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J Neurol Surg B Skull Base 2022; 83(01): 044-052
DOI: 10.1055/s-0040-1716693
Original Article

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

João Mangussi-Gomes 
1   Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
João T. Alves-Belo
1   Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Huy Q. Truong
1   Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Gustavo F. Nogueira
2   Instituto de Neurologia de Curitiba, INC Hospital, Curitiba, Paraná, Brazil
,
Eric W. Wang
3   Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Juan C. Fernandez-Miranda
1   Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
4   Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Paul A. Gardner
1   Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
4   Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Carl H. Snyderman
3   Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
› Author Affiliations Funding The authors declare no sources of financial and material support directly related to the conception and/or production of this study.
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Abstract

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

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

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

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

Keywords

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

Note

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




Publication History

Received: 16 May 2020

Accepted: 27 July 2020

Article published online:
10 September 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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