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We report a challenging and uncommon case involving a 53-year-old Japanese man with cerebrospinal fluid (CSF) leakage caused by a meningocele in the lateral recess of the sphenoid sinus. Our innovative treatment approach involved a combination of transpterygoid and endoscopic modified medial maxillectomy techniques, with special emphasis on the preservation of the sphenopalatine artery. This strategic preservation was pivotal to the successful use of the ipsilateral nasoseptal flap for reconstruction, which played a crucial role in the prevention of postoperative CSF leakage. Otolaryngologists and neurosurgeons collaborated to perform the bath-plugging technique; effective collaboration was instrumental to the success of the procedure. This report highlights significant advancement from conventional frontal craniotomy to a more sophisticated endoscopic technique, shows the importance of meticulous surgical planning and execution, emphasizes careful preservation of critical anatomical structures during complex neurosurgical and otolaryngological procedures, and underscores the evolving landscape of surgical approaches for managing complex medical conditions.

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BACKGROUND: The endoscopic endonasal approach to paramedian skull base lesions has garnered increasing attention in recent reports. However, it is still a challenging approach. While the primary objective of the approach is the maximal removal of tumors through a minimally invasive procedure, discussions of the approach rarely include information about the maximum preservation of nasal structures. This study aimed to retrospectively review the clinical outcomes of patients who had undergone an endoscopic endonasal approach to paramedian lesions, describe the technical and anatomical nuances related to this approach at the authors' institution, and discuss the maximal preservation of nasal structures. OBSERVATIONS: The authors conducted a descriptive retrospective study of 17 surgical cases of paramedian endoscopic endonasal approaches performed jointly by otolaryngologists and neurosurgeons from August 2018 to August 2022 at a tertiary hospital. LESSONS: The approach to the paramedian region of the skull base was examined. Creating an appropriate corridor to maximize the surgical field is essential to allow a safe and accurate procedure. From an otolaryngologist's perspective, the endoscopic modified medial maxillectomy is an essential procedure that maximizes the surgical corridor and maximally preserves nasal morphology. https://thejns.org/doi/10.3171/CASE24218.

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Presently, endoscopic skull base surgery has undergone significant advancements since its inception over two decades ago. Nevertheless, it is imperative to underscore that the fundamental basis of all surgical procedures lies in the meticulous understanding of anatomy, with particular emphasis on the ventral anatomy. This facet has recently garnered increased attention.Following the advancements in endoscopic skull base surgery techniques, this chapter will concentrate on the pertinent anatomical considerations that serve as key foundations for successful procedures. These considerations are categorized into two planes: the sagittal plane and the coronal plane.The sagittal plane is further subdivided into five distinct approaches, namely,(1) the transcribriform approach, (2) the transplanum approach, (3) the transsellar approach, (4) the transclival approach, and (5) the transodontoid approach.On the other hand, the coronal plane is delineated into seven specific zones to facilitate comprehension and potential applications: (1) the petrous apex approach, (2) the intrapetrous approach, (3) the suprapetrous approach, (4) the cavernous sinus approach, (5) the infratemporal approach, (6) the medial condyle approach, and (7) the jugular foramen approach.By organizing the anatomical aspects in this systematic manner, the information provided becomes more accessible, fostering a comprehensive understanding of the subject matter for potential future application.

