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Donofrio CA, Corrivetti F, Riccio L, Corvino S, Dallan I, Fioravanti A, de Notaris M. Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications. J Clin Med 2024; 13:2713. [PMID: 38731242 PMCID: PMC11084429 DOI: 10.3390/jcm13092713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
The endoscopic contralateral transmaxillary (CTM) approach has been proposed as a potential route to widen the corridor posterolateral to the internal carotid artery (ICA). In this study, we first refined the surgical technique of a combined multiportal endoscopic endonasal transclival (EETC) and CTM approach to the petrous apex (PA) and petroclival synchondrosis (PCS) in the dissection laboratory, and then validated its applications in a preliminary surgical series. The combined EETC and CTM approach was performed on three cadaver specimens based on four surgical steps: (1) the nasal, (2) the clival, (3) the maxillary and (4) the petrosal phases. The CTM provided a "head-on trajectory" to the PA and PCS and a short distance to the surgical field considerably furthering surgical maneuverability. The best operative set-up was achieved by introducing angled optics via the endonasal route and operative instruments via the transmaxillary corridor exploiting the advantages of a non-coaxial multiportal surgery. Clinical applications of the combined EETC and CTM approach were reported in three cases, a clival chordoma and two giant pituitary adenomas. The present translational study explores the safety and feasibility of a combined multiportal EETC and CTM approach to access the petroclival region though different corridors.
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Affiliation(s)
- Carmine Antonio Donofrio
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Faculty of Medicine, University of Brescia, 25121 Brescia, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
| | - Lucia Riccio
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
| | - Sergio Corvino
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy
| | - Iacopo Dallan
- Otorhinolaryngology, Audiology and Phoniatrics Operative Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Antonio Fioravanti
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
| | - Matteo de Notaris
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy
- Otorhinolaryngology, Audiology and Phoniatrics Operative Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
- Department of Neurosurgery, San Luca Hospital, Vallo della Lucania, 84078 Salerno, Italy
- Unit of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, 84131 Salerno, Italy
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Karadag A, Yuncu ME, Middlebrooks EH, Tanriover N. Endoscopic trans-eustachian tube approach: identifying the precise landmarks, a novel radiological and anatomical evaluation. Surg Radiol Anat 2024; 46:625-634. [PMID: 38530385 DOI: 10.1007/s00276-024-03344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE The endoscopic trans-eustachian approach (ETETA) is a less invasive approach to the infratemporal fossa (ITF), providing superior exposure compared to traditional transcranial approaches. The anatomy of the pharyngotympanic (eustachian) tube and adjacent neurovascular structures is complex and requires in-depth knowledge to safely perform this approach. We present a cadaveric and radiological assessment of critical anatomic considerations for ETETA. METHODS Six adult cadaveric heads were dissected alongside examination of 50 paranasal sinus CT scans. Key anatomic relationships of the pharyngotympanic tube and adjacent structures were qualitatively and quantitatively evaluated. Descriptive statistics were performed for quantitative data. RESULTS Anatomical and radiological measurements showed lateralization of the pharyngotympanic tube allows access to the ITF. The pharyngotympanic tube has bony and cartilaginous parts with the junction formed by the sphenoid spine and foramen spinosum. The bony part and tendon of the tensor tympani muscle were located at the posterior genu of the internal carotid artery. The anterior and inferior wall of the carotid canal was located between the horizontal segment of the internal carotid artery and petrous segment of the cartilaginous pharyngotympanic tube. CONCLUSION The combination of preoperative radiographic assessment and anatomical correlation demonstrates a safe and effective approach to ETETA, which allowed satisfactory visualization of ITF. The morphological evaluation showed that the lateralization of the pharyngotympanic tube and related structures allowed a surgical corridor to reach the ITF. Endoscopic surgery through the pharyngotympanic tube is challenging, and in-depth understanding of the key anatomic relationships is critical for performing this approach.
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Affiliation(s)
- Ali Karadag
- Izmir Faculty of Medicine, Department of Neurosurgery, University of Health Sciences, Izmir, Turkey.
- Department of Neurosurgery, Izmir City Hospital, Laka, Bornova / Izmir, 35040, Turkey.
| | - Mustafa Eren Yuncu
- Department of Neurosurgery, Izmir City Hospital, Laka, Bornova / Izmir, 35040, Turkey
| | - Erik H Middlebrooks
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Cerrahpasa Faculty of Medicine, Department of Neurosurgery, Istanbul University - Cerrahpasa, Istanbul, Turkey
- Cerrahpasa Faculty of Medicine, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul University - Cerrahpasa, Istanbul, Turkey
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Agosti E, Rezende NC, Leonel LCPC, Alexander AY, Pinheiro-Neto CD, Peris-Celda M. Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches. J Neurol Surg B Skull Base 2024; 85:81-94. [PMID: 38274480 PMCID: PMC10807960 DOI: 10.1055/s-0042-1759874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/07/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction The endoscopic endonasal transpterygoid approach (EETPA) with or without the addition of the endoscopic-assisted sublabial anterior transmaxillary approach (ESTA) has become increasingly utilized for lesions posterior to the pterygopalatine fossa (PPF), including infratemporal fossa (ITF), lateral recess of the sphenoid sinus, Meckel's cave, petrous apex, and parapharyngeal space. The main goal of this study is to develop an educational resource to learn the steps of the EETPA for trainees. Methods EETPA and ESTA were performed in 12 specimens by neurosurgery trainees, under supervision from the senior authors. One EETPA and one ESTA were performed on each specimen on opposite sides. Dissections were supplemented with representative cases. Results After a wide unilateral sphenoidotomy, ethmoidectomy, and partial medial maxillectomy, the anteromedial bone limits of the PPF were identified and drilled out. The pterygoid progress was modularly removed. By enlarging the opening of the posterior and lateral walls of the maxillary sinus through EETPA and ESTA, respectively, the neurovascular and muscular compartments of the PPF and ITF were better identified. The EETPA opens direct corridors to the PPF, medial ITF, middle cranial fossa, cavernous sinus, Meckel's cave, petrous apex, and internal carotid artery. If a more lateral exposure of the ITF is needed, the ESTA is an appropriate addition. Conclusion Despite the steep learning curve of the EETPA, granular knowledge of its surgical anatomy and basic surgical steps are vital for those advancing their learning in complex endoscopic approaches to the ventral skull base when expanding the approach laterally in the coronal plane.
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Affiliation(s)
- Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Natália Cerqueira Rezende
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - A. Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Carlos D. Pinheiro-Neto
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Cao Z, Wang T, Lin B, Cai B, Peng H, Liu H, Liao J. Infratemporal Fossa Schwannoma Surgery via a Combined Prelacrimal Recess, Caldwell-Luc, and Distal Intraoral Approach. J Craniofac Surg 2024:00001665-990000000-01311. [PMID: 38299847 DOI: 10.1097/scs.0000000000009947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/19/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND The deep location of infratemporal fossa (ITF) combined with the abundant vascular plexus in it increased the difficulty of removing the mass in ITF through endoscope surgery approach. However, under appropriate circumstances, the excision of ITF tumors through a combined prelacrimal recess, Caldwell-Luc, and distal intraoral approach can be safely performed with minimal impact on the surrounding tissues. CASE PRESENTATION The Department of Neurology received a 69-year-old male patient who had been experiencing headache, dizziness, and numbness from the mastoid region of his left ear to the corner of his mouth for a duration of 22 days. Cranial magnetic resonance imaging revealed the presence of a tumor located in the ITF. Following transfer to our department, surgical intervention was performed using a combined approach involving the prelacrimal recess, the anterior wall of maxillary sinus, and lateral ITF to successfully remove the tumor. Postoperative pathologic examination confirmed schwannoma as its nature. The patient was discharged in excellent condition without any functional impairment. CONCLUSIONS On the basis of this case, the authors believe that this combined approach can offer a distinct endoscopic perspective and adequate surgical workspace, which is crucial for tumor removal while preserving the integrity of surrounding normal tissues. Moreover, the utilization of multiple small incisions has minimal impact on postoperative recovery.
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Affiliation(s)
- Zhiwen Cao
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
- Department of Otolaryngology-Head and Neck Surgery, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Tianyu Wang
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
| | - Bojian Lin
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
| | - Boyu Cai
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
| | - Hu Peng
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
| | - Huanhai Liu
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
| | - Jianchun Liao
- Department of Otolaryngology-Head and Neck Surgery, Second Affiliated Hospital of Naval Medical University
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Liu J, Yang Z, Lu B, Bi Z, Liu P. An endoscopic transnasal prelacrimal recess transmaxillary approach to the pterygopalatine fossa and infratemporal fossa. Front Surg 2023; 10:1264847. [PMID: 38033534 PMCID: PMC10687372 DOI: 10.3389/fsurg.2023.1264847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Objective In this paper, the goal of the authors is to present the anatomic nuances and their clinical experience with lesions of the pterygopalatine fossa and infratemporal fossa using an endoscopic transnasal prelacrimal recess transmaxillary approach (PLRMA). Methods An endoscopic anatomical dissection of three fresh cadaveric heads was performed bilaterally to evaluate the feasibility of the PLRMA. Prior to dissection, stereotactic computed tomography scans were obtained for each head to obtain anatomical measurements. The area of exposure on the posterior wall of the maxillary sinus was determined using stereotaxis. The cases of six patients with schwannomas or epidermoid cysts who underwent the transnasal PLRMA were illustrated. Results The mean area of exposure on the posterior wall of the maxillary sinus was 9.55 cm2. Total resection was achieved in all six patients. The mean follow-up time was 16 months, and one patient complained of postoperative facial numbness, which resolved gradually. No cases of chronic sinusitis were reported. Conclusions The endoscopic transnasal PLRMA provides efficient operative exposure to the pterygopalatine fossa and infratemporal fossa. Preserving the integrity of the mucosa on the nasal lateral wall is an advantage of this approach.
