Endoscopic anatomy of a double nostrils surgical approach to Meckel’s cave

doi:10.3969/j.issn.0529-1356.2014.01.016

Abstract

Abstract:

Objective To study the structures relevant to the endoscopic approach to the Meckel’s cave via the amphirhinal in order to provide the anatomy and morphology information for the Meckel’s cave surgery. Methods By simulating the operative approach to the Meckel’s cave via the amphirhinal under the endoscope, the operative approach-relevant anatomic landmarks in 10 cadaveric heads (20 sides) were observed, analyzed, photographied and measured. The cadavers were arterially and venously perfused with colored latex. Results The approach to the Meckel’s cave via the amphirhinal was divided into 4 steps: finding ostium of the maxillary sinus，entering the maxillary sinus，entering pterygopalatine fossa（PPF）and entering the Meckel’s cave. The distance from the nasal columella to the ostium of the maxillary sinus was (45.07±2.01) mm；the distance from the nasal columella to the sphenopalatine foramen was(64.84±3.00) mm；the distance from the nasal columella to the anterior foramen of the pterygoid canal was (71.34±2.99) mm. The angle between the lines from nasal columella to posterior nasal spine and from nasal columella to apertura maxillaries was (38.81±1.72)°. The angle between the lines from nasal columella to posterior nasal spine and from nasal columella to sphenopalatine foramen was(25.92±2.05) °. The diameter of sphenopalatine artery was (2.21±0.24)mm, and the diameter of vidian artery was (1.07±0.27)mm. The PPF region was structurally complicated due to the inside maxillary artery and its terminal branch-sphenopalatine artery, and great variation of the descending palatine artery. Tracing the sphenopalatine artery made it easier to localize the maxillary artery and its branches. When the constitutions such as pterygopalatine ganglions, veins were carefully departed, the vidian nerve and vessel bundles were tracked. The vidian ending was characterized to face with the ruptured fractions of the internal carotid artery. Meckel’s cave was straightly accessed by anatomically departing the quadrangular space (QS). Conclusion The selection of the operative approach to Meckel’s cave should be individualized. The location and the size of the lesion in Meckel’s cave are the major factors in deciding approaches for surgical treatment. The endoscopic approach of double nostrils-Meckel’s cave provides direct exposure to the anteromedial compartment of Meckel’s cave and PPF. Notable anatomical landmarks for the endoscopic surgeon are the sphenopalatine foramen, the vidian nerve and its canal and maxillarynerve (V2). A dissection superficial to the vascular structures preserves the neural elements. The nerves, such as the vidian nerve and V2, and their bony foramina are critical anatomical landmarks to identify and control the ICA( internal carotid artery) at the skull base.

Key words: Double nostrils, Meckel’s cave, Applied anatomy, Endoscope, Human

BAI Zhi-qiang JIN Yong* TAO Bao-hong WU Zhong-min. Endoscopic anatomy of a double nostrils surgical approach to Meckel’s cave[J]. AAS, 2014, 45(1): 84-88.

