Endoscopic Endonasal Petrosectomy: Anatomical Investigation, Limitations, and Surgical Relevance

2018 ◽  
Vol 16 (5) ◽  
pp. 557-570 ◽  
Author(s):  
Hamid Borghei-Razavi ◽  
Huy Q Truong ◽  
David T Fernandes Cabral ◽  
Xicai Sun ◽  
Emrah Celtikci ◽  
...  
Keyword(s):  
Abducens Nerve ◽  
Jugular Foramen ◽  
Petrous Apex ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Computed Tomographic ◽  
Alternative Approach ◽  
Computed Tomographic Scan ◽  
Internal Acoustic Canal

Abstract BACKGROUND The endoscopic endonasal approach (EEA) was recently added to the neurosurgical armamentarium as an alternative approach to the petrous apex (PA) region. However, the maximal extension, anatomical landmarks, and indications of this procedure remain to be established. OBJECTIVE To investigate the limitations and suggest a classification of PA lesions for endoscopic petrosectomy. METHODS Five anatomical specimens were dissected with EEA to the PA. Anatomical landmarks for the surgical steps and maximal limits were noted. Pre- and postprocedural computed tomographic scan and image-guidance were used. Relevant surgical cases were reviewed and presented. RESULTS We defined 3 types of petrosectomy: medial, inferior, and inferomedial. Medial petrosectomy was limited within the paraclival internal carotid artery (ICA) anteriorly, lacerum ICA inferiorly, abducens nerve superiorly, and petrous ICA laterally. Among those, abducens nerve and petrous ICA are surgical limits. Full skeletonization of the paraclival ICA and removal of the lingual process are essential for better access to the medial aspect of PA. Inferior petrosectomy was defined by the lacerum foramen synchondrosis anteriorly, jugular foramen inferiorly, internal acoustic canal posteriorly, and PA superolaterally. Those are surgical limits except for the foramen lacerum synchondrosis. The connective tissue at the pterygosphenoidal fissure was a key landmark for the sublacerum approach. Clinical cases in 3 types of PA lesions were presented. CONCLUSION The EEA provides access to the medial and inferior aspects of the PA. Several technical maneuvers, including paraclival and lacerum ICA skeletonization, sublacerum approach, and lingual process removal, are key to maximize PA drilling.

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

2020 ◽  
Author(s):  
João Mangussi-Gomes ◽  
João T. Alves-Belo ◽  
Huy Q. Truong ◽  
Gustavo F. Nogueira ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Surgical Techniques ◽  
Abducens Nerve ◽  
Petrous Apex ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Medial Approach ◽  
Petroclival Region ◽  
Computed Tomographic ◽  
Average Angle ◽  
Internal Acoustic Canal

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.

Comparison of Endoscopic Endonasal Approach and Lateral Microsurgical Infratemporal Fossa Approach to the Jugular Foramen: An Anatomical Study

2021 ◽  
Author(s):  
Jianfeng Liu ◽  
Carlos D. Pinheiro-Neto ◽  
Dazhang Yang ◽  
Eric Wang ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Infratemporal Fossa ◽  
Deep Understanding ◽  
Type A ◽  
Jugular Foramen ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Complex Anatomy

Abstract Objective The jugular foramen is one of the most challenging surgical regions in skull base surgery. With the development of endoscopic techniques, the endoscopic endonasal approach (EEA) has been undertaken to treat some lesions in this area independently or combined with open approaches. The purpose of the current study is to describe the anatomical steps and landmarks for the EEA to the jugular foramen and to compare it with the degree of exposure obtained with the lateral infratemporal fossa approach. Materials and Methods A total of 15 osseous structures related to the jugular foramen were measured in 33 adult dry skulls. Three silicone-injected adult cadaveric heads (six sides) were dissected for EEA and three heads (six sides) were used for a lateral infratemporal fossa approach (Fisch type A). The jugular foramen was exposed, relevant landmarks were demonstrated, and the distances between relevant landmarks and the jugular foramen were obtained. High-quality pictures were obtained. Results The jugular foramen was accessed in all dissections by using either approach. Important anatomical landmarks for EEA include internal carotid artery (ICA), petroclival fissure, inferior petrosal sinus, jugular tubercle, and hypoglossal canal. The EEA exposed the anterior and medial parts of the jugular foramen, while the lateral infratemporal fossa approach (Fisch type A) exposed the lateral and posterior parts of the jugular foramen. With EEA, dissection and transposition of the facial nerve was avoided, but the upper parapharyngeal and paraclival ICA may need to be mobilized to adequately expose the jugular foramen. Conclusion The EEA to the jugular foramen is anatomically feasible but requires mobilization of the ICA to provide access to the anterior and medial aspects of the jugular foramen. The lateral infratemporal approach requires facial nerve transposition to provide access to the lateral and posterior parts of the jugular foramen. A deep understanding of the complex anatomy of this region is paramount for safe and effective surgery of the jugular foramen. Both techniques may be complementary considering the different regions of the jugular foramen accessed with each approach.

