Abstract
Background
Trigeminal schwannomas (TSs) with solitary extracranial location are rare, and surgical excision is challenging. In recent years, the endoscopic endonasal transmaxillary transpterygoid approach (EETPA) has been advocated as an effective strategy for TSs in the infratemporal fossa (ITF).
Method
We describe the steps of the EETPA combined with the sublabial transmaxillary approach for the surgical excision of a giant mandibular schwannoma of the ITF. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video.
Conclusion
A combined EETPA and sublabial transmaxillary approach represents a safe and effective option for the surgical excision of extracranial TSs.
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Acknowledgements
We thank the Fondazione Beretta for their constant devotion to supporting brain cancer.
Funding
This work was supported in part by Joseph I. and Barbara Ashkins Endowed Professorship in surgery.
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Approval was obtained from the ethics committee of the Mayo Clinic. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.
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Ten key points
1. TSs represent between 0.07 and 0.36% of all intracranial tumors.
2. TSs with a solitary or predominantly extracranial component represent only 7–15% of all TSs.
3. EETPA, with or without a sublabial transmaxillary approach, has become a standard technique for the PPF, ITF, and upper PFS.
4. EETPA is mainly indicated for TSs involving the PPF or ITF with or without intracranial extension and for TSs stemming from Meckel’s cave.
5. Intraoperative neuromonitoring is useful to verify the physiological function of the motor root of V3 – which directs whether a nerve-sparing technique will be used.
6. In the case of ITF lesions, intraoperative neuronavigation is pivotal to direct the surgical corridor toward the lesion and reduce the risk of residual tumor.
7. TSs tend to displace the surrounding neurovascular structures, preserving a good plane of dissection.
8. Internal debulking of TS is key to safely dissect the capsule away from surrounding structures.
9. TS capsule must be carefully and completely dissected in order to avoid residual disease.
10. Hypoesthesia or anesthesia in the affected branch is a common occurrence after surgery, especially in large tumors.
This article is part of the Topical Collection on Tumor - Schwannoma
Supplementary Information
Video 1 Surgical video of a step-by-step excision of a V3 trigeminal schwannoma of the infratemporal fossa through a combined EETPA and sublabial transmaxillary approach. Below is the link to the electronic supplementary material.
Supplementary file1 (MP4 96782 KB)
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Agosti, E., Alexander, A.Y., Choby, G. et al. Combined endoscopic endonasal transpterygoid and sublabial transmaxillary approaches for a large infratemporal fossa trigeminal schwannoma. Acta Neurochir 164, 2525–2531 (2022). https://doi.org/10.1007/s00701-022-05327-2
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DOI: https://doi.org/10.1007/s00701-022-05327-2