Complications Associated with a Transpterygoid Approach to Meningoencephalocele Repair

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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“…However, risk of CSF leak can be reduced by utilizing multilayer reconstruction techniques, and vascularized flaps. 50,51…”

Section: Discussionmentioning

confidence: 99%

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches

Agosti

Rezende

Leonel

et al. 2022

J Neurol Surg B Skull Base

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“…Damage to the vidian nerve or pterygopalatine ganglion may result in dry eye, nasal dryness, decreased lacrimation secondary to emotional stimuli, and, rarely, palatal hypoesthesia. 30,31 In accessing the LRSS using EEA/cMTO, we propose certain novel modifications to the existing dissection techniques to reduce morbidity, as described above. A bilateral rescue flap helps preserve both nasoseptal flaps.…”

Section: Access To the Lrssmentioning

confidence: 99%

Endoscopic precaruncular medial transorbital and endonasal multiport approaches to the contralateral skull base: a clinicoanatomical study

Bhuskute,

Gosal,

Alsavaf

et al. 2024

Neurosurgical Focus

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OBJECTIVE Minimally invasive endoscopic endonasal multiport approaches create additional visualization angles to treat skull base pathologies. The sublabial contralateral transmaxillary (CTM) approach and superior eyelid lateral transorbital approach, frequently used nowadays, have been referred to as the "third port" when used alongside the endoscopic endonasal approach (EEA). The endoscopic precaruncular contralateral medial transorbital (cMTO) corridor, on the other hand, is an underrecognized but unique port that has been used to repair CSF rhinorrhea originating from the lateral sphenoid sinus recess. However, no anatomical feasibility studies or clinical experience exists to assess its benefits and demonstrate its potential role in multiport endoscopic access to the other contralateral skull base areas. In this study, the authors explored the application and potential utility of multiport EEA combined with the endoscopic cMTO approach (EEA/cMTO) to three target areas of the contralateral skull base: lateral recess of sphenoid sinus (LRSS), petrous apex (PA) and petroclival region, and retrocarotid clinoidocavernous space (CCS). METHODS Ten cadaveric specimens (20 sides) were dissected bilaterally under stereotactic navigation guidance to access contralateral LRSS via EEA/cMTO. The PA and petroclival region and retrocarotid CCS were exposed via EEA alone, EEA/cMTO, and EEA combined with the sublabial CTM approach (EEA/CTM). Qualitative and quantitative assessments, including working distance and visualization angle to the PA, were recorded. Clinical application of EEA/cMTO is demonstrated in a lateral sphenoid sinus CSF leak repair. RESULTS During the qualitative assessment, multiport EEA/cMTO provides superior visualization from a high vantage point and better instrument maneuverability than multiport EEA/CTM for the PA and retrocarotid CCS, while maintaining a similar lateral trajectory. The cMTO approach has significantly shorter working distances to all three target areas compared with the CTM approach and EEA. The mean distances to the LRSS, PA, and retrocarotid CCS were 50.69 ± 4.28 mm (p < 0.05), 67.11 ± 5.05 mm (p < 0.001), and 50.32 ± 3.6 mm (p < 0.001), respectively. The mean visualization angles to the PA obtained by multiport EEA/cMTO and EEA/CTM were 28.4° ± 3.27° and 24.42° ± 5.02° (p < 0.005), respectively. CONCLUSIONS Multiport EEA/cMTO to the contralateral LRSS offers the advantage of preserving the pterygopalatine fossa contents and the vidian nerve, which are frequently sacrificed during a transpterygoid approach. This approach also offers superior visualization and better instrument maneuverability compared with EEA/CTM for targeting the petroclival region and retrocarotid CCS.

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“…Although the transpterygoid endoscopic approach is associated with a significantly reduced morbidity when compared to the open approach, the extent of dissection that may be required often results in complications such as hemipalatal hypoesthesia and lacrimal gland hyposecretion. 4 Transorbital endoscopic approaches have recently gained favor as an alternative approach to the skull base. 5 We describe the use of a contralateral precaruncular approach to provide a surgical pathway to the lateral aspect of the sphenoid sinus, allowing for better direct visualization and instrument manipulation, obviating the need for transpterygoid dissection.…”

Section: Introductionmentioning

confidence: 99%

Contralateral Precaruncular Approach to the Lateral Sphenoid Sinus—A Case Report Detailing a New, Multiportal Approach to Lesions, and Defects in the Lateral Aspect of Well-Pneumatized Sphenoid Sinuses

et al. 2019

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Introduction: Conventional surgical approaches to the lateral aspect of a well-pneumatized sphenoid sinus are associated with significant surgical morbidity. Transorbital endoscopic approaches have recently gained favor as an alternative approach to the skull base. We describe the use of a contralateral precaruncular endoscopic approach to provide a surgical pathway to the lateral aspect of the sphenoid sinus, allowing for improved and direct visualization of the surgical field, with limited morbidity. Case Report: A 60-year-old female patient, with a spontaneous cerebrospinal fluid leak from a Sternberg canal defect in the sphenoid sinus, underwent repair of the defect at Groote Schuur Hospital (Cape Town, South Africa). A contralateral precaruncular approach, using the left medial orbital portal, was utilized to access the defect in the lateral aspect of a well-pneumatized right sphenoid sinus. Computer modeling software was used to predetermine the surgical pathway, and the case was performed under navigation guidance. Adequate surgical access was obtained to the lateral sphenoid sinus and sinus defect, with superior visualization compared to a pure transnasal or transpterygoid approach to the lateral sphenoid sinus. Conclusions: This case validates the use of computer simulation to plan and decide on the best operative approaches in skull base surgery and describes the contralateral precaruncular approach as a surgical pathway to the lateral sphenoid sinus. Advantages of the contralateral precaruncular approach include a direct trajectory toward the sinus defect, easy access with a standard 18-cm, 4-mm, 0-degree rigid endoscope, and straight instruments, with sparing of the pterygoid base and contents of the pterygopalatine fossa.

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Complications Associated with a Transpterygoid Approach to Meningoencephalocele Repair

Cited by 4 publications

References 0 publications

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches

Endoscopic precaruncular medial transorbital and endonasal multiport approaches to the contralateral skull base: a clinicoanatomical study

Contralateral Precaruncular Approach to the Lateral Sphenoid Sinus—A Case Report Detailing a New, Multiportal Approach to Lesions, and Defects in the Lateral Aspect of Well-Pneumatized Sphenoid Sinuses

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