Endoscopic Infratemporal Resection as an Adjunct to Open Middle Fossa Approach for Residual Grade 2 Infratemporal Fossa Meningioma

Transnasal approaches to the lateral skull base and infratemporal fossa are rapidly evolving, and recently these approaches have been used adjunctively with open approaches to the lateral skull base. Compared with open lateral approaches to the infratemporal fossa, transnasal approaches do not require manipulation of the temporomandibular joint and facial nerve, or retraction of the temporal lobe. Tumors medial and inferior to the critical neurovascular structures in the infratemporal fossa are most amenable to resection through this approach.

A 40-year-old gentleman previously underwent a middle cranial fossa approach for resection of a meningioma of the middle fossa, extending into the epitympanum. A subtotal resection was achieved. Anaplastic elements were noted on pathology, and he was followed with serial imaging over the next 8 years. The tumor grew very slowly, and the patient subsequently developed a near complete facial nerve paralysis. He then underwent a revision middle cranial fossa and transzygomatic approach, but visualization of the tumor was limited inferiorly. Total resection could not be obtained. Six weeks later, a staged endoscopic expanded transnasal approach was used to obtain a gross total resection of his recurrent tumor. Now 6 months out, imaging shows no residual or recurrent disease. He has no persistent nasal crusting, quality-of-life surveys show high scores, and smell testing remains normal.