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OBJECTIVE: Tumors located within the Meckel's cave (MC) pose a significant surgical challenge. Although several corridors to access this complex region have been described, the endoscopic transpterygoid approach (ETPA) and the endoscopic transorbital superior eyelid approach (ETOA) have emerged in recent years, as viable alternatives to traditional microsurgical transcranial approaches (MTA). To date, there is a limited literature on surgical series considering endoscopic-assisted approaches to the MC. METHODS: We conducted a retrospective analysis of patients with primary MC tumors treated at our Institution between 2015 and 2022, specifically those managed via the ETPA assisted by intraoperative Endoscopic Diving Technique (EDT). Lesion resection extent was evaluated using pre- and post-intervention radiological images and surgical videos. Moreover, a literature review on ETPA was performed. RESULTS: This series comprises 7 patients affected by 4 trigeminal schwannomas, 1 benign notochordal cell tumor, 1 dermoid cyst and 1 mesenchymal tumor. In 71 % of cases, trigeminal neuralgia was the presenting symptom. Post-operative clinical improvement was observed in all but one case. Notably, 85.7 % of patients achieved total or near-total resection (NTR), with the remaining case undergoing subtotal resection (STR). No significant intraoperative complications occurred, and no recurrences were observed during the mean follow-up period of 41 months. CONCLUSIONS: In selected cases, the ETPA offers a direct and safe path to lesions located into the MC. This approach circumvents complications and constraints associated with ETOA or MTA. Moreover, the use of the EDT reduces manipulation of critical neurovascular structures, enhancing the efficacy of the ETPA.

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Advances in technology, instrumentation, and reconstruction have paved the way for extended endoscopic approaches to skull base tumors. In the sagittal plane, the endonasal approach may safely access pathologies from the frontal sinus to the craniocervical junction in the sagittal plane, the petrous apex in the coronal plane, and extend posteriorly to the clivus and posterior cranial fossa. This review article describes these modular extended endoscopic approaches, along with crucial anatomic considerations, illustrative cases, and practical operative pearls.

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Sphenoid meningoencephaloceles are rare, and their treatment is challenging. In this report, we describe two clinical cases of sphenoid meningoencephalocele, in which one patient presented with a cerebrospinal fluid leak after repeated head trauma, while in the other, sphenoid meningoencephalocele was detected during the study of memory impairment as the patient was otherwise asymptomatic. The CT scans showed bony dehiscence on the lateral wall of the sphenoid sinus filled with soft tissue that was confirmed by MRI as being herniated brain tissue. A transpterygoid endoscopic endonasal approach was performed with a multilayer reconstruction of the defect with success in both cases without perioperative complications. Imaging techniques are fundamental for diagnosis and surgical planning. Treatment using an endoscopic endonasal approach is efficient with very low morbidity.

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Introduction The endoscopic endonasal transpterygoid approach (EETPA) with or without the addition of the endoscopic-assisted sublabial anterior transmaxillary approach (ESTA) has become increasingly utilized for lesions posterior to the pterygopalatine fossa (PPF), including infratemporal fossa (ITF), lateral recess of the sphenoid sinus, Meckel's cave, petrous apex, and parapharyngeal space. The main goal of this study is to develop an educational resource to learn the steps of the EETPA for trainees. Methods EETPA and ESTA were performed in 12 specimens by neurosurgery trainees, under supervision from the senior authors. One EETPA and one ESTA were performed on each specimen on opposite sides. Dissections were supplemented with representative cases. Results After a wide unilateral sphenoidotomy, ethmoidectomy, and partial medial maxillectomy, the anteromedial bone limits of the PPF were identified and drilled out. The pterygoid progress was modularly removed. By enlarging the opening of the posterior and lateral walls of the maxillary sinus through EETPA and ESTA, respectively, the neurovascular and muscular compartments of the PPF and ITF were better identified. The EETPA opens direct corridors to the PPF, medial ITF, middle cranial fossa, cavernous sinus, Meckel's cave, petrous apex, and internal carotid artery. If a more lateral exposure of the ITF is needed, the ESTA is an appropriate addition. Conclusion Despite the steep learning curve of the EETPA, granular knowledge of its surgical anatomy and basic surgical steps are vital for those advancing their learning in complex endoscopic approaches to the ventral skull base when expanding the approach laterally in the coronal plane.

