PMC5569397_01
Pre- and postoperative computed tomography (CT). Preoperative CT in the bone window in the axial plane (a and b) demonstrating hypertrophy of the left sphenoid wing, orbital lateral wall, and floor of the middle fossa. Pre-operative CT in the bone window in the coronal plane (c) showing development of the lateral recess of the sphenoid sinus beyond the sphenoid body into the greater wing. Postoperative CT in the bone window (d-f) showing extensively drilled sphenoid wing, orbital lateral wall, floor of the middle fossa, ethmoid sinus, and sphenoid sinus. Arrow, vidian canal; arrowhead, foramen rotundum
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F1
CT performed in our hospital revealed hypertrophy of the left sphenoid wing, orbital lateral wall, and floor of the middle fossa [Figure 1a and b]. Postoperative CT showed extensively drilled skull base bone [Figure 1d-f]. Because the tumor had expanded laterally along with development of the lateral recess of sphenoid sinus beyond the sphenoid body into the greater wing [Figure 1c], the transmaxillary transpterygoid approach was employed to approach the tumor extending laterally over the vidian canal.
Pre- and postoperative magnetic resonance imaging. Pre-operative axial T1-weighted imaging with gadolinium contrast (a and b) and sagittal T1-weighted imaging with gadolinium contrast (c) demonstrating a homogeneously enhancing tumor extending into extracranial structures as well as adjacent structures. Postoperative axial T1-weighted imaging with gadolinium contrast (d and e) and sagittal T1-weighted imaging with gadolinium contrast (f) demonstrating residual tumor only in the cavernous sinus and superior orbital fissure. Arrows, tumor extending into the sphenoid sinus; arrowhead, tumor extending into the pterygopalatine fossa
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MRI showed a Gd-enhancing tumor occupying the left sphenoid wing and orbital lateral wall [Figure 2a]. Extension of the tumor into extracranial structures such as the sphenoid sinus, pterygopalatine fossa, and infratemporal fossa as well as adjacent structures such as the cavernous sinus and SOF was also revealed [Figure 2b and c]. Follow-up MRI at 3 months postoperatively demonstrated residual tumor only in the cavernous sinus and SOF [Figure 2d-f].
Pre- and postembolization angiogram. Pre-embolization angiogram (a) showing hypervascular tumor blush arising from the branches of the internal maxillary artery. Postembolization angiogram (b) demonstrating disappearance of the tumor blush. Arrow, internal maxillary artery
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F3
Cerebral angiography demonstrated hypervascularity of the tumor supplied by the branches of the internal maxillary artery [Figure 3a]. Preoperative embolization using N-butyl cyanoacrylate was performed 1 day before the surgical resection [Figure 3b].
Intraoperative photographs. (a) Intraoperative photograph from the transcranial side showing the large bone defect of the sphenoid sinus after tumor resection. Arrow indicates suction from the endonasal side. (b) Intraoperative photograph demonstrating repair of the defect with a free graft of fascia lata. (c) Intraoperative photograph from the endonasal side showing tumor extending into the sphenoid sinus. SF, sellar floor; CP, carotid prominence. (d) Intraoperative photograph demonstrating repair of the defect with a pedicled nasoseptal flap. Dotted line indicates the margin of the nasoseptal flap
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During these procedures, the tumor mass extending into the sphenoid sinus was exposed and the sphenoid sinus was then widely opened by resection of the tumor mass [Figure 4a]. The large bone defect of the sphenoid sinus was covered with a free graft of fascia lata and then fixed with fibrin glue from the transcranial side [Figure 4b]. Tumor expanding laterally in the sphenoid sinus was then removed en bloc [Figure 4c]. After resection of the tumor from the transcranial approach, the large skull base defect between the middle fossa and sphenoid sinus was covered with a pedicled NSF and then fixed with fibrin glue [Figure 4d].