Short- and Long-Term Neurologic Outcomes After an Endoscopic Endonasal Transpterygoid Approach

Introduction: The endoscopic endonasal transpterygoid approach (EETPA) is a minimally invasive approach to the lateral skull base. It can be classified based on the extent of bony removal, vidian nerve dissection, and Eustachian tube sacrifice (CPK classification). The main transient or permanent neurologic approach-related deficits are: keratoconjunctivitis sicca (vidian nerve injury), trigeminal neuropathy or neuralgia (injury to trigeminal nerve), trismus (injury to lingual or inferior alveolar nerves), abducens palsy, hearing loss (secondary to Eustachian tube injury), and palatal numbness (injury to greater palatine nerve). Postoperative radiation can lead to similar neurologic sequelae and/or impair resolution. We aim to describe the evolution of these neurologic deficits over time in patients undergoing an EETPA.

Methods: This is a retrospective review of patients who underwent a unilateral or bilateral EETPA for tumor resection from April 2014 until October 2023. Patients with follow-up of less than 60 days from surgery or postoperative radiotherapy when received were excluded. We analyzed how preoperative deficit, radiation, and approach type affect symptom resolution ([Fig. 1]).

Results: Cohort characteristics are illustrated in Table 1.

Fig. 1 Demonstrates deficit incidence by approach type.

Trigeminal neuropathy was significantly more likely to resolve if the approach type was A-D compared with E (p < 0.05). Patients undergoing the E type of approach were significantly more likely to have trigeminal neuralgia than those undergoing a type A-D approach (p < 0.05). Hearing loss was significantly more likely to resolve if absent pre-operatively (p < 0.005). Patients with preoperative hearing loss and trismus were significantly more likely to have postoperative hearing loss and trismus (p < 0.005 and p < 0.05, respectively). Preoperative trismus is the most likely to improve with surgical resection. Half of the patients with preoperative hearing loss will improve with surgical resection. However, only 8% of patients with new, approach-related, hearing loss will see improvement ([Fig. 2]).

Fig. 2

The most common delayed onset neurologic deficits were hearing loss and trismus. Approach-related palatal numbness has a high rate (86%) of self-improvement over time. Patients with neurologic deficits were more likely to have undergone postoperative radiation and vice versa ([Fig. 3]).

Fig. 3

Postoperative radiation was not significantly associated with a likelihood of symptom resolution.

Conclusion: Understanding the evolution over time of these neurologic deficits allows for data-driven patient counseling regarding the incidence and likelihood of resolution of neurologic deficits both pre- and postoperatively in patients undergoing an EETPA. Furthermore, early multidisciplinary planning can occur to optimize management of each deficit.

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Artikel online veröffentlicht:
07. Februar 2025