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Affiliation(s)
- Jian Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Lu
- Department of Neurosurgery, Tangshan Gongren Hospital, Tangshan, China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Finger G, Gun R, Wu KC, Carrau RL, Prevedello DM. Endoscopic Endonasal Transpterygoid Approach: Technical Lessons. Oper Neurosurg (Hagerstown) 2023; 25:e272. [PMID: 37350591 DOI: 10.1227/ons.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/03/2023] [Indexed: 06/24/2023] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE The endoscopic endonasal transpterygoid approach (EETPA) provides direct access to the petrous apex, lateral clivus, inferior cavernous sinus compartment, jugular foramen, and infratemporal fossa. 1,2 In the coronal plane, it provides exposure far beyond a traditional sphenoidotomy. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT The pterygoid process of the sphenoid bone forms the junction between the body and greater sphenoid wing before bifurcating because it descends into medial and lateral plates. The key to this exposure lies in the region's bony foramina: the palatovaginal canal, vidian canal, and foramen rotundum. 3. ESSENTIALS STEPS OF THE PROCEDURE After performing a maxillary antrostomy, stepwise exposure of these foramina leads to the pterygopalatine fossa. The sphenopalatine artery is cauterized as it becomes the posterior septal artery at the sphenopalatine foramen, and the maxillary sinus' posterior wall is opened to expose the pterygopalatine fossa. After mobilizing and retracting the contents of the pterygopalatine fossa, the pterygoid process is removed, improving access in the coronal plane. 4. PITFALLS/AVOIDANCE OF COMPLICATIONS Vidian neurectomy causes decreased or absent lacrimation. Injury to the maxillary nerve or its branches results in facial, palatal, or odontogenic anesthesia or neuralgia. In addition, the EEPTA precludes the ability to raise an ipsilateral nasal septal flap, making it crucial to plan reconstruction preoperatively. 4,5. VARIANTS AND INDICATIONS FOR THEIR USE There are 5 variants of the EEPTA: extended pterygopalatine fossa, lateral recess of the sphenoid sinus, petrous apex, infratemporal fossa and petrous carotid artery, and middle and posterior skull base. 5The patient consented to the procedure.Images in the video used with permission as follows: images at 0:33 and 1:15 reused from Bozkurt et al, 3 © Georg Thieme Verlag KG; image at 0:39 from Prosser et al, 5 © John Wiley and Sons; images at 0:54, 9:03, and 9:38 from Kasemsiri et al, 1 © John Wiley and Sons; images at 1:07 and 9:44 from Falcon et al, 2 © John Wiley and Sons; image at 1:15 from Sandu et al, 4 © Springer Nature.
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Affiliation(s)
- Guilherme Finger
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ramazan Gun
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Alqurashi A, Albaharna H, Alshareef M, Noor Elahi B, Alromaih S, Alrasheed A, Alroqi A, Alsaleh S, Ajlan A. Classification of Endoscopic Transnasal Lateral Skull Base Approaches: Anatomical Study. World Neurosurg 2023; 173:e559-e570. [PMID: 36842530 DOI: 10.1016/j.wneu.2023.02.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
OBJECTIVE Endoscopic transnasal approaches (ETAs) to the ventrolateral skull base are commonly classified according to coronal planes or anatomical structures. Our goal is to simplify the description of the ETA to lateral skull base regions in a sequential dissection with correlation to computed tomography, helping in preoperative planning and efficient surgical exposure, and exposing the surgical anatomy limitations. METHODS Five freshly injected cadaver heads were dissected using an extended ETA to the lateral skull base. Each specimen underwent a high-resolution computed tomography scan. A classification of the lateral skull base based on well-defined zones was proposed. RESULTS We divided the lateral target into four different zones, in a craniocaudal orientation: zone 1 is the space lying between the orbital floor superior and the level of the sellar floor inferior, zone 2 is on the coronal plane, located between the level of the sellar floor and the vidian canal, zone 3 is the area lateral to the anterior limb of the petro-occipital fissure, located between the vidian canal and the carotid canal, and zone 4 is the space located between the carotid canal and the extracranial opening of the hypoglossal canal, lateral to the anterior part of the posterior limb of petro-occipital fissure. CONCLUSIONS Multiple previous works have described and classified the coronal plane and its lateral extensions. Our classification system for the proposed lateral zones enables preoperative planning to select a suitable approach. The craniocaudal orientation facilitates the understanding of surgical corridors and tailored exposure.
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Affiliation(s)
- Ashwag Alqurashi
- Division of Neurosurgery, Department of Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hussain Albaharna
- Department of Otolaryngology-Head & Neck Surgery, Qatif Central Hospital, Qatif, Saudi Arabia
| | - Mohammad Alshareef
- Department of Otolaryngology-Head & Neck Surgery, Khamis Mushait General Hospital, Khamis Mushait, Saudi Arabia
| | - Basim Noor Elahi
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alrasheed
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Ahmad Alroqi
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Li L, London NR, Kim LR, Prevedello DM, Carrau RL. Endonasal access to the lateral poststyloid space: Far lateral extension of an endoscopic endonasal corridor. Head Neck 2022; 44:2342-2349. [PMID: 35766255 PMCID: PMC9543384 DOI: 10.1002/hed.27135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 05/09/2022] [Accepted: 06/16/2022] [Indexed: 12/20/2022] Open
Abstract
The styloid process constitutes the posterolateral boundary for an endonasal exposure of the infratemporal fossa. This study aims to explore the feasibility of a far-lateral extension to the lateral poststyloid space via an endonasal corridor. An endonasal dissection was performed on six cadaveric specimens (12 sides). Following an endoscopic endonasal access to the parapharyngeal space, the styloid process and the tympanic portion of the temporal bone were removed to reveal the jugular bulb and the extratemporal facial nerve. Distances from the anterior nasal spine to the relevant landmarks were measured using a surgical navigation device. Through an endonasal corridor, only the anteroinferior aspect of the jugular bulb was exposed. Conversely, the extratemporal facial nerve could be sufficiently exposed, and the deep temporal nerve could be transposed to the stylomastoid foramen. The average horizontal distances from the nasal spine to the posterior tract of V3 , styloid process, and facial nerve were 79.33 ± 3.41, 97.10 ± 4.74, and 104.77 ± 4.42 mm, respectively. Access to the lateral poststyloid space via an endonasal corridor is feasible, potentially providing an alternative approach to address select lesions extending to this region. The deep temporal nerve has a similar diameter to that of the facial nerve; thus, providing potential reinnervation of the facial nerve.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology - Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Nyall R London
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Leslie R Kim
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Daniel M Prevedello
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
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Zoli M, Sollini G, Zaccagna F, Fabbri VP, Cirignotta L, Rustici A, Guaraldi F, Asioli S, Tonon C, Pasquini E, Mazzatenta D. Infra-Temporal and Pterygo-Palatine Fossae Tumors: A Frontier in Endoscopic Endonasal Surgery—Description of the Surgical Anatomy of the Approach and Report of Illustrative Cases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116413. [PMID: 35681999 PMCID: PMC9180479 DOI: 10.3390/ijerph19116413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
Infratemporal and pterygopalatine fossae (ITF and PPF) represent two complex paramedian skull base areas, which can be defined as jewelry boxes, containing a large number of neurovascular and osteomuscular structures of primary importance. They are in close communication with many craniofacial areas, such as nasal/paranasal sinuses, orbit, middle cranial fossa, and oral cavities. Therefore, they can be involved by tumoral, infective or inflammatory lesions spreading from these spaces. Moreover, they can be the primary site of the development of some primitive tumors. For the deep-seated location of ITF and PPF lesions and their close relationship with the surrounding functional neuro-vascular structures, their surgery represents a challenge. In the last decades, the introduction of the endoscope in skull base surgery has favored the development of an innovative anterior endonasal approach for ITF and PPF tumors: the transmaxillary-pterygoid, which gives a direct and straightforward route for these areas. It has demonstrated that it is effective and safe for the treatment of a large number of benign and malignant neoplasms, located in these fossae, avoiding extensive bone drilling, soft tissue demolition, possibly unaesthetic scars, and reducing the risk of neurological deficits. However, some limits, especially for vascular tumors or lesions with lateral extension, are still present. Based on the experience of our multidisciplinary team, we present our operative technique, surgical indications, and pre- and post-operative management protocol for patients with ITF and PPF tumors.
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Affiliation(s)
- Matteo Zoli
- Programma Neurochirurgia Ipofisi—Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.G.); (S.A.); (D.M.)
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
- Correspondence: ; Tel.: +39-051-622-5514; Fax: +39-051-622-5347
| | - Giacomo Sollini
- ENT Unit, Bellaria Hospital, Azienda Unità Sanitaria Locale, 40133 Bologna, Italy; (G.S.); (E.P.)
| | - Fulvio Zaccagna
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
- Programma Neuroimmagini Funzionali e Molecolari, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Viscardo Paolo Fabbri
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
| | - Lorenzo Cirignotta
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (L.C.); (A.R.)
| | - Arianna Rustici
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (L.C.); (A.R.)
| | - Federica Guaraldi
- Programma Neurochirurgia Ipofisi—Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.G.); (S.A.); (D.M.)
| | - Sofia Asioli
- Programma Neurochirurgia Ipofisi—Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.G.); (S.A.); (D.M.)
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
- Programma Neuroimmagini Funzionali e Molecolari, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Ernesto Pasquini
- ENT Unit, Bellaria Hospital, Azienda Unità Sanitaria Locale, 40133 Bologna, Italy; (G.S.); (E.P.)
| | - Diego Mazzatenta
- Programma Neurochirurgia Ipofisi—Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.G.); (S.A.); (D.M.)
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40125 Bologna, Italy; (F.Z.); (V.P.F.); (C.T.)
