Tag: Infratemporal fossa

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Combined endoscopic endonasal transpterygoid and sublabial transmaxillary approaches for a large infratemporal fossa trigeminal schwannoma

Acta Neurochirurgica (2022) 164:2525–2531

Trigeminal schwannomas (TSs) with solitary extracranial location are rare, and surgical excision is challenging. In recent years, the endoscopic endonasal transmaxillary transpterygoid approach (EETPA) has been advocated as an effective strategy for TSs in the infratemporal fossa (ITF).

Method We describe the steps of the EETPA combined with the sublabial transmaxillary approach for the surgical excision of a giant mandibular schwannoma of the ITF. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video.

Conclusion A combined EETPA and sublabial transmaxillary approach represents a safe and effective option for the surgical excision of extracranial TSs.

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Endoscopic endonasal treatment of maxillary nerve (V2) painful neuropathy: cadaveric study with clinical correlation

Acta Neurochirurgica (2020) 162:223–229

Surgical access to the second (V2, maxillary) and third (V3, mandibular) branches of the trigeminal nerve (V) has been classically through a transoral approach. Increasing expertise with endoscopic anatomy has achieved less invasive, more efficient access to skull base structures. The authors present a surgical technique using an endoscopic endonasal approach for the treatment of painful V2 neuropathy.

Methods Endoscopic endonasal dissections using a transmaxillary approach were performed in four formalin-fixed cadaver heads to expose the V2 branch of the trigeminal nerve. Relevant surgical anatomy was evaluated and anatomic parameters for neurectomy were identified.

Results Endoscopic endonasal transmaxillary approaches completed bilaterally to the pterygopalatine and pterygomaxillary fossae exposed the V2 branch where it emerged from the foramen rotundum. The anatomy defined for the location of neurectomy was determined to be the point where V2 emerged from the foramen rotundum into the pterygopalatine fossa. The technique was then performed in 3 patients with intractable painful V2 neuropathy.

Conclusions In our cadaveric study and clinical cases, the endoscopic endonasal approach to the pterygopalatine fossa achieved effective exposure and treatment of isolated V2 painful neuropathy. Important surgical steps to visualize the maxillary nerve and its branches and key landmarks of the pterygopalatine fossa are discussed. This minimally invasive approach appears to be a valid alternative for select patients with painful V2 trigeminal neuropathy.

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The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave

J Neurosurg 113:967–974, 2010. DOI: 10.3171/2009.10.JNS09157

In this paper the authors’ goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base.

Methods. Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin.

Results. A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy.

Conclusions. An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.

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Trigeminal neurinomas with extracranial extension: analysis of 28 surgically treated cases

J Neurosurg 113:1079–1084, 2010.DOI: 10.3171/2009.10.JNS091149

The object of this paper was to review the authors’ experience with 28 cases of trigeminal neurinomas having an extracranial extension.

Methods. The authors analyzed 28 cases of trigeminal neurinoma in which there was an extracranial extension of the tumor. All patients were treated in their department between the years 1989 and 2009.

Results. There was tumor extension along the ophthalmic division of the nerve in 4 cases, along the maxillary division in 5, and along the mandibular division in 13. In 6 tumors there was diffuse extracranial extension and the exact extracranial division of nerve involvement could not be ascertained. In 10 cases, the tumor had a multicompartmental location—in the posterior fossa, the middle fossa, and the extracranial compartment. Tingling paraesthesiae, numbness, and diffuse pain in the distribution of the trigeminal nerve were common symptoms and were present in 90% of patients. The extracranial component had a well-defined perineural/meningeal membrane cover that was continuous with the middle fossa dura mater and isolated the tumor tissue from the adjoining critical structures. In 7 out of 10 cases, even the posterior fossa component of the tumor was entirely “interdural” (within the confines of the dura). The maximum dimension of the tumor was > 4 cm in 22 cases. A limited “transcranial” approach with (12 cases) or without (16 cases) zygomatic osteotomy was found suitable for resection of these tumors. In 4 cases a lateral orbitotomy was performed. Total tumor resection was performed in 20 cases and partial resection in 8. The duration of follow-up ranged from 6 months to 19 years. Two patients required additional surgery for symptomatic recurrence.

Conclusions. Extracranial extensions of trigeminal neurinomas have a well-defined meningeal covering. In most cases resection was performed via a minimally invasive cranial avenue (a “reverse skull base approach”). Radical resection was associated with an excellent long-term outcome.

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Fully Endoscopic Transnasal Approach to the Jugular Foramen: Anatomic Study and Clinical Considerations

Neurosurgery 67[ONS Suppl 1]:ons00-ons00, 2010. DOI: 10.1227/01.NEU.0000354351.00684.B9

To describe a transnasal endoscopic route to the jugular foramen and the endoscopic anatomy of the infratemporal fossa.

CLINICAL PRESENTATION: Endoscopic transnasal dissection of the infratemporal fossa was performed in 3 injected fresh heads (1 head only in arteries and 2 heads in arteries and veins). Two other double-injected specimens were dissected externally (2 of them side laterally and 1 anteriorly) to compare the different views and better understand the 3-dimensionality of the region. Detailed endoscopic anatomy of the infratemporal fossa was clearly observed. The realization of a septal and posterior maxillary window allows surgeons to gain space to the jugular foramen. The ability to manage the vessels, especially the veins, and identify the muscles is mandatory. The fundamental role of the vidian canal in targeting the anterior genu of the internal carotid artery is confirmed. The role of the maxillary and mandibular branches of the trigeminal nerve and the eustachian tube in this kind of approach is critical.

CONCLUSION: A fully transnasal endoscopic route to the jugular foramen is feasible. The most important landmark for this kind of approach is the eustachian tube.

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