scholarly journals Endoscopic endonasal translacerum approach to the inferior petrous apex

2016 ◽  
Vol 124 (4) ◽  
pp. 1032-1038 ◽  
Author(s):  
Masaaki Taniguchi ◽  
Nobuyuki Akutsu ◽  
Katsu Mizukawa ◽  
Masaaki Kohta ◽  
Hidehito Kimura ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Surgical Simulation ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Petrous Apex ◽  
Partial Removal ◽  
Endoscopic Endonasal ◽  
Anatomical Features ◽  
Petrous Portion ◽  
Sufficient Space

OBJECT The surgical approach to lesions involving the inferior petrous apex (IPA) is still challenging. The purpose of this study is to demonstrate the anatomical features of the IPA and to assess the applicability of an endoscopic endonasal approach through the foramen lacerum (translacerum approach) to the IPA. METHODS The surgical simulation of the endoscopic endonasal translacerum approach was conducted in 3 cadaver heads. The same technique was applied in 4 patients harboring tumors involving the IPA (3 chordomas and 1 chondro-sarcoma). RESULTS By removing the fibrocartilaginous component of the foramen lacerum, a triangular space was created between the anterior genu of the petrous portion of the carotid artery and the eustachian tube, through which the IPA could be approached. The range of the surgical maneuver reached laterally up to the internal auditory canal, jugular foramen, and posterior vertical segment of the petrous portion of the carotid artery. In clinical application, the translacerum approach provided sufficient space to handle tumors at the IPA. Gross-total and partial removal was achieved in 3 and 1 cases, respectively, without permanent surgery-related morbidity and mortality. CONCLUSIONS The endoscopic endonasal translacerum approach provides reliable access to the IPA. It is indicated alone for lesions confined to the IPA and in combination with other approaches for more extensive lesions.

Anterior inferior petrosectomy: defining the role of endonasal endoscopic techniques for petrous apex approaches

2014 ◽  
Vol 120 (6) ◽  
pp. 1321-1325 ◽  
Author(s):  
Jamie J. Van Gompel ◽  
Puya Alikhani ◽  
Mark H. Tabor ◽  
Harry R. van Loveren ◽  
Sivero Agazzi ◽  
...  
Keyword(s):  
3D Modeling ◽  
Jugular Foramen ◽  
Contralateral Side ◽  
Petrous Apex ◽  
Endoscopic Endonasal ◽  
Endoscopic Techniques ◽  
Inferior Portion ◽  
Anterior Petrosectomy ◽  
Superior Portion

Object Historically, surgery to the petrous apex has been addressed via craniotomy and open microscopic anterior petrosectomy (OAP). However, with the popularization of endoscopic approaches, the petrous apex can further be approached endonasally by way of an endoscopic endonasal anterior petrosectomy (EAP). Endonasal anterior petrosectomy is a relatively new procedure and has not been compared anatomically with OAP. The authors hypothesized that the EAP and OAP techniques approach different portions of the petrous apex and therefore may have different applications. Methods Four cadaveric heads were used. An OAP was performed on one side and an EAP was performed on the contralateral side; the limits of bony resection were defined. The extent of bony resection was then evaluated using predissection and postdissection thin-slice CT scans. The comparative resection was then reconstructed using 3D modeling on Brainlab workstations. Results The average resection volumes for EAP and OAP were 0.297 cm3 and 0.649 cm3, respectively, representing a comparative percentage of 46% (EAP/OAP). An EAP and OAP achieved resection of 29% and 64% of the total petrous apex volume, respectively. Indeed, EAP addressed the inferior portion of the petrous apex located adjacent to the petroclival suture more completely than OAP, where 45% of the bone overlying the petroclival suture (petroclival angle to the jugular foramen) was resected with the EAP, while 0% was resected with the OAP. Conclusions In anatomically normal cadavers, OAP achieved nearly a 50% larger volumetric resection than EAP. Furthermore, while OAP appears to completely address the superior portion of the petrous apex, EAP appears to have a niche in approaches to lesions in the inferior petrous apex. Given these results, the authors propose that OAP be redefined as the “superior anterior petrosectomy,” while EAP be referred to as the “inferior anterior petrosectomy,” which more clearly defines the role of each approach in anterior petrosectomy.

