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Liu J, Zhao J, Wang Y, Zhao Y, Han J, Yang D. Endoscopic endonasal transpterygoid nasopharyngectomy: Anatomical considerations and technical note. Head Neck 2024; 46:306-320. [PMID: 37987238 DOI: 10.1002/hed.27581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/01/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND The study was designed to identify new landmarks in the parapharyngeal segment of the internal carotid artery (ICA) for nasopharyngectomy and describe a surgical procedure of endoscopic endonasal transpterygoid nasopharyngectomy (EETPN). METHODS Four cadaveric specimens were injected with colored silicone and subjected to CT scanning before dissection. The nasopharyngeal skull base was exposed using the endoscopic endonasal transpterygoid approach. The clinical data of four patients with nasopharyngeal malignances who underwent EETPN were reviewed. RESULTS The lateral edge of the longus capitis muscle medially; the foramen lacerum, petrous apex spine and the stump of the levator veli palatini muscle superior laterally; and the upper parapharyngeal ICA laterally constitute the ICA-longus capitis muscle-petrous apex spine triangle which was a novel landmark for the upper parapharyngeal segment of the ICA. CONCLUSION The ICA-longus capitis muscle-petrous apex spine triangle are important landmarks of the upper parapharyngeal segment of the ICA.
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Affiliation(s)
- Jianfeng Liu
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianhui Zhao
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yibei Wang
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yu Zhao
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jun Han
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Dazhang Yang
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
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Roschina DV, Godkov IM, Grin AA, Tovmasyan AS, Garov EV. [Endonasal repair of spontaneous CSF fistulas of the lateral recess of the sphenoid sinus]. Vestn Otorinolaringol 2023; 88:97-103. [PMID: 37970777 DOI: 10.17116/otorino20238805197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
CSF fistulas of the lateral recess of the sphenoid sinus are a rare surgical pathology. Cerebrospinal fluid leak from lateral recess of the sphenoid sinus is observed with a frequency of 7.7% among all leakafe of the skull base. The article presents 3 clinical cases of patients with spontaneous cerebrospinal fluid leak from lateral recess of the sphenoid sinus and surgical treatments by transsphenoidal and transpterygoid (transpterygoid) endoscopic approaches with various postoperative results. The plastic surgery success of CSF fistulas from lateral recess of the sphenoid sinus doesn`t depend on the type of endonasal surgical approach, but on the plastic quality and the preoperative level of CSF pressure.
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Affiliation(s)
- D V Roschina
- N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - I M Godkov
- N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multidisciplinary Clinical Center «Kommunarka», Moscow, Russia
| | - A A Grin
- N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A S Tovmasyan
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - E V Garov
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
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He C, Zhen HT. Management of Cerebrospinal Fluid Rhinorrhea in the Sphenoid Sinus Lateral Recess Through an Endoscopic Endonasal Transpterygoid Approach With Obliteration of the Lateral Recess. Ear Nose Throat J 2020; 101:319-325. [PMID: 32921179 DOI: 10.1177/0145561320955140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess is a rare occurrence and poses unique challenges due to limited surgical access for surgical repair. OBJECTIVE To report our experience of surgical repair of cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess through an endoscopic endonasal transpterygoid approach with obliteration of the lateral recess. To evaluate the efficiency of this surgical procedure. METHODS A retrospective study. Twelve cases with cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess were reviewed. Assisted by image-guided navigation, cerebrospinal fluid rhinorrhea was repaired through an endoscopic endonasal transpterygoid approach, with obliteration of the lateral recess. Complications and recurrence were recorded. Medical photographs were used. RESULTS This surgical approach provided a relatively spacious corridor to dissect the sphenoid sinus lateral recess and do postoperative surveillance. The repair area completely healed in 3 months after surgery. Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess was successfully repaired on the first attempt in all cases (100%). No main complications or recurrence was observed during a mean follow-up time of 40.3 months. CONCLUSION The endoscopic endonasal transpterygoid approach gives appropriate access for the treatment of spontaneous cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess. Multilayer reconstruction of a skull base defect with obliteration of the lateral recess is a reliable and simple method.
