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

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.

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Endoscopic Endonasal Transclival Approach and Retrosigmoid Approach to the Clival and Petroclival Regions

Operative Neurosurgery ◽

10.1227/01.neu.0000347001.62158.57 ◽

2009 ◽

Vol 65 (suppl_6) ◽

pp. ons42-ons52 ◽

Cited By ~ 8

Author(s):

Matteo de Notaris ◽

Luigi Maria Cavallo ◽

Alberto Prats-Galino ◽

Isabella Esposito ◽

Arnau Benet ◽

...

Keyword(s):

Internal Carotid ◽

Abducens Nerve ◽

Anatomic Study ◽

Lateral Extension ◽

Anatomic Landmarks ◽

Endoscopic Endonasal ◽

Fresh Cadaver ◽

Definition Of ◽

Surgical Corridor ◽

Neurovascular Structures

Abstract Objective: The removal of clival lesions, mainly those located intradurally and with a limited lateral extension, may be challenging because of the lack of a surgical corridor that would allow exposure of the entire lesion surface. In this anatomic study, we explored the clival/petroclival area and the cerebellopontine angle via both the endonasal and retrosigmoid endoscopic routes, aiming to describe the respective degree of exposure and visual limitations. Methods: Twelve fresh cadaver heads were positioned to simulate a semisitting position, thus enabling the use of both endonasal and retrosigmoid routes, which were explored using a 4-mm rigid endoscope as the sole visualizing tool. Results: The comparison of the 2 endoscopic surgical views (endonasal and retrosigmoid) allowed us to define 3 subregions over the clival area (cranial, middle, and caudal levels) when explored via the endonasal route. The definition of these subregions was based on the identification of some anatomic landmarks (the internal carotid artery from the lacerum to the intradural segment, the abducens nerve, and the hypoglossal canal) that limit the bone opening via the endonasal route and the natural well-established corridors via the retrosigmoid route. Conclusion: Different endoscopic surgical corridors can be delineated with the endonasal transclival and retrosigmoid approaches to the clival/petroclival area. Some relevant neurovascular structures may limit the extension of the approach and the view via both routes. The combination of the 2 approaches may improve the visualization in this challenging area.

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Giant Frontoethmoid Mucocele with Intracranial Extension: Case Report

Ear Nose & Throat Journal ◽

10.1177/014556130308200115 ◽

2003 ◽

Vol 82 (1) ◽

pp. 50-52 ◽

Cited By ~ 10

Author(s):

Harun Cansiz ◽

Murat Yener ◽

M. Güven Güvenç ◽

Bülent Canbaz

Keyword(s):

Case Report ◽

Surgical Approaches ◽

Intracranial Extension ◽

Combined Approach ◽

Advantages And Disadvantages ◽

Left Orbit ◽

Transcranial Approach

We report the case of a 31-year-old woman who came to us with a giant frontoethmoid mass that had extended into the intracranial region and invaded the left orbit. We removed the lesion in its entirety via a combined intranasal and transcranial approach. We discuss the advantages and disadvantages of different surgical approaches, and we explain why we recommend a combined approach for the type of giant lesion that we encountered.

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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.

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The Lateral Facial Approach to the Nasopharynx and Infratemporal Fossa

Otolaryngology ◽

10.1177/019459988809900310 ◽

1988 ◽

Vol 99 (3) ◽

pp. 321-325 ◽

Cited By ~ 33

Author(s):

George A. Gates

Keyword(s):

Single Case ◽

Infratemporal Fossa ◽

Operating Time ◽

Petrous Apex ◽

Surgical Approaches ◽

Intracranial Extension ◽

Surgical Access ◽

Technical Control ◽

Ethmoid Sinuses ◽

And Control

Surgical access to the nasopharynx and infratemporal fossa is restricted by the bony structures that support and define these areas. Traditional surgical approaches to the nasopharynx for removal of benign neoplasms follow three directions: (1) the anterior route via the nasal cavity and the maxillary and, if necessary, the ethmoid sinuses; (2) the inferior route through the palate; and (3) the anterolateral retromaxillary pathway via the gingivobuccal sulcus into the pterygoid space. These approaches provide fair access, but limited visibility and little technical control of the neurovascular supply. For the small- to medium-sized tumor, the experienced surgeon is able to successfully manage the majority of cases using these approaches, singly or in combination. However, in patients with larger tumors—when recurrence is more common—approaches offering greater visualization have been developed, such as Panje's facial bifiap,1 Mann's transmaxillary,2 and Fisch's transtemporal.3 These provide better access and control at the cost of increased locoregional morbidity, long operating time, and considerable technical complexity. I have developed a simpler, more direct surgical approach that combines the exposure concepts of the head and neck surgeon with the microsurgical techniques of the otosurgeon. It has been applied to eight cases, with minimal morbidity and excellent results, and appears to be the procedure of choice for cases of angiofibroma with early intracranial extension. Subsequently, a similar approach, developed previously by Holliday,4 has been published in which access into the anterior temporal lobe, petrous apex, and clivus are gained. In this report, I describe and illustrate the anatomic and technical considerations of this approach and report a single case in which it was first applied.

