Surgical Neurology International

Transcription

1 Surgicl Neurology Interntionl OPEN ACCESS For entire Editoril Bord visit : Editor: Jmes I. Ausmn, MD, PhD University of Cliforni, Los Angeles, CA, USA Originl Article Anlysis of sphenoid sinus lterl pneumtiztion for endonsl endoscopic surgery Ryogo Kikuchi, Mshiro Tod, Toshiki Tomit 1, Koru Ogw 1, Kzunri Yoshid Deprtments of Neurosurgery nd 1 Otorhinolryngology, Hed nd Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Jpn E mil: *Ryogo Kikuchi fi020084@yhoo.co.jp; Mshiro Tod todm@z2.keio.jp; Toshiki Tomit tomitmt@gmil.com; Koru Ogw ogwk@5.keio.jp; Kzunri Yoshid kzrmky@z3.keio.jp *Corresponding uthor Received: 25 My 15 Accepted: 23 August 15 Pulished: 27 Octoer 15 Astrct Bckground: The purpose of this study ws to nlyze sphenoid sinus lterl pneumtiztion (SSLP), especilly in Asin popultions, nd to identify cutionry items when using the endoscopic endonsl pproch (EEA) for prsellr/lterl lesions. Methods: We nlyzed SSLP nd the width of SS (SSW) in 121 ptients who hd undergone EEA from 2008 to 2013 t the Division of Neurosurgery, Keio University Hospitl. SSLP ws defined s the distnce etween the SS lterl edge nd the medil spect of the pterygoid process on coronl reconstruction computed tomogrphy. SSW ws defined s the distnce etween the midline nd lterl wll. We recorded SSLP nd SSW for 242 sides. Further, we present two chrcteristic cses. Results: The verge SSLP nd SSW were 7.0 mm ( mm) nd 21.8 mm ( mm), respectively. No correltion etween pneumtiztion nd ge ws oserved t ge 15 or more. Sphenoid pneumtiztion ws significntly wider in mle thn in femle ptients. There ws no reltionship etween lterl nd sgittl plne pneumtiztion. In ptient with recurrent chordom who hd n undeveloped SSLP, the tumor ws removed vi the medil spce in the internl crotid rtery. In nother ptient who hd gint pituitry denom nd verge SSLP, the tumor ws locted in the middle crnil foss nd ws removed vi the lterl internl crotid spce through the left SSLP. Conclusions: Wide vritions were oserved in SSLP nd SSW. For EEA, pneumtiztion is n instrument corridor. Preopertive ssessment of SSLP is importnt, especilly for prsellr lesions. Access this rticle online Wesite: DOI: / Quick Response Code: Key Words: Endoscopic endonsl surgery, pneumtiztion, sphenoid sinus INTRODUCTION Consequent to recent developments in endoscopic techniques nd instruments, the endoscopic endonsl pproch (EEA) hs evolved to provide ccess to lterl cvernous sinus lesions. Due to expnded indictions, numerous studies hve focused on the endoscopic ntomy of the sphenoid sinus (SS), which is the pltform for EEA. [1,2,6,7,10,11,13] The vidin cnl, [4,12] medil This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution-NonCommercil-ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non-commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Kikuchi R, Tod M, Tomit T, Ogw K, Yoshid K. Anlysis of sphenoid sinus lterl pneumtiztion for endonsl endoscopic surgery. Surg Neurol Int 2015;6: Surgicl Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 opticocrotid recess, nd lterl opticocrotid recess [8] re importnt lndmrks of the internl crotid rtery. However, it is difficult to recognize these structures when the lterl pneumtiztion of the SS is not developed. SS pneumtiztion hs een clssified into three types nteroposteriorly: Conchl, presellr, nd sellr. [9] Regrding lterl pneumtiztion, clssifiction of the SS lterl recess ws reported, which ws defined y the formen rotundum nd vidin cnl. [14] However, there re few studies of SS lterl pneumtiztion (SSLP), especilly in Asin popultions. The purpose of this study ws to nlyze SSLP in Asins nd revel cutionry items when using EEA for prsellr nd lterl lesions. MATERIALS AND METHODS