The endoscopic endonasal approach to the Meckel's cave tumors: surgical technique and indications

Many benign and malignant tumors as well as other inflammatory or vascular diseases may be located in the areas of Meckel's cave or the cavernous sinus. Except for typical features such as for meningiomas, imaging may not by itself be sufficient to choose the best therapeutic option. Thus, even though modern therapy (chemotherapy, radiotherapy, or radiosurgery) dramatically reduces the field of surgery in this challenging location, there is still some place for surgical biopsy or tumor removal in selected cases. Until recently, the microscopic subtemporal extradural approach with or without orbitozygomatic removal was classically used to approach Meckel's cave but with a non-negligible morbidity. Percutaneous biopsy using the Hartel technique has been developed for biopsy of such tumors but may fail in the case of firm tumors, and additionally it is not appropriate for anterior parasellar tumors. With the development of endoscopy, the endonasal route now represents an interesting alternative approach to Meckel's cave as well as the cavernous sinus. Through our experience, we describe the modus operandi and discuss what should be the appropriate indication of the use of the endonasal endoscopic approach for Meckel's cave disease in the armamentarium of the skull base surgeon.