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Trans-zygomatic middle cranial fossa approach to access lesions around the cavernous sinus and anterior parahippocampus: a minimally invasive skull base approach

  • Neurosurgical Techniques
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Abstract

Purpose

Exposure of the cavernous sinus or anterior parahippocampus often involves a wide exposure of the temporal lobe and mobilization of the temporalis muscle associated with temporal lobe retraction. The authors present a cadaveric study to illustrate the feasibility, advantages and landmarks necessary to perform a trans-zygomatic middle fossa approach to lesions around the cavernous sinus and anterior parahippocampus.

Methods

The authors performed bilateral trans-zygomatic middle fossae exposures to reach the cavernous sinus and parahippocampus in five cadavers (10 sides). We assessed the morbidity associated with this procedure and compared the indications, advantages, and disadvantages of this method versus more extensive skull base approaches. A vertical linear incision along the middle portion of the zygomatic arch was extended one finger breadth inferior to the inferior edge of the zygomatic arch. Careful dissection inferior to the arch allowed preservation of facial nerve branches. A zygomatic osteotomy was followed via a linear incision through the temporalis muscle and exposure of the middle cranial fossa floor.

Results

A craniotomy along the inferolateral temporal bone and middle fossa floor allowed extradural dissection along the middle fossa floor and exposure of the cavernous sinus including all three divisions of the trigeminal nerve. Intradural inspection demonstrated adequate exposure of the parahippocampus. Exposure of the latter required minimal or no retraction of the temporal lobe.

Conclusions

The trans-zygomatic middle fossa approach is a simplified skull base exposure using a linear incision, which may avoid the invasivity of more extensive skull base approaches while providing an adequate corridor for resection of cavernous sinus and parahippocampus lesions. The advantages of this approach include its efficiency, ease, minimalism, preservation of the temporalis muscle, and minimal retraction of the temporal lobe.

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Authors and Affiliations

  1. Clarian Neurological Institute, Indianapolis Neurosurgical Group (ING), Indianapolis, IN, USA

    Itay Melamed, Troy D. Payner & Aaron A. Cohen-Gadol

  2. Department of Neurosurgery, Indiana University, 1801 North Senate Blvd # 610, Indianapolis, IN, 46202, USA

    Aaron A. Cohen-Gadol

  3. Section of Pediatric Neurosurgery, Children’s Hospital, Birmingham, AL, USA

    R. Shane Tubbs

Authors
  1. Itay Melamed
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  2. R. Shane Tubbs
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  3. Troy D. Payner
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  4. Aaron A. Cohen-Gadol
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Corresponding author

Correspondence to Aaron A. Cohen-Gadol.

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Comment

The authors describe a less invasive approach to the lateral cavernous sinus and medialtemporal region using a small lateral temporal window and a subtemporal approachthrough a linear incision. The approach does have merit, but has been well described previously. C. Hunter Shelden popularized a subtemporal approach to the gasserian ganglion in the 1950s. This was used by many surgeons, including Poppen to treat trigeminal neuralgia by direct compression of the ganglion. The operation was performed using a linear temporal incision as described. The current publication reminds us of the advantages of this approach to the cavernous sinus.

W.T. Couldwell

Utah, USA

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Melamed, I., Tubbs, R.S., Payner, T.D. et al. Trans-zygomatic middle cranial fossa approach to access lesions around the cavernous sinus and anterior parahippocampus: a minimally invasive skull base approach. Acta Neurochir 151, 977–982 (2009). https://doi.org/10.1007/s00701-009-0376-4

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  • DOI: https://doi.org/10.1007/s00701-009-0376-4

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