What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach

Abstract

Background?Traditionally, a pterional approach is utilized to access the Meckel cave. Depending on the tumor location, extradural dissection of the Gasserian ganglion can be performed. An endoscopic endonasal access could potentially avoid a craniotomy in these cases. Methods?We performed an endoscopic endonasal approach as well as a lateral approach to the Meckel cave on six anatomic specimens. To access the Meckel cave endoscopically, a complete sphenoethmoidectomy and maxillary antrostomy followed by a transpterygoid approach was performed. For lateral access, a pterional craniotomy with extradural dissection was performed. Results?The endoscopic endonasal approach allowed adequate access to the Gasserian ganglion. All the relevant anatomy was identified without difficulty. Both approaches allowed for a similar exposure, but the endonasal approach avoided brain retraction and improved anteromedial exposure of the Gasserian ganglion. The lateral approach provided improved access posterolaterally and to the superior portion. Conclusion?The endoscopic endonasal approach to the Meckel cave is anatomically feasible. The morbidity associated with brain retraction from the open approaches can be avoided. Further understanding of the endoscopic anatomy within this region can facilitate continued advancement in endoscopic endonasal surgery and improvement in the safety and efficacy of these procedures.

Subtemporal Retrolabyrinthine (Posterior Petrosal) versus Endoscopic Endonasal Approach to the Petroclival Region: An Anatomical and Computed Tomography Study

“…Surgical corridors created inside the nasal cavity have had significant success in the complete resection of skull base tumors with minimal cosmetic and neurologic deficits. [7][8][9][10][11][12] This study provides useful points of comparison to help the surgical team when deciding between a posterior petrosal approach and an EEA. With the wide craniotomy and extensive temporal bone resection, there was more than three times the amount of bone removal with the transpetrosal approach for both men and women.…”

“…10,11 For example, Meckel cave, which traditionally was approached with a wide pterional craniotomy involving brain retraction, has been directly accessed using EEA with minimal brain manipulation and less overall invasiveness. 12 Endoscopic skull base surgery has been widely integrated across skull base practices and warrants further study and improvement. 13 The challenge remains on deciding when to utilize EEA and when a traditional approach would be more advantageous.…”

Rhino-Neurochirurgie

“…Meist wird keine vollständige Freilegung der A. carotis interna vorgenommen und die Öffnung zum Ganglion nur bis zur Höhe von N. V 2 angelegt, um N. VI sicher zu schonen. Für Läsionen im lateralen Cavum Meckeli wird der transorale Zugang ergänzend vorgeschlagen; posterior-laterale oder superiore Anteile des Cavum sollten alternativ durch einen konventionellen neurochirurgischen Zugang angegangen werden [119,256,277,361,[489][490][491]. Der endoskopische transnasale Zugang ist vorteilhaft für Läsionen im Bereich der unteren-vorderen Felsenbeinspitze; für obere-vordere Abschnitte ist jedoch der konventionelle transkranielle Zugang überlegen [492].…”

Comprehensive review on rhino-neurosurgery

“…There is a close spatial relation to the internal carotid artery and the cavernous sinus. From anterior, an accordingly narrow surgical access (“front door to Meckel’s cave”, see below) can be defined especially to the anterior-medial parts of the ganglion [ 101 ], [ 231 ], [ 232 ], [ 233 ]. The maxillary nerve is found about 7 mm supero-lateral of the sphenopalatine foramen.…”