Endoscopic-Assisted Lateral Corridor to the Infratemporal Fossa: Proposal and Quantitative Comparison to the Endoscopic Transpterygoid Approach

Abstract Objectives This study was aimed to propose an expanded endoscopic-assisted lateral approach to the infratemporal fossa (ITF) and compare its area of exposure and surgical freedom with the endoscopic endonasal transptergyoid approach (EETA). Methods Anatomical dissections were performed in five cadaver heads (10 sides). The ITF was first examined through the endoscopically assisted lateral corridor, herein referred to as the endoscopic-assisted transtemporal fossa approach (TTFA). After that, the EETA was performed and coupled with two sequential maxillary procedures (medial maxillectomy [MM], and endoscopic-assisted Denker's approach [DA]). Using the stereotactic neuronavigation, measurements of the area of exposure and surgical freedom at the foramen ovale were determined for the previously mentioned approaches. Results Bimanual exploration of the ITF through the endoscopic-assisted lateral approach was achieved in all specimens. The DA (729 ± 49 mm2) provided a larger area of exposure than MM (568 ± 46 mm2; p < 0.0001). However, areas of exposure were similar between the DA and the TTFA (677 ± 35 mm2; p = 0.09). The surgical freedom offered by the TTFA (109.3 ± 19 cm2) was much greater than the DA (24.7 ± 4.8 cm2; p < 0.0001), and the MM (15.2 ± 3.2 cm2, p < 0.0001). Conclusion The study demonstrates the feasibility of the proposed approach to provide direct access to the extreme extensions of the ITF. The lateral corridor offers an ideal working area in the posterior compartment of the ITF without crossing over important neurovascular structures. The new technique may be used alone in selected primary ITF lesions or in combination with endonasal approaches in pathologies spreading laterally from the nose or nasopharynx.

Download Full-text

Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.1.7 ◽

2005 ◽

Vol 19 (1) ◽

pp. 1-10 ◽

Cited By ~ 269

Author(s):

Amin B. Kassam ◽

Paul Gardner ◽

Carl Snyderman ◽

Arlan Mintz ◽

Ricardo Carrau

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Surgical Anatomy ◽

Illustrative Case ◽

Endonasal Approach ◽

Transnasal Approach ◽

Endoscopic Endonasal ◽

Expanded Endonasal Approach ◽

Neurovascular Structures

Object The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. Methods The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. Conclusions The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.

Download Full-text

Expanded endoscopic endonasal transpterygoid transmaxillary approach for a giant trigeminal schwannoma

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19904 ◽

2020 ◽

Vol 2 (2) ◽

pp. V15

Author(s):

Rafael Martínez-Pérez ◽

Marcus Zachariah ◽

Ruychen Li ◽

Giuliano Silveira-Bertazzo ◽

Ricardo L. Carrau ◽

...

Keyword(s):

Vision Loss ◽

Direct Access ◽

Total Removal ◽

Endoscopic Endonasal ◽

Temporal Fossa ◽

Secondary Invasion ◽

Trigeminal Schwannoma ◽

Severe Vision Loss ◽

The Right ◽

Neurovascular Structures

Atypical trigeminal schwannomas (ATSs) are notorious for their ability to invade the skull base. An expanded endoscopic endonasal approach (eEEA) provides direct access to the tumor with no need for cerebral retraction or manipulation of neurovascular structures. Herein, we present a case of a large temporal fossa extradural lesion with secondary invasion of the sella, clivus, and temporal and infratemporal fossae in a 49-year-old male with severe vision loss. A transpterygoid transmaxillary approach was performed. Gross-total removal was achieved and pathology revealed the diagnosis of ATS. Visual function fully recovered in the right side and the patient has been uneventfully followed since surgery.The video can be found here: https://youtu.be/6pSwdYsN9hk.

Download Full-text

Anatomic comparison of the endonasal and transpetrosal approaches for interpeduncular fossa access

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14329 ◽

2014 ◽

Vol 37 (4) ◽

pp. E12 ◽

Cited By ~ 4

Author(s):

Kenichi Oyama ◽

Daniel M. Prevedello ◽

Leo F. S. Ditzel Filho ◽

Jun Muto ◽

Ramazan Gun ◽

...