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BACKGROUND: The study was designed to identify new landmarks in the parapharyngeal segment of the internal carotid artery (ICA) for nasopharyngectomy and describe a surgical procedure of endoscopic endonasal transpterygoid nasopharyngectomy (EETPN). METHODS: Four cadaveric specimens were injected with colored silicone and subjected to CT scanning before dissection. The nasopharyngeal skull base was exposed using the endoscopic endonasal transpterygoid approach. The clinical data of four patients with nasopharyngeal malignances who underwent EETPN were reviewed. RESULTS: The lateral edge of the longus capitis muscle medially; the foramen lacerum, petrous apex spine and the stump of the levator veli palatini muscle superior laterally; and the upper parapharyngeal ICA laterally constitute the ICA-longus capitis muscle-petrous apex spine triangle which was a novel landmark for the upper parapharyngeal segment of the ICA. CONCLUSION: The ICA-longus capitis muscle-petrous apex spine triangle are important landmarks of the upper parapharyngeal segment of the ICA.

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OBJECTIVE: The expanded endonasal transpterygoid approach (EETA) is used to access the middle and posterior fossa through the pterygoid process. Traditionally, the eustachian tube (ET) was resected during EETA, which often required subsequent myringotomy for inner ear drainage. Anterolateral transposition of the ET was proposed to decrease potential morbidity associated with resection. However, a comparison of resection versus transposition regarding the need for subsequent myringotomy has not been reported. METHODS: This is a retrospective cohort study of patients who underwent an EETA. Patient demographics, tumor characteristics, management of ET with resection versus transposition, and need for subsequent myringotomy were collected. Analysis was performed with JMP software in standard fashion and univariate and multivariate logistic regression analysis performed with a p < 0.05 was considered significant. RESULTS: Ninety-one patients underwent EETA for various malignant and benign tumors. Twenty-seven patients required myringotomy, with tumors of the pterygopalatine fossa accounting for the most common location (n = 8). Malignant pathology had the highest myringotomy rate compared to benign tumors (48.9% vs. 10.9%, p < 0.001), as did receiving postoperative radiation (p < 0.001), ET resection (p < 0.001), and increasing CPK class. Multivariate analysis of these variables suggests that only ET resection significantly correlated with the need for myringotomy (LR 7.97, p = 0.005). CONCLUSIONS: ET resection during EETA can lead to ET dysfunction and require myringotomy post-operatively, and patients should be counseled of this risk. Radiation treatment, malignant pathology, and CPK class, all reflecting situations where more extensive surgery was needed, were associated with the need for myringotomy on univariate analysis but did not reach significance with multivariate analysis. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1203-1207, 2024.

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CSF fistulas of the lateral recess of the sphenoid sinus are a rare surgical pathology. Cerebrospinal fluid leak from lateral recess of the sphenoid sinus is observed with a frequency of 7.7% among all leakafe of the skull base. The article presents 3 clinical cases of patients with spontaneous cerebrospinal fluid leak from lateral recess of the sphenoid sinus and surgical treatments by transsphenoidal and transpterygoid (transpterygoid) endoscopic approaches with various postoperative results. The plastic surgery success of CSF fistulas from lateral recess of the sphenoid sinus doesn`t depend on the type of endonasal surgical approach, but on the plastic quality and the preoperative level of CSF pressure.

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BACKGROUND: Direct access to the sphenoid lateral recess offers the best chance of sealing spontaneous cerebrospinal fluid (CSF) rhinorrhea caused by lateral sphenoid encephaloceles of the Sternberg canal defect. METHOD: We present a case of spontaneous left-sided sphenoid lateral recess CSF leak after previous unsuccessful transcranial surgery managed with an endoscopic endonasal transpterygoid approach (EETA). An anatomical-based step-by-step illustration of the EETA was presented in the surgical video. CONCLUSION: This case demonstrates the value of endoscopic endonasal transpterygoid corridor in the exposure and manipulation of the sphenoid lateral recess.