scholarly journals Modified classification of infralabyrinthie cholesteatoma and scale of cholesteatoma extention

2020 ◽  
pp. 86-94
Author(s):  
K. M. Diab ◽  
O. S. Panina ◽  
O. A. Pashchinina
Keyword(s):  
Temporal Bone ◽  
Surgical Approach ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Jugular Foramen ◽  
Petrous Apex ◽  
Occipital Condyle ◽  
Epidermal Cyst ◽  
Scientific Center

Introduction. Petrous temporal bone (PTB) cholesteatoma is an epidermal cyst, which is the result of uncontrolled growth of keratinizing squamous epithelium in the petrous part of the temporal bone. Cholesteatoma is classified into congenital, acquired, and iatrogenic.Objective. To discuss the classification of infralabyrinthine petrous bone cholesteatoma (PBC), add modified classificationand to propose adequate differential surgical management.Methods. The setting was a National Medical Scientific Center of Otorhinolaryngology FMBA (Russia). The data of 14 patients who underwent surgery for different variations of infralabyrinthine PBC from 2017 till 2020 were analyzed and included into the study (with respect to localization type of the approach used, complications, recurrences and outcome). The follow-up period ranged from 6 to 34 months with a median of 18 months.Results. Based on preoperative CT scans and intraoperative findings a Scale of Cholesteatoma extension CLIF(APO) and Modified classification of infralabyrinthine cholesteatoma (in relation to mastoid segment of the facial nerve) are proposed. The scale includes the main anatomical structures of the temporal bone and the adjacent parts of the occipital and sphenoid bones, which may be involved in the cholesteatoma process: cochlea, vestibule and semicircular canals, internal auditory canal, jugular foramen, bony chanal of the internal carotid artery, petrous apex, occipital condyle. Based on the modified classification and scale we present an algorithm for decision making and surgical approach choosing.Conclusion. The implementation of the Scale of Cholesteatoma Extension in Otology and Radiology practice will allow to preoperatively diagnose the extension of PBC, unify the data of the localization of cholesteatoma; allows standardization in reporting and continuity at all stages of treatment. The modified classification proposed by us in this article facilitate the algorithm for selecting the type of surgical approach and determine whether to perform less aggressive combined microscopic approaches with endoscopic control.

Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region

2016 ◽  
Vol 125 (5) ◽  
pp. 1171-1186 ◽  
Author(s):  
Jun Muto ◽  
Daniel M. Prevedello ◽  
Leo F. S. Ditzel Filho ◽  
Ing Ping Tang ◽  
Kenichi Oyama ◽  
...  
Keyword(s):  
Abducens Nerve ◽  
Direct Access ◽  
Petrous Apex ◽  
Horizontal Line ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Petroclival Region ◽  
Advantages And Disadvantages ◽  
Anterior Transpetrosal Approach

OBJECTIVE The endoscopic endonasal approach (EEA) offers direct access to midline skull base lesions, and the anterior transpetrosal approach (ATPA) stands out as a method for granting entry into the upper and middle clival areas. This study evaluated the feasibility of performing EEA for tumors located in the petroclival region in comparison with ATPA. METHODS On 8 embalmed cadaver heads, EEA to the petroclival region was performed utilizing a 4-mm endoscope with either 0° or 30° lenses, and an ATPA was performed under microscopic visualization. A comparison was executed based on measurements of 5 heads (10 sides). Case illustrations were utilized to demonstrate the advantages and disadvantages of EEA and ATPA when dealing with petroclival conditions. RESULTS Extradurally, EEA allows direct access to the medial petrous apex, which is limited by the petrous and paraclival internal carotid artery (ICA) segments laterally. The ATPA offers direct access to the petrous apex, which is blocked by the petrous ICA and abducens nerve inferiorly. Intradurally, the EEA allows a direct view of the areas medial to the cisternal segment of cranial nerve VI with limited lateral exposure. ATPA offers excellent access to the cistern between cranial nerves III and VIII. The quantitative analysis demonstrated that the EEA corridor could be expanded laterally with an angled drill up to 1.8 times wider than the bone window between both paraclival ICA segments. CONCLUSIONS The midline, horizontal line of the petrous ICA segment, paraclival ICA segment, and the abducens nerve are the main landmarks used to decide which approach to the petroclival region to select. The EEA is superior to the ATPA for accessing lesions medial or caudal to the abducens nerve, such as chordomas, chondrosarcomas, and midclival meningiomas. The ATPA is superior to lesions located posterior and/or lateral to the paraclival ICA segment and lesions with extension to the middle fossa and/or infratemporal fossa. The EEA and ATPA are complementary and can be used independently or in combination with each other in order to approach complex petroclival lesions.

