Introduction: Facial pain refractory to conventional medical and surgical treatments is particularly
difficult to treat. Neurectomy, in the form of surgical sectioning of the trigeminal
nerve’s cisternal portion intracranially or its individual divisions through external
incisions, has been reported for treatment of these patients.
Methods: We describe the technique and results of an endonasal endoscopic approach to the
maxillary division of the trigeminal nerve at the foramen rotundum for neurectomy
and treatment of refractory facial pain in the V2 distribution. Using a unilateral
endonasal endoscopic approach (EEA), the foramen rotundum is accessed after ipsilateral
maxillary antrostomy, sphenoidotomy and partial removal of the posterior wall of the
maxillary sinus for exposure of the pterygopalatine fossa (PPF). Following clip ligation
of the sphenopalatine artery, the superior part of the periosteum that covers the
PPF is sharply incised toward the pterygoid base. The vidian nerve is identified and
the periosteum of the pterygoid base is elevated laterally. This step is important
to preserve the structural integrity and functionality of the vidian nerve. Finally
the V2 nerve is identified exiting the foramen rotundum, a few millimeters lateral
and superior to the vidian nerve. The maxillary nerve is sharply divided, and then
cauterized deep within the foramen.
Results: Three patients (1 trigeminal neuralgia, 1 atypical facial pain, and 1 posttraumatic
facial pain) with predominantly maxillary division trigeminal distribution pain that
had failed other medical and surgical treatments were treated with EEA V2 neurectomy
at the foramen rotundum. One patient had an intraoperative cerebrospinal fluid (CSF)
leak successfully repaired with a free mucosal graft from the inferior nasal floor
without a postoperative CSF fistula. There were no other early complications of treatment.
All patients obtained complete pain relief in the early postoperative period with
complete anesthesia in the V2 distribution.
Conclusion: EEA to the foramen rotundum for neurectomy at the cranial base appears to be a safe
and effective treatment for patients with refractory or atypical V2 facial pain or
patients with contraindications to more invasive procedures due to advanced age or
medical comorbidities.