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10
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Li L, London NR, Prevedello DM, Carrau RL. Endoscopic Endonasal Approach to the Pterygopalatine Fossa and Infratemporal Fossa: Comparison of the Prelacrimal and Denker's Corridors. Am J Rhinol Allergy 2022; 36:599-606. [PMID: 35506931 DOI: 10.1177/19458924221097159] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Both the endoscopic transnasal Denker's and prelacrimal approaches provide surgical access to the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). OBJECTIVES This study compares the potential maximum exposure of the PPF and ITF and quantifies the difference in surgical freedom via endoscopic Denker's and prelacrimal approaches. METHODS Six cadaveric specimens (12 sides) were dissected using a prelacrimal approach on one side and an endoscopic Denker's approach on the contralateral side. The contents of the PPF and ITF were sequentially exposed. Surgical freedom for each corridor was subsequently calculated. RESULTS This study confirms that both the prelacrimal and Denker's approaches provide adequate exposure of the PPF and ITF. The maximum exposure boundaries were similar for both approaches, including the middle cranial fossa superiorly, floor of the maxillary sinus inferiorly, zygomatic arch and temporomandibular joint laterally, and post-styloid space posteriorly. However, the data revealed a statistically significant difference (p < 0.05) regarding the surgical freedom of the prelacrimal (388.17 ± 32.86 mm2) and the endoscopic Denker's approaches (906.35 ± 38.38 mm2). CONCLUSION When compared with an endoscopic Denker's approach, a prelacrimal approach seems to achieve a similar extent of exposure (ie, visualization) of the PPF and ITF. Nonetheless, the endoscopic Denker's approach offers superior surgical freedom; thus, it is preferred for the management of complex lesions which requires increased instrument maneuverability with a 3- or 4-handed technique.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head & Neck Surgery, 117902Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, 1501Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
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11
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Li L, London NR, Prevedello DM, Carrau RL. Anatomy of the sphenoidal spine and its implications in endoscopic endonasal surgery of the infratemporal fossa. Head Neck 2022; 44:835-843. [PMID: 35014742 DOI: 10.1002/hed.26975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/11/2021] [Accepted: 01/03/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The sphenoidal spine protrudes from the roof of the infratemporal fossa (ITF). This study aims to assess the anatomic relationships among the sphenoidal spine and other structures within the ITF from the perspective of an endoscopic endonasal access (EEA), and to explore the implications of these relationships. METHODS An EEA to the ITF was completed on six cadaveric specimens (12 sides). The anatomical relationships among the sphenoidal spine and adjacent structures were explored and associated distances from each other were measured using a navigation system. RESULTS The foramen spinosum is located anterosuperior to the sphenoidal spine, whereas the chorda tympani courses caudal and medial to the sphenoidal spine and the Eustachian tube and parapharyngeal internal carotid artery (pICA) are at its posterior aspect. Two virtual vertical planes, at the anterior and posterior aspects of the sphenoidal spine, respectively, correspond to the posterior trunk of V3 and middle meningeal artery, and the stylopharyngeal aponeurosis. The average length of sphenoidal spine was 8.5 ± 2.43 mm, and the distance from distal apex of the sphenoidal spine to the foramen ovale, foramen spinosum, and pICA were 10.82 ± 0.83 mm, 6.42 ± 0.52 mm, and 5.02 ± 0.54 mm, respectively. CONCLUSIONS The sphenoidal spine is a meaningful landmark for endonasal approaches to the ITF. Measurements and conceptualization of vertical planes prior and posterior to the sphenoidal spine are beneficial to better appreciate the anatomic relationships in the ITF.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology - Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Nyall R London
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Prevedello
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
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12
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Li L, London NR, Prevedello DM, Carrau RL. Anatomical Variations and Relationships of the Infratemporal Fossa: Foundation of a Novel Endonasal Approach to the Foramen Ovale. J Neurol Surg B Skull Base 2021; 82:668-674. [PMID: 34745835 DOI: 10.1055/s-0040-1715815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/02/2020] [Indexed: 10/23/2022] Open
Abstract
Objective Access to the infratemporal fossa (ITF) is complicated by its complex neurovascular relationships. In addition, copious bleeding from the pterygoid plexus adds to surgical challenge. This study aims to detail the anatomical relationships among the internal maxillary artery (IMA), pterygoid plexus, V 3, and pterygoid muscles in ITF. Furthermore, it introduces a novel approach that displaces the lateral pterygoid plate (LPP) to access the foramen ovale. Design and Main Outcome Measures Six cadaveric specimens (12 sides) were dissected using an endonasal approach to the ITF modified by releasing and displacing the LPP and lateral pterygoid muscle (LPTM) as a unit. Subperiosteal elevation of the superior head of LPTM revealed the foramen ovale. The anatomic relationships among the V 3 , pterygoid muscles, pterygoid plexus, and IMA were surveyed. Results In 9/12 sides (75%), the proximal IMA ran between the temporalis and the LPTM, whereas in 3/12 sides (25%), the IMA pierced the LPTM. The deep temporal nerve was a consistent landmark to separate the superior and inferior heads of LPTM. An endonasal approach displacing the LPP in combination with a subperiosteal elevation of the superior head of LPTM provided access to the posterior trunk of V 3 and foramen ovale while sparing injury of the LPTM and exposing the pterygoid plexus. The anterior trunk of V 3 traveled anterolaterally along the greater wing of sphenoid in all specimens. Conclusion Displacement of the LPP and LPTM provided direct exposure of foramen ovale and V 3 avoiding dissection of the muscle and pterygoid plexus; thus, this maneuver may prevent intraoperative bleeding and postoperative trismus.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States.,Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, Maryland, United States
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
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13
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Li L, London NR, Li S, Chen X, Carrau RL. Endoscopic Transoral Approach for Resection of Basal Cell Adenoma Arising in Parapharyngeal Space. J Neurol Surg B Skull Base 2021; 82:675-681. [PMID: 34745836 DOI: 10.1055/s-0040-1715574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/11/2020] [Indexed: 02/02/2023] Open
Abstract
Objectives The clinical and radiological characteristics of the basal cell adenoma (BCA) and its association with the internal carotid artery (ICA) in the parapharyngeal space (PPS), have not been sufficiently explored. This study aims to analyze the characteristics of patients with BCA arising in the PPS and to evaluate the feasibility of a total resection via an endoscopic transoral corridor. Design and Main Outcome Measures The clinical, radiological, and histopathological characteristics of four patients with BCA arising in the PPS were retrospectively analyzed. The endoscopic transoral approach was performed for resection of BCA. Its technical nuances, perioperative comorbidities, and outcomes are introduced. Results The clinical presentation, symptoms, and signs of patients with BCA are variable. The tumor was lateral to the ICA in two patients and anterior to the ICA in the remaining two. All four BCA were successfully removed en bloc ( n = 3) or by piecemeal ( n = 1) via an endoscopic transoral approach. The ICA was not injured, and no additional nerve damage, venous bleeding, postoperative infection, or salivary gland fistula were encountered in any of the four patients. Cystic degeneration is the predominant appearance of BCA on MRI; however, they are difficult to differentiate from other lesions arising in the PPS. No recurrence was detected at the time of the study analysis. Conclusion BCA of the PPS could have variable relationships with the ICA. An endoscopic transoral approach can provide an adequate corridor for total resection of BCA in PPS with seemingly low morbidity.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States.,Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, Maryland, United States
| | - Shuling Li
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaohong Chen
- Department of Otolaryngology-Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
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14
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Magnetic resonance angiographic study of variations in course of paraclival and parasellar internal carotid artery in relation to expanded endonasal endoscopic approaches. Eur Arch Otorhinolaryngol 2021; 279:3459-3465. [PMID: 34652526 DOI: 10.1007/s00405-021-07123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
AIMS To study the variations in the course of the paraclival and parasellar carotid arteries in normal subjects using magnetic resonance angiography as is relevant from an endoscopic endonasal perspective. METHODS Two hundred MR angiographies of normal subjects were analyzed in a prospective study. The intercarotid distances were measured at fixed points along the paraclival and parasellar segments of the internal carotid artery. The intercarotid spaces thus obtained were categorized into trapezoid, square and hourglass shapes. The angle between the posterior ascending vertical and horizontal bend of the parasellar ICA was also measured and analyzed. RESULTS The trapezoid shape of intercarotid space is the most common (52.5%), followed by the square (35%) and the hourglass (12.5%) shaped spaces. Angle of < 80° between the posterior ascending vertical and horizontal bend of the parasellar ICA was found in 39% of subjects, angle between 80° and 100° was found in 9% subjects, angle > 100° was found in 43% while asymmetric angles on the two sides was found in 9% of subjects. CONCLUSION A thorough understanding of the course of the ICA is important in planning the approach and preventing injury to the ICA.
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15
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Li L, London NR, Prevedello DM, Carrau RL. An Endoscopic Endonasal Nasopharyngectomy with Posterolateral Extension. J Neurol Surg B Skull Base 2021; 83:e537-e544. [DOI: 10.1055/s-0041-1735557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/25/2021] [Indexed: 01/15/2023] Open
Abstract
Abstract
Background Invasion depth influences the choice for extirpation of nasopharyngeal malignancies. This study aims to validate the feasibility of endoscopic endonasal resection of lesions with a posterolateral invasion. As a secondary goal, the study intends to propose a classification system of endoscopic endonasal nasopharyngectomy determined by the depth of posterolateral invasion.
Methods Eight cadaveric specimens (16 sides) underwent progressive nasopharyngectomy using an endoscopic endonasal approach. Resection of the torus tubarius, Eustachian tube (ET), medial pterygoid plate and muscle, lateral nasal wall, and lateral pterygoid plate and muscle were sequentially performed to expose the fossa of Rosenmüller, petroclival region, parapharyngeal space (PPS), and jugular foramen, respectively.