References

［1］Kouyialis AT, Stranjalis G, Papadogiorgakis N, et al. Giant dumbbell- shaped middle cranial fossa trigeminal schwannoma with extension to the infratemporal and posterior fossae ［J］. Acta Neurochir (Wien), 2007,149(9):959-964.
［2］Verstappen CC, Beems T, Erasmus CE, et al. Dumbbell trigeminal schwannoma in a child: complete removal by a one- stage pterional surgical approach［J］.Childs Nerv Syst, 2005,21(11):1008-1011.
［3］Zhu JJ, Padillo O, Duff J, et al. Cavernous sinus and leptomeningeal metastases arising from a squamous cell carcinoma of the face: Case report［J］. Neurosurgery, 2004, 54(2):492-499.
［4］Inoue T, Rhoton AL Jr, Theele D, et al. Surgical approaches to the cavernous sinus: a microsurgical study［J］. Neurosurgery, 1990, 26(6):903-932.
［5］Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome［J］. J Neurosurg, 2000, 92(2):235-241.
［6］Samii M, Carvalho GA, Tatagiba M, et al. Surgical management of meningiomas originating in Meckel’s cave［J］. Neurosurgery, 1997, 41(4):767-775.
［7］Wormald PJ，Van Hasselt A.Endoscopic removal of juvenile angiofibromas［J］.Otolaryngol Head Neck Surg, 2003, 129(6):684-691.
［8］Cavallo LM, Dal Fabbro M, Jalalod’din H, et al. Endoscopic endonasal transsphenoidal surgery. Before scrubbing in: Tips and tricks. ［J］. Surg Neurol, 2007, 67(4):342-347.
［9］ALFIERI A，JHO HD，SCHETTINO R，et al. Endonasal approach to the pterygomaxillary fossa：anatomic study［J］.Neurosurg, 2003, 52(2):374 -380.
［10］Jian FZ, Santoro A, Innocenzi G, et al. Fronto -temporal orbitozygomatic craniotomy to exposure the cavernous sinus and its surrounding regions: microsurgical anatomy ［J］. J Neurosurg Sci,2001, 45(1):19-28.
［11］Krisht AF. Transcavernous approach to diseases of the anterior upper third of the posterior fossa［J］. Neurosurg Focus, 2005, 19(2):E2.
［12］Taha JM, Tew JM Jr, van Loveren HR, et al. Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas［J］. J Neurosurg, 1995, 82(5):719-725.
［13］Yasuda A, Campero A, Martins C, et al. Microsurgical anatomy and approaches to the cavernous sinus［J］. Neurosurgery, 2005, 56(1):4-27.
［14］Roche PH, Mercier P, Fournier HD. Temporopolar epidural transcavernous transpetrous approach: Technique and indications［J］. Neurochirurgie, 2007, 53(1):23-31. (in French)
［15］Sanna M, Bacciu A, Pasanisi E, et al. Posterior petrous face meningiomas: an algorithm for surgical management［J］. Otol Neurotol, 2007, 28(7):942-950. 
［16］Yasuda A, Campero A, Martins C, et al. The medial wall of the cavernous sinus: microsurgical anatomy［J］. Neurosurgery,2004, 55(1):179-190.
［17］DelGaudio JM. Endoscopic transnasal approach to the pterygopalatine fossa［J］. Arch Otolaryngol Head Neck Surg, 2003, 129(4):441-446.
［18］Bolger WE. Endoscopic transpterygoid approach to the lateral recess: surgical approach and clinical experience［J］. Otolaryngol Head Neck Surg, 2005, 133(1):20-26.
［19］Har-El G. Combined endoscopic transmaxillary-transnasal approach to the pterygoid region, lateral sphenoid sinus, and retrobulbar orbit［J］. Ann Otol Rhin Laryngol, 2005, 114(6):439-442.
［20］Douglas R, Wormald PJ. Endoscopic surgery for juvenile nasopharyngeal angiofibroma: where are the limits［J］? Curr Opin Otolaryngol Head Neck Surg, 2006, 14(1):1-5.
［21］Kassam AB, Gardner P, Snyderman C, et al. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa［J］. Neurosurg Focus,2005,19(1):1-10.
［22］Qin SJ, Zhang KQ, Wang F, et al. Clinical anatomy of the pterygopaIatine segment of the maxillary artery ［J］. Acta Anatomica Sinica, 2012, 43(2): 240-245. (in Chinese)
秦泗佳，张奎启，王福，等. 上颌动脉翼腭段的应用解剖［J］.解剖学报，2012，43(2)：240-245.

