Endoscopic Endonasal Transrotundum Middle Fossa Exposure: Technique of Transpterygoid Maxillary Nerve Transposition

Abstract BACKGROUND: The maxillary nerve (V2) can be approached via the open middle fossa approach. OBJECTIVE: To delineate the anatomy of V2 and its specific segments with respect to the endonasal landmarks. We present the endoscopic endonasal interdural middle fossa approach to V2 and its potential application for the treatment of perineural spread in sinonasal/skull base tumors. METHODS: Five human head silicon-injected specimens underwent bilateral endoscopic endonasal transpterygoid approaches. V2 prominence and the maxillary strut were identified in the lateral recess along with paraclival carotid protruberance. The regions superior and inferior to V2 corresponding to the anteromedial and anterolateral triangles of the middle fossa were exposed. RESULTS: V2 can be classified into 3 segments: interdural (from the Gasserian ganglion to the proximal part of the maxillary strut), intracanalicular (corresponding to the anteroposterior length of the maxillary strut), and pterygopalatine (distal to the maxillary strut and the site of its divisions). Endonasally, the average length of the interdural and the intracanalicular segments were approximately 9 and 4.4 mm, respectively. V2, following its division distal to the maxillary strut, was successfully dissected off the middle fossa dura and transected just distal to the Gasserian ganglion. CONCLUSION: Endonasally, the interdural segment can be safely mobilized between the periosteal and meningeal dural layers while ensuring the integrity of the middle fossa dura. This allows transection of infiltrated V2 to facilitate tumor resection without entering the intradural/arachnoidal space. Posteriorly, this is limited by the Gasserian ganglion and superomedially by the dural envelope surrounding the cavernous sinus and the paraclival carotid artery.

Download Full-text

Vidian Nerve Transposition for Endoscopic Endonasal Middle Fossa Approaches

Neurosurgery ◽

10.1227/01.neu.0000393361.87423.b7 ◽

2011 ◽

Vol 68 (2) ◽

pp. Bottom of TOC-Bottom of TOC

Keyword(s):

Middle Fossa ◽

Endoscopic Endonasal ◽

Vidian Nerve ◽

Nerve Transposition

Download Full-text

Vidian Nerve Transposition for Endoscopic Endonasal Middle Fossa Approaches

Operative Neurosurgery ◽

10.1227/neu.0b013e3181faaa70 ◽

2010 ◽

Vol 67 ◽

pp. ons478-ons484 ◽

Cited By ~ 9

Author(s):

Daniel M Prevedello ◽

Carlos D Pinheiro-Neto ◽

Juan C Fernandez-Miranda ◽

Ricardo L Carrau ◽

Carl H Snyderman ◽

...

Keyword(s):

Middle Fossa ◽

Endoscopic Endonasal ◽

Vidian Nerve ◽

Nerve Transposition

Download Full-text

Endoscopic Endonasal Petrosectomy for Resection of Giant Petrous Apex Cholesterol Granuloma with Posterior and Middle Fossa Extension: Case Report

Skull Base ◽

10.1055/s-2009-1222344 ◽

2009 ◽

Vol 19 (01) ◽

Author(s):

Juan Fernandez-Miranda ◽

Victor Morera ◽

Rick Madhok ◽

Daniel Prevedello ◽

Paul Gardner ◽

...

Keyword(s):

Case Report ◽

Petrous Apex ◽

Cholesterol Granuloma ◽

Middle Fossa ◽

Endoscopic Endonasal

Download Full-text

Endoscopic transorbital and endonasal approach for trigeminal schwannomas: a retrospective multicenter analysis (KOSEN-005)

Journal of Neurosurgery ◽

10.3171/2019.3.jns19492 ◽

2020 ◽

Vol 133 (2) ◽

pp. 467-476 ◽

Cited By ~ 3

Author(s):

Hun Ho Park ◽

Sang Duk Hong ◽

Yong Hwy Kim ◽

Chang-Ki Hong ◽

Kyung In Woo ◽

...

Keyword(s):

