Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

Dolci, Ricardo Landini Lutaif; Upadhyay, Smita; Filho, Leo F. S. Ditzel; Fiore, Mariano E.; Buohliqah, Lamia; Lazarini, Paulo Roberto; Prevedello, Daniel M.; Carrau, Ricardo L.

doi:10.1002/hed.24301

Cited by 19 publications

(18 citation statements)

References 46 publications

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“…First, duplicates (n = 89) and non-English abstracts (n = 25) were removed; thereafter, 157 abstracts were screened for relevance resulting in the full-text evaluation of 112 articles. Subsequently, 75 articles were identified for our qualitative synthesis and included case reports (n = 21) , cadaveric studies (n = 32) [3,6,7,10,13,, clinical articles (n = 16) [2,5,8,9,16,[61][62][63][64][65][66][67][68][69][70][71], review of the literatures (n = 3) [72][73][74], as well as technical notes (n = 2) [75,76] and a radiological manuscript (n = 1) [77]. These outlined articles were published between February 1978 and November 2018.…”

Section: Resultsmentioning

confidence: 99%

“…A quadrangular space delineated by the ICA medially and inferiorly, the V2 nerve laterally, which is superolateral to the ICA [7], and the abducens nerve with the CS superiorly, provides access to Meckel's cave [79]. The ICA course should be carefully studied to define the feasibility of this approach [13] and avoid injury while drilling.…”

Section: Transpterygoid Approachmentioning

confidence: 99%

“…The introduction of rod-lensendoscopes allowed for minimal-access routes to the sellar and parasellar region affording exposure of the anterolateral and inferior portion of Meckel's cave [5], thus improving cosmetic results and potentially decreasing surgical morbidity [10]. Since these approaches offer a wide visualization of relevant structures through a small surgical window, both biopsies and larger resections are feasible [5,7,[11][12][13][14].…”

Section: Introductionmentioning

confidence: 99%

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Access to Meckel’s cave for biopsies of indeterminate lesions: a systematic review

et al. 2020

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Accessing Meckel's cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel's cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (n = 21), cadaveric studies (n = 32), clinical articles (n = 16), review of the literatures (n = 3), as well as technical notes (n = 2) and a radiological manuscript (n = 1). Open routes included lateral approaches with many variations, mainly intra-and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.

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Section: Resultsmentioning

confidence: 99%

Section: Transpterygoid Approachmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Access to Meckel’s cave for biopsies of indeterminate lesions: a systematic review

et al. 2020

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“…16 The anterior genu and anterior vertical segment are referred to as the lacerum segment by Bouthillier et al 1 Many studies have reported how to find the anterior end of the VC and follow the VN toward the lacerum segment of the petrous horizontal ICA. 3,5,10,15,16,19 The VC is a useful landmark to reach the lacerum segment of the ICA at its transition from the horizontal petrous segment to its vertical paraclival segment, especially in patients with poor sphenoid sinus pneumatization or those with recurrent pathology in whom the conventional surgical anatomy may be distorted. Moreover, exposure of the VN allows further exposure of the pterygoid base and lateral wall of the sphenoid sinus, as part of the transpterygoid approach.…”

Section: Discussionmentioning

confidence: 99%

“…10 Many publications focus on different anatomical landmarks of the anterior end of the VC and how the endonasal transpterygoid approach may be performed safely. [3][4][5]16,17,19,23 However, the literature is lacking a thorough anatomical description of the posterior and inferior limits of the endonasal transpterygoid avenue. Although the identification of the VN in the proximal aspect of its canal may permit us to safely identify the anterior genu of the ICA, the endoscopic anatomy of the most inferior and posterior area surrounding the ICA in this region-that is, the deepest and most posterior limit of the endoscopic endonasal transpterygoid route-has not been well documented.…”

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confidence: 99%

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

Kaen¹,

Ruiz‐Valdepeñas²,

Somma

et al. 2019

Journal of Neurosurgery

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T he endoscopic endonasal transpterygoid approach is a lateral extension of the midline endonasal route; although it was initially described to access only the lateral recess of the sphenoid sinus, currently this route is used to reach the most lateral aspect of the skull base. In this surgical scenario, injury to the internal carotid artery (ICA) is one of the most feared complications.The vidian nerve (VN) has been clearly described as a critical landmark for the safe identification of the petrous ICA in the foramen lacerum (FL) during the endoscopic ABBREVIATIONS ET = eustachian tube; FL = foramen lacerum; ICA = internal carotid artery; VC = vidian canal; VELPPHA = vidian nerve, eustachian tube, foramen lacerum, petroclival fissure, and pharyngobasilar fascia; VN = vidian nerve. OBJECTIVEThe endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway. METHODS Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed. RESULTS The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym-VELPPHA-to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach. CONCLUSIONS The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the e...

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Characterization and implications of the lingual process of the sphenoid bone: a cadaveric and radiographic study

London

Chen

et al. 2020

Int Forum Allergy Rhinol

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Background: The surgical significance of the lingual process of the sphenoid bone (LPSB) has not been sufficiently addressed. The purpose of this study was to describe the anatomical details of the LPSB in relation to the quadrangular space. Moreover, the incidence of the LPSB and its correlation with the pneumatization of the sphenoid sinus and the development of the lateral recess of the sphenoid sinus (LRSS) were also evaluated. Methods: A dissection and exposure of the LPSB and the quadrangular space was performed on 10 cadaveric specimens (20 sides). The incidence, length, and height of the LPSB were also assessed on computed tomography (CT) images (60 patients, 120 sides). The association between the presence of the LPSB with the pneumatization type of the sphenoid sinus and the presence of a LRSS was evaluated. Results: In a cadaveric model, the LPSB, in association with the petrolingual ligament extending from the LPSB to the petrous apex, was identified on 7 sides (35%). The LPSB was continuous with the mandibular strut. The overall incidence of a LPSB was 48.33% on CT images, and the average length and height of the LPSB was (mean ± standard deviation) 5.30 ± 1.44 mm and 6.51 ± 1.32 mm, respectively. A significant correlation was identified between presence of the LPSB with the pneumatization type of the sphenoid sinus (p = 0.004) but no correlation was identified with the presence of the LRSS (p = 0.071). Conclusion: The LPSB and the petrolingual ligament are useful landmarks for procedures in the quadrangular space and Meckel's cave. However, the LPSB is not consistently present.

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Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

Abstract: The trajectory of the internal carotid artery (ICA) significantly impacts the quadrangular space area and may be a potential parameter for defining the feasibility of this corridor. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1680-E1687, 2016.

Cited by 19 publications

References 46 publications

Access to Meckel’s cave for biopsies of indeterminate lesions: a systematic review

Access to Meckel’s cave for biopsies of indeterminate lesions: a systematic review

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

Characterization and implications of the lingual process of the sphenoid bone: a cadaveric and radiographic study

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