Endoscopic endonasal approach for the treatment of schwannomas of the pterygopalatine fossa: case report and review of the literature.

INTRODUCTION: Pterygopalatine fossa (PPF) schwannomas are rare lesions most often arising from branches of the trigeminal nerve. Symptomatic lesions have been traditionally treated by conventional external approaches. However, the development of an expanded endonasal approach (EEA) enables skull base surgeons to reach these deeply seated lesions via a different route with its own advantages and drawbacks. METHODS: Case report and review of the literature. CASE DESCRIPTION: A 41-year-old woman presented with a 6-year history of right facial pain and numbness. Her symptoms had increased progressively over a year, and she recently had developed right-sided otalgia. MRI revealed a right PPF mass, hypointense on T1 and T2 sequences with homogeneous enhancement following the use of gadolinium. A biopsy, attempted at another institution, was considered non-diagnostic. We totally removed the lesion through an endoscopic endonasal transmaxillary approach. Final pathology confirmed the diagnosis of schwannoma. Post-operatively, the patient noted a significant improvement of her facial pain (V2 territory). CONCLUSION: The endonasal endoscopic transmaxillary approach provides adequate access to the PPF, thus enabling safe tumor removal with less morbidity than conventional routes.

The supraorbital approach for recurrent or residual suprasellar tumors.

BACKGROUND: Suprasellar tumors can be removed through a variety of approaches including conventional frontotemporal craniotomies, the transsphenoidal route, or the supraorbital (SO) eyebrow craniotomy. Herein we assess the utility of the SO route for recurrent or residual suprasellar tumors previously treated by an alternative route. MATERIAL AND METHODS: A retrospective analysis of all consecutive patients who underwent an SO approach for removal of a recurrent/residual tumor was undertaken. RESULTS: Between December 2007 and February 2010, 11 patients underwent an SO craniotomy for a recurrent or growing residual tuberculum sellae meningioma (n=7) or craniopharyngioma (n=4). All 11 patients had prior craniotomies, 5 had transsphenoidal surgery, 6 had radiation treatment, and 1 had chemotherapy. In the last 5 cases, the endoscope was used in addition to the microscope for intraoperative visualization. 3 patients underwent decompression of multicystic craniopharyngiomas and the remaining 8 patients had tumor debulking, all achieving 70% or more tumor removal. Of 9 patients with preoperative visual deterioration, 6 (67%) had improvement and no patient had visual worsening. No new adenohypophysis or neurohypophysis dysfunction was noted. One patient had a postoperative CSF leak requiring reoperation. CONCLUSION: The SO approach should be considered as a safe and effective alternative route for recurrent or residual suprasellar tumors previously treated by conventional craniotomy or TS surgery. It typically offers a simplified trajectory that minimizes scar tissue from prior approaches and provides excellent access for optic apparatus decompression. Endoscopy is helpful to visualize hidden tumor remnants and maximize safe tumor removal.

Vidian nerve neurofibroma removed via a transpterygoid approach.

BACKGROUND: Lesions originating in the vidian canal are extremely rare. Most frequently, they are extensions from contiguous carcinomas. We present a rare case of a vidian nerve neurofibroma and discuss its surgical management. CASE REPORT: A 62-year-old woman with a history of a basal cell skin cancer was evaluated for bilateral tinnitus. Imaging revealed a left-sided lesion at the medial aspect of the pterygoid process base, over the vidian canal. Under image-guidance, an endonasal endoscopic transpterygoid approach was performed. The histopathological examination supported the diagnosis of neurofibroma. CONCLUSION: Benign nerve sheath tumors of the vidian nerve should be considered in the differential diagnosis of a vidian canal lesion. Given the propensity of more aggressive tumors, a tissue diagnosis should be warranted in order to coordinate appropriate subsequent treatment. The expanded endonasal transpterygoid approach offers a safe, less invasive, and effective route to perform the excisional biopsy of such a lesion.