Results Technical feasibility of endonasal nasopharyngectomy toward a posterolateral direction was validated in all 16 sides. Nasopharyngectomy was classified into four types as follows: (1) type 1: resection restricted to the posterior or superior nasopharynx; (2) type 2: resection includes the torus tubarius which is suitable for lesions extended into the petroclival region; (3) type 3: resection includes the distal cartilaginous ET, medial pterygoid plate, and muscle, often required for lesions extending laterally into the PPS; And (4) type 4: resection includes the lateral nasal wall, pterygoid plates and muscles, and all the cartilaginous ET. This extensive resection is required for lesions involving the carotid artery or extending to the jugular foramen region.
Conclusion Selected lesions with posterolateral invasion into the PPS or jugular foramen is amenable to a resection via expanded endonasal approach. Classification of nasopharyngectomy based on tumor depth of posterolateral invasion helps to plan a surgical approach.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology—Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology—Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
| | - Nyall R. London
- Department of Otolaryngology—Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
- Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Daniel M. Prevedello
- Department of Otolaryngology—Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
| | - Ricardo L. Carrau
- Department of Otolaryngology—Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, United States
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16
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Gerges MM, Godil SS, Younus I, Rezk M, Schwartz TH. Endoscopic transorbital approach to the infratemporal fossa and parapharyngeal space: a cadaveric study. J Neurosurg 2020; 133:1948-1959. [PMID: 31675695 DOI: 10.3171/2019.7.jns191743] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The infratemporal fossa (ITF) and parapharyngeal space are anatomical regions that can be challenging to access without the use of complex, cosmetically disfiguring approaches. With advances in endoscopic techniques, a new group of surgical approaches to access the intracranial space through the orbit has been recently referred to as transorbital neuroendoscopic surgery (TONES). The objective of this study was to establish a transorbital endoscopic approach utilizing the inferior orbital fissure (IOF) to gain access to the ITF and parapharyngeal space and provide a detailed endoscopic anatomical description of this approach. METHODS Four cadaveric heads (8 sides) were dissected using a TONES approach through the IOF to reach the ITF and parapharyngeal space, providing stepwise dissection with detailed anatomical findings and a description of each step. RESULTS An inferior eyelid approach was made with subperiosteal periorbital dissection to the IOF. The zygomatic and greater wing of the sphenoid were drilled, forming the boundaries of the IOF. The upper head of the lateral pterygoid muscle in the ITF and parapharyngeal space was removed, and 7 distinct planes were described, each with its own anatomical contents. The second part of the maxillary artery was mainly found in plane 1 between the temporalis laterally and the lateral pterygoid muscle in plane 2. The branches of the mandibular nerve (V3) and middle meningeal artery (MMA) were identified in plane 3. Plane 4 was formed by the fascia of the medial pterygoid muscle (MTM) and the tensor veli palatini muscle. The prestyloid segment, found in plane 5, was composed mainly of fat and lymph nodes. The parapharyngeal carotid artery in the poststyloid segment, found in plane 7, was identified after laterally dissecting the styloid diaphragm, found in plane 6. V3 and the origin of the levator and tensor veli palatini muscles serve as landmarks for identification of the parapharyngeal carotid artery. CONCLUSIONS The transorbital endoscopic approach provides excellent access to the ITF and parapharyngeal space compared to previously described complex and morbid transfacial or transcranial approaches. Using the IOF is an important and useful landmark that permits a wide exposure.
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Affiliation(s)
- Mina M Gerges
- 1Department of Neurosurgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
- Departments of2Neurosurgery and
| | - Saniya S Godil
- 1Department of Neurosurgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
- 3Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Iyan Younus
- 4Weill Cornell Medical College, New York, New York
| | - Michael Rezk
- 5Otolaryngology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Theodore H Schwartz
- 1Department of Neurosurgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
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17
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Li DF, Shi L, Wang J, Yue B, Ding ZJ, Chen FQ. Endoscopic Trans-Lateral Molar Approach to Infratemporal Fossa Lesions. EAR, NOSE & THROAT JOURNAL 2020; 100:1017S-1022S. [PMID: 32538672 DOI: 10.1177/0145561320934593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To study the endoscopic trans-lateral molar (ETLM) approach to infratemporal fossa (ITF) lesions and analyze the advantages and disadvantages of this method. METHODS Four cases of ITF lesions were analyzed retrospectively. The clinical features, diagnosis and treatments, the operative process, and clinical applications of this surgical approach were discussed. RESULTS Postoperative pathologies were 2 pleomorphic adenomas, 1 schwannoma, and 1 inflammatory lesion. All patients had self-resolving cheek swelling and pharyngalgia in the short term, but 2 patients had numbness in the long term. There was no infection or bleeding in the postoperative period, and no difficulty in chewing after disease recovery. There was no tumor recurrence during the follow-up period. CONCLUSION The ETLM approach is convenient, minimally invasive, and allows complete excision of benign ITF lesions, posterior to the lateral pterygoid muscle and mainly below the level of the hard palate. It is a simple and direct access to the ITF, but it is a narrow access because of the limitations of bones and soft tissues. Appropriate patient selection is mandatory for successful surgery.
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Affiliation(s)
- Dan-Feng Li
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Jian Wang
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Bo Yue
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Zhong-Jia Ding
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Fu-Quan Chen
- Department of Otolaryngology-Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
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18
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Li L, London NR, Prevedello DM, Carrau RL. Endonasal endoscopic transpterygoid approach to the upper parapharyngeal space. Head Neck 2020; 42:2734-2740. [PMID: 32129556 DOI: 10.1002/hed.26127] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/26/2020] [Accepted: 02/20/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Lesions of the upper parapharyngeal space (UPPS) present a surgical challenge. The objective of this study was to ascertain the feasibility of a novel technique of modified transpterygoid approach to the UPPS. METHODS Six fresh cadaveric specimens (12 sides) were dissected, developing a technique that includes en bloc mobilization of the lateral pterygoid plate and muscle to access the UPPS. RESULTS Following an endoscopic Denker's approach and the removal of posterolateral wall of the antrum, the lateral pterygoid plate was detached from the pterygoid process. Subsequently, the lateral pterygoid plate and muscle were displaced laterally as a unit, allowing the identification of the posterior trunk of V3 and the fat in prestyloid compartment. Dissecting off the styloid aponeurosis affords entering the poststyloid UPPS exposing the internal carotid artery, internal jugular vein, and cranial nerves IX to XII. CONCLUSION This novel modification of the endonasal transpterygoid approach offers a viable alternative for access to the UPPS.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, Maryland, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA
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19
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Lima F, Andaluz N, Zimmer LA. Endoscopic endonasal treatment of maxillary nerve (V2) painful neuropathy: cadaveric study with clinical correlation. Acta Neurochir (Wien) 2020; 162:223-229. [PMID: 31811464 DOI: 10.1007/s00701-019-04126-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/29/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical access to the second (V2, maxillary) and third (V3, mandibular) branches of the trigeminal nerve (V) has been classically through a transoral approach. Increasing expertise with endoscopic anatomy has achieved less invasive, more efficient access to skull base structures. The authors present a surgical technique using an endoscopic endonasal approach for the treatment of painful V2 neuropathy. METHODS Endoscopic endonasal dissections using a transmaxillary approach were performed in four formalin-fixed cadaver heads to expose the V2 branch of the trigeminal nerve. Relevant surgical anatomy was evaluated and anatomic parameters for neurectomy were identified. RESULTS Endoscopic endonasal transmaxillary approaches completed bilaterally to the pterygopalatine and pterygomaxillary fossae exposed the V2 branch where it emerged from the foramen rotundum. The anatomy defined for the location of neurectomy was determined to be the point where V2 emerged from the foramen rotundum into the pterygopalatine fossa. The technique was then performed in 3 patients with intractable painful V2 neuropathy. CONCLUSIONS In our cadaveric study and clinical cases, the endoscopic endonasal approach to the pterygopalatine fossa achieved effective exposure and treatment of isolated V2 painful neuropathy. Important surgical steps to visualize the maxillary nerve and its branches and key landmarks of the pterygopalatine fossa are discussed. This minimally invasive approach appears to be a valid alternative for select patients with painful V2 trigeminal neuropathy.
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Affiliation(s)
- Franklin Lima
- Departments of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
- Departments of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
- Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - Norberto Andaluz
- Departments of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA.
- Departments of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA.
- Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA.
- Mayfield Clinic, Cincinnati, OH, USA.
- Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA.
| | - Lee A Zimmer
- Departments of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
- Departments of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
- Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
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20
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Li L, London NR, Prevedello DM, Carrau RL. Anatomy based corridors to the infratemporal fossa: Implications for endoscopic approaches. Head Neck 2019; 42:846-853. [PMID: 31880379 PMCID: PMC9292508 DOI: 10.1002/hed.26055] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/31/2019] [Accepted: 12/10/2019] [Indexed: 11/21/2022] Open
Abstract
Background The infratemporal fossa (ITF) represents an area densely packed with neurovascular structures within irregular boundaries. The goal of this study was to classify the ITF into zones corresponding to its anatomical spaces and the order in which they are encountered during an endonasal approach (anteroposterior axis). Methods Six cadaveric specimens (12 sides) with injected colored latex were dissected. Following an endoscopic medial maxillectomy and Denker's approach, a progressive exploration of the masticator space and upper parapharyngeal space was completed. A classification of the ITF based on well‐defined spaces was ascertained. Results The ITF was divided into five zones:Zone 1 (retromaxillary space)—space lying between the posterolateral wall of the maxillary sinus and the temporalis and pterygoid muscles. Zone 2 (superior interpterygoid space)—area including the superior head of the lateral pterygoid muscle, V3, and foramen ovale. Zone 3 (inferior interpterygoid space)—includes the inferior head of lateral pterygoid muscle, medial pterygoid, and temporalis muscles, and the space enclosed by these muscles. Zone 4 (temporo‐masseteric space)—space lateral to the temporalis muscle (comprising fat mostly). Zone 5 (tubopharyngeal space)—includes the Eustachian tube, tensor, and levator veli palatini muscles, and structures in upper parapharyngeal space.
