Meckel’s cave access: anatomic study comparing the endoscopic transantral and endonasal approaches

Abstract

Recent advances in endonasal endoscopy have facilitated the surgical access to the lateral skull base including areas such as Meckel's cave. This approach has been well documented, however, few studies have outlined transantral specific access to Meckel's. A transantral approach provides a direct pathway to this region obviating the need for extensive endonasal and transsphenoidal resection. Our aim in this study is to compare the anatomical perspectives obtained in endonasal and transantral approaches. We prepared 14 cadaveric specimens with intravascular injections of colored latex. Eight cadavers underwent endoscopic endonasal transpterygoid approaches to Meckel's cave. Six additional specimens underwent an endoscopic transantral approach to the same region. Photographic evidence was obtained for review. 30 CT scans were analyzed to measure comparative distances to Meckel's cave for both approaches. The endoscopic approaches provided a direct access to the anterior and inferior portions of Meckel's cave. However, the transantral approach required shorter instrumentation, and did not require clearing of the endonasal corridor. This approach gave an anterior view of Meckel's cave making posterior dissection more difficult. A transantral approach to Meckel's cave provides access similar to the endonasal approach with minimal invasiveness. Some of the morbidity associated with extensive endonasal resection could possibly be avoided. Better understanding of the complex skull base anatomy, from different perspectives, helps to improve current endoscopic skull base surgery and to develop new alternatives, consequently, leading to improvements in safety and efficacy.

Surgical management of trigeminal schwannomas: defining the role for endoscopic endonasal approaches

“…8,10,18,20 Numerous reports have documented the management of a spectrum of middle fossa pathologies in this region-ranging from encephaloceles to perineural spread of adenoid cystic carcinoma. With the transposition of the PPF contents and a supravidian approach, V2 can be identified at the foramen rotundum toward the superior aspect of the pterygoid wedge and followed back to the gasserian ganglion.…”

“…8,10,16,20 Working through an anteromedial window into this region, endoscopic approaches provide the theoretical benefit of panoramic access. While several series have reported the feasibility of endoscopic approaches to Meckel's cave, there is no clear understanding of the relative advantages and disadvantages for this approach as regards the management of trigeminal schwannomas.…”

Transantral endoscopic approach for the treatment of lesions affecting the maxillary nerve

“…It provides an easier access to the whole course of V2 and a shorter work distance, compared with a transpterygoid endonasal approach [2]. Endonasal endoscopic approaches to this region can damage the nasolacrymal duct when trying to extend laterally.…”

Analysis of the petrous portion of the internal carotid artery: Landmarks for an endoscopic endonasal approach

“…Traditional open ITF approaches carry the risk of substantial morbidity and mortality, with limitations frequently imposed by critical anatomic structures. The advent of endoscopic technology and endoscopic endonasal techniques allows for an alternative approach to the ITF and skull base that provides potentially equivalent exposure with decreased morbidity and mortality …”

“…The advent of endoscopic technology and endoscopic endonasal techniques allows for an alternative approach to the ITF and skull base that provides potentially equivalent exposure with decreased morbidity and mortality. [1][2][3][4][5] The development of the transnasal approach to the anterior, middle, and posterior cranial fossae allows for appropriate surgical exposure with a minimization of cosmetic defects. Compared to the lateral approaches, the transnasal approach offers a less invasive procedure.…”