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BACKGROUND: Transpterygoid transposition of the temporoparietal fascia flap (TPFF) is a feasible selection for ventral skull base defect (VSBD) reconstruction, but not anterior skull base defect (ASBD) reconstruction, after expanded endoscopic endonasal approach (EEEA). The goal of this study is to introduce the transorbital transposition of the TPFF for skull base defects reconstruction after EEEA, and make quantitative comparison between the transpterygoid transposition and transorbital transposition. METHODS: Cadaveric dissections were performed in five adult cadaveric heads with creating three transporting corridors bilaterally, encompassing superior transorbital corridor, inferior transorbital corridor, and transpterygoid corridor. For each transporting corridor, the minimum necessary length of the TPFF for skull base defects reconstruction was measured. RESULTS: The areas of ASBD and VSBD were 1019.63 ± 176.32 mm2 and 572.99 ± 126.21 mm2 . The length of the harvested TPFF was 149.38 ± 6.21 mm. In contrast to the transpterygoid transposition with incomplete coverage, transorbital transposition of the TPFF allowed full coverage of ASBD with a minimum necessary length of 109.75 ± 8.31 mm. For VSBD reconstruction, transorbital transposition of the TPFF needs shorter minimum necessary length (123.88 ± 4.49 mm) than transpterygoid transposition (138.00 ± 6.28 mm). CONCLUSIONS: Transorbital corridor is a novel pathway for transporting the TPFF into the sinonasal cavity for skull base defects reconstruction after EEEA. In comparison with transpterygoid transposition, transorbital transposition provides wider coverage of skull base defects with a fixed length of the TPFF.

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PURPOSE: Inverted papilloma of the sphenoid sinus (IPSS) is a rare tumor with debated surgical management due to its proximity to vital structures. The aim of this manuscript is to highlight the role of a transpterygoid approach (TPA) and pedicle-orientated strategy in case of involvement of critical structures in IPSS and compare it with data from the literature. METHODS: Patients with primary IPSS between January 2000 and June 2021 were included. Pre-operative CT/MRI were analyzed to classify the pneumatization of the SS and predict the insertion point of the inverted papilloma. All patients were treated with a trans-sphenoidal approach which was combined with a TPA in case of lateral insertion point. A systematic search was also performed to summarize the available literature. RESULTS: Twenty-two patients were treated for IPSS. By CT, the SS was categorized with type III pneumatization in 72.8% of cases. Eleven patients (50%) were treated with a TPA with a statistical association with the insertion point on the SS lateral wall (p = 0.01), rather than a SS pneumatization (p = 0.63). The overall success was 95.5% after a mean follow-up of 35.9 months. For the literature, 26 publications were included on 97 patients and described a trans-sphenoidal approach with a success rate of 84.6% after a mean follow-up of 24.5 months. CONCLUSION: IPSS is generally treated with a sphenoidotomy approach, although in selected cases, a TPA should be preferred to expose the whole SS lateral wall though allowing a complete pedicled oriented resection of the tumor.

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BACKGROUND: Caudal pneumatization of the pterygoid process may impact endonasal exposure of the lateral recess of sphenoid sinus (LRSS). OBJECTIVES: This study aims to explore the implications of a pneumatized pterygoid process for an endonasal transpterygoid approach to the LRSS and to define strategies regarding the preservation or sacrifice of the vidian nerve. METHODS: Dissection of the LRSS (11 sides) was performed on 6 cadaveric specimens, preselected for the radiographic presence of an LRSS. In addition, the dimensions of the LRSS were measured on the deidentified CT images of 120 patients (240 sides). The sphenoid sinus was subdivided into 3 categories: Type 1 (no identifiable LRSS), Type 2 (lateral pneumatization of the greater wing above the vidian canal), and Type 3 (pneumatization of both the greater wing and the pterygoid process). RESULTS: On the cadaveric specimens, a Type 2 pneumatization often allowed access to the LRSS above the level of the vidian canal; thus, sparing the vidian neurovascular bundle. In Type 3 pneumatization, a frontal corridor through the pterygoid base could be created to reach the LRSS with preservation of the vidian nerve. Extreme Type 3 pneumatization, however, required the transposition or sacrifice of the vidian nerve to facilitate a full direct access to the superolateral LRSS. Measurements on CT images revealed that the extent of caudal pneumatization of the pterygoid process had no statistically significant correlation with the superolateral extension of the lateral recess in patients with Type 3 LRSS (P > .05). CONCLUSION: Pneumatization of the LRSS toward a caudal or superolateral direction may develop independent from each other. Caudal pneumatization of the pterygoid process seems to variably impact the endonasal exposure of the LRSS.