Conclusion The ITF can be visualized as five zones based on spaces enclosed by the masticator muscles and upper parapharyngeal structures. This novel classification system is useful to guide endoscopic approaches to the ITF, while decreasing the potential for injury of neurovascular structures and pterygoid muscles.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Division of Otolaryngology-Head and Neck Surgery, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, Maryland
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
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21
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Yacoub A, Schneider D, Ali A, Wimmer W, Caversaccio M, Anschuetz L. Endoscopic-Assisted Lateral Corridor to the Infratemporal Fossa: Proposal and Quantitative Comparison to the Endoscopic Transpterygoid Approach. J Neurol Surg B Skull Base 2019; 82:357-364. [PMID: 34026413 DOI: 10.1055/s-0039-3399553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective This study was aimed to propose an expanded endoscopic-assisted lateral approach to the infratemporal fossa (ITF) and compare its area of exposure and surgical freedom with the endoscopic endonasal transptergyoid approach (EETA). Methods Anatomical dissections were performed in five cadaver heads (10 sides). The ITF was first examined through the endoscopically assisted lateral corridor, herein referred to as the endoscopic-assisted transtemporal fossa approach (TTFA). After that, the EETA was performed and coupled with two sequential maxillary procedures (medial maxillectomy [MM], and endoscopic-assisted Denker's approach [DA]). Using the stereotactic neuronavigation, measurements of the area of exposure and surgical freedom at the foramen ovale were determined for the previously mentioned approaches. Results Bimanual exploration of the ITF through the endoscopic-assisted lateral approach was achieved in all specimens. The DA (729 ± 49 mm 2 ) provided a larger area of exposure than MM (568 ± 46 mm 2 ; p < 0.0001). However, areas of exposure were similar between the DA and the TTFA (677 ± 35 mm 2 ; p = 0.09). The surgical freedom offered by the TTFA (109.3 ± 19 cm 2 ) was much greater than the DA (24.7 ± 4.8 cm 2 ; p < 0.0001), and the MM (15.2 ± 3.2 cm 2 , p < 0.0001). Conclusion The study demonstrates the feasibility of the proposed approach to provide direct access to the extreme extensions of the ITF. The lateral corridor offers an ideal working area in the posterior compartment of the ITF without crossing over important neurovascular structures. The new technique may be used alone in selected primary ITF lesions or in combination with endonasal approaches in pathologies spreading laterally from the nose or nasopharynx.
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Affiliation(s)
- Abraam Yacoub
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Switzerland.,Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Daniel Schneider
- Image-Guided Therapy, ARTORG Center for Biomedical Research, University of Bern, Switzerland
| | - Ahmed Ali
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Wilhelm Wimmer
- Hearing Research Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Switzerland
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22
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Kaen A, Cárdenas Ruiz-Valdepeñas E, Di Somma A, Esteban F, Márquez Rivas J, Ambrosiani Fernandez J. Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the "VELPPHA area" concept. J Neurosurg 2019; 131:911-919. [PMID: 30239316 DOI: 10.3171/2018.4.jns173070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway. METHODS Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed. RESULTS The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym-VELPPHA-to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach. CONCLUSIONS The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the endoscopic endonasal transpterygoid approach expanded to the lateral aspect of the skull base, especially when treating patients with poorly pneumatized sphenoid sinuses.
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Affiliation(s)
| | | | - Alberto Di Somma
- 2Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli Federico II, Naples, Italy
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23
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Li W, Chae R, Rubio RR, Benet A, Meybodi AT, Feng X, Huang G, El-Sayed IH. Characterization of Anatomical Landmarks for Exposing the Internal Carotid Artery in the Infratemporal Fossa Through an Endoscopic Transmasticator Approach: A Morphometric Cadaveric Study. World Neurosurg 2019; 131:e415-e424. [PMID: 31376554 DOI: 10.1016/j.wneu.2019.07.185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Eustachian tube and sphenoid spine have been previously described as landmarks for endonasal surgical identification of the most distal segment of the parapharyngeal internal carotid artery (PhICA). However, the intervening space between the sphenoid spine and PhICA allows for error during exposure of the artery. In the present study, we have characterized endoscopic endonasal transmasticator exposure of the PhICA using the sphenoid spine, vaginal process of the tympanic bone, and the "tympanic crest" as useful anatomical landmarks. METHODS Endonasal dissection was performed in 13 embalmed latex-injected cadaveric specimens. Two open lateral dissections and osteologic analysis of 10 dry skulls were also performed. RESULTS A novel and palpable bony landmark, the inferomedial edge of the tympanic bone, referred to as the tympanic crest, was identified, leading from the sphenoid spine to the lateral carotid canal. Additionally, the vaginal process of the tympanic bone, viewed endoscopically, was a guide to the PhICA. The sphenoid spine was bifurcate in 20% of the skulls, with an average length of 5.98 mm (range, 3.9-8.2 mm), width of 5.81 mm (range, 3.0-10.6 mm), and distance to the carotid canal of 4.48 mm (range, 2.5-6.1 mm). CONCLUSION The sphenoid spine and pericarotid space has variable anatomy. Using an endoscopic transmasticator approach to the infratemporal fossa, we found that the closest landmarks leading to the PhICA were the tympanic crest, sphenoid spine, and vaginal process of the tympanic bone.
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Affiliation(s)
- Wei Li
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ricky Chae
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Arnau Benet
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ali Tayebi Meybodi
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Xuequan Feng
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Tianjin First Center Hospital, Nankai District, Tianjin, China
| | - Guanglong Huang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA.
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24
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Recurrence Rate after Endoscopic vs. Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis. J Neurol Surg B Skull Base 2018; 80:577-585. [PMID: 31750043 DOI: 10.1055/s-0038-1676562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022] Open
Abstract
Context The effect on recurrence rate between patients with juvenile nasopharyngeal angiofibroma (JNA), treated by an endoscopic versus open approach, has not been well established. Objective A meta-analysis of the available literature concerning recurrence rate in patients who underwent surgery for JNA. Methods A retrospective meta-analysis of studies analyzing recurrence rate after endoscopic or open surgery for patients with JNA was performed using the DerSimonian-Laird random-effects method. English and non-English articles were reviewed using Embase, Medline, and Cochrane databases. Results Among nine studies, including 362 patients from 1981 to 2015, with a mean follow-up of 49.4 months, a total of 89 patients (24.5%) had recurrence. Our analysis revealed a total effect size of -0.16 in favor of endoscopic approach (-0.25 to -0.06, CI [confidence interval] 95%). When analyzing tumor by stage (Radkowski's IA-IIIB n = 299), the endoscopic approach proved to be superior independent of tumor stage (2 vs. 17% for tumors stage IA-IIA, and 26 vs. 32% for tumor stage IIB-IIIB for endoscopic and open approaches respectively; p < 0.05). The endoscopic approach has a statistical significant lower recurrence rate in patients without intracranial compromise when compared with the open approach (13 vs. 28%; p < 0.02). No statistical difference was seen in patients with intracranial compromise ( p = 0.5) Conclusion The use of an endoscopic approach to treat JNA has a significantly lower recurrence rate when compared with open approaches. Independent of disease stage, an endoscopic approach should be the standard of care to surgically treat JNA. For cases with intracranial compromise, either approach can be used for surgical resection.
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25
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Servian DA, Beer-Furlan A, Lima LR, Montaser AS, Galarce MG, Carrau RL, Prevedello DM. Pharyngobasilar fascia as a landmark in endoscopic skull base surgery: The triangulation technique. Laryngoscope 2018; 129:1539-1544. [PMID: 30585330 DOI: 10.1002/lary.27608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - André Beer-Furlan
- Department of Neurological Surgery, Columbus, Ohio.,Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | | | | | - Ricardo L Carrau
- Department of Neurological Surgery, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Daniel M Prevedello
- Department of Neurological Surgery, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
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26
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The pterygopalatine fossa: morphometric CT study with clinical implications. Surg Radiol Anat 2018; 41:161-168. [DOI: 10.1007/s00276-018-2136-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/16/2018] [Indexed: 11/27/2022]
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27
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Hanakita S, Chang WC, Watanabe K, Ronconi D, Labidi M, Park HH, Oyama K, Bernat AL, Froelich S. Endoscopic Endonasal Approach to the Anteromedial Temporal Fossa and Mobilization of the Lateral Wall of the Cavernous Sinus Through the Inferior Orbital Fissure and V1-V2 Corridor: An Anatomic Study and Clinical Considerations. World Neurosurg 2018; 116:e169-e178. [PMID: 29709753 DOI: 10.1016/j.wneu.2018.04.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/15/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The aim of this study was to identify key anatomic landmarks useful in gaining access to the anteromedial temporal region via the corridor formed by the inferior orbital fissure (IOF), the ophthalmic branch of the trigeminal nerve (V1), and the maxillary branch of the trigeminal nerve (V2) via an endoscopic endonasal approach (EEA). METHODS An anatomic dissection of 6 cadaver heads was performed to confirm the feasibility and applicability of an EEA for accessing the anteromedial temporal region. RESULTS After middle turbinectomy, the lateral recess of the sphenoid sinus was opened, the orbital apex was exposed, and the posterior wall of the maxillary sinus was removed, in sequence. The IOF and the pterygopalatine fossa (PPF) were then identified. After opening the foramen rotundum (FR) and removing the bony structure between the FR, V2 was transposed downward. The orbital muscle of Müller was removed. The PPF was mobilized downward exposing the greater wing of the sphenoid bone (GWS). The GWS between V1 and V2 was drilled, therefore exposing the temporal dura. With blunt dissection, the medial temporal dura was peeled away from the cavernous sinus to increase access to the anteromedial temporal region. CONCLUSIONS The anteromedial temporal fossa was exposed by drilling the V1-V2 triangle corridor via an EEA. Endoscopic endonasal exposure of the anteromedial temporal fossa is feasible and requires limited endonasal work. This approach may be considered as an alternate surgical corridor to the temporomesial lobe that offers the advantages of a direct route with less temporal lobe retraction.