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Affiliation(s)
- Chao He
- Department of Otolaryngology-Head and Neck Surgery, 66375Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Hong-Tao Zhen
- Department of Otolaryngology-Head and Neck Surgery, 66375Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Rai SKR, Dandpat SK. Modified Ipsilateral Endonasal Endoscopic Trans-Sphenoidal Approach to Sphenoid Sinus Lateral Recess Cerebrospinal Fluid Leak Management in Two Cases: A Technical Note. J Neurosci Rural Pract 2020; 11:459-462. [PMID: 32801593 PMCID: PMC7426184 DOI: 10.1055/s-0040-1713338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background Cerebrospinal fluid (CSF) leak from the sphenoid sinus lateral recess (SSLR) is very rare. Majority prefer transpterygoid approach which is extensive and time consuming. Two such cases were managed with least possible dissection/destruction of paranasal sinus. Methods Two cases of SSLR were accessed through the ipsilateral nostril from the side of CSF leak. Wide ipsilateral anterior sphenoidotomy was done preserving intersinus septum of sphenoid sinus. Middle turbinate was lateralized and remaining paranasal structures were preserved. Two handed single nostril approach was done in both the cases by 45- and 70-degree endoscope along with angled instruments. SSLR defects were visualized and packed with autologous fat graft and glue. Results SSLR defects could be visualized and packed with fat graft in both the cases from ipsilateral side. Both cases had uneventful outcome with no leak with mean -follow-up of 11.5 months. Conclusion Modified ipsilateral endonasal endoscopy trans-sphenoidal approach is least invasive technique for SSLR leak. Use of angled scope and instruments help in defect visualization, avoiding extensive paranasal sinus dissection and bony removal. Tedious time-consuming reconstructive procedures can be avoided with simple fat graft with good outcome.
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Affiliation(s)
- Survendra Kumar R Rai
- Department of Neurosurgery, King Edward Memorial Hospital, Seth Gordhandas Memorial Hospital, Mumbai, Maharashtra, India
| | - Saswat Kumar Dandpat
- Department of Neurosurgery, King Edward Memorial Hospital, Seth Gordhandas Memorial Hospital, Mumbai, Maharashtra, India
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Maxfield AZ, Mueller SK, Raquib AR, Sedaghat AR, Bergmark RW, Metson RB, Holbrook EH, Bleier BS, Gray ST. Endoscopic management of lateral sphenoid cerebrospinal fluid leaks: Identifying a radiographic parameter for surgical planning. Laryngoscope Investig Otolaryngol 2020; 5:375-380. [PMID: 32596479 PMCID: PMC7314466 DOI: 10.1002/lio2.412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/20/2020] [Accepted: 05/17/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach. METHODS Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed. RESULTS Twenty-two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively.The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; P = .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm3 ± 0.48, 0.39 cm3 ± 0.40, respectively; P = .04). A LRS volume of 0.400 cm3 or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity. CONCLUSION This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Alice Z Maxfield
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Sarina K Mueller
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
- Department of Otolaryngology, Head and Neck Surgery University of Erlangen-Nuremberg Erlangen Germany
| | - Aaishah R Raquib
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Ahmad R Sedaghat
- Department of Otolaryngology, Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Regan W Bergmark
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA
- Center for Surgery and Public Health Brigham and Women's Hospital Boston Massachusetts USA
- Patient Reported Outcomes, Value and Experience (PROVE) Center Brigham and Women's Hospital Boston Massachusetts USA
| | - Ralph B Metson
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Eric H Holbrook
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Benjamin S Bleier
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA
- Department of Otolaryngology-Head and Neck Surgery Massachusetts Eye and Ear Boston Massachusetts USA
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Rajasekar G, Nair P, Abraham M, Felix V, Karthikayan A. Cerebrospinal fluid rhinorrhea from the lateral recess of sphenoid sinus: More to it than meets the eye. Neurol India 2019; 67:201-206. [PMID: 30860122 DOI: 10.4103/0028-3886.253634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Cerebrospinal fluid (CSF) leak from the lateral recess of the sphenoid sinus is rare when compared to leaks from other sites. The extended endonasal approach along with a transpterygoid extension provides adequate exposure for repair of these defects. Materials and Methods We retrospectively analyzed a series of seven patients who underwent eight transpterygoid approaches for repair of the CSF leak from the lateral recess of the sphenoid sinus. We analyzed the patient characteristics, site of leaks, type of repair done, and presence of increased intracranial pressure (ICP) in these individuals. Results Seven patients underwent eight transpterygoid approaches for CSF leaks from the lateral recess of the sphenoid sinus. The leak was bilateral in one patient. The materials used for repair consisted of fat, fascia lata, free mucosal flap or a vascularised nasoseptal flap, and fibrin glue. Evidence of increased ICP was found in five of the seven patients. CSF diversion was needed in three of the seven patients (two ventriculoperitoneal shunt and one thecoperitoneal shunt). Conclusion Endoscopic endonasal transpterygoid approach provides an excellent visualization of the skull-base defect and facilitates adequate instrument manipulation within the corridor, allowing successful repair of the defect with low rates of recurrence. Increased ICP can have a role in causing spontaneous CSF rhinorrhea from this location.