Endoscopic Surgery ◽

Infratemporal Fossa ◽

Endonasal Approach ◽

Middle Fossa ◽

Surgical Morbidity ◽

Total Resection ◽

Endoscopic Endonasal ◽

Preoperative Symptom ◽

Endoscopic Transorbital ◽

Multicenter Analysis

OBJECTIVETrigeminal schwannomas are rare neoplasms with an incidence of less than 1% that require a comprehensive surgical strategy. These tumors can occur anywhere along the path of the trigeminal nerve, capable of extending intradurally into the middle and posterior fossae, and extracranially into the orbital, pterygopalatine, and infratemporal fossa. Recent advancements in endoscopic surgery have suggested a more minimally invasive and direct route for tumors in and around Meckel’s cave, including the endoscopic endonasal approach (EEA) and endoscopic transorbital superior eyelid approach (ETOA). The authors assess the feasibility and outcomes of EEA and ETOA for trigeminal schwannomas.METHODSA retrospective multicenter analysis was performed on 25 patients who underwent endoscopic surgical treatment for trigeminal schwannomas between September 2011 and February 2019. Thirteen patients (52%) underwent EEA and 12 (48%) had ETOA, one of whom underwent a combined approach with retrosigmoid craniotomy. The extent of resection, clinical outcome, and surgical morbidity were analyzed to evaluate the feasibility and selection of surgical approach between EEA and ETOA based on predominant location of trigeminal schwannomas.RESULTSAccording to predominant tumor location, 9 patients (36%) had middle fossa tumors (Samii type A), 8 patients (32%) had dumbbell-shaped tumors located in the middle and posterior cranial fossae (Samii type C), and another 8 patients (32%) had extracranial tumors (Samii type D). Gross-total resection (GTR, n = 12) and near-total resection (NTR, n = 7) were achieved in 19 patients (76%). The GTR/NTR rates were 81.8% for ETOA and 69.2% for EEA. The GTR/NTR rates of ETOA and EEA according to the classifications were 100% and 50% for tumors confined to the middle cranial fossa, 75% and 33% for dumbbell-shaped tumors located in the middle and posterior cranial fossae, and 50% and 100% for extracranial tumors. There were no postoperative CSF leaks. The most common preoperative symptom was trigeminal sensory dysfunction, which improved in 15 of 21 patients (71.4%). Three patients experienced new postoperative complications such as vasospasm (n = 1), wound infection (n = 1), and medial gaze palsy (n = 1).CONCLUSIONSETOA provides adequate access and resectability for trigeminal schwannomas limited in the middle fossa or dumbbell-shaped tumors located in the middle and posterior fossae, as does EEA for extracranial tumors. Tumors predominantly involving the posterior fossa still remain a challenge in endoscopic surgery.

Download Full-text

Extirpation of Recurrent Petrous Apex Cholesterol Granuloma Through the Zygomatic Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab156 ◽

2021 ◽

Author(s):

Mark Eisenberg ◽

Walid Ibn Essayed ◽

Ossama Al-Mefty

Keyword(s):

Short Distance ◽

Petrous Apex ◽

Cholesterol Granuloma ◽

Middle Fossa ◽

Resonance Imaging ◽

Endoscopic Endonasal ◽

Middle Fossa Approach ◽

Weighted Magnetic Resonance Imaging ◽

Year 2000 ◽

Air Cells

Abstract Petrous apex cholesterol granulomas are believed to result from blockage of the normal aeration of the petrous air cells, resulting in a repetitive cycle of mucosal engorgement, hemorrhage, and granuloma formation.1 The lesion usually progressively expands causing compressive symptoms. The thick granulomatous wall envelopes various ages of breakdown products, including a cholesterol-containing fluid, which is typically hyperintense on T1 and T2 weighted magnetic resonance imaging. Drainage procedures, regardless of the route (endoscopic, endonasal, or transtemporal), with or without stenting or marsupialization, will only temporarily drain this cholesterol-containing fluid, with consequently frequent recurrences.2-5 A total exoneration of the granuloma and obliteration of the cavity with vascularized tissue will assure a more durable outcome.1 The extradural zygomatic/middle fossa approach provides a short distance to the petrous apex and is purely extradural. By sectioning the zygoma, temporal lobe retraction is avoided.6 We present a case of a 29-yr-old male who presented in the year 2000 with progression of a left petrous apex cholesterol granuloma despite 2 previous drainage and stenting procedures. The patient consented for surgery and photo publication. Images in video at 2:41 © JNSPG, republished from Eisenberg et al1 with permission.

Download Full-text

Anatomical Step-by-Step Endoscopic Endonasal Approach for Maxillary Nerve (V2) Rhizotomy and Case Series

10.1055/s-0041-1725556 ◽

2021 ◽

Author(s):

Michael O'Brien ◽

Luciano Leonel ◽

Tyler Kenning ◽

Carlos Pinheiro-Neto ◽

Maria Peris-Celda

Keyword(s):

Case Series ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Maxillary Nerve

Download Full-text

Endoscopic Anatomy of the Zygomatic Nerve: Implications for the Endoscopic Transmaxillary Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1739237 ◽

2021 ◽

Author(s):

Yuanzhi Xu ◽

Maximiliano Alberto Nunez ◽

Ahmed Mohyeldin ◽

Juan C. Fernandez-Miranda ◽

Aaron A. Cohen-Gadol

Keyword(s):

