• Nathan S Alexander, Mohamad R Chaaban, Kristen O Riley, and Bradford A Woodworth.
• Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0012, USA.
• Arch. Otolaryngol. Head Neck Surg. 2012 May 1; 138 (5): 471-8.

ObjectiveTo highlight concepts critical to achieving successful repair and avoiding intracranial complications in the treatment of cerebrospinal fluid (CSF) leaks from the lateral recess of the sphenoid sinus (LRS).DesignOutcomes study.SettingTertiary referral university hospital.PatientsEleven patients with LRS CSF leaks from June 2008 to June 2010.InterventionsEndoscopic transpterygoid approach and multilayer repair of skull base defect in the LRS.Main Outcome MeasuresRecurrence, graft techniques, postoperative intracranial pressure (ICP), and use of ventriculoperitoneal (VP) shunt.ResultsThirteen CSF leaks originating in the LRS were surgically repaired in 11 patients; 2 patients required bilateral leak repair. The endoscopic transpterygoid approach was used in 12 of 13 repairs. Eight patients had failed attempts at repair prior to presentation (4 endoscopic sphenoidotomies and 4 middle cranial fossa [MCF] approaches). One patient presented with a temporal lobe abscess following hydroxyapatite "obliteration" to seal off the LRS. This required a combined MCF/transpterygoid approach to drain the abscess, remove the encephalocele and hydroxyapatite, and seal the skull base defect. In 2 cases, the LRS was left patent owing to concerns of inadequate mucosal extirpation. The median duration of follow-up was 10.8 months (range, 2-29 months). One patient experienced a failure (2 months after repair), which was successfully sealed on the second attempt. Postoperatively, 5 patients required VP shunts, and 5 were maintained on acetazolamide for elevated ICP (average, 26.7 cm H₂O in 8 patients; presumed elevated in 2 patients).ConclusionsThe current study demonstrated a 92% success rate using the endoscopic transpterygoid approach for LRS skull base defects providing support for routine use in the treatment algorithm. Poor outcomes were observed with previous surgical attempts to obstruct the LRS without repairing the skull base defect.

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