Limits of endoscopic endonasal transpterygoid approach to cavernous sinus and Meckel's cave

The endoscopic endonasal approach (EEA) to the ventral skull base has greatly increased in popularity over the last two decades. So-called expanded EEA have opened corridors to pathology off-midline, including lesions within the cavernous sinus and Meckel's cave. A standard EEA exposure into the sphenoid sinus allows visualization of the medial cavernous sinus; a transpterygoid approach allows for surgical manipulation of the lateral cavernous sinus and Meckel's cave contents. Pituitary adenomas, meningiomas, and schwannomas are the most common pathologies in this region. This approach to the "front door" of the cavernous sinus and Meckel's cave should be considered complementary to traditional craniotomy techniques as each have benefits and limitations. Herein we review the published literature regarding endoscopic endonasal transpterygoid surgery for pathology in the lateral cavernous sinus and Meckel's cave, and the anatomical and functional limitations of these approaches.