Keyword(s):

Direct Access ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Interpeduncular Cistern ◽

Fresh Cadaver ◽

Surgical Options ◽

Surgical Corridor ◽

Retrochiasmatic Area ◽

Neurovascular Structures

Object The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern Methods Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. “Water balloon tumors” (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8). Results Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume was 6 ml. Conclusions Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.

Download Full-text

The far lateral/combined supra- and infratentorial approach

Journal of Neurosurgery ◽

10.3171/jns.1994.81.1.0060 ◽

1994 ◽

Vol 81 (1) ◽

pp. 60-68 ◽

Cited By ~ 83

Author(s):

Hillel Z. Baldwin ◽

Christopher G. Miller ◽

Harry R. van Loveren ◽

Jeffrey T. Keller ◽

C. Phillip Daspit ◽

...

Keyword(s):

Brain Stem ◽

Craniovertebral Junction ◽

Foramen Magnum ◽

Lateral Approach ◽

Direct Access ◽

Content Type ◽

Far Lateral Approach ◽

Far Lateral ◽

Lower Clivus ◽

Neurovascular Structures

✓ A far lateral approach to the ventral brain stem, lower clivus, and anterior foramen magnum is described. Methods for further exposure of the superior petroclival region by incorporating a subtemporal craniotomy and posterior petrosectomy are also demonstrated. Eight sequentially illustrated steps depict this technique. The far lateral/combined supra- and infratentorial exposure is a comprehensive surgical approach that provides direct access to the entire anterior and lateral brain stem and craniovertebral junction. It minimizes brain-stem retraction and maximizes visualization of the neurovascular structures.

Download Full-text

Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19964 ◽

2020 ◽

Vol 2 (2) ◽

pp. V16

Author(s):

James K. Liu ◽

Kevin Zhao ◽

Alejandro Vazquez ◽

Jean Anderson Eloy

Keyword(s):

Infratemporal Fossa ◽

Nasolacrimal Duct ◽

Surgical Approaches ◽

Intracranial Extension ◽

Combined Approach ◽

Lateral Extension ◽

Endoscopic Endonasal ◽

Direct Head ◽

Surgical Corridor ◽

Neurovascular Structures

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.The video can be found here: https://youtu.be/gy-pkjLdDgE.

Download Full-text

Endoscopic Endonasal Approaches to Infratemporal Fossa Tumors: A Classification System & Case Series

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0034-1370451 ◽

2014 ◽

Vol 75 (S 01) ◽

Author(s):

Adam Zanation ◽

Robert Taylor ◽

Mihir Patel ◽

Stephen Wheless ◽

Kibwei McKinney ◽

...

Keyword(s):

Classification System ◽

Infratemporal Fossa ◽

Case Series ◽

Endoscopic Endonasal

Download Full-text

Endoscopic Endonasal Approach to the Infratemporal Fossa

Skull Base ◽

10.1055/s-2007-981749 ◽

2007 ◽

Vol 17 (S 2) ◽

Author(s):

Lee Zimmer ◽

Aaron Brescia ◽

Bharat Guthikonda ◽

Jeffrey Keller ◽

Philip Theodosopoulos

Keyword(s):

Infratemporal Fossa ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

Download Full-text

How I do it: endoscopic endonasal resection of tuberculum sellae meningioma

Acta Neurochirurgica ◽

10.1007/s00701-021-04784-5 ◽

2021 ◽

Author(s):

Markus Wiedmann ◽

Aslan Lashkarivand ◽

Jon Berg-Johnsen ◽

Daniel Dahlberg

Keyword(s):

Team Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Ongoing Debate ◽

Endoscopic Endonasal ◽

Microsurgical Technique ◽

Tuberculum Sellae Meningioma ◽

Tuberculum Sellae ◽

Dedicated Team ◽

Neurovascular Structures

Abstract Background Tuberculum sellae meningiomas (TSMs) adherent to neurovascular structures are particularly challenging lesions requiring delicate and precise microneurosurgery. There is an ongoing debate about the optimal surgical approach. Method We describe technical nuances and challenges in TSM resection using the endoscopic endonasal approach (EEA) in two cases of fibrous tumors with adherence to neurovascular structures. The cases are illustrated with a video (case 1) and figures (cases 1 and 2). Conclusion A dedicated team approach and precise microsurgical technique facilitate safe resection of complex TSMs through the EEA.

Download Full-text

Endoscopic Endonasal Approach to the Pterygopalatine Fossa: Anatomic Study

Neurosurgery ◽

10.1227/01.neu.0000044562.73763.00 ◽

2003 ◽

Vol 52 (2) ◽

pp. 374-380 ◽

Cited By ~ 82

Author(s):

Alessandra Alfieri ◽

Hae-Dong Jho ◽

Raffaele Schettino ◽

Manfred Tschabitscher

Keyword(s):

Minimally Invasive ◽

Infratemporal Fossa ◽

Lateral View ◽

Pterygopalatine Fossa ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Anatomic Study ◽

Endoscopic Endonasal ◽

Arteries And Veins ◽

Anatomic Region

Abstract OBJECTIVE The pterygopalatine fossa is a relatively small anatomic region. Because of its rich vasculonervous contents and its connections with several intracranial and extracranial compartments, it is of particular surgical interest. Because of its deep localization and despite its small size, however, it can require extensive anatomic approaches, especially for invasive cranial base lesions. We performed a cadaveric study through a minimally invasive endoscopic endonasal approach to the pterygopalatine fossa. METHODS We studied 16 pterygopalatine fossae in eight adult cadaveric heads in which the arteries and veins were injected with latex. For visualization, we used rod-lens endoscopes, 4 mm in diameter and 18 cm in length, with 0-, 30-, 45-, and 70-degree lenses. An endonasal middle meatal transpalatine approach, an endonasal middle meatal transantral approach, and an endonasal inferior turbinectomy transantral approach were used. RESULTS The middle meatal transpalatine approach allows for medial exposure of the pterygopalatine fossa contents, the middle meatal transantral approach allows a lateral view, and the inferior turbinectomy transantral approach allows the widest view and room for surgical maneuvering in the medial and lateral compartments of the pterygopalatine fossa and the infratemporal fossa. CONCLUSION Our anatomic study shows that this approach can be considered a valid minimally invasive option to approach pterygopalatine fossa lesions.

Download Full-text

The Infratemporal Retro-Eustachian Transposition of the Temporoparietal Fascial Flap for Clival Reconstruction After Endoscopic Endonasal Approach: An Anatomic Conceptual Technique

Operative Neurosurgery ◽

10.1093/ons/opab105 ◽

2021 ◽

Author(s):

Giulio Cecchini ◽

Huy Q Truong ◽

Francesco Di Biase ◽

Antonio Musio ◽

Juan C Fernandez Miranda

Keyword(s):

Infratemporal Fossa ◽

Surgical Techniques ◽

Pedicled Flap ◽

Reconstruction Technique ◽

Clinical Validation ◽

Endoscopic Endonasal Approach ◽

Endoscopic Endonasal ◽

Fascial Flap ◽

The Times ◽

Lower Clivus

Abstract BACKGROUND Reconstruction after endoscopic endonasal approaches is a key element. Lower clivus reconstruction is difficult and most of the times a pedicled flap is not available. As the complexity and the dimensions of the exposure increase, a reliable reconstruction technique becomes more and more important. OBJECTIVE To describe the anatomic and technical nuances of the transposition of the temporoparietal fascial flap for lower clivus reconstruction. METHODS A specific temporoparietal fascial flap (TPFF) design and tunneling technique has been studied using 4 head specimens, microscopic and endoscopic surgical techniques, and neuronavigation. RESULTS The L-shaped flap offers several advantages. It can be tunneled directly toward the lower clivus passing through the infratemporal fossa. CONCLUSION The infratemporal retro-eustachian transposition of an L-shaped TPFF provides a vascularized tissue virtually without dimension limits. This is the only technique that allows the flap to be tunneled directly in the lower clivus with the most vascular portion being at the bottom of the defect. Clinical validation is still required since more issues may become relevant in a real-surgery setting. Though, due to its possible complications, this methodology needs further testing and should not be attempted in less experienced hands.

Download Full-text