[1]	LIU Xiao-li XU Lin WU Ai-xue WEN Cai-yun LI Ru-hua WU An-ting CHEN Dai-qian CHEN Cheng-chun. Analysis of cerebral gray matter structure in multiple sclerosis and neuromyelitis optica [J]. Acta Anatomica Sinica, 2024, 55(1): 17-24.
[2]	BAI He TENG Ye FENG Lei MENG Hai-wei1 TANG Yu-chun LIU Shu-wei. 3D hippocampal segmentation based on spatial and frequency domain features adaptive fusion and inter-class boundary region enhancement [J]. Acta Anatomica Sinica, 2024, 55(1): 73-81.
[3]	YIN Shi-qin YANG Si-yi WANG Rui-han YOU Gui-xuan YANG Ying-qiu ZHANG Lei. Distal tibiofibular syndesmosis fibular notch typing and its clinical significance based on CT [J]. Acta Anatomica Sinica, 2024, 55(1): 82-87.
[4]	YANG Yang SHI Jun LI Kun MA Yuan ZHANG Shao-jie HOU Er-fei WANG Chao-qun CHEN Jie WANG Xing LI Zhi-jun. Finite element analysis of cervical intervertebral discs after removing different ranges of uncinate processes [J]. Acta Anatomica Sinica, 2024, 55(1): 88-97.
[5]	SUN Lei WANG Xing-yu XIE Shui-hua. Risk analysis of re-fracture after percutaneous kyphoplasty in elderly patients with osteoporotic thoracolumbar compression fractures and construction of acolumnar graph prediction model#br# [J]. Acta Anatomica Sinica, 2024, 55(1): 98-104.
[6]	LIU Li-ping ZHU Meng-ni XU Hui . Effect of interleukin-6 on nucleated erythrocytes in lipopolysaccharide induced preeclampsia rats [J]. Acta Anatomica Sinica, 2023, 54(6): 722-729.
[7]	ZHAO Wei-ming LI Xiao YU Guo-ying WANG Gai-ping CHANG Cui-fang . Effect of serine protease inhibitor Kazaltype 1 on the proliferation of hepatocellular carcinoma cell and its mechanism [J]. Acta Anatomica Sinica, 2023, 54(6): 695-702.
[8]	HAN Yi CAI Li FENG Xiao . Risk analysis of bone cement leakage after percutaneous puncture vertebroplasty for osteoporotic spinal compression fractures and construction of a predictive model with column line drawings [J]. Acta Anatomica Sinica, 2023, 54(6): 710-715.
[9]	DU Da-peng SUN Yu ZHANG Min WANG Han-qin . Shear stress regulateing the phosphorylation of endothelial nitric oxide synthase Ser633 and Ser1177 in human umbilical vein endothelial cells through Pim1/Akt pathway [J]. Acta Anatomica Sinica, 2023, 54(5): 546-552.
[10]	ZHOU Chun-hui XIE Sheng-qiang WANG Jiang-ting LAN Xiao-juan ZHANG Jian-ning ZHAO Hu-lin . Application of multimodal electromagnetic navigation in endoscopic endonasal skull base anatomical measurement of fresh cadavers [J]. Acta Anatomica Sinica, 2023, 54(5): 560-566.
[11]	LIU Yan-jing SHI Yong-hong . Automatic extraction of point cloud on cartilage surface of intraoperative knee using FPFH-PointNet [J]. Acta Anatomica Sinica, 2023, 54(5): 553-559.
[12]	MI Si-rong LIU Guang-xing ZHANG Zhen-wu YU Peng-hui JU Xiao-jun RAO Li-bing LI Li . Accuracy of 3D printing skull under different CT layer thickness [J]. Acta Anatomica Sinica, 2023, 54(5): 575-581.
[13]	ZHU Qiu-liang YU Xiang-ping MA Jun CHEN Yun-yun LIN Fang RUAN Wen-bin . Adjustment of X-ray angle intraoperation based on the anatomic shape of femoral neck section [J]. Acta Anatomica Sinica, 2023, 54(5): 586-592.
[14]	LI Xiao-jun ZHANG Ya-min. Screening ferroptosis related genes influencing prognosis of colon cancer through bioinformatics analysis [J]. Acta Anatomica Sinica, 2023, 54(4): 445-452.
[15]	LIU Hai-lan MEI Yi-xuan ZHANG Yi LIU Cheng LIU Shu-wei. Classification and clinical significance of the branching patterns of the right pulmonary arteries based on the intravital CT data [J]. Acta Anatomica Sinica, 2023, 54(4): 453-459.