Endoscopic Surgery ◽

Surgical Anatomy ◽

Exit Point ◽

Endoscopic Endonasal ◽

Maxillary Nerve ◽

Endonasal Endoscopic Surgery ◽

Point Of Entry ◽

Facial Numbness ◽

Course Length ◽

Müller’S Muscle

Abstract Background Understanding the anatomic features of the zygomatic nerve is critical for performing the endoscopic transmaxillary approach properly. Injury to the zygomatic nerve can result in facial numbness and corneal problems. Objective To evaluate the surgical anatomy of the zygomatic nerve and its segments from an endoscopic endonasal perspective for clinical implications of performing the endoscopic transmaxillary approach. Methods The origin, course, length, and segments of the zygomatic nerve were studied in four specimens from an endonasal perspective. Results The zygomatic nerve arises 4.1 ± 1.7 mm from the foramen rotundum of the maxillary nerve in the superolateral pterygopalatine fossa (PPF). According to its anatomic region in endonasal endoscopic surgery, we divided the zygomatic nerve into two segments: the PPF segment, from origin to the point of entry under Muller's muscle, which runs superolaterally to the inferior orbital fissure (IOF) (length, 4.6 ± 1.3 mm), and the IOF segment, starting at the entry point in Muller's muscle and terminating at the exit point in the IOF, which travels between Muller's muscle and the great wing of the sphenoid bone (length, 19.6 ± 3.6 mm). In the transmaxillary approach, the zygomatic nerve is a critical landmark in the superolateral PPF. Conclusion The zygomatic nerve travels in the PPF and the IOF; better visualization and preservation of this nerve during endonasal endoscopic surgery are crucial for successful outcomes.

Download Full-text

Endoscopic Endonasal Study of the Maxillary Nerve: A New Orientation

American Journal of Rhinology ◽

10.2500/ajr.2007.21.3084 ◽

2007 ◽

Vol 21 (5) ◽

pp. 637-643 ◽

Cited By ~ 6

Author(s):

Islam R. Herzallah ◽

Ezzeddin M. Elsheikh ◽

Roy R. Casiano

Keyword(s):

Video Recording ◽

Video Camera ◽

Recording System ◽

Endoscopic Endonasal ◽

Maxillary Nerve ◽

Infraorbital Canal ◽

Foramen Rotundum ◽

Extended Endoscopic Approach ◽

Vascular Structures ◽

Adult Cadaver

Background Endoscopic endonasal procedures for advanced lesions involving the pterygopalatine fossa (PPF) and its various communications are increasingly performed. The maxillary division of the trigeminal nerve (V2) passes through the foramen rotundum and crosses the upper part of the PPF, with a risk of partial or complete injury during surgery in this complex region. Despite the available knowledge of the sinonasal anatomy, the endoscopic orientation of the V2 remains unclear and requires further analysis from this unique view. Methods Using an extended endoscopic approach, the PPF was dissected in 20 sides of 10 adult cadaver heads. The V2 also was followed anteriorly from the trigeminal ganglion, toward the infraorbital canal. The course and the neurovascular relationships of the V2 were studied. High-quality endoscopic images have been produced by coupling the video camera to a digital video recording system. Results The endoscopic course and relations of the V2 were carefully described. Important landmarks to identify and avoid injury of the nerve were discussed in relation to this unique view. Conclusion This study updates our understanding of the V2 anatomy from an endoscopic perspective. The medial to lateral inclination and drooping of the V2, as well as different relationships of the V2 with the vascular structures are important findings to be taken into consideration while endoscopically addressing related lesions.

Download Full-text

Endoscopic Endonasal Resection of a Giant Middle Fossa Epidermoid Cyst

Allergy & Rhinology ◽

10.2500/ar.2015.6.0133 ◽

2015 ◽

Vol 6 (3) ◽

pp. ar.2015.6.0133 ◽

Cited By ~ 6

Author(s):

Jennifer Best ◽

John S. Schneider ◽

Justin H. Turner

Keyword(s):

Epidermoid Cyst ◽

Complete Resolution ◽

Complete Removal ◽

Middle Fossa ◽

Resonance Imaging ◽

Endoscopic Endonasal ◽

Postoperative Magnetic Resonance Imaging ◽

The Right ◽

Intracranial Epidermoid

Intracranial epidermoid cysts are rare. We report a case of a 55-year-old man who presented with trigeminal neuralgia and was found, on imaging, to have an epidermoid cyst located in the right middle fossa. He was managed via an entirely endoscopic endonasal approach. Postoperative magnetic resonance imaging confirmed complete removal of the mass, and the patient continued to have complete resolution of symptoms at a 1-year follow-up.

Download Full-text