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Affiliation(s)
- Gopikrishnan Rajasekar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Vinod Felix
- Department of ENT, SUT Hospital, Pattom, Trivandrum, Kerala, India
| | - Arunkumar Karthikayan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Tayebi Meybodi A, Little AS, Vigo V, Benet A, Kakaizada S, Lawton MT. The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach. J Neurosurg 2018; 130:1-11. [PMID: 29775148 DOI: 10.3171/2017.12.jns172435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/05/2017] [Indexed: 11/06/2022]
Abstract
Objective The transpterygoid extension of the endoscopic endonasal approach provides exposure of the petrous apex, Meckel's cave, paraclival area, and the infratemporal fossa. Safe and efficient localization of the lacerum segment of the internal carotid artery (ICA) is a crucial part of such exposure. The aim of this study is to introduce a novel landmark for localization of the lacerum ICA. Methods Ten cadaveric heads were prepared for transnasal endoscopic dissection. The floor of the sphenoid sinus was drilled to expose an extension of the pharyngobasilar fascia between the sphenoid floor and the pterygoid process (the pterygoclival ligament). Several features of the pterygoclival ligament were assessed. In addition, 31 dry skulls were studied to assess features of the bony groove harboring the pterygoclival ligament. Results The pterygoclival ligament was identified bilaterally during drilling of the sphenoid floor in all specimens. The ligament started a few millimeters posterior to the posterior end of the vomer alae and invariably extended posterolaterally and superiorly to blend into the fibrous tissue around the lacerum ICA. The mean length of the ligament was 10.5 ± 1.7 mm. The mean distance between the anterior end of the ligament and midline was 5.2 ± 1.2 mm. The mean distance between the posterior end of the ligament and midline was 12.3 ± 1.4 mm. The bony pterygoclival groove was identified at the confluence of the vomer, pterygoid process of the sphenoid, and basilar part of the occipital bone, running from posterolateral to anteromedial. The mean length of the groove was 7.7 ± 1.8 mm. Its posterolateral end faced the anteromedial aspect of the foramen lacerum medial to the posterior end of the vidian canal. A clinical case illustration is also provided. Conclusions The pterygoclival ligament is a consistent landmark for localization of the lacerum ICA. It may be used as an adjunct or alternative to the vidian nerve to localize the ICA during endoscopic endonasal surgery.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Andrew S Little
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Arnau Benet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Sofia Kakaizada
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
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Sun X, Yan B, Truong HQ, Borghei-Razavi H, Snyderman CH, Fernandez-Miranda JC. A Comparative Analysis of Endoscopic-Assisted Transoral and Transnasal Approaches to Parapharyngeal Space: A Cadaveric Study. J Neurol Surg B Skull Base 2017; 79:229-240. [PMID: 29765820 DOI: 10.1055/s-0037-1606551] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/30/2017] [Indexed: 12/19/2022] Open
Abstract
Background Surgical resection of parapharyngeal space (PPS) tumors is very challenging. An endoscopic-assisted surgical approach to this region requires detailed and precise anatomic knowledge. The main purpose of this study is to describe and compare the detailed anatomy of the PPS via transnasal transpterygoid (TP) and endoscopic-assisted transoral (TO) approaches. Materials and Methods Six fresh injected cadaver heads (12 sides) were prepared for dissection of the PPS via TP and TO approaches. Computed tomography (CT) with image-based navigation (Navigation System II; Stryker, Kalamazoo, Michigan, United States) was used to identify bony structures around the PPS. Results TP and TO approaches could both expose the detailed anatomical structures in the PPS. The TP approach can provide a direct route to the upper PPS, but it is limited inferiorly by the hard palate and laterally by the medial and lateral pterygoid muscles. However, the TO approach can provide a direct route to the lower PPS, but it is difficult to expose the area around the Eustachian tube. The styloglossus and stylopharyngeus muscles could be considered as the safe anterior boundary of the parapharyngeal internal carotid artery (ICA) with the TO approach. Dissection between the stylopharyngeus muscle and the superior pharyngeal constrictor muscle provides direct access to the parapharyngeal ICA. Conclusion The TP and TO approaches provide new strategies to manage lesions in the PPS. The important neurovascular structures of the PPS could be identified with these approaches. The endoscopic-assisted TO approach can provide direct access to the parapharyngeal ICA.
