Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application

2018 ◽  
Vol 130 (1) ◽  
pp. 227-237 ◽  
Author(s):  
Huy Q. Truong ◽  
Xicai Sun ◽  
Emrah Celtikci ◽  
Hamid Borghei-Razavi ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Maxillary Sinus ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Middle Cranial Fossa ◽  
Anatomical Landmarks ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Cranial Fossa ◽  
Greater Wing

OBJECTIVEMultiple approaches have been designed to reach the medial middle fossa (for lesions in Meckel’s cave, in particular), but an anterior approach through the greater wing of the sphenoid (transalisphenoid) has not been explored. In this study, the authors sought to assess the feasibility of and define the anatomical landmarks for an endoscopic anterior transmaxillary transalisphenoid (EATT) approach to Meckel’s cave and the middle cranial fossa.METHODSEndoscopic dissection was performed on 5 cadaver heads injected intravascularly with colored silicone bilaterally to develop the approach and define surgical landmarks. The authors then used this approach in 2 patients with tumors that involved Meckel’s cave and provide their illustrative clinical case reports.RESULTSThe EATT approach is divided into the following 4 stages: 1) entry into the maxillary sinus, 2) exposure of the greater wing of the sphenoid, 3) exposure of the medial middle fossa, and 4) exposure of Meckel’s cave and lateral wall of the cavernous sinus. The approach provided excellent surgical access to the anterior and lateral portions of Meckel’s cave and offered the possibility of expanding into the infratemporal fossa and lateral middle fossa and, in combination with an endonasal transpterygoid approach, accessing the anteromedial aspect of Meckel’s cave.CONCLUSIONSThe EATT approach to Meckel’s cave and the middle cranial fossa is technically feasible and confers certain advantages in specific clinical situations. The approach might complement current surgical approaches for lesions of Meckel’s cave and could be ideal for lesions that are lateral to the trigeminal ganglion in Meckel’s cave or extend from the maxillary sinus, infratemporal fossa, or pterygopalatine fossa into the middle cranial fossa, Meckel’s cave, and cavernous sinus, such as schwannomas, meningiomas, and sinonasal tumors and perineural spread of cutaneous malignancy.

A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

2017 ◽  
Vol 13 (5) ◽  
pp. 614-621 ◽  
Author(s):  
Blake Harrison Priddy ◽  
Cristian Ferrareze Nunes ◽  
Andre Beer-Furlan ◽  
Ricardo Carrau ◽  
Iacopo Dallan ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Navigation ◽  
Cranial Nerves ◽  
Anatomical Study ◽  
Middle Cranial Fossa ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Side Door ◽  
Meckel's Cave ◽  
Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients

Neurosurgery ◽  
2017 ◽  
Vol 80 (2) ◽  
pp. 309-322 ◽  
Author(s):  
Joseph D. Chabot ◽  
Paul A. Gardner ◽  
S. Tonya Stefko ◽  
Nathan T. Zwagerman ◽  
Juan Carlos Fernandez- Miranda
Keyword(s):  
Visual Acuity ◽  
Cavernous Sinus ◽  
Middle Cranial Fossa ◽  
Symptomatic Improvement ◽  
Middle Fossa ◽  
Total Resection ◽  
Patients Âgés ◽  
Lateral Orbitotomy ◽  
Patient Reported ◽  
Cranial Fossa

Abstract BACKGROUND: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa. OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa. METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed. RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1). CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

scholarly journals Endoscopic-Assisted Microsurgical Resection of Right Recurrent Meckel's Cave Meningioma Extended to Cavernous Sinus

2021 ◽  
Author(s):  
Arianna Fava ◽  
Paolo di Russo ◽  
Lorenzo Giammattei ◽  
Sébastien Froelich
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Tumor Resection ◽  
Lateral Wall ◽  
Complete Removal ◽  
Meckel’S Cave ◽  
Large Tumor ◽  
Postoperative Mri ◽  
Meckel's Cave

