Anatomical Limits of the Endoscopic Contralateral Transmaxillary Approach to the Petrous Apex and Petroclival Region

Abstract

Objectives This study aimed to establish the anatomical landmarks for performing a contralateral transmaxillary approach (CTM) to the petrous apex (PA) and petroclival region (PCR), and to compare CTM with a purely endoscopic endonasal approach (EEA).

Design EEA and CTM to the PA and PCR were performed bilaterally in eight human anatomical specimens. Surgical techniques and anatomical landmarks were described, and EEA was compared with CTM with respect to ability to reach the contralateral internal acoustic canal (IAC). Computed tomographic scans of 25 cadaveric heads were analyzed and the “angle” and “reach” of CTM and EEA were measured.

Results Entry to the PA via a medial approach was limited by (1) abducens nerve superiorly, (2) internal carotid artery (ICA) laterally, and (3) petroclival synchondrosis inferiorly (Gardner's triangle). With CTM, it was possible to reach the contralateral IAC bilaterally in all specimens dissected, without dissection of the ipsilateral ICAs, pterygopalatine fossae, and Eustachian tubes. Without CTM, reaching the contralateral IAC was possible only if: (1) angled endoscopes and instruments were employed or (2) the pterygopalatine fossa was dissected with mobilization of the ICA and resection of the Eustachian tube. The average “angle” and “reach” advantages for CTM were 25.6-degree greater angle of approach behind the petrous ICA and 1.4-cm more lateral reach.

Conclusion The techniques and anatomical landmarks for CTM to the PA and PCR are described. Compared with a purely EEA, the CTM provides significant “angle” and “reach” advantages for the PA and PCR.

Keywords

endoscopic endonasal approach - internal carotid artery - cholesterol granuloma - chordoma - chondrosarcoma - clivus - petrous apex - petroclival - surgical technique - transmaxillary

Note

Portions of this work were presented in poster format at the 28th Annual Meeting of the North American Skull Base Society, NASBS, Coronado, California, United States, February 16–18, 2018.

Publikationsverlauf

Eingereicht: 16. Mai 2020

Angenommen: 27. Juli 2020

Artikel online veröffentlicht:
10. September 2020

• References

• 1 Fournier HD, Mercier P, Roche PH. Surgical anatomy of the petrous apex and petroclival region. Adv Tech Stand Neurosurg 2007; 32: 91-146
• 2 Muto J, Prevedello DM, Ditzel Filho LFS. et al. Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg 2016; 125 (05) 1171-1186
• 3 Fernandez-Miranda JC, Morera VA, Snyderman CH, Gardner P. Endoscopic endonasal transclival approach to the jugular tubercle. Neurosurgery 2012;71(01, suppl operative ):146–158, discussion 158–159
• 4 Beer-Furlan A, Abi-Hachem R, Jamshidi AO, Carrau RL, Prevedello DM. Endoscopic trans-sphenoidal surgery for petroclival and clival meningiomas. J Neurosurg Sci 2016; 60 (04) 495-502
• 5 Koutourousiou M, Fernandez-Miranda JC, Vaz-Guimaraes Filho F. et al. Outcomes of endonasal and lateral approaches to petroclival meningiomas. World Neurosurg 2017; 99: 500-517
• 6 Jacquesson T, Simon E, Berhouma M, Jouanneau E. Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery. Surg Radiol Anat 2015; 37 (10) 1199-1207
• 7 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
• 8 Borghei-Razavi H, Truong HQ, Fernandes Cabral DT. et al. Endoscopic endonasal petrosectomy: anatomical investigation, limitations, and surgical relevance. Oper Neurosurg (Hagerstown) 2019; 16 (05) 557-570
• 9 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
• 10 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
• 11 Freeman JL, Sampath R, Quattlebaum SC. et al. Expanding the endoscopic transpterygoid corridor to the petroclival region: anatomical study and volumetric comparative analysis. J Neurosurg 2017; 128 (06) 1855-1864
• 12 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
• 13 Patel CR, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex. J Neurosurg 2017; 129 (01) 211-219
• 14 Pamias-Portalatin E, Mahato D, Rincon-Torroella J, Vivas-Buitrago T, Quiñones-Hinojosa A, Boahene KO. Endoscope-assisted contralateral transmaxillary approach to the clivus and the hypoglossal canal: technical case report. J Neurosurg 2018;
• 15 Snyderman CH, Gardner PA. Letter to the editor. Contralateral transmaxillary approach. J Neurosurg 2018; 130 (05) 1769-1771
• 16 Ryu G, So YK, Seo MY. et al. Using the nasoseptal flap for reconstruction after endoscopic debridement of radionecrosis in nasopharyngeal carcinoma. Am J Rhinol Allergy 2018; 32 (01) 61-65
• 17 Schilder AGM, Bhutta MF, Butler CC. et al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 2015; 40 (05) 407-411
• 18 Liu J, Pinheiro-Neto CD, Fernandez-Miranda JC. et al. Eustachian tube and internal carotid artery in skull base surgery: an anatomical study. Laryngoscope 2014; 124 (12) 2655-2664
• 19 Taniguchi M, Akutsu N, Mizukawa K, Kohta M, Kimura H, Kohmura E. Endoscopic endonasal translacerum approach to the inferior petrous apex. J Neurosurg 2016; 124 (04) 1032-1038
• 20 Simal-Julián J-A, Miranda-Lloret P, Beltrán-Giner A, Plaza-Ramirez E, Botella-Asunción C. Full endoscopic endonasal extreme far-medial approach: Eustachian tube transposition. J Neurosurg Pediatr 2013; 11 (05) 584-590
• 21 Dinç AE, Damar M, Uğur MB. et al. Do the angle and length of the eustachian tube influence the development of chronic otitis media?. Laryngoscope 2015; 125 (09) 2187-2192
• 22 Datta RK, Viswanatha B, Shree Harsha M. Caldwell Luc surgery: revisited. Indian J Otolaryngol Head Neck Surg 2016; 68 (01) 90-93