scholarly journals Contralateral Transmaxillary Approach for Resection of Chondrosarcoma of the Petrous Apex: A Case Report

2021 ◽  
pp. 014556132098216
Author(s):  
Jesse D. Lawrence ◽  
Robert Marsh ◽  
Meghan T. Turner
Keyword(s):  
Abducens Nerve ◽  
Petrous Apex ◽  
Lytic Lesion ◽  
Adjuvant Radiation ◽  
Low Grade ◽  
Endoscopic Endonasal ◽  
Postoperative Mri ◽  
Novel Approach ◽  
Magnetic Resonance Imaging Mri

Background: Deep location and neurovascular structures make access to lesions of the petrous apex a significant challenge. A novel approach for these tumors is the contralateral transmaxillary approach. Clinical Presentation: A 31-year-old male was evaluated for left abducens nerve palsy. Magnetic resonance imaging (MRI) and computed tomography revealed an enhancing, lytic lesion of the petrous apex with extension to the cavernous sinus and petroclival junction. The patient underwent a combined endoscopic contralateral transmaxillary and endoscopic endonasal transclival approach for resection of the lesion. No new or worsening neurologic deficits were noted following the procedure. Pathology revealed low-grade chondrosarcoma (grade I). Postoperative MRI revealed gross total resection of the lesion. Patient underwent adjuvant radiation therapy at the discretion of radiation oncology. Conclusion: The contralateral transmaxillary approach to the petrous apex allows for resection of lesions of the petrous apex with the ability to extend the dissection laterally. Excellent results achieved by institutions with advanced extended endoscopic endonasal experience can be reproduced in institutions with less experience. Further characterization of the risks and benefits of this approach is needed.

Supratotal Resection of Residual Clival Chordoma With Combined Endoscopic Endonasal and Contralateral Transmaxillary Approaches: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (3) ◽  
pp. E88-E89 ◽  
Author(s):  
Philippe Lavigne ◽  
Eric W Wang ◽  
Juan C Fernandez-Miranda
Keyword(s):  
Skull Base ◽  
Surgical Resection ◽  
Abducens Nerve ◽  
Surgical Anatomy ◽  
Petrous Apex ◽  
Complication Rates ◽  
Curative Intent ◽  
Endoscopic Endonasal ◽  
Clival Chordoma ◽  
Supratotal Resection

Abstract The optimal treatment for skull base chordomas is gross total resection followed by radiotherapy and not radiation of partially resected tumors. Supratotal resection, defined as removal beyond all involved bone and dura, is ideal but difficult to achieve.  In this video, we present the case of a 37-yr-old man with new onset of progressive cranial nerve sixth palsy and a skull base lesion compatible with clival chordoma. He underwent partial surgical resection at an outside institution via transcranial approach, with significant tumor residual at the clivus, dorsum sella, posterior clinoids, and petrous apex, extensive dural invasion, and intradural extension with attachment to the basilar artery and its long perforating branches.  Supratotal surgical resection was achieved using an endoscopic endonasal transclival approach, ipsilateral transpteryoid approach to the foramen lacerum for carotid artery mobilization, bilateral interdural transcavernous approach with posterior clinoidectomies, and con-tralateral transmaxillary approach to the petrous apex. Reconstruction was performed in a multilayer fashion with fascia lata and fat grafts, extended nasoseptal flap, a lumbar drainage for 3 d. No cerebrospinal fluid leak occurred, and the abducens nerve palsy significantly improved at 3-mo follow-up. Proton therapy is planned.  Recent advances in endoscopic endonasal surgery allow for very high rates of complete and even supratotal resection despite the challenging location. A long learning curve to acquire the technical skills and complex surgical anatomy is required to decrease complication rates and achieve maximal resection in chordomas. Reoperations are more challenging and risky; therefore, first attempt should have curative intent.  The patient signed informed consent including the use of photographic and video material for educational or academic purposes