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Affiliation(s)
- Xicai Sun
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.,Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China
| | - Bo Yan
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.,Department of Otorhinolaryngology Head and Neck Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huy Q Truong
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Hamid Borghei-Razavi
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.,Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Surgical Neuroanatomy Lab, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.,Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Freeman JL, Sampath R, Quattlebaum SC, Casey MA, Folzenlogen ZA, Ramakrishnan VR, Youssef AS. Expanding the endoscopic transpterygoid corridor to the petroclival region: anatomical study and volumetric comparative analysis. J Neurosurg 2017; 128:1855-1864. [PMID: 28731399 DOI: 10.3171/2017.1.jns161788] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal transmaxillary transpterygoid (TMTP) approach has been the gateway for lateral skull base exposure. Removal of the cartilaginous eustachian tube (ET) and lateral mobilization of the internal carotid artery (ICA) are technically demanding adjunctive steps that are used to access the petroclival region. The gained expansion of the deep working corridor provided by these maneuvers has yet to be quantified. METHODS The TMTP approach with cartilaginous ET removal and ICA mobilization was performed in 5 adult cadaveric heads (10 sides). Accessible portions of the petrous apex were drilled during the following 3 stages: 1) before ET removal, 2) after ET removal but before ICA mobilization, and 3) after ET removal and ICA repositioning. Resection volumes were calculated using 3D reconstructions generated from thin-slice CT scans obtained before and after each step of the dissection. RESULTS The average petrous temporal bone resection volumes at each stage were 0.21 cm3, 0.71 cm3, and 1.32 cm3 (p < 0.05, paired t-test). Without ET removal, inferior and superior access to the petrous apex was limited. Furthermore, without ICA mobilization, drilling was confined to the inferior two-thirds of the petrous apex. After mobilization, the resection was extended superiorly through the upper extent of the petrous apex. CONCLUSIONS The transpterygoid corridor to the petroclival region is maximally expanded by the resection of the cartilaginous ET and mobilization of the paraclival ICA. These added maneuvers expanded the deep window almost 6 times and provided more lateral access to the petroclival region with a maximum volume of 1.5 cm3. This may result in the ability to resect small-to-moderate sized intradural petroclival lesions up to that volume. Larger lesions may better be approached through an open transcranial approach.
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Affiliation(s)
| | | | | | | | | | | | - A Samy Youssef
- Departments of1Neurosurgery and.,2Otolaryngology, University of Colorado, Aurora, Colorado
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10
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Golbin DA, Lasunin NV, Cherekaev VA, Polev GA. The Pedicled Buccal Fat Pad: Anatomical Study of the New Flap for Skull Base Defect Reconstruction After Endoscopic Endonasal Transpterygoid Surgery. J Neurol Surg B Skull Base 2017; 78:75-81. [PMID: 28180047 PMCID: PMC5288118 DOI: 10.1055/s-0036-1584895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022] Open
Abstract
Objectives To evaluate the efficacy and safety of using a buccal fat pad for endoscopic skull base defect reconstruction. Design Descriptive anatomical study with an illustrative case presentation. Setting Anatomical study was performed on 12 fresh human cadaver specimens with injected arteries (24 sides). Internal carotid artery was exposed in the coronal plane via the endoscopic transpterygoid approach. The pedicled buccal fat pad was used for reconstruction. Participants: 12 human cadaver head specimens; one patient operated using the proposed technique. Main outcome measures: Proximity of the buccal fat pad flap to the defect, compliance of the flap, comfort and safety of harvesting procedure, and compatibility with the Hadad-Bassagasteguy nasoseptal flap. Results: Harvesting procedure was performed using anterior transmaxillary corridor. The pedicled buccal fat pad flap can be used to pack the sphenoid sinus or cover the internal carotid artery from cavernous to upper parapharyngeal segment. Conclusion The buccal fat pad can be safely harvested through the same approach without external incisions and is compliant enough to conform to the skull base defect. The proposed pedicled flap can replace free abdominal fat in central skull base reconstruction. The volume of the buccal fat pad allows obliteration of the sphenoid sinus or upper parapharyngeal space.