Abstract Objective This study was aimed to present the complete removal of a large recurrent Meckel's cave meningioma. Design This study is a case report. Setting The study was conducted at Department of Neurosurgery and Skull Base Laboratory at Lariboisiére Hospital, Paris. Participant A 53-year-old male was presented with a severe V1, V2, and V3 hypoesthesia and pain. He was operated 7 years ago for a right Meckel's cave meningioma with postoperative V1–V2 hypoesthesia. Magnetic resonance imaging (MRI) showed a large tumor recurrence extending into the cavernous sinus (CS), posterior fossa (PF), sphenoid sinus (SS), pterygopalatine (PPF), and infratemporal fossa (ITF; Fig. 1). Main Outcome Measures Radiological results and postoperative course were assessed for this study. Results The previous right frontotemporal approach was used. The lateral wall of the orbit, the middle fossa floor and the anterior temporal base were drilled to expose the orbit, PPF, and ITF. Foramen ovale (FO), foramen rotondum (FR), and superior orbital fissure (SOF) were opened. The meningoorbital band was cut and the lateral wall of CS was elevated (Fig. 2). The inferior orbital fissure was opened and tumor removed into the ITF, PPF, and orbit. After entering Meckel's cave from above, tumor was removed from PF. After microsurgical tumor removal, a 45-degree endoscope was used to remove tumor remnant and mucosa into SS. A watertight dural closure with pericranium was performed, reinforced with autologous fat and fibrin glue. Postoperative MRI showed complete tumor resection (Fig. 1). The patient experienced a right-side keratitis that resolved within 10 days and a V3 hypoesthesia that improved at 2 months. Conclusion This surgical case shows how the anatomical knowledge is mandatory in skull base surgery and how the integration of microsurgical and endoscopic-assisted techniques allows to obtain optimal results.The link to the video can be found at: https://youtu.be/qxt_389AdWU.

A combined frontotemporal and lateral infratemporal fossa approach to the skull base

1988 ◽  
Vol 68 (5) ◽  
pp. 678-683 ◽  
Author(s):  
Bruce Mickey ◽  
Lanny Close ◽  
Steven Schaefer ◽  
Duke Samson
Keyword(s):  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Middle Cranial Fossa ◽  
Low Grade ◽  
Orbital Apex ◽  
Upper Aerodigestive Tract ◽  
Temporalis Muscle ◽  
Anterior Portion ◽  
Content Type ◽  
Cranial Fossa

✓ A variety of neoplasms involve both the infratemporal fossa and the base of the middle cranial fossa, in medial proximity to the cavernous sinus and orbital apex. To provide simultaneous access to both the intracranial and extracranial aspects of these tumors, a temporal or frontotemporal craniotomy may be combined with a lateral exposure of the infratemporal fossa. The approach, which is readily achieved by a neurosurgeon and an otolaryngologist acting as a team, involves a unilateral frontotemporal incision extended inferiorly onto the neck, a lateral facial flap reflected anteriorly, and transection of the zygoma followed by its reflection inferolaterally with the temporalis muscle. This exposure provides excellent visualization of both the intradural and extradural aspects of the anterior portion of the cavernous sinus, allowing for an aggressive resection of neoplasms involving this region. Experience with this procedure is reported here in the management of nine patients: three with nasopharyngeal angiofibromas, three with low-grade malignancies of the upper aerodigestive tract, and three with sphenoid ridge meningiomas.

scholarly journals Endoscopic Endonasal Resection of Meckel’s Cave Epidermoid Cysts: Case Discussion and Literature Review

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Jehad Zakaria ◽  
Pravesh Saini ◽  
Mariya Yanovskaya ◽  
John T. Tsiang ◽  
Krishnan Ravindran ◽  
...  
Keyword(s):  
Residual Disease ◽  
Surgical Excision ◽  
Middle Cranial Fossa ◽  
Anterolateral Approach ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Epidermoid Cysts ◽  
Meckel's Cave ◽  
Cranial Fossa ◽  
Brain Retraction