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OBJECTIVE: Carotid sympathetic plexus (CSP) schwannomas are rare brain tumors located in a complex site around the cavernous sinus and carotid canal in the petrous bone. This study describes 3 cases of CSP schwannomas that underwent surgical removal of the tumor through an endoscopic endonasal transpterygoid approach. METHODS: Between 2016 and 2021, 3 cases of CSP schwannomas were treated using an endoscopic endonasal transpterygoid approach. Preoperative tumor size, preoperative and postoperative symptoms, internal carotid artery (ICA) displacement, extent of tumor resection, intraoperative findings showing tumor origin, and surgical complications were evaluated in all patients. RESULTS: Two tumors were in the petrous region, and the other one was in both the petrous and cavernous regions. The median tumor diameter was 41.3 mm. In the 3 cases, the ICA was displaced to the superolateral side, the anterolateral side, and the posterior side, respectively. Near-total resection was achieved in all 3 cases via an endoscopic endonasal transpterygoid approach. There were no endonasal postoperative complications, and the cranial nerve disability improved in all 3 patients at 1-year follow-up. CONCLUSIONS: The surgical technique for CPS schwannoma using an endoscopic endonasal transpterygoid approach may be a viable option because endoscopy has been proven to offer better intraoperative visualization and reduce postoperative discomfort for patients. Tumors located medial and inferior to the ICA pars cavernous sinus or anterior, inferior, and medial to the paraclival ICA are ideal candidates for surgery using this endoscopic approach.

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Background: The petroclival area is a technically challenging region to operate owing to the proximity of the internal carotid artery (ICA) and the need to obtain gross total excision of tumors in this area as they are often resistant to radiotherapy. Objective: We present our experience with the endonasal endoscopic transpterygoid approach in managing tumors of the petroclival region and discuss various operative nuances for safer resection. Materials and Methods: A retrospective study of all consecutive cases of lesions occupying the petroclival region that were operated via endonasal endoscopic transpterygoid approach at our center between January 2016 and December 2021 was performed. Results: The study included 14 cases of lesions occupying the petroclival region. Gross total resection by intraoperative observation was achieved in 10 patients, near total decompression was performed in two patients, and the remaining two patients underwent marsupialization of lesion. Postoperatively, one patient had right Lower motor neuron (LMN) facial nerve palsy and one patient required surgery for Cerebrospinal fluid (CSF) rhinorrhea on postoperative day 8. The mean duration of follow-up was 13.8 ± 16.6 months (range: 2-59 months). Four of six patients with visual symptoms on presentation reported improvement in vision, and the other two patients had a stable vision on follow-up. Two patients received radiotherapy postsurgery. No mortality was noted. Conclusion: The extended endonasal endoscopic transpterygoid approach can be safely and efficiently used for petroclival lesions. Very sound knowledge of anatomical relationship, use of intraoperative image guidance to avoid injury to ICA, and multilayer reconstruction with a vascularized nasoseptal flap are required to optimize the clinical outcome.

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Petroclival meningiomas are surgically challenging tumors because of their deep location and involvement of critical neurovascular structures. A variety of approaches have been described, and selection of approach should be tailored to the location of the tumor relative to neurovascular structures and surgical experience. The authors present two patients with petroclival meningiomas with varying relationships to cranial nerves and skull base anatomy who underwent endoscopic endonasal and open petrosectomy approaches, to demonstrate the complementarity of the endonasal transpetrous and open transpetrosal corridors. Proficiency in both open and endonasal approaches is critical to appropriate approach selection and maximal safe resection. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21252.

