symptoms. Clinical analysis of blood, urine,
cerebrospin al fluid is normal. The patient was
prescribed antibiotic therapy, tampons from the nose
were removed on the firs t day after the operation,
lumbar drainage was removed by 3 day after the
operation. The patient is discharged to the polyclinic at
the place o f residence under the care of a physician
Discussion.
The development of the sphenoid bone is a
complex process and involves the fusion of several
cartilage precursors into a single bone structure. The
sphenoid sinus is fully formed only by adolescence. F or
different people, it can vary in size, shape and degree
of pneumatization. [17, 18].
Presence of the lateral craniopharyngeal canal was
discovered for the frst time by Cruveilhier in 1877, and
11 years later by Sternberg in 1888 [7, 8]. Over the last
decade, most authors have used the term Sternberg’s
canal. Sternberg described constant presence of the
canal in t he skulls of 3 –4 year old children. The
ossifcation process continues up to the age of 10, until
the canal is closed. Under unknown circumstanc es,
Sternberg’s canal may persist patent until adulthood
(Photo 1). When the sphenoid sinus develops and
reaches the fusion plane, Sternberg’s canal may create
a connection between the middle fossa and the
sphenoid sinus, and thus become a potential source of
cerebrospinal leak, meningoencephalocele or
meningitis [19].
Второй механизм возникает при изначально
нормал ьном развитии клиновидной пазухи.
Elevated intracranial pressure (ICP) and obesity
were associated with spontaneous meningocele. Far
lateral pneumatization of the sphenoid bone, a normal
variant in 22 to 40%, is commonly present in cases of
spontaneous me ningocele of the sphenoid wing. CSF
rhinorrhea is the most common presentation of
spontaneous meningocele of the sphenoid wing with
lateral sphenoid sinus extension. [20 -22].
Various epidemiological studies r eport that the
Sternberg canal occurs from 0.42 % to 6.1%. [23]. Sinus
hyperpneumatization laterally according to world
studies is found in 25% of patients [24].
There is debate in the literature about the existence
of the Sternberg canal and its location with respect to
the round opening and the maxil lary nerve [25 -26]. In
our case, the patient has bilateral deep lateral recesses
of the sphenoid sinus, with the defect located lateral to
the round opening. Which is most likely associated
with congenital mal formations of the base of the skull.
Provoking factors in the development of meningocele
and nasal liquorrhea were increased intracranial
pressure and metabolic disturbances (obesity).
No matter what is the etiology and pathogenesis of
the cerebrospinal fl uid leak in the lateral recess of the
sphenoid sinus, the treatment strategy is reconstruction
of the complex skull base. Due to the complex
anatomical location and the inability approach the
defect directly, surgeries in this area have a high
percentage o f relapses (25%) [27].
Our case is unique in th at the patient has bilateral
lateral recesses with defects in them. In the PubMed
database we have found over 5 articles dedicated to this
problem [28 -32]. The majority of them describe
separate cases, and ser ies of observation studies, the
data from them is presented in Table 1. Elisa Illing et
al. [32] describe the largest number of observations in
an article. The authors analyze a series of 59 patients
with defects in the base of the skull / encephalocele in
the lateral recess of the sphenoid bone, of wh ich 18
patients had bilateral injuries. They analyze in detail the
causes of this pathology, but do not concern the tactics
of treating patients.
Nathan et al. [31] report five cases of bilateral
defects from 13 patients. They recommend performing
transsph enoidal approach for reconstruction when the
defect is located more medially than the second branch
of the trigeminal nerve, that is, with minimal sinus
pneumatization. In the presence of a defect, lateral to
the second branch of the trigeminal nerve, acco rding to
the authors, it is necessary to perform transpterigoid
approach.
In the case presented by us, endoscopic endonasal
transpterigoid approach provided a convenient
approach to encephalocele. When perform ing access,
the maxillary sinus was opened, the back wall of which
served as a guide when performing access.
In the literature, it has been shown that
transpterigoid approach is effective for the treatment of
cerebrospinal fluid in the lateral recess. Tra nspterygoid
approach however is the most traumatic of all. Among
the associated complications the most common are
facial hypaesthesia, infections (meningitis,
sphenoiditis), dry eye on the surgical site [33 -34].
The number of authors, however, noted that the
rate of success in the surgery is higher in the cases
where multilayer plasty was carried out (fat, fascia lata,
mucoperiosteum, cartilage/bone of the nasal septum)
[28 -32]. The method of using a mucoperiosteum
attached to the nasal septum by a vascula r stem to cover
large skull base defects was invented in 2004. Authors
claim that the percentage of relapses d ecreases when
mucoperiosteum is used [29, 31 -33]. Using the
navigation system allows to improve the technique of
endoscopic interventions, to avoi d damage to nearby
vital anatomical structures, to plan the volume of
surgical intervention, which leads to a decrease in the
number of postoperative complications [35]
In our case, we used lumbar drainage to control
intracranial hypertension. Most recomme nd lumbar
drainage in case of bilateral defects of the sphenoid
sinus. And Nathan and Marston [30 -31] even
per formed lumbar -peritoneal shunting in the
postoperative period due to the onset of symptoms of
congestive optic nerve discs.

