A Cranio-Orbital-Zygomatic Approach to Dumbbell-Shaped Trigeminal Neurinomas Using the Petrous Window

ABSTRACT

We applied a cranio-orbital-zygomatic approach that extends the temporal craniotomy more posteriorly and minimizes the frontal orbitotomy of an ordinary orbitozygomatic approach in order to provide wide access to the already eroded petrous apices along the long axis of trigeminal neurinomas. We treated seven dumbbell-shaped trigeminal neurinomas between 1991 and 1998 (mean follow-up, 38 months; range, 9 to 109 months). The configuration of the tumor mass was assessed on magnetic resonance imaging by measuring its long diameter in the middle and posterior fossae and the width of petrous erosion. Tumors were then classified into five types based on their distribution over the petrous ridge. Total removal was achieved in six patients, who showed no evidence of tumor recurrence during the follow-up period. The only major complication was one case of anesthesia dolorosa. The one patient with a subtotal removal developed a recurrence 12 months after surgery, in the posterior fossa. The cranio-orbital-zygomatic approach could be an effective method for removing dumbbell-shaped trigeminal neurinomas, particularly in cases of wide petrous erosion from the tumor. If, however, the tumor has a larger posterior fossa component, this approach may not provide adequate exposure to achieve a total resection.

KEYWORD

Dumbbell-shaped tumors - cranio-orbital-zygomatic approach - petrous bone - trigeminal neurinomas

REFERENCES

• 1 Bordi L, Compton J, Symon L. Trigeminal neuroma. A report of eleven cases.  Surg Neurol . 1989;  31 272-276
• 2 Cushing H, Eisenhardt L. Meningiomas: Their Classification, Regional Behavior, Life History and Surgical End Results.  Springfield, IL: Charles C Thomas; 1938
• 3 Schisano G, Olivercrona H. Neurinomas of the gasserian ganglion and trigeminal root.  J Neurosurg . 1960;  17 306-322
• 4 Hakuba A, Liu S, Nishimura S. The orbitozygomatic infratemporal approach: a new surgical technique.  Surg Neurol . 1986;  26 271-276
• 5 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningioma: surgical method and results in 10 patients.  Neurosurgery . 1991;  28 869-876
• 6 McCormick P C, Bello J A, Post K D. Trigeminal schwannoma. Surgical series of 14 cases with review of the literature.  J Neurosurg . 1988;  69 850-860
• 7 Hakuba A, Tanaka K, Suzuki T, Nishimura S. A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus.  J Neurosurg . 1989;  71 699-704
• 8 Samii M, Migliori M M, Tatagiba M, Babu R. Surgical treatment of trigeminal schwannomas.  J Neurosurg . 1995;  82 711-718
• 9 Al-Mefty O. Supraorbital-pterional approach to skull base lesions.  Neurosurgery . 1987;  21 474-477
• 10 Bowels Jr A P, Anand V K. Cranioorbital approach. In: Donald PJ. Surgery of the Skull Base. Philadelphia: Lippincott-Raven 1998: 263-286
• 11 Yasui T, Hakuba A, Kim S H, Nishimura S. Trigeminal neurinomas: operative approach in eight cases.  J Neurosurg . 1989;  71 506-511
• 12 Sekhar L N, Swamy N K, Jaiswal V, Rubinstein E, Hirsch Jr E W, Wright D C. Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration.  J Neurosurg . 1994;  81 860-868
• 13 Pollack I F, Sekhar L N, Jannetta P J, Janecka I P. Neurilemmomas of the trigeminal nerve.  J Neurosurg . 1989;  70 737-745
• 14 Day J D, Fukushima T. The surgical management of trigeminal neuromas.  Neurosurgery . 1998;  42 233-241
• 15 Konovalov A N, Spallone A, Mukhamedjanov D J, Tcherekajev V A, Makhmudov U B. Trigeminal neurinomas: a series of 111 surgical cases from a single institution.  Acta Neurochir (Wien) . 1996;  138 1027-1035
• 16 Lesoin F, Rousseaux M, Villette L. Neurinomas of the trigeminal nerve.  Acta Neurochir (Wien) . 1986;  82 118-122
• 17 Visot A, Dermoe P, de Leon L M J. Sphenocavernous and infratemporal trigeminal neurinomas: surgical series of 15 cases.  Skull Base Surg . 1992;  2 142-149
• 18 Jefferson G. The trigeminal neurinoma with some remarks on malignant invasion of the gasserian ganglion.  Clin Neurosurg . 1955;  1 11-54
• 19 Taha J M, Tew Jr M J, van Loveren R H, Keller J T, El-Kalliny M. Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas.  J Neurosurg . 1995;  82 719-725
• 20 Spetzler R F, Daspit C P, Pappas C T. The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases.  J Neurosurg . 1992;  76 588-599
• 21 Tancioni F, Gaetani P, Villani L, Zappoli F, Rodriguez Y, Baena R. Neurinoma of the trigeminal root and atypical trigeminal neuralgia: case report and review of the literature.  Surg Neurol . 1995;  44 36-42