Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex

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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.

ABBREVIATIONS CTM = contralateral transmaxillary; EEA = endoscopic endonasal approach; GTR = gross-total resection; ICA = internal carotid artery.

Article Information

Correspondence Carl Snyderman, UPMC Center for Cranial Base Surgery, The Eye & Ear Institute, 200 Lothrop St., Ste. 500, Pittsburgh, PA 15213. email: snydermanch@upmc.edu.

INCLUDE WHEN CITING Published online October 20, 2017; DOI: 10.3171/2017.4.JNS162483.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Anatomical dissection of an endonasal approach to the petrous apex. An extended dissection has been performed to demonstrate key anatomical structures and landmarks. Copyright Carl Snyderman. Published with permission. Figure is available in color online only.

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    Left: Anterior view of face of maxillary sinus after anterior and medial maxillotomies. Right: Axial CT scan from navigation software showing the lateral extent of anterior maxillotomy. Left panel copyright Carl Snyderman. Published with permission. Figure is available in color online only.

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    A: Axial CT scan from navigation software showing the standard endonasal trajectory to the right superior petrous apex. B: Endoscopic view of the standard endonasal approach to the right petrous apex. C: Axial CT scan from navigation software showing the CTM trajectory to the right superior petrous apex. D: Endoscopic view of the left CTM approach to the right petrous apex. Panels B and D copyright Carl Snyderman. Published with permission. Figure is available in color online only.

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    Illustrative view of measurements being taken of the angle of approach with respect to the axis of the petrous ICA for the endonasal approach (A) and the CTM approach (B). The dashed line represents the axis of the petrous ICA. Figure is available in color online only.

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    Schematic drawing of a right petrous apex tumor. In comparison with an endonasal approach, the CTM approach decreases the angle of the corridor by 25°. Copyright Jon Coulter. Published with permission.

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    Anatomical dissection demonstrating a left CTM approach to the right petrous apex. BA = basilar artery; FL = foramen lacerum; ICA = right paraclival portion of the ICA; IoN = infraorbital nerve; MC = Meckel’s cave; Pit = pituitary; VN = vidian nerve; * = right medial petrous apex. Copyright Carl Snyderman. Published with permission. Figure is available in color online only.

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    Case 2. Preoperative imaging studies. A: Axial T1-weighted contrast-enhanced MR image demonstrating recurrent chordoma of the left petrous apex (asterisk). B: Axial T2-weighted MR image showing recurrent chordoma of the left petrous apex (asterisk). C: Coronal T1-weighted contrast-enhanced MR image demonstrating recurrent chordoma encasing the left paraclival ICA. D: Axial CT scan of prior surgical defect showing intact bone over second genu of the ICA (asterisk).

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    Case 2. Intraoperative navigation screen captures demonstrating the endonasal angle of approach. The probe is displacing the paraclival ICA. Figure is available in color online only.

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    Case 2. Intraoperative navigation screen captures demonstrating the angle with the CTM approach. The probe is displacing the paraclival ICA. Figure is available in color online only.

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    Case 2. Postoperative images demonstrating a GTR of the chordoma: axial T1-weighted contrast-enhanced MR image (A); axial T2-weighted MR image (B); coronal T1-weighted contrast-enhanced MR image (C); and axial CT scan (D) demonstrating additional bone removal accomplished.

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    Postoperative nasal endoscopy of the right nasal cavity demonstrates a right CTM approach to the left petrous apex. The nasoseptal flap covers the posterior fossa defect, left petrous apex, and paraclival ICA. IT = inferior turbinate; MS = maxillary sinus; NSF = nasoseptal flap reconstruction. Figure is available in color online only.

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