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Affiliation(s)
- Shunya Hanakita
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Wei-Chieh Chang
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Kentaro Watanabe
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Daniel Ronconi
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Moujahed Labidi
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Hun-Ho Park
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Kenichi Oyama
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, University Paris Diderot, Paris, France.
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28
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Kutlay M, Durmaz A, Özer İ, Kural C, Temiz Ç, Kaya S, Solmaz İ, Daneyemez M, Izci Y. Extended endoscopic endonasal approach to the ventral skull base lesions. Clin Neurol Neurosurg 2018; 167:129-140. [DOI: 10.1016/j.clineuro.2018.02.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 02/08/2023]
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29
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Yacoub A, Anschuetz L, Schneider D, Wimmer W, Caversaccio M. Minimally Invasive Lateral Endoscopic Multiport Approach to the Infratemporal Fossa: A Cadaveric Study. World Neurosurg 2018; 112:e489-e496. [PMID: 29391297 DOI: 10.1016/j.wneu.2018.01.065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Expanded endoscopic endonasal approaches to the infratemporal fossa (ITF) are increasingly performed owing to improved visualization and less morbidity compared with classic open approaches. Only a few studies in the literature investigated lateral endoscopic access to the ITF. The aim of this study was to examine the ITF with the minimally invasive endoscopically assisted Gillies approach with a trial of its expansion through a double port technique. METHODS The ITF was examined in 10 sides of 5 cadaveric heads using a lateral endoscopic assisted approach. A double portal technique was developed to allow bimanual dissection. Specific long angled skull base instruments were used for dissection under stereotactic guidance. RESULTS The endoscopic assisted Gillies approach permitted minimally invasive access to the complete anteroposterior extension of the ITF with sufficient mobility of surgical instruments. A new anatomic classification for the ITF from a lateral endoscopic perspective was introduced. The addition of the second port allowed bimanual dissection. CONCLUSIONS This cadaveric study shows the feasibility of an endoscopically assisted lateral approach to the ITF. The addition of a posterior port expands the approach through increasing the working area and enabling a bimanual dissection technique. Performed alone or combined with an anterior endoscopic transnasal approach, this technique offers minimally invasive access to the ITF. The development of specifically designed instruments would further improve this promising approach.
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Affiliation(s)
- Abraam Yacoub
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland; Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
| | - Daniel Schneider
- ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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30
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Komune N, Matsuo S, Miki K, Akagi Y, Kurogi R, Iihara K, Nakagawa T. Surgical Anatomy of the Eustachian Tube for Endoscopic Transnasal Skull Base Surgery: A Cadaveric and Radiologic Study. World Neurosurg 2018; 112:e172-e181. [PMID: 29325963 DOI: 10.1016/j.wneu.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach to the anatomically complex lateral skull base presents technical challenges. The use of the eustachian tube as a landmark to identify the petrous internal carotid artery has recently been reported, and this study aims to define the anatomic relationship between the eustachian tube and its surrounding structures using cadaveric dissection and radiologic analysis. METHODS To clarify the relationship of the eustachian tube with its surrounding structures, we performed endoscopic and microscopic dissection of 4 adult cadaveric heads and analyzed computed topography scans from 20 patients. RESULTS The eustachian tube is divided into the osseous and cartilaginous parts. The cartilaginous part can be further subdivided into the posterolateral, middle, and anteromedial parts, based on its relationship to the skull base. The eustachian tube is closely related to the pterygoid process of the sphenoid bone, the foramen lacerum, and the petrosal apex and is directed away from the oblique sagittal plane almost parallel to the vidian canal at 12.2° ± 6.2° (mean ± standard deviation). The relationship between the course of the vidian canal and the eustachian tube can aid the estimation of the anatomic course of the horizontal segment of the petrous carotid artery. CONCLUSIONS The eustachian tube is a useful landmark for predicting the course of the internal carotid artery when accessing the lateral skull base regions via an endonasal route. A profound understanding of the relationship between the eustachian tube and the surrounding skull base structures is important for endoscopic endonasal skull base surgeries.
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Affiliation(s)
- Noritaka Komune
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Koichi Miki
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka University, Fukuoka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Nakagawa
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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31
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Oakley GM, Ebenezer J, Hamizan A, Sacks PL, Rom D, Sacks R, Winder M, Davidson A, Teo C, Solares CA, Harvey RJ. Finding the Petroclival Carotid Artery: The Vidian-Eustachian Junction as a Reliable Landmark. J Neurol Surg B Skull Base 2017; 79:361-366. [PMID: 30009117 DOI: 10.1055/s-0037-1608650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Introduction Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian-eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Methods Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. Results In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in 80%. The vertical paraclival segment was at or behind VEJ in 100%, above in 100%, and medial in 100%. The second genu was at or behind VEJ in 100% (3.3 ± 2.4 mm), at or above in 100% (2.5 ± 1.6 mm), and medial in 100% (3.4 ± 2.0 mm). The VEJ was successfully used to locate the ICA in nine consecutive patients (53.3 ± 13.6 years, 55.6% female) where pathology was also present. The VEJ was 15.0 ± 6.0 mm from the ET and 17.4 ± 4.1 mm from the PPF. Conclusion The VEJ is an excellent landmark as it defines both superior and posterior limits when isolating the ICA in skull base surgery.
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Affiliation(s)
- Gretchen M Oakley
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, United States.,Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Jareen Ebenezer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Aneeza Hamizan
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Peta-Lee Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Darren Rom
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Mark Winder
- Department of Neurosurgery, St Vincent's Hospital, Sydney, Australia
| | - Andrew Davidson
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, Australia
| | - C Arturo Solares
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, United States
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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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; 129:211-219. [PMID: 29053078 DOI: 10.3171/2017.4.jns162483] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has been shown to be an effective means of accessing lesions of the petrous apex. Lesions that are lateral to the paraclival segment of the internal carotid artery (ICA) require lateralization of the paraclival segment of the ICA or a transpterygoid infrapetrous approach. In this study the authors studied the feasibility of adding a contralateral transmaxillary (CTM) corridor to provide greater access to the petrous apex with decreased need for manipulation of the ICA. METHODS Using image guidance, EEA and CTM extension were performed bilaterally on 5 cadavers. The anterior wall of the sphenoid sinus and rostrum were removed. The angle of the surgical approach from the axis of the petrous segment of the ICA was measured. Five illustrative clinical cases are presented. RESULTS The CTM corridor required a partial medial maxillectomy. When measured from the axis of the petrous ICA, the CTM corridor decreased the angle from 44.8° ± 2.78° to 20.1° ± 4.31°, a decrease of 24.7° ± 2.58°. Drilling through the CTM corridor allowed the drill to reach lateral aspects of the petrous apex that would have required lateralization of the ICA or would not have been accessible via EEA. The CTM corridor allowed us to achieve gross-total resection of the petrous apex region in 5 clinical cases with significant paraclival extension. CONCLUSIONS The CTM corridor is a feasible extension to the standard EEA to the petrous apex that offers a more lateral trajectory with improved access. This approach may reduce the risk and morbidity associated with manipulation of the paraclival ICA.
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Affiliation(s)
- Chirag R Patel
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric W Wang
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Liu CL, Hsu NI, Shen PH. Endoscopic endonasal nasopharyngectomy: tensor veli palatine muscle as a landmark for the parapharyngeal internal carotid artery. Int Forum Allergy Rhinol 2017; 7:624-628. [DOI: 10.1002/alr.21921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/06/2016] [Accepted: 01/10/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Chiung-Lin Liu
- Department of Otolaryngology; Kuang-Tien General Hospital; Taichung Taiwan
| | - Ning-I Hsu
- Department of Otolaryngology; Kuang-Tien General Hospital; Taichung Taiwan
| | - Ping-Hung Shen
- Department of Otolaryngology; Kuang-Tien General Hospital; Taichung Taiwan
- Department of Nursing; Hung-Kuang University; Taichung Taiwan
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Anatomical landmarks for maxillary nerve block in the pterygopalatine fossa: A radiological study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:90-94. [PMID: 28345519 DOI: 10.1016/j.jormas.2016.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/13/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed. METHODS This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route. RESULTS No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°. DISCUSSION With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block.
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Endoscopic Resection of Pterygopalatine Fossa and Infratemporal Fossa Malignancies. Otolaryngol Clin North Am 2017; 50:301-313. [PMID: 28162242 DOI: 10.1016/j.otc.2016.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The endoscopic resection of pterygopalatine and infratemporal fossa malignancies allows excellent visualization and manipulation of tissues in an anatomically complex area compared with open approaches. With less approach morbidity, endoscopic endonasal surgery allows an easier recovery and earlier transition to adjuvant radiotherapy. The endoscopic approach is minimal access but rarely minimally invasive. Surgeons should not hesitate to gain wide surgical exposure of the pterygopalatine, infratemporal fossa, and petrocavernous carotid artery to ensure comfortable maneuverability and easy visualization of the tumor and its normal tissue margins. This method maximizes the chances of complete resection and effective postoperative surveillance.
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Gagliardi F, Donofrio CA, Spina A, Bailo M, Gragnaniello C, Gallotti AL, Elbabaa SK, Caputy AJ, Mortini P. Endoscope-Assisted Transmaxillosphenoidal Approach to the Sellar and Parasellar Regions: An Anatomic Study. World Neurosurg 2016; 95:246-252. [DOI: 10.1016/j.wneu.2016.08.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/08/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
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Abdulrauf SI, Ashour AM, Marvin E, Coppens J, Kang B, Hsieh TYY, Nery B, Penanes JR, Alsahlawi AK, Moore S, Abou Al-Shaar H, Kemp J, Chawla K, Sujijantarat N, Najeeb A, Parkar N, Shetty V, Vafaie T, Antisdel J, Mikulec TA, Edgell R, Lebovitz J, Pierson M, Pires de Aguiar PH, Buchanan P, Di Cosola A, Stevens G. Proposed clinical internal carotid artery classification system. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:161-70. [PMID: 27630478 PMCID: PMC4994148 DOI: 10.4103/0974-8237.188412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.