Rdiologicl mesurements We collected dt from consecutive ptients who underwent the EEA etween 2008 nd 2013 in the Division of Neurosurgery t Keio University Hospitl. Ptients with pthologicl legions involving the SSLP were excluded. We ssessed the SS in 69 men nd 52 women, with n verge ge of 53 yers (15 81 yers). Ptient chrcteristics re shown in Tle 1. High resolution preopertive computed tomogrphy (CT) scns were performed on ll these ptients. SSLP ws defined s the distnce from the lterl SS to the medil spect of the pterygoid process, which is the ntomicl limittion for the EEA, on coronl reconstruction imges. The width of SS (SSW) ws defined s the distnce etween the midline nd the lterl spect of the SS s shown in Figure 1. In undeveloped lterl pneumtiztion, SSLP ws recorded with negtive vlues. We recorded SSLP nd SSW Tle 1: Ptient chrcteristics Chrcteristics Numer Numer of ptients 121 Mle 69 Men ge (y/o) (rnge) 53 (15-81) Pthologies Pituitry denom 76 Chordom 11 Rthke s cleft cyst 8 Nsl nd prnsl cncer 5 Cholesterol grnulom 4 Crniophryngiom 3 Meningiom 3 Olfctory neurolstom 2 Spontneous CSF lekge 2 Mucous cyst 2 Others 5 CSF: Cererospinl fluid mesurements in 121 ptients, totling 242 mesured sides. Sttisticl nlyses were performed using SPSS 22.0 softwre (IBM, Chicgo, Illinois, USA). Comprisons etween mle nd femle groups were nlyzed using the Student s t test or the Mnn Whitney nonprmetric test, s pproprite. A P < 0.05 ws considered sttisticlly significnt. Illustrtive cse presenttion We reviewed clinicl dt nd rdiologicl ssessments of SSLP in 2 ptients who underwent the EEA for prsellr nd lterl lesions in the Division of Neurosurgery t Keio University Hospitl. RESULTS Rdiologicl results SSW verged 21.7 mm ( mm) on the right side nd 21.9 mm ( mm) on the left. The verge SSW for oth sides ws 21.8 mm ( mm) s shown in Tle 2. The verge SSLP ws 7.0 mm ( mm) on the right side nd 7.1 mm on the left ( mm). The verge SSLP for ll 242 sides ws 7.0 mm ( mm). Wide vritions of SSLP nd SSW were oserved s shown in Figure 2. No correltion of pneumtiztion with ptient ge ws oserved. SS pneumtiztion ws significntly wider in mles thn femles [Tle 3]. There ws no reltionship etween lterl pneumtiztion nd pneumtiztion in the sgittl plne, such s sellr, presellr, or conchl type. Cse presenttion Chrcteristic cses re shown in Figures 3 nd 4. Cse 1 A 43 yer old mle ws presented with doule vision. Contrst enhnced mgnetic resonnce imging (MRI) showed right prsellr tumor locted ehind the right internl crotid rtery [Figure 3 nd c]. Although sellr type SS pneumtiztion ws seen, the right SSLP ws undeveloped [Figure 3]. By preopertive CT nd MRI evlution, we considered the tumor pprochle vi the spce medil to the internl crotid rtery Figure 1: Exmples re shown of sphenoid sinus lterl pneumtiztion (SSLP) nd the width of sphenoid sinus (SSW) on coronl CT scns. () In developed lterl pneumtiztion, SSLP is reported with positive vlues. () In undeveloped lterl pneumtiztion, SSLP is reported with negtive vlues

3 [Figure 3c, rrow]. Gross totl removl of the tumor ws chieved using the EEA, ut it ws difficult to hndle instruments due to the undeveloped SSLP nd required long opertion time. After the opertion, his doule vision ws improved. Cse 2 A 77 yer old femle with lmost complete left eye lindness noticed worsening right eye heminopi. Contrst enhnced MRI showed gint pituitry denom extending to the left middle foss eyond the internl crotid rtery [Figure 4]. Although the right SSLP ws undeveloped, the left SSLP ws verge sized [Figure 4]. We ssessed preopertive xil CT imges nd considered using the spce lterl to the left internl crotid rtery for the EEA through the SSLP to rech the tumor [Figure 4, rrow]. Optic nerve decompression Tle 2: SS pneumtiztion