8 American Scientific Journal № ( 36) / 2020
Table 1.
Overview of t reatment of bilateral defects in the base of the skull of the lateral recesses
of the sphenoid sinus
Authors,
year

Number of patients

Accompanying illnesses

Approach

Plasty materials

Lumbar drainage

Complications

Seth M.
Lieberman
et. all 2015
[28]
1 Obe sity No data No data No No data
Varun
Aggarwal et.
all. 2017
[29]
1
dural
arteriovenous
fistula
Transpterygoid
Bone, fat, fascia
lata,
mucoperiosteum
Yes No
Alexander P.
Marston et.
all. 2015
[30]
1 Obesity Transpterygoid Bone, fat , fascia
lata
Yes,
lum bar -
peritoneal
shun
No
Nathan S.
Alexander
et. all. 2012
[31]
5 Obesity Transpterygoid
Fascia lata, fat,
bone from the
nasal septum,
mucoperiosteum
Yes,
lumbar -
peritoneal
shun
No data
Elisa Illing
et. all 2014
[32]
18 Obesity,
empty sella No data No data No data No data

Conclusions .
Bilateral meningoencephalocele in the lateral
recesses of the sphenoid sinus probably results from an
anomaly in the development of the base of the skull
(Sternberg congenital canal, hyperpneumatization of
the sphenoid sinus ).
Endoscopic endonasal multilayer repair is the
treatment of choice for treating defects in the base of
the skull in the lateral recesses of the sphenoid sinus.
Disclaimer
The authors report no conflict of interest
concerning the materials or methods used in this study
or the findings specified i n this paper.

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For correspondence:
Elizaveta Vladimirovna Shelesko, Candidate of
Medical Sciences (PhD), Researcher of the
otoneurology group Federal State Autonomous
Institution “N.N. Burdenko National Scientific and
Practical Center for Neurosurgery” of the Ministry of
Healthcare of the Russian Federation, 4 -Tv erskaya -
Yamskaya Str. 16, Moscow, Russia, 125047
https://orcid.or g/0000 -0002 -8249 -9153 phone: 8 926
923 29 91
Fomichev Dmitry Vladislavovich Candidate of
Medical Sciences (PhD), Senior Researcher,
Department of Neurosurgery of the Skull Ba se Federal
State Autonomous Institution “N.N. Burdenko
National S cientific and Practical Center for
Neurosurgery” of the Ministry of Healthcare of the
Russian Federation, 4 -Tverskaya -Yamskaya Str. 16,
Moscow, Russia, 125047 https://orcid.org/0000 -0002 -
5323 -1000 : phone:8 499 972 -86 -72
Nadezhda Alekseevna Chernikova doctor of
otoneurology otoneurology Federal State Autonomous
Institution “N.N. Burdenko National Scientific and
Practical Cent er for Neurosurgery” of the Ministry of
Healthcare of the Russian Federation, 4 -Tverskaya -
Yamskaya Str. 16, Moscow, Russia, 125047
https://orcid.org/0000 -0002 -4895 -233, phone: 8 965
420 87 19
Denis Nikolaevich Zhinkevich doctor of
oto neurology otoneurology Federal State Autonomous
Institution “N.N. Burdenko National Scientific and
Practical Center for Neurosurgery” of the Ministry of
Healthcare of the Russian Federation, 4 -Tverskaya -
Yamskaya Str. 16, Moscow, Russia, 125047
https://orcid.org/0000 -0003 -1295 -0612 phone: 8 926
923 -29 -91

ЭФФЕКТИВНОСТЬ ИСПОЛЬ ЗОВАНИЯ ОТЕЧЕСТВЕННО ГО ОСТЕОПЛАСТИЧЕСКОГ О
МАТЕРИАЛА «BIO OSS» ДЛЯ ЗАПОЛНЕНИЯ ВНУТР ИКОСТНЫХ ДЕФЕКТОВ ЧЕ ЛЮС ТЕЙ

Ефимов Ю.В. 1 , Стоматов Д.В, 2
Ефимова Е.Ю. 1, Стоматов А.В. 2,
Долгова И.В. 1, Киреев П.В 1.
1ФГБОУ ВО «Волгоградский государственный медицинский университет»,
Волгоград, Россия. 2 ФГБОУ ВО «Пензаеский государственный университет», медицинский институт »,
Пенза, Ро ссия

EFFICIENCY OF USING DOMESTIC OSSEOPLASTI C MATERIAL “BIO OSST ”
FOR FILLING INTRACRO SS JAW DEFECTS

Efimov Yu.V. 1 , Stomatov D.V. 2 ,
Efimova E.Yu. 1 , Stomatov A.V. 2,
Dolgova I.V. 1, Kireev P.V. 1
1Volgograd State Medica l University ,
Volgograd, Russian Federation 2 Penza State Medical University,
Penza, Russian Federation

Резюме . Цель – повышение эффективности лечения послеоперационных внутрикостных дефектов
челюстей с использованием отечественного остеозамещающего материала «BIO OS T».
Материал и методы. Проведена сравнительная оценка эффективности хирургич еского лечения 63
больных око локорневыми кистами челюстей с заполнением костного дефекта остеопластическим
материалом Osseo Biol » (группа сравнения) и « Bio Oss » (исследуемая группа).
Результаты. Динамика клинико -рентгенологических показателей свидетельств овала о том, что у
больных гр уппы сравнения тенденция к отторжению имплантата стала более выраженной, у больных
основной группы сохранилась активность остеогенеза.
Заключение. Данные, полученные у больных исследуемой группы свидетельствуют о преобладании
скорости процессов остеогенеза , над скоростью процессов резорбции, что, в свою очередь, характеризует
остеозамещающий материал « Bio Osst » как отвечающий современным требованиям, предъявляемым к
таким материалам.
Summary . The objective is increasing the effectiveness of the treatment of postoperative intraosseous defects
of the jaw using the domestic «BIO OST» ma terial.