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Objectives Endoscopic endonasal approaches (EEAs) for petrosectomies are evolving to reduce perioperative brain injuries and complications. Surgical terminology, techniques, landmarks, advantages, and limitations of these approaches remain ill defined. We quantitatively analyzed the anatomical relationships and differences between EEA exposures for medial, inferior, and inferomedial petrosectomies. Design This study presents anatomical dissection and quantitative analysis. Setting Cadaveric heads were used for dissection. EEAs were performed using the medial petrosectomy (MP), the inferior petrosectomy (IP), and the inferomedial petrosectomy (IMP) techniques. Participants Six cadaver heads (12 sides, total) were dissected; each technique was performed on four sides. Main Outcomes and Measures Outcomes included the area of exposure, visible distances, angles of attack, and bone resection volume. Results The IMP technique provided a greater area of exposure ( p < 0.01) and bone resection volume ( p < 0.01) when compared with the MP and IP techniques. The IMP technique had a longer working length of the abducens nerve (cranial nerve [CN] VI) than the MP technique ( p < 0.01). The IMP technique demonstrated higher angles of attack to specific neurovascular structures when compared with the MP (midpons [ p = 0.04], anterior inferior cerebellar artery [ p < 0.01], proximal part of the cisternal CN VI segment [ p = 0.02]) and IP (flocculus [ p = 0.02] and the proximal [ p = 0.02] and distal parts [ p = 0.02] of the CN VII/VIII complex) techniques. Conclusion Each of these approaches offers varying degrees of access to the petroclival region, and the surgical approach should be appropriately tailored to the pathology. Overall, the IMP technique provides greater EEA surgical exposure to vital neurovascular structures than the MP and the IP techniques.

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Background: Extradural transcranial release of the meningo-orbital band occupying the lateral part of the superior orbital fissure is used to approach the orbital apex and middle cranial fossa. The authors tested the feasibility of the release of the meningo-orbital band via an endonasal transmaxillary approach. Materials and Methods: Five injected cadaveric heads were assessed for dimensions of superior orbital fissure by computerized tomography. An endonasal transsphenoid transpterygoid approach was done to the superior orbital fissure and annulus of Zinn medially, down to the maxillary nerve. The periorbita was dissected superolaterally to expose the greater wing of the sphenoid and the meningo-orbital band. The superior orbital fissure was decompressed inferiorly by drilling the greater wing of the sphenoid and the maxillary strut after transposition of the maxillary nerve. The meningoorbital band was cut at the junction of the lateral part of the superior orbital fissure and the periorbita exposing the frontotemporal dural junction. The edge of the lesser wing of the sphenoid was drilled toward the annulus of Zinn and the optic canal. The temporal lobe dura was separated from the periorbita and lateral cavernous dural wall at the meningo-orbital band and the ophthalmic nerve. Results: The superior orbital fissure had an oblique angle (mean: 39 ± 2.75 degrees) to the midsagittal plane, the length of its lateral part corresponding to the meningo-orbital band was (mean: 6.08 ± 2.58 mm) and the distance from its lateral end to midline was (mean 2.97 ± 0.11 cm). The meningo-orbital band was released in 10 cadaveric head sides with a distinct plane between the periorbita and the dura propria. Transmaxillary endoscopy provided less orbital retraction and better visualization of the lateral wall of the cavernous sinus. Conclusion: Endonasal transmaxillary release of the meningoorbital band is feasible, allowing exposure of the orbital apex and the middle cranial fossa.

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BACKGROUND: Trigeminal schwannomas (TSs) with solitary extracranial location are rare, and surgical excision is challenging. In recent years, the endoscopic endonasal transmaxillary transpterygoid approach (EETPA) has been advocated as an effective strategy for TSs in the infratemporal fossa (ITF). METHOD: We describe the steps of the EETPA combined with the sublabial transmaxillary approach for the surgical excision of a giant mandibular schwannoma of the ITF. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. CONCLUSION: A combined EETPA and sublabial transmaxillary approach represents a safe and effective option for the surgical excision of extracranial TSs.

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