Averge (rnge, SD) (mm) SSLP 7.0 ( 10.0 to 25.8, 5.9) Mle 7.9 ( 8.6 to 25.8, 5.9) Femle 5.8 ( 10.0 to 20.8, 5.6) SSW 21.8 ( , 6.6) Mle 23.0 ( , 6.6) Femle 19.9 ( , 5.7) SSLP: Sphenoid sinus lterl pneumtiztion defined s the distnce from the lterl sphenoid sinus to the medil spect of the pterygoid process, SSW: The width of sphenoid sinus defined s the distnce etween the midline nd the lterl spect of the sphenoid sinus, SD: Stndrd devition, SS: Sphenoid sinus P ws chieved y prtil tumor removl using the trnssphenoidl nd trnsmxillry trnspterygoid pproch. Her right eye heminopi nd left vision cuity recovered fter the opertion. DISCUSSION We mesured SSW nd SSLP in 121 ptients, totling 242 sides. There were wide vritions in SSLP nd SSW. No reltionship ws oserved etween the lterl nd sgittl plne pneumtiztion or ptient ge. Tle 3 summrizes SS pneumtiztion mesurements from this nd previous reports. There re few reports of SSLP mesurements in Asin people. Wng et l. defined the SS lterl recess y the formen rotundum nd vidin cnl [14] nd nlyzed SS pneumtiztion in hed CT imges of 100 ptients. The spce lterl to the vidin cnl ws 7.8 mm on verge nd SSW ws 22.3 mm on verge. The vidin cnl is locted slightly medil to the medil pterygoid plte in nerly 90% of people; [7] therefore, it is difficult to compre their results with SSLP findings of the present study. SSW mesured y Wng et l. [14] ws lrger thn tht in the present study nd previous reports. [5-10] Furthermore, Tomovic et l. reported lterl pneumtiztion in 84.6% Africn Americn, 58.2% Hispnic, 80.8% Cucsin, nd 66.7% Asin ptients. [5] Although Wng et l. did not report rce Tle 3: Comprison with previous literture Present study Iked nd Iinum [3] Lu et l. [5] Wng et l. [14] Rce Asin Asin Asin Cses (sides) SSW (rnge) (mm) 21.8 (6-40.2) 18.1 ( ) 17.2 ( ) 22.3 ( ) SSLP (rnge) (mm) 7.0 ( 10 to 25.8) Distnce etween SS lterl wll nd vidin cnl (rnge) (mm) 5.1 ( 9 to 19.1) 7.8 ( 5.6 to 24.7) SSLP: Sphenoid sinus lterl pneumtiztion defined s the distnce from the lterl sphenoid sinus to the medil spect of the pterygoid process, SSW: The width of sphenoid sinus defined s the distnce etween the midline nd the lterl spect of the sphenoid sinus, SS: Sphenoid sinus Figure 2: Sctter plots of sphenoid sinus lterl pneumtiztion (SSLP). () nd the width of sphenoid sinus (SSW). () Wide vritions of SSLP re oserved. There is no pprent correltion etween SSLP or SSW nd ptient ge. SSLP nd SSW in mles tend to e greter thn in femles

4 c d c Figure 4: Cse 2: A cse of gint pituitry denom. () Preopertive olique-coronl contrst enhnced CT showing gint pituitry denom tht encses the ilterl internl crotid rteries (ICs). The rrow shows the pproch to the middle foss vi left SSLP. () Preopertive coronl CT scn showing the right SSLP is 1.6 mm nd the left is 6.2 mm. (c) Intropertive view showing the left middle foss tumor through the spce lterl to the left IC. CT, computed tomogrphy; IC, internl crotid rtery; Lt, left; MT, middle turinte; MRI, mgnetic resonnce imging; NS, nsl septum; SPF, sphenopltine formen; SS, the width of sphenoid sinus; SSLP, sphenoid sinus lterl pneumtiztion. CONCLUSIONS e Figure 3: Cse 1: A cse of recurrent chordom. () Preopertive coronl contrst enhnced MRI reveling right prsellr tumor. () Preopertive coronl CT scn showing the left SSLP is 3.7 mm nd the right SSLP is 0.0 mm. (c) Preopertive xil contrst enhnced MRI showing the tumor is locted ehind the right IC. The rrow shows the pproch vi the spce medil to the IC. (d) Intropertive view showing the sell turcic nd left crotid prominence fter removl of the nterior wll of the SS during endoscopic endonsl surgery. The right crotid prominence ws uncler. (e) Intropertive view showing the right IC nd removl of tumor ehind the rtery. CT, computed