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Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Ahmed M Ashour
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Eric Marvin
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jeroen Coppens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Brian Kang
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tze Yu Yeh Hsieh
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Breno Nery
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Juan R Penanes
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Aysha K Alsahlawi
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Shawn Moore
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Hussam Abou Al-Shaar
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Joanna Kemp
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Kanika Chawla
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nanthiya Sujijantarat
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Alaa Najeeb
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nadeem Parkar
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Vilaas Shetty
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tina Vafaie
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jastin Antisdel
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tony A Mikulec
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Randall Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jonathan Lebovitz
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Matt Pierson
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | | | - Paula Buchanan
- Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Angela Di Cosola
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - George Stevens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
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Mattavelli D, Bolzoni Villaret A, Ferrari M, Ravanelli M, Rampinelli V, Lancini D, Rodella LF, Fontanella M, Maroldi R, Nicolai P, Doglietto F. Different Perspectives of Internal Carotid Artery in Transnasal Endoscopic Surgery. World Neurosurg 2016; 95:222-228. [PMID: 27530718 DOI: 10.1016/j.wneu.2016.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several endoscopic landmarks for the internal carotid artery (ICA) have been identified, but they have always been proposed in a "static" perspective. The aim of this study was to investigate how the surgical corridor and optical distortion can influence the perception of carotid landmarks in transnasal endoscopic surgery. METHODS Computed tomography images of skulls in 20 subjects were analyzed. The petrous carotid angle (PCA) was calculated as the angle between the petrous carotid axis and the coronal plane connecting stylomastoid foramina. The angle of incidence (AI) on the anterior carotid genu of 3 different surgical corridors (contralateral nostril, ipsilateral nostril, and transmaxillary ipsilateral route) was evaluated. PCA, AI, and their differences were studied by Spearman's correlation test. Two cadaver heads were dissected, simulating the studied surgical corridors. The fish-eye effect was empirically quantified. RESULTS Mean PCA was 31° (range, 21-41°). PCA and AI are linked by an inverse proportion relationship. A transmaxillary approach always ensures the highest value of AI on the target. The cadaveric dissection qualitatively confirmed the radiologic data. The fish-eye effect can cause a compression of distance perception as high as 37%. CONCLUSIONS The surgical corridor and endoscope optic distortion can influence ICA visualization and the perception of its anatomic landmarks. In a 2-nostril, 4-handed approach, it is advisable to place the endoscope and instrument for dissection in the nostril that is ipsilateral to the lesion. Awareness of the different perspectives and related optical distortions is essential when working in proximity to the ICA.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Andrea Bolzoni Villaret
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Davide Lancini
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Marco Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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Zoghlami A, Bon Mardion N, Callonnec F, Dehesdin D, Proust F, Marie JP. Transalar transsphenoidal meningoencephalocele presenting in the form of recurrent meningitis: Report of two cases and discussion of the diagnosis and treatment. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133:423-427. [PMID: 27431342 DOI: 10.1016/j.anorl.2016.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Skull base meningoencephaloceles are rare congenital malformations. The two cases of transalar transsphenoidal malformation reported here differ from the classical transsphenoidal meningoencephalocele. CASE REPORTS Case 1 was a three-and-a-half-year-old boy and case 2 was a 36-year-old man. Both cases presented with clinical features of recurrent meningitis. Surgical management of case 1 was performed via an intradural infratemporal fossa craniotomy with reoperation 2years later. In the second case, surgery was initially performed via an endonasal approach and then via pterional craniotomy. Reoperation via Sekhar's transpetrosal approach was also a failure. Only closure of the trigeminal-pontine angle via a suboccipital retrosigmoid approach allowed repair of the defect. DISCUSSION Surgical access to the pterygopalatine fossa is complex due to its anatomical position and its anatomical relations with nerves and vessels. An endoscopic approach appears to be a valuable alternative to classical craniotomy. CONCLUSION In the two cases reported here, neurosurgery allowed lasting closure of the defect.
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Affiliation(s)
- A Zoghlami
- Service d'ORL-CCF, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - N Bon Mardion
- Service d'ORL-CCF, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - F Callonnec
- Service d'imagerie, centre Henri-Becquerel, rue d'Amiens, 76000 Rouen, France
| | - D Dehesdin
- Service d'ORL-CCF, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - F Proust
- Service de neurochirurgie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - J-P Marie
- Service d'ORL-CCF, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France.
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Simon F, Vacher C, Herman P, Verillaud B. Surgical landmarks of the nasopharyngeal internal carotid using the maxillary swing approach: A cadaveric study. Laryngoscope 2016; 126:1562-6. [DOI: 10.1002/lary.25870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/08/2015] [Accepted: 12/17/2015] [Indexed: 12/28/2022]
Affiliation(s)
- François Simon
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
| | - Christian Vacher
- Department of Maxillofacial Surgery; AP-HP, Beaujon Hospital, Paris Diderot University; Paris France
| | - Philippe Herman
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
| | - Benjamin Verillaud
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
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Horiguchi K, Nishioka H, Fukuhara N, Yamaguchi-Okada M, Yamada S. A new multilayer reconstruction using nasal septal flap combined with fascia graft dural suturing for high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. Neurosurg Rev 2016; 39:419-27. [PMID: 26886779 DOI: 10.1007/s10143-016-0703-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 08/12/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
Abstract
This study aimed to evaluate the usefulness and reliability of a new endoscopic multilayer reconstruction using nasal septal flap (NSF) to prevent high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. This study was a retrospective review on 97 patients who underwent multilayer reconstructions using NSF combined with fascia graft dural suturing after endoscopic endonasal surgery between July 2012 and March 2014. Patients were divided into two groups, third ventricle opening group and nonopening group, based on the presence of a direct connection between the third ventricle and the paranasal sinus after tumor removal. Furthermore, we compared this procedure with our previous reconstruction after resection of craniopharyngioma. Finally, we checked the patients who had postoperative prolonged discomfort of the nasal cavity for over a year. Postoperative cerebrospinal fluid (CSF) leak occurred in three patients (3.1 %): one from the third ventricle opening group and the remaining two from the nonopening group. External lumbar drain was performed after surgery in only seven patients (7.2 %). The incidence of postoperative CSF leak was similar in both groups, whereas the rate of craniopharyngioma in the third ventricle opening group was significantly higher. The incidence of postoperative CSF leak after resection of craniopharyngioma was not statistically significant but obviously higher in the previous group (12.2 %) compared with that in the present group (2.3 %). Twelve patients (12.4 %) had postoperative nasal discomfort of the nasal cavity for over a year. Multilayer reconstruction using NSF combined with fascia graft dural suturing is a more reliable method for preventing postoperative high-flow CSF leakage after endoscopic endonasal surgery even if there is a direct connection between the third ventricle and the paranasal sinus. However, we should pay close attention especially to prolonged discomfort of the nasal cavity after harvesting NSF.
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Affiliation(s)
- Kentaro Horiguchi
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan. .,Department of Neurosurgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | | | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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Dolci RLL, Upadhyay S, Ditzel Filho LFS, Fiore ME, Buohliqah L, Lazarini PR, Prevedello DM, Carrau RL. Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships. Head Neck 2016; 38 Suppl 1:E1680-7. [PMID: 26875705 DOI: 10.1002/hed.24301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The quadrangular space permits an anterior entry into Meckel's cave while obviating the need for cerebral or cranial nerve retraction. This avenue is intimately associated with the cavernous sinus; thus, from this ventral perspective, it is feasible to visualize the anteromedial, anterolateral, and Parkinson triangles. METHODS Twenty middle cranial fossae were dissected endonasally under direct endoscopic visualization. Measurements of the surface area of the quadrangular space and the ventrally accessible cavernous sinus triangles were performed using 3 coordinates under image-guided navigation. RESULTS The surface area of the quadrangular space was 16.36 mm(2) (±2.89 mm(2) ). The anterolateral triangle was the largest (47.27 ± 5.37 mm(2) ), whereas Parkinson's was the smallest (22.46 ± 5.54 mm(2) ); the anteromedial triangle presented an average surface area 36.07 mm(2) (±4.15 mm(2) ). CONCLUSION The trajectory of the internal carotid artery (ICA) significantly impacts the quadrangular space area and may be a potential parameter for defining the feasibility of this corridor. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1680-E1687, 2016.
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Affiliation(s)
- Ricardo L L Dolci
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Otolaryngology - Head and Neck Surgery, Santa Casa de Misericórida de São Paulo, São Paulo, SP, Brazil
| | - Smita Upadhyay
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Leo F S Ditzel Filho
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Mariano E Fiore
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Lamia Buohliqah
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Paulo R Lazarini
- Department of Otolaryngology - Head and Neck Surgery, Santa Casa de Misericórida de São Paulo, São Paulo, SP, Brazil
| | - Daniel M Prevedello
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Liu J, Sun X, Liu Q, Wang D, Wang H, Ma N. Eustachian Tube as a Landmark to the Internal Carotid Artery in Endoscopic Skull Base Surgery. Otolaryngol Head Neck Surg 2015; 154:377-82. [PMID: 26598497 DOI: 10.1177/0194599815616799] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/21/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The purpose of this study was to probe the relationship between the eustachian tube and the internal carotid artery in skull base surgery by an intranasal endoscopic approach. STUDY DESIGN Cadaver study and illustrative cases. SETTING Minimally invasive surgery laboratory and operating room. SUBJECTS AND METHODS A series of 5 cadaveric heads were dissected to elaborate on the relevant surgical anatomy about the eustachian tube and the internal carotid artery. Three cases were presented to illustrate the application of our laboratory findings. RESULTS The bony-cartilaginous junction of the eustachian tube was just anterior to the first genu of the internal carotid artery by an intranasal endoscopic approach. The 3 patients in our study tolerated the procedure well and experienced no serious complications after surgery. CONCLUSIONS The anatomic data and clinical cases in this study confirmed that the eustachian tube is a consistent and reliable landmark to the internal carotid artery to avoid its injury in skull base surgery through the endoscopic endonasal route.
