Landmarks to Identify Petrous Apex Through Endonasal Approach Without Transgression of Sinus

Abstract

Objectives The use of nasopharyngeal landmarks to localize the petrous apex has not been previously described. We describe a purely endoscopic endonasal corridor to localize the petrous apex without transgressing any of the paranasal sinuses.

Methods Anatomical dissections of four formalin preserved cadaveric heads (eight petrous apices) were performed to evaluate the feasibility of a nonsinus-based approach and illustrate the surgical landmarks and measurements that are useful for surgery in this area.

Results The Eustachian tubes, fossa of Rosenmüller (FR), and posterior end of the middle and inferior turbinates are constant landmarks, which can be identified without opening any nasal sinuses. The petrous apex is located on an extended straight line connecting the upper end of the torus tubarius (TT) and the roof of the FR. The distance from upper end of TT to the roof of FR measured 9.875 (±0.99) mm, and the distance from roof of the FR to the petrous apex measured 9.75 (±1) mm.

Conclusion With well-defined landmarks, the inferior, medial petrous apex can be reached using the endoscopic endonasal approach without crossing the sinus cavities.

Keywords

endoscopic endonasal approach - petrous apex - torus tubarius - fossa of Rosenmüller

• References

• 1 Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009; 119 (01) 19-25
• 2 Hofstetter CP, Singh A, Anand VK, Kacker A, Schwartz TH. The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave. J Neurosurg 2010; 113 (05) 967-974
• 3 Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 2008; 62 (05) 991-1002 ; discussion 1002–1005
• 4 Roth J, Singh A, Nyquist G. , et al. Three-dimensional and 2-dimensional endoscopic exposure of midline cranial base targets using expanded endonasal and transcranial approaches. Neurosurgery 2009; 65 (06) 1116-1128 ; discussion 1128–1130
• 5 Chatrath P, Nouraei SA, De Cordova J, Patel M, Saleh HA. Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study. Clin Otolaryngol 2007; 32 (04) 255-260
• 6 Paluzzi A, Gardner P, Fernandez-Miranda JC. , et al. Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients: clinical article. J Neurosurg 2012; 116 (04) 792-798
• 7 McLaughlin N, Kelly DF, Prevedello DM, Shahlaie K, Carrau RL, Kassam AB. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. J Neurol Surg B Skull Base 2012; 73 (03) 190-196
• 8 Van Gompel JJ, Alikhani P, Youssef AS, Loveren HR, Boyev KP, Agazzi S. Anterior petrosectomy: consecutive series of 46 patients with attention to approach-related complications. J Neurol Surg B Skull Base 2015; 76 (05) 379-384
• 9 Van Gompel JJ, Alikhani P, Tabor MH. , et al. Anterior inferior petrosectomy: defining the role of endonasal endoscopic techniques for petrous apex approaches. J Neurosurg 2014; 120 (06) 1321-1325
• 10 Jacquesson T, Berhouma M, Tringali S, Simon E, Jouanneau E. Which routes for petroclival tumors? A comparison between the anterior expanded endoscopic endonasal approach and lateral or posterior routes. World Neurosurg 2015; 83 (06) 929-936
• 11 Schaberg MR, Evans JJ, Rosen MR. Endoscopic approaches to the petrous apex. Oper Tech Otolaryngol Head Neck Surg 2011; 22 (04) 269-273
• 12 Kasemsiri P, Solares CA, Carrau RL. , et al. Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope 2013; 123 (04) 811-815
• 13 Romero ADCB, Gangadharan JL, Bander ED, Gobin YP, Anand VK, Schwartz TH. Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. Oper Neurosurg 2017; 13 (01) 138-149