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Affiliation(s)
- Denis A. Golbin
- Department of Skull Base and Craniofacial Surgery, Burdenko Neurosurgery Institute, Moscow, Russia
| | - Nikolay V. Lasunin
- Department of Skull Base and Craniofacial Surgery, Burdenko Neurosurgery Institute, Moscow, Russia
| | - Vasily A. Cherekaev
- Department of Skull Base and Craniofacial Surgery, Burdenko Neurosurgery Institute, Moscow, Russia
| | - Georgiy A. Polev
- Department of Diseases of Nose and Pharynx, Federal State ENT Centre, Moscow, Russia
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11
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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: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Karligkiotis A, Bignami M, Terranova P, Ciniglio-Appiani M, Shawkat A, Verrilaud B, Meloni F, Herman P, Castelnuovo P. Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex. Int Forum Allergy Rhinol 2015; 5:747-53. [PMID: 25821119 DOI: 10.1002/alr.21521] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/18/2015] [Accepted: 02/17/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nowadays the endoscopic approach represents a useful alternative to traditional surgical approaches in the treatment of cholesterol granulomas (CGs) of the petrous apex (PA). Recently the nasoseptal flap (NSF) has been employed to permit long-term patency of drainage site. The purpose of this study is to report our experience with the NSF in the endoscopic management of CG and to analyze the advantages, limitations, and outcomes of the technique. METHODS A retrospective analysis was carried out on 10 patients affected by CG of the PA who had been treated endoscopically, using the NSF. RESULTS An endoscopic transpterygoid approach was used for 6 patients and the remaining 4 were treated using the transclival approach. A NSF was used in all 10 cases. In 6 cases the flap was ipsilateral to the lesion whereas in 4 it was contralateral. In 90% of our patients no evidence of disease was observed after a mean follow-up period of 35.7 months, with resolution of their symptoms. One patient presented a recurrence because of a technical error (inadequate placement of the flap in the cavity), and has been retreated endoscopically. CONCLUSION The pedicled NSF seems to be helpful in avoiding the concentric growth of the granulomatous cyst epithelium while assuring ventilation and drainage of the cyst. However, bigger studies with longer-term follow-up are needed to confirm these findings. Correct and meticulous placement of the flap inside the cystic cavity is the most critical issue for the success of the procedure.
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Affiliation(s)
- Apostolos Karligkiotis
- Division of Otorhinolaryngology, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Maurizio Bignami
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Paola Terranova
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Mario Ciniglio-Appiani
- Ear, Nose, and Throat (ENT) Section, Department of Sensory Organs, Sapienza University of Rome, Rome, Italy
| | - Abdulrahman Shawkat
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Benjamin Verrilaud
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hopitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Equipe d'accueil (EA) Recherche Clinique Cordonnée Ville-Hôpital, Méthodologies et Société (REMES), Paris, France
| | - Francesco Meloni
- Division of Otorhinolaryngology, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Philippe Herman
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hopitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Equipe d'accueil (EA) Recherche Clinique Cordonnée Ville-Hôpital, Méthodologies et Société (REMES), Paris, France
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Moussazadeh N, Kulwin C, Anand VK, Ting JY, Gamss C, Iorgulescu JB, Tsiouris AJ, Cohen-Gadol AA, Schwartz TH. Endoscopic endonasal resection of skull base chondrosarcomas: technique and early results. J Neurosurg 2015; 122:735-42. [PMID: 25594323 DOI: 10.3171/2014.11.jns14827] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors of this study sought to report the technique and early clinical outcomes of a purely endonasal endoscopic approach for resection of petroclival chondrosarcomas. METHODS Between 2010 and 2014, 8 patients (4 men and 4 women) underwent endonasal endoscopic operations to resect petroclival chondrosarcomas at 2 institutions. The patients' mean age was 44.8 years (range 30-64 years). One of the patients had previously undergone radiation therapy and another a staged craniotomy. Using volumetric software, an independent neuroradiologist assessed the extent of the resections on MRI scans taken immediately after surgery and at the 3-month follow-up. Immediate complications and control of symptoms were also recorded. In addition, the authors reviewed the current literature on surgical treatment of chondrosarcoma. RESULTS The mean preoperative tumor diameter and volume were 3.4 cm and 9.8 cm(3), respectively. Six patients presented with cranial neuropathies. Endonasal endoscopic surgery achieved > 95% resection in 5 of the 8 patients and < 95% resection in the remaining 3 patients. One of the 6 neuropathies resolved, and the remaining 5 partially improved. One instance of postoperative CSF leakage required a reoperation for repair; no other complications associated with these operations were observed. All of the patients underwent adjuvant radiotherapy. CONCLUSIONS According to the authors' experience, the endoscopic endonasal route is a safe and effective approach for the resection of appropriately selected petroclival chondrosarcomas.