scholarly journals Chondrosarcoma in the Petrous Apex: Case Report and Review

2018 ◽  
Vol 79 (04) ◽  
pp. e83-e87 ◽  
Author(s):  
F. Banaz ◽  
I. Edem ◽  
I. Moldovan ◽  
S. Kilty ◽  
G. Jansen ◽  
...  
Keyword(s):  
Surgical Procedure ◽  
Nerve Palsy ◽  
Tumor Resection ◽  
Abducens Nerve ◽  
Abducens Nerve Palsy ◽  
Guidance System ◽  
Petrous Apex ◽  
Endoscopic Endonasal ◽  
Invasive Approach ◽  
Number Of Patients

Introduction Surgical treatment of petrous apex chondrosarcoma is challenging due to the location of the tumor. Using an endoscopic technique for tumor resection is favored since it provides a minimally invasive approach. Case Presentation A 57 years old female was admitted for acute onset of left abducens nerve palsy and occasional headache mainly on the left side of the retro-orbital area with some radiation to the left occiput. Magnetic resonance imaging (MRI) and computed tomography (CT), at the time of admission, were showed lytic lesion on the left petrous apex and left part of the clivus. Results of metastatic workup were negative. The surgical procedure considered was expanded endoscopic endonasal transclival approach to the left of the petrous apex and reconstruction with a pedicled nasoseptal flap with image guidance system. The pathology confirmed chondrosarcoma on myxoid background. The surgical procedure was uncomplicated. The abducens nerve palsy was resolved in few weeks and no new deficits occurred. Postoperative MRI showed complete resection of the tumor. Conclusion Expanded endoscopic endonasal transclival approach to petrous apex and reconstruction appears to be safe and feasible technique, capable of achieving total removal of identified lesions near the petrous apex. Nonetheless, future studies with a greater number of patients are crucial to confirm and consolidate this initial impression.

The Abducens Nerve: Microanatomic and Endoscopic Study

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-7-ONS-14 ◽  
Author(s):  
Giorgio Iaconetta ◽  
Mario Fusco ◽  
Luigi M. Cavallo ◽  
Paolo Cappabianca ◽  
Madjid Samii ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Rectus Muscle ◽  
Abducens Nerve ◽  
Nerve Injuries ◽  
Endoscopic Endonasal ◽  
Lateral Rectus Muscle ◽  
Endoscopic Study ◽  
Anatomic Dissection ◽  
Neurovascular Structures

Abstract Objective: Only a few anatomic studies concerning the intra- or extracranial course of the abducens nerve (Cranial Nerve VI) have been reported. This is likely because the nerve passes through anatomically intricate areas, making its neurovascular relationships complex. Here we provide an anatomically and surgically oriented classification of the abducens nerve, analyze the microanatomy of the nerve and the surrounding connective and/or neurovascular structures, and provide measurements and anatomic topography. Patients and Methods: A microsurgical anatomic dissection of 55 cadaveric human heads was performed using different skull base approaches to explore the entire course of the VIth cranial nerve, from its origin at the pontomedullary sulcus to the lateral rectus muscle. We then approached the same areas via an endoscopic endonasal transsphenoidal route, analyzed the neurovascular relationships from an anteromedial perspective, and made comparisons with the microsurgical views. Results: The abducens nerve is divided into five segments, of which three are intracranial (cisternal, gulfar, and cavernous) and two are orbital (fissural and intraconal). Using two opposing surgical routes (microsurgical transcranial and endoscopic endonasal approaches) allows us to clearly reveal the spatial relationships of the abducens nerve with other neurovascular structures on the different nerve segments. Conclusion: The classification of five segments for the abducens nerve seems anatomically valid and is surgically oriented with respect to both the microscopic and endonasal endoscopic approaches. It would be useful to explain, segment by segment, the pathogenic mechanism(s) for nerve injuries that are evidenced by lesions that exist along the entire intra- and extracranial course.

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