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Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

Neurosurgical FOCUS ◽

10.3171/2016.9.focus16284 ◽

2016 ◽

Vol 41 (6) ◽

pp. E5 ◽

Cited By ~ 20

Author(s):

James K. Liu ◽

Ilesha A. Sevak ◽

Peter W. Carmel ◽

Jean Anderson Eloy

Keyword(s):

Radical Resection ◽

Extent Of Resection ◽

Cranial Base ◽

Preoperative Imaging ◽

Surgical Approaches ◽

Endoscopic Endonasal ◽

Tailored Approach ◽

The Individual ◽

Surgical Corridor ◽

Distinct Features

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications. Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another. The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.

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Combined Approach of the Anterior Skull Base in Sinonasal Tumours

Revista de Chimie ◽

10.37358/rc.18.5.6286 ◽

2018 ◽

Vol 69 (5) ◽

pp. 1191-1193

Author(s):

Dragos Octavian Palade ◽

Bogdan Mihail Cobzeanu ◽

Petronela Zaharia ◽

Marius Dabija

Keyword(s):

Skull Base ◽

Surgical Techniques ◽

Anterior Skull Base ◽

Disease Stage ◽

Surgical Approaches ◽

Intracranial Extension ◽

Combined Approach ◽

Endoscopic Techniques ◽

Complex Anatomy ◽

Insidious Onset

Malignancies of the nasal cavity and the paranasal sinuses are rare, counting for less than 3 % of the ENT-cancers. The insidious onset of these tumours with non-specific symptoms often leads to a delayed diagnostic. Advanced disease stage combined with the complex anatomy of the sinonasal cavities and anterior skull base encouraged surgeons to extend beyond the boundaries the classic surgical techniques. Surgical approaches to anterior skull base lesions can be divided into open approches: craniofacial, subcranial, endoscopic techniques or combined approaches when a craniotomy is associated with an endonasal endoscopic approach. The indication must take into consideration the oncologic principles, histopathology exam, extent of disease and surgeon skill and experience. Combined approach should be taken into consideration for patients with extended disease or significant intraorbital or intracranial extension. For certain tumours that require a craniotomy for the superior, superolateral, and anterior extensions of the disease and also a nasal and paranasal sinus tumor that could be removed endoscopically, an endoscopic-assisted approach can be considered.

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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.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-3399553 ◽

2019 ◽

Author(s):

Abraam Yacoub ◽

Daniel Schneider ◽

Ahmed Ali ◽

Wilhelm Wimmer ◽

Marco Caversaccio ◽

...

Keyword(s):

Infratemporal Fossa ◽

Lateral Approach ◽

Quantitative Comparison ◽

Direct Access ◽

Crossing Over ◽

Foramen Ovale ◽

Posterior Compartment ◽

Endoscopic Endonasal ◽

Medial Maxillectomy ◽

Neurovascular Structures

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.

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Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach

Journal of Neurosurgery ◽

10.3171/2014.12.jns141696 ◽

2016 ◽

Vol 124 (5) ◽

pp. 1328-1338 ◽

Cited By ~ 10

Author(s):

James K. Liu ◽

Qasim Husain ◽

Vivek Kanumuri ◽

Mohemmed N. Khan ◽

Zachary S. Mendelson ◽

...

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Vascular Complications ◽

Csf Leak ◽

Intracranial Extension ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Nasopharyngeal Angiofibroma ◽

Transseptal Approach

OBJECT Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring. METHODS This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1–3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1–4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus. RESULTS A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected endoscopically. There were no vascular complications. CONCLUSIONS An individualized, multiangle, multicorridor approach allows for safe and effective surgical customization of access for resection of JNAs depending on the size and exact location of the tumor. Combining the endoscopic endonasal approach with a transcranial approach via an orbitozygomatic, extradural, transcavernous approach may be considered in giant extensive JNAs that have intracranial extension and intimate involvement of the cavernous sinus.

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

Operative Neurosurgery ◽

10.1093/ons/opx009 ◽

2017 ◽

Vol 13 (3) ◽

pp. 367-373 ◽

Cited By ~ 2

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.

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