Meckel’s cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches—such as the retrosigmoid approach—challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

scholarly journals Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

2019 ◽  
Vol 131 (4) ◽  
pp. 1126-1135 ◽  
Author(s):  
Chiman Jeon ◽  
Chang-Ki Hong ◽  
Kyung In Woo ◽  
Sang Duk Hong ◽  
Do-Hyun Nam ◽  
...  
Keyword(s):  
Surgical Techniques ◽  
Middle Cranial Fossa ◽  
Csf Leak ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Working Space ◽  
Early Results ◽  
Endoscopic Transorbital ◽  
Meckel's Cave ◽  
Cranial Fossa

OBJECTIVETumors involving Meckel’s cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel’s cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach.METHODSBetween September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel’s cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded.RESULTSGross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa “peeling” technique, and full visualization of Meckel’s cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak.CONCLUSIONSThe eTOA affords a direct route to access Meckel’s cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.

Surgical Approaches to the Cavernous Sinus: A Microsurgical Study

Neurosurgery ◽  
1990 ◽  
Vol 26 (6) ◽  
pp. 903-932 ◽  
Author(s):  
Tooru Inoue ◽  
Albert L. Rhoton ◽  
Dan Theele ◽  
Margaret E. Barry
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Surgical Approaches ◽  
Anterior Clinoid Process ◽  
Anatomic Variants ◽  
Cranial Fossa ◽  
Extradural Approach

Abstract The surgical approaches to the cavernous sinus were examined in 50 adult cadaveric cavernous sinuses using magnification of ×3 to ×40. The following approaches were examined: 1) the superior intradural approach directed through a frontotemporal craniotomy and the roof of the cavernous sinus: 2) the superior intradural approach combined with an extradural approach for removing the anterior clinoid process and unroofing the optic canal and orbit; 3) the superomedial approach directed through a supraorbital craniotomy and subfrontal exposure to the wall of the sinus adjacent to the pituitary gland; 4) the lateral intradural approach directed below the temporal lobe to the lateral wall of the sinus; 5) the lateral extradural approach for exposure of the internal carotid artery in the floor of the middle cranial fossa proximal to the sinus; 6) the combined lateral and inferolateral approach, in which the infratemporal fossa was opened and the full course of the petrous carotid artery and the lateral wall of the sinus were exposed and; 7) the inferomedial approach, in which the medial wall of the sinus was exposed by the transnasal-transsphenoidal route. It was clear that a single approach was not capable of providing access to all parts of the sinus. The intracavernous structures best exposed by each route are reviewed. The osseous relationships in the region were examined in dry skulls. Anatomic variants important in exposing the cavernous sinus are reviewed.

The Endoscopic Endonasal Transmaxillary Approach to Meckel's Cave Through the Inferior Orbital Fissure

2017 ◽  
Vol 13 (3) ◽  
pp. 367-373 ◽  
Author(s):  
Xin Zhang ◽  
Halima Tabani ◽  
Ivan El-Sayed ◽  
Matthew Russell ◽  
Xuequan Feng ◽  
...  
Keyword(s):  
Infratemporal Fossa ◽  
Middle Cranial Fossa ◽  
Nasolacrimal Duct ◽  
Neurovascular Bundle ◽  
Infraorbital Nerve ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Maxillary Nerve ◽  
Surgical Access ◽  
Meckel's Cave

Abstract BACKGROUND: Surgical access to Meckel's Cave (MC) is challenging due to its deep location and surrounding important neurovascular structures. Currently existing endoscopic endonasal (EE) approaches require dissecting near the internal carotid artery (ICA) or require transposition of the pterygopalatine neurovascular bundle. OBJECTIVE: To describe a novel approach to access the anterolateral aspect of the MC using a minimally invasive EE route. METHODS: The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured. RESULTS: The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2). CONCLUSION: The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

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