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Affiliation(s)
- Juan Liu
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | - Xicai Sun
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | - Quan Liu
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | - Dehui Wang
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | - Huan Wang
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | - Na Ma
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
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Upadhyay S, Dolci RLL, Buohliqah L, Fiore ME, Ditzel Filho LFS, Prevedello DM, Otto BA, Carrau RL. Effect of Incremental Endoscopic Maxillectomy on Surgical Exposure of the Pterygopalatine and Infratemporal Fossae. J Neurol Surg B Skull Base 2015; 77:66-74. [PMID: 26949591 DOI: 10.1055/s-0035-1564057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022] Open
Abstract
Objective Access to the pterygopalatine and infratemporal fossae presents a significant surgical challenge, owing to their deep-seated location and complex neurovascular anatomy. This study elucidates the benefits of incremental medial maxillectomies to access this region. We compared access to the medial aspect of the infratemporal fossa provided by medial maxillectomy, anteriorly extended medial maxillectomy, endoscopic Denker approach (i.e., Sturmann-Canfield approach), contralateral transseptal approach, and the sublabial anterior maxillotomy (SAM). Methods We studied 10 cadaveric specimens (20 sides) dissecting the pterygopalatine and infratemporal fossae bilaterally. Radius of access was calculated using a navigation probe aligned with the endoscopic line of sight. Area of exposure was calculated as the area removed from the posterior wall of maxillary sinus. Surgical freedom was calculated by computing the working area at the proximal end of the instrument with the distal end fixed at a target. Results The endoscopic Denker approach offered a superior area of exposure (8.46 ± 1.56 cm(2)) and superior surgical freedom. Degree of lateral access with the SAM approach was similar to that of the Denker. Conclusion Our study suggests that an anterior extension of the medial maxillectomy or a cross-court approach increases both the area of exposure and surgical freedom. Further increases can be seen upon progression to a Denker approach.
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Affiliation(s)
- Smita Upadhyay
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Ricardo L L Dolci
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Lamia Buohliqah
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Mariano E Fiore
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Leo F S Ditzel Filho
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Daniel M Prevedello
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States; Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Bradley A Otto
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States; Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Ricardo L Carrau
- Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States; Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
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Taniguchi M, Akutsu N, Mizukawa K, Kohta M, Kimura H, Kohmura E. Endoscopic endonasal translacerum approach to the inferior petrous apex. J Neurosurg 2015; 124:1032-8. [PMID: 26252453 DOI: 10.3171/2015.1.jns142526] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 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.
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Affiliation(s)
- Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Katsu Mizukawa
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Gao Z, Chi FL. Anatomy Relationship around Internal Carotid Artery in the Endoscopic Surgery of Nasopharynx: A Study Based on Computed Tomography Angiography. J Neurol Surg B Skull Base 2015. [PMID: 26225298 DOI: 10.1055/s-0034-1395488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective Anatomic knowledge is needed to avoid injury to internal carotid artery (ICA) during the endoscopic surgery around nasopharynx and its surrounding space. Design We prospectively studied the computed tomography angiography (CTA) data of 28 patients with image processing software. Special attention was given to ICA and various landmarks around nasopharynx. Results The anatomic relationship between ICA and different landmarks around nasopharynx was clearly presented in three-dimension. The fossa of Rosenmuller is the nearest point of the nasopharyngeal cavity to ICA. The opening of the Vidian canal in the middle cranial fossa could be either above, below, or at the level of the horizontal segment of petrous ICA. The pharyngeal trunk of the ascending pharyngeal artery can also be clearly identified in most reconstructed CTA images. Multiple anatomic relationships were also quantified. Conclusions Reconstructed CTA can provide key anatomic information for a safe and accurate endoscopic dissection around nasopharynx.
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Affiliation(s)
- Zhen Gao
- Department of Otology and Skull Base Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
| | - Fang-Lu Chi
- Department of Otology and Skull Base Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
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Benet A, Plata Bello J, El-Sayed I. Combined Endonasal-Transcervical Approach to a Metastatic Parapharyngeal Space Papillary Thyroid Carcinoma. Cureus 2015. [PMID: 26203403 PMCID: PMC4509622 DOI: 10.7759/cureus.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Although papillary thyroid carcinoma metastases to the parapharyngeal space are rare, the high amount of fat tissue allows tumors to grow clinically undetectable until they invade most of the parapharyngeal space. We describe for the first time a combined endonasal and transcervical approach for a parapharyngeal metastasis from a papillary thyroid carcinoma. MATERIALS AND METHODS A 51-year-old male with a previous history of papillary thyroid carcinoma presented with left ear fullness and left-sided facial numbness. Imaging revealed a 4x3 cm pre-styloid parapharyngeal space mass invading the foramen ovale and extending below the palate. Needle biopsy confirmed metastatic papillary thyroid carcinoma. RESULTS The lesion was resected with a combined endoscopic endonasal and transcervical approach. Postoperative MRI revealed gross total resection, and the patient recovered from his symptoms. CONCLUSION This novel approach provides access to pre-styloid parapharyngeal tumors with superior extension to the skull base, avoiding more extensive traditional open approaches.
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Affiliation(s)
- Arnau Benet
- Department of Otolaryngology-Head and Neck surgery. Department of Neurosurgery, University of California San Francisco
| | | | - Ivan El-Sayed
- Otolaryngology Head and Neck Surgery, University of California San Francisco
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Ditzel Filho LFS, Prevedello DM, Dolci RL, Jamshidi AO, Kerr EE, Campbell R, Otto BA, Carrau RL. The Endoscopic Endonasal Approach for Removal of Petroclival Chondrosarcomas. Neurosurg Clin N Am 2015; 26:453-62. [PMID: 26141363 DOI: 10.1016/j.nec.2015.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chondrosarcomas of the skull base are rare, locally invasive tumors that typically arise in the petroclival region, from degenerated chondroid cells located within the synchondrosis. Given their usually slow growth rate, they are capable of reaching sizable dimensions, promoting bone erosion and significant displacement of neurovascular structures before causing symptomatology that will eventually lead to diagnosis; cranial neuropathies and headaches are common complaints. This article discusses the pertinent surgical anatomy, patient selection criteria, technical nuances and complication management of the endonasal resection of skull base chondrosarcomas.
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Affiliation(s)
- Leo F S Ditzel Filho
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA.
| | - Ricardo L Dolci
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Ali O Jamshidi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Edward E Kerr
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Raewyn Campbell
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Bradley A Otto
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
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Youssef A, Carrau RL, Tantawy A, Ibraheim A, Solares AC, Otto BA, Prevedello DM, Filho LD. Endoscopic versus Open Approach to the Infratemporal Fossa: A Cadaver Study. J Neurol Surg B Skull Base 2015; 76:358-64. [PMID: 26401477 DOI: 10.1055/s-0035-1549003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 01/26/2015] [Indexed: 10/23/2022] Open
Abstract
Introduction Various lateral and anterior approaches to access the infratemporal fossa (ITF) have been described. We provide our observations regarding the endoscopic transpterygoid and preauricular subtemporal approaches, listing their respective advantages and limitations through cadaveric dissection. Methods A cadaver study was performed on five adult specimens. An endoscopic transpterygoid approach to the ITF was completed bilaterally in three specimens, and an open preauricular ITF approach was performed bilaterally in two specimens. Results After completing the cadaveric dissections, we studied differences between the endoscopic transpterygoid approach and open preauricular subtemporal approaches in regard to exposure and ease of dissection of different structures in the ITF. Conclusions In comparison with a lateral approach, the endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure of median structures such as the nasopharynx, eustachian tube, sella, and clivus. We concluded that the endoscopic transpterygoid approach can be utilized to resect benign lesions and some select group of malignancies involving the infratemporal and middle cranial fossae. Open approaches continue to play an important role, especially in the resection of extensive malignant tumors extending to these regions.
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Affiliation(s)
- Ahmed Youssef
- Department of Otolaryngology-Head and Neck Surgery, Alexandria University, El Azareeta, Alexandria, Egypt
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Ahmed Tantawy
- Department of Otolaryngology-Head and Neck Surgery, Alexandria University, El Azareeta, Alexandria, Egypt
| | - Ahmed Ibraheim
- Department of Otolaryngology, Alexandria Medical School, Ramel Station, Alexandria, Egypt
| | - Arturo C Solares
- Department of Otolaryngology-Head and Neck Surgery, Georgia Regents Medical Center, Augusta, Georgia, United States
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, United States
| | - Daniel M Prevedello
- Department of Neurosurgery, The University of Ohio, Columbus, Ohio, United States
| | - Leo Ditzel Filho
- Department of Neurosurgery, The University of Ohio, Columbus, Ohio, United States
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Comparison of lateral microsurgical preauricular and anterior endoscopic approaches to the jugular foramen. The Journal of Laryngology & Otology 2015; 129 Suppl 2:S12-20. [DOI: 10.1017/s0022215114002321] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:This project compares access to the anterolateral part of the jugular foramen provided by the lateral microsurgical preauricular and the anterior endoscopic approaches, and defines the important landmarks involved in each approach.Study Design:Cadaveric study.Results:The endoscopic transnasal/transmaxillary transpterygoid corridor provides a less invasive route for selected lesions in the jugular foramen than the traditional open route through the preauricular subtemporal infratemporal fossa approach. However, the anterior endoscopic approach provides a smaller channel to the jugular foramen than the preauricular approach.Conclusions:The anterior endoscopic approach to the anterolateral part of the jugular foramen is a useful alternative to the lateral microsurgical preauricular approach in carefully selected cases. The vaginal process of the tympanic part of the temporal bone provides a valuable landmark to aid in accessing the jugular foramen in both procedures and can be drilled to open the foramen in the preauricular approach.
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