tomogrphy; IC, internl crotid rtery; Lt, left; MRI, mgnetic resonnce imging; Rt, right; SSW, the width of sphenoid sinus; SSLP, sphenoid sinus lterl pneumtiztion demogrphics, SSW nd SSLP my e smller in Asins thn in Euro Americns. SSLP did not develop in Cse 1. In this cse, we could remove the tumor, ut it ws very difficult ecuse of limited opertion field. In Cse 2, we could find the spce lterl to the internl crotid rtery through SSLP, nd optic nerve decompression ws successfully chieved. In endoscopic endonsl surgery, working spce is very importnt, even if the field of view cn e secured. SSLP is n importnt corridor to rech the lterl lesions of the cvernous sinus. If SSLP is not developed, we hve to drill one round the internl crotid rtery to pproch lterl lesions of the cvernous sinus, which is not n esy endoscopic opertion field. Therefore, the preopertive ssessment of SS pneumtiztion is importnt in choosing n pproch for opertions of prsellr nd lterl lesions. Wide vritions of SSLP were oserved. SSLP nd SSW in Asins re possily smller thn in Euro Americns. In endoscopic endonsl surgery, SS pneumtiztion is n importnt instrument corridor. With undeveloped SSLP, it is difficult to rech lterl lesions of the internl crotid rtery nd the opertion field is restricted. Therefore, preopertive ssessment of SSLP is importnt for using the EEA, especilly for prsellr nd lterl lesions. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Amin SM, Nsr AY, Sleh HA, Fod MM, Herzllh IR. Endoscopic orienttion of the prsellr region in sphenoid sinus with ill defined ony lndmrks: An ntomic study. Skull Bse 2010;20: Elkmmsh TH, En MM, Awdll AM. Vriility in sphenoid sinus pneumtiztion nd its impct upon reduction of complictions following sellr region surgeries. Egypt J Rdiol Nucl Med 2014;45: Iked T, Iinum T. Surgicl ntomy of the sphenoid sinus Development nd intersinus septum. Nihon Jiiinkok Gkki Kiho 1992;95: Kssm AB, Vescn AD, Crru RL, Prevedello DM, Grdner P, Mintz AH, et l. Expnded endonsl pproch: Vidin cnl s lndmrk to the petrous internl crotid rtery. J Neurosurg 2008;108: Lu Y, Pn J, Qi S, Shi J, Zhng X, Wu K. Pneumtiztion of the sphenoid sinus in Chinese: The differences from Cucsin nd its ppliction in the extended trnssphenoidl pproch. J Ant 2011;219: Mgro F, Solri D, Cvllo LM, Smii A, Cppinc P, Pternò V, et l. The endoscopic endonsl pproch to the lterl recess of the sphenoid sinus

5 vi the pterygopltine foss: Comprison of endoscopic nd rdiologicl lndmrks. Neurosurgery 2006;59 4 Suppl 2: Mto D, Y okot H, Hirono S, Mrtino J, Seki N. The vidin cnl: Rdiologicl fetures in Jpnese popultion nd clinicl implictions. Neurol Med Chir (Tokyo) 2015;55: Peris Celd M, Kucukyuruk B, Monroy Sos A, Funki T, Vlentine R, Rhoton AL. The recesses of the sellr wll of the sphenoid sinus nd their intrcrnil reltionships. Neurosurgery 2013;73: Renn WH, Rhoton AL Jr. Microsurgicl ntomy of the sellr region. J Neurosurg 1975;43: Tomovic S, Esmeili A, Chn NJ, Shukl PA, Choudhry OJ, Liu JK, et l. High resolution computed tomogrphy nlysis of vritions of the sphenoid sinus. J Neurol Surg B Skull Bse 2013;74: Vezi A, Crdens E, Pinheiro Neto C, Pluzzi A, Brnstetter BF 4 th, Grdner PA, et l. Clssifiction of sphenoid sinus pneumtiztion: Relevnce for endoscopic skull se surgery. Lryngoscope 2015;125: Vescn AD, Snydermn CH, Crru RL, Mintz A, Grdner P, Brnstetter B 4 th, et l. Vidin cnl: Anlysis nd reltionship to the internl crotid rtery. Lryngoscope 2007;117: Wkut N, Ue T, Ae H, Inoue T, Tschitscher M. Endoscopic endonsl surgicl pproch to the oculomotor trigone from the cvernous sinus. Neurol Med Chir (Tokyo) 2014;54: Wng J, Bidri S, Inoue K, Yng H, Rhoton A Jr. Extensions of the sphenoid sinus: A new clssifiction. Neurosurgery 2010;66: