Middle Fossa Approach for Resection of a Giant Trigeminal Schwannoma Through an Expanded Meckel Cave: 2-Dimensional Operative Video

AbstractTrigeminal schwannomas are rare benign tumors, it is second most common intracranial schwannomas after vestibular schwannomas. The management includes not limited to observation, stereotactic radiosurgery/radiotherapy, and/or surgical resection. Tumor size and patient clinical status are the most important factors in management.In this video, we describe the technical nuances of an extended middle fossa approach for large trigeminal schwannoma with cavernous sinus extension resection. A 44-year-old right-handed female with several months' history of progressive right facial paresthesia and pain in the distribution of V3 mainly. On physical examination, she had decreased sensation to light touch over the right V1 to V3 distribution with loss of cornel reflex. The brain MRI showed 3.5 cm bilobed mass extends from the pontine root entry zone to the cavernous sinus. Craniotomy was performed and followed by middle fossa dural peeling, peeling of temporal lobe dura away from the wall of the cavernous sinus, extradurally anterior clinoidectomy, drilling of the petrous apex, coagulation of superior petrosal sinus followed incision of the tentorium up to the tentorial notch with preservation the fourth cranial nerve, and tumor dissected away from V1 and then gradually removed from the superior wall of the cavernous sinus.The technique presented here allows for complete tumor resection, safe navigation through the relative cavernous sinus compartments, and minimizes the possibility of inadvertent injury to the cranial nerves.The postoperative course was uneventful except for right eye incomplete ptosis from the swelling. Her facial pain subsided after the surgery without any extra ocular movement impairment.The link to the video can be found at: https://youtu.be/zxi2XK2R9QU.

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Extended middle fossa approach for trigeminal schwannoma resection

Interdisciplinary Neurosurgery ◽

10.1016/j.inat.2020.100874 ◽

2021 ◽

Vol 23 ◽

pp. 100874

Author(s):

Edinson Najera ◽

Baha'eddin A. Muhsen ◽

Hamid Borghei-Razavi ◽

Badih Adada

Keyword(s):

Middle Fossa ◽

Middle Fossa Approach ◽

Trigeminal Schwannoma

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Middle Fossa Approach For Acoustic Tumor Removal

Otolaryngologic Clinics of North America ◽

10.1016/s0030-6665(20)30991-9 ◽

1992 ◽

Vol 25 (2) ◽

pp. 347-359 ◽

Cited By ~ 2

Author(s):

William F. House ◽

Clough Shelton

Keyword(s):

Middle Fossa ◽

Tumor Removal ◽

Middle Fossa Approach ◽

Acoustic Tumor

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Complications of Middle Fossa Approach

Skull Base ◽

10.1055/s-2005-916606 ◽

2005 ◽

Vol 15 (S 2) ◽

Author(s):

Emilio García-Ibánez ◽

Luis García-Ibánez ◽

Elena Hernández ◽

G. Martínez-Monche

Keyword(s):

Middle Fossa ◽

Middle Fossa Approach

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Cadaveric Study to Find a Novel Method of Identifying the Internal Acoustic Canal in the Middle Fossa Approach: The Rule of 2s

Skull Base ◽

10.1055/s-2009-1242371 ◽

2009 ◽

Vol 19 (03) ◽

Author(s):

Raghuram Sampath ◽

Chad Glenn ◽

Shashikant Patil ◽

Prasad Vannemreddy ◽

Anil Nanda ◽

...

Keyword(s):

Cadaveric Study ◽

Middle Fossa ◽

Middle Fossa Approach ◽

Novel Method ◽

Internal Acoustic Canal

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Endoscopic Endonasal Interdural Middle Fossa Approach to the Maxillary Nerve: Anatomic Considerations and Surgical Relevance

Operative Neurosurgery ◽

10.1093/ons/opx010 ◽

2017 ◽

Vol 13 (4) ◽

pp. 522-528 ◽

Cited By ~ 3

Author(s):

Kumar Abhinav ◽

David Panczykowski ◽

Wei-Hsin Wang ◽

Carl H. Synderman ◽

Paul A. Gardner ◽

...

Keyword(s):

Average Length ◽

Tumor Resection ◽

Human Head ◽

Proximal Part ◽

Gasserian Ganglion ◽

Middle Fossa ◽

Perineural Spread ◽

Endoscopic Endonasal ◽

Middle Fossa Approach ◽

Maxillary Nerve

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.

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19 The Extended Petrosal Middle Fossa Approach

Chordomas ◽

10.1055/b-0036-141750 ◽

2017 ◽

Keyword(s):

Middle Fossa ◽

Middle Fossa Approach

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Presigmoid Approach to Dumbbell Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669977 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S391-S392

Author(s):

Katherine Kunigelis ◽

Daniel Craig ◽

Alexander Yang ◽

Samuel Gubbels ◽

A. Youssef

Keyword(s):

Trigeminal Nerve ◽

Treatment Options ◽

Extent Of Resection ◽

Direct Access ◽

Petrous Apex ◽

Total Resection ◽

Middle Fossa Approach ◽

Nerve Preservation ◽

Presigmoid Approach ◽

Trigeminal Schwannoma

This case is a 15-year-old male, presenting with headaches, right face, and arm numbness, and ataxia. MRI (magnetic resonance imaging) revealed a large right sided dumbbell shaped lesion, extending into the middle and posterior fossa with compression of the brainstem consistent with a trigeminal schwannoma. Treatment options here would be a retrosigmoid suprameatal approach or a lateral presigmoid approach. Given the tumor extension into multiple compartments, a presigmoid craniotomy, combining a middle fossa approach with anterior petrosectomy, and retrolabyrinthine approach with posterior petrosectomy were used to maximize the direct access corridor for resection. The petrous apex was already expanded and remodeled by the tumor. Nerve fascicles preservation technique is paramount to the functional preservation of the trigeminal nerve. The extent of resection should be weighed against the anatomical functional integrity of the nerve. Near total resection is considered if that means more nerve preservation. Postoperatively, the patient had a slight (House–Brackman grade II) facial droop, which resolved over days and developed right trigeminal hypesthesia at several weeks. This case is presented to demonstrate a combined petrosectomy technique for resection of lesions extending into both the middle and posterior cranial fossa with near total resection and trigeminal nerve preservation.The link to the video can be found at: https://youtu.be/kA9GyFhL1dg.

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Resection of a Dumbbell-Shaped Facial Nerve Schwannoma With Preservation of Facial Nerve Function Through the Extended Middle Fossa Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab335 ◽

2021 ◽

Author(s):

Kaith K Almefty ◽

Wenya Linda Bi ◽

Walid Ibn Essayed ◽

Ossama Al-Mefty

Keyword(s):

Facial Nerve ◽

Cerebellopontine Angle ◽

Internal Auditory Canal ◽

Growth Patterns ◽

Geniculate Ganglion ◽

Nerve Function ◽

Middle Fossa ◽

Facial Nerve Function ◽

Large Tumor ◽

Middle Fossa Approach

Abstract Facial nerve schwannomas are rare and can arise from any segment along the course of the facial nerve.1 Their location and growth patterns present as distinct groups that warrant specific surgical management and approaches.2 The management challenge arises when the facial nerve maintains good function (House-Brackmann grade I-II).3 Hence, a prime goal of management is to maintain good facial animation. In large tumors, however, resection with facial nerve function preservation should be sought and is achievable.4,5 While tumors originating from the geniculate ganglion grow extradural on the floor of the middle fossa, they may extend via an isthmus through the internal auditory canal to the cerebellopontine angle forming a dumbbell-shaped tumor. Despite the large size, they may present with good facial nerve function. These tumors may be resected through an extended middle fossa approach with preservation of facial and vestibulocochlear nerve function. The patient is a 62-yr-old man who presented with mixed sensorineural and conductive hearing loss and normal facial nerve function. Magnetic resonance imaging (MRI) revealed a large tumor involving the middle fossa, internal auditory meatus, and cerebellopontine angle. The tumor was resected through an extended middle fossa approach with a zygomatic osteotomy and anterior petrosectomy.6 A small residual was left at the geniculate ganglion to preserve facial function. The patient did well with hearing preservation and intact facial nerve function. He consented to the procedure and publication of images. Image at 1:30 © Ossama Al-Mefty, used with permission. Images at 2:03 reprinted from Kadri and Al-Mefty,6 with permission from JNSPG.

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