RESUMO
BACKGROUND: A temporo-sphenoidal encephalocoele occurs when temporal lobe herniates through a defect in the greater wing of the sphenoid bone into the sphenoid air sinus. The natural history is not well-understood, though presentation in adulthood with CSF rhinorrhoea and/or meningitis is typical. Lateral pneumatisation of the sphenoid sinus and elevated BMI may be contributory. AIMS: We explored the feasibility of a transorbital approach (TOA) for repair, using a combination of 3D modelling and simulation. We then successfully deployed this technique in vivo. METHODS: CT imaging for three patients who had previously undergone transcranial repair of lateral temporo-sphenoidal encephalocoele was used to generate data allowing 3D printed models of the skull base to be produced. The transorbital approach was simulated by performing a lateral orbitotomy followed by drilling of the sphenoid wing to expose the antero-basal middle fossa. 3D object scanning was used to create virtual models of the skull base post-surgery, from which surgical access was quantified in two ways: the area (mm2) of the middle fossa exposed by the TOA and the vertical attack angle. RESULTS: The mean surface area of the cranial access window achieved by simulated TOA was 325mm2. The mean vertical attack angle was 25°. One patient was subsequently treated successfully via TOA with no recurrence of their CSF leak, no orbital morbidity, excellent cosmesis, but resolving V2 numbness (follow-up 7 months). CONCLUSIONS: We have shown that the transorbital approach provides adequate surgical access. In our single case, surgical repair of a lateral temporo-sphenoidal encephalocoele via TOA was feasible, safe, and effective. This approach may offer some advantages compared with transcranial or endonasal approaches.
RESUMO
The endoscopic endonasal approach is more disruptive to normal anatomy (particularly nasal mucosa) than the transseptal submucosal microscopic approach. This may result in greater postoperative nasal morbidity, in turn reducing quality of life. We aimed to assess the severity and time course of nasal morbidity, and its impact on quality of life, following endoscopic endonasal skull base surgery in this retrospective cohort study. We identified 95 patients who underwent endoscopic endonasal skull base surgery for anterior skull base pathologies. Nasal-specific questions from the Sino-Nasal Outcome Test-22 (SNOT-22) and the Anterior Skull Base inventory (ASB-12) were combined with quality-of-life questions. Patient demographics, diagnosis, and operative data were collected from electronic records. Age of the cohort ranged from 14-83 years. Time elapsed since surgery ranged from 3-85 months. 85/95 (89%) felt that nasal morbidity associated with surgery was acceptable, given the underlying reason for, and outcome of surgery; 10/95 (11%) did not. 71/95 (75%) reported no change or improvement in olfaction 3-months following surgery. 24/95 (25%) reported a deterioration in olfaction which was mild in 7%, moderate in 7%, and severe in 11%. Nasal crusting, nasal obstruction, and headache were moderately problematic symptoms but improved significantly by 3-month follow-up. Nasal discharge, nasal pain, and nasal whistling were mildly problematic and improved significantly by 3-months. 62/95 (65%) patients reported 'no change' in day-to-day activities due to the effects on their nose after surgery. 19/95 (20%) had 'mild inconvenience', 8/95 (8%) 'moderate inconvenience' and 6/95 (6%) 'severe inconvenience'. Endoscopic anterior skull base surgery is associated with nasal morbidity. Whilst 35% of patients appreciate a consequent negative impact on day-to-day life, the overwhelming majority feel that nasal morbidity is acceptable, given the wider surgical goals.