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Youssef A, Carrau RL, Tantawy A, Ibrahim AA, Prevedello DM, Otto BA, Solares AC, Ditzel Filho LFS, Rompaey J. Clinical correlates of the anatomical relationships of the foramen ovale: a radioanatomical study. J Neurol Surg B Skull Base 2014; 75:427-34. [PMID: 25452902 DOI: 10.1055/s-0034-1386654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 05/27/2014] [Indexed: 10/24/2022] Open
Abstract
Introduction Endonasal endoscopic transpterygoid approaches are commonly used techniques to access the infratemporal fossa and parapharyngeal space. Important endoscopic endonasal landmarks for the poststyloid parapharyngeal space, hence the internal carotid artery, include the mandibular nerve at the level of foramen ovale and the lateral pterygoid plate. This study aims to define the anatomical relationships of the foramen ovale, establishing its distance to other important anatomical landmarks such as the pterygoid process and columella. Methods Distances between the foramen ovale, foramen rotundum, and fixed anatomical landmarks like the columella and pterygoid process were measured using computed tomography (CT) scans and cadaveric dissections of the pterygopalatine and infratemporal fossae. Results The mean distances from the foramen ovale to columella and from the foramen rotundum to columella were found to be 9.15 cm and 7.09 cm, respectively. Analysis of radiologic measurements detected no statistically significant differences between sides or gender. Conclusions The pterygoid plates and V3 are prominent landmarks of the endonasal endoscopic approach to the infratemporal fossa and poststyloid parapharyngeal space. A better understanding of the endoscopic anatomy of the infratemporal fossa and awareness of the approximate distances and geometry among anatomical landmarks facilitates a safe and complete resection of lesions arising or extending to these regions.
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Affiliation(s)
- Ahmed Youssef
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, United States ; Department of Otolaryngology-Head and Neck Surgery, Alexandria University, El Azareeta, Alexandria, Egypt
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, United States
| | - Ahmed Tantawy
- Department of Otolaryngology-Head and Neck Surgery, Alexandria University, El Azareeta, Alexandria, Egypt
| | - Ahmed Ali Ibrahim
- Department of Otolaryngology-Head and Neck Surgery, Alexandria University, El Azareeta, Alexandria, Egypt
| | - Daniel M Prevedello
- Department of Neurosurgery, The University of Ohio, Columbus, Ohio, United States
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, United States
| | - Arturo C Solares
- Department of Otolaryngology-Head and Neck Surgery, Georgia Regents Medical Center, Augusta, Georgia, United States
| | - Leo F S Ditzel Filho
- Department of Neurosurgery, The University of Ohio, Columbus, Ohio, United States
| | - Jason Rompaey
- Department of Otolaryngology-Head and Neck Surgery, Georgia Regents Medical Center, Augusta, Georgia, United States
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Ibrahim T, Ackerman PD, Welch KC, Prabhu VC. Transpterygoid stent placement for management of a recurrent infratemporal fossa epidermoid cyst: a technical note. J Neurol Surg Rep 2013; 74:123-8. [PMID: 24294567 PMCID: PMC3836887 DOI: 10.1055/s-0033-1358377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 08/15/2013] [Indexed: 10/31/2022] Open
Abstract
Epidermoid cysts (ECs) are benign congenital cysts that typically develop from misplaced stratified squamous epithelium during neural tube closure. They are most commonly encountered in the cerebellopontine angle, the fourth ventricle, and the region of the sella turcica. Recurrence of an EC or regrowth of residual components following surgery is known to occur, but the exact incidence is not defined. Repeat surgical removal is generally considered but may be complicated by significant morbidity. We present a novel endoscopic method by which to manage a recurrent EC of the infratemporal fossa using a silastic stent through a transpterygoid approach that permits periodic drainage of recurrent cyst material in the outpatient setting with minimal morbidity.
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Affiliation(s)
- Tarik Ibrahim
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, United States
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