Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches

Edoardo Agosti; Natália Cerqueira Rezende; Luciano C. P. C. Leonel; A. Yohan Alexander; Carlos D. Pinheiro-Neto; Maria Peris-Celda

doi:10.1055/s-0042-1759874

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2024; 85(01): 081-094
DOI: 10.1055/s-0042-1759874

Original Article

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches

Edoardo Agosti^*

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

³Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

,

Natália Cerqueira Rezende^*

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Luciano C. P. C. Leonel

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

A. Yohan Alexander

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Carlos D. Pinheiro-Neto

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Maria Peris-Celda

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

› Author Affiliations

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.

Keywords

step-by-step anatomical dissections - skull base surgery - endonasal endoscopy - transmaxillary - sublabial - transpterygoid - pterygopalatine fossa - infratemporal fossa - Meckel's cave

Full Text

References

References
1 Cappello ZJ, Potts KL. Anatomy, Pterygopalatine Fossa. [Updated 2021 Sep 20]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2022
2 Silveira-Bertazzo G, Martinez-Perez R, Carrau RL, Prevedello DM. Surgical anatomy and nuances of the expanded transpterygoid approach to the pterygopalatine fossa and upper parapharyngeal space: a stepwise cadaveric dissection. Acta Neurochir (Wien) 2021; 163 (02) 415-421
3 Wang L, Gun R, Youssef A. et al. Anatomical study of critical features on the posterior wall of the maxillary sinus: clinical implications. Laryngoscope 2014; 124 (11) 2451-2455
4 Derinkuyu BE, Boyunaga O, Oztunali C, Alimli AG, Ucar M. Pterygopalatine Fossa: Not a Mystery!. Can Assoc Radiol J 2017; 68 (02) 122-130
5 Branovan DI, Schaefer SD. Lateral craniofacial approaches to the skull base and infratemporal fossa. Otolaryngol Clin North Am 2001; 34 (06) 1175-1195 , x
6 Saadi RA, Benyo S, Shokri T, Isildak H. Open and endoscopic approaches to the infratemporal fossa. Oper Tech Otolaryngol–Head Neck Surg 2021; ISSN 1043–1810
7 Nakao N, Fukai J, Nishibayashi H, Fujita K. Surgical strategies for aggressive skull base meningiomas. J Neurol Surg B Skull Base 2016; 2016: 77-A064
8 Fortes FSG, Sennes LU, Carrau RL. et al. Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model. Laryngoscope 2008; 118 (01) 44-49
9 Karkas A, Zimmer LA, Theodosopoulos PV, Keller JT, Prades JM. Endonasal endoscopic approach to the pterygopalatine and infratemporal fossae. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138 (05) 391-395
10 Bolger WE. Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience. Otolaryngol Head Neck Surg 2005; 133 (01) 20-26
11 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 2018; 131 (03) 911-919
12 Gu Y, Yu Y, Zhang X. et al. Endoscopic endonasal transmaxillary transpterygoid approach to Meckel cave: anatomical study and preliminary clinical results. J Neurol Surg A Cent Eur Neurosurg 2015; 76 (03) 205-210
13 Hardesty DA, Montaser AS, Carrau RL, Prevedello DM. Limits of endoscopic endonasal transpterygoid approach to cavernous sinus and Meckel's cave. J Neurosurg Sci 2018; 62 (03) 332-338
14 Fortes FSG, Pinheiro-Neto CD, Carrau RL, Brito RV, Prevedello DM, Sennes LU. Endonasal endoscopic exposure of the internal carotid artery: an anatomical study. Laryngoscope 2012; 122 (02) 445-451
15 Martínez-Pérez R, Zachariah M, Li R, Silveira-Bertazzo G, Carrau RL, Prevedello DM. Expanded endoscopic endonasal transpterygoid transmaxillary approach for a giant trigeminal schwannoma. Neurosurg Focus Video 2020; 2 (02) V15
16 Mehta GU, Raza SM. Endoscopic endonasal transpterygoid approach to petrous pathologies: technique, limitations and alternative approaches. J Neurosurg Sci 2018; 62 (03) 339-346
17 Devaiah AK, Reiersen D, Hoagland T. Evaluating endoscopic and endoscopic-assisted access to the infratemporal fossa: a novel method for assessment and comparison of approaches. Laryngoscope 2013; 123 (07) 1575-1582
18 Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005; 19 (01) E6
19 Oakley GM, Harvey RJ. Endoscopic resection of pterygopalatine fossa and infratemporal fossa malignancies. Otolaryngol Clin North Am 2017; 50 (02) 301-313
20 Hofstetter CP, Singh A, Anand VK, Kacker A, Schwartz TH. The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave. J Neurosurg 2010; 113 (05) 967-974
21 Theodosopoulos PV, Guthikonda B, Brescia A, Keller JT, Zimmer LA. Endoscopic approach to the infratemporal fossa: anatomic study. Neurosurgery 2010; 66 (01) 196-202 , discussion 202–203
22 Youssef A, Carrau RL, Tantawy A. et al. Endoscopic versus open approach to the infratemporal fossa: a cadaver study. J Neurol Surg B Skull Base 2015; 76 (05) 358-364
23 Kasemsiri P, Solares CA, Carrau RL. et al. Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope 2013; 123 (04) 811-815
24 Carrau RL, Otto BA, Prevedello DM. et al. Practical surgical landmarks for the planning of a transpterygoid endoscopic endonasal approach. J Neurol Surg B Skull Base 2012; 73: A267
25 Hosseini SM, McLaughlin N, Carrau RL. et al. Endoscopic transpterygoid nasopharyngectomy: correlation of surgical anatomy with multiplanar CT. Head Neck 2013; 35 (05) 704-714
26 Falcon RT, Rivera-Serrano CM, Miranda JF. et al. Endoscopic endonasal dissection of the infratemporal fossa: anatomic relationships and importance of Eustachian tube in the endoscopic skull base surgery. Laryngoscope 2011; 121 (01) 31-41
27 Leonel LCP, Carlstrom LP, Graffeo CS. et al. Foundations of advanced neuroanatomy: technical guidelines for specimen preparation, dissection, and 3D-photodocumentation in a surgical anatomy laboratory. J Neurol Surg B Skull Base 2021; 82 (Suppl. 03) e248-e258
28 Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM. et al. Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches. Laryngoscope 2012; 122 (01) 6-12
29 Vescan AD, Snyderman CH, Carrau RL. et al. Vidian canal: analysis and relationship to the internal carotid artery. Laryngoscope 2007; 117 (08) 1338-1342
30 Prevedello DM, Pinheiro-Neto CD, Fernandez-Miranda JC. et al. Vidian nerve transposition for endoscopic endonasal middle fossa approaches. Neurosurgery 2010; 67 (2, Suppl Operative): 478-484
31 Pinheiro-Neto CD, Fernandez-Miranda JC, Prevedello DM, Carrau RL, Gardner PA, Snyderman CH. Transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches. J Neurol Surg B Skull Base 2013; 74 (05) 266-270
32 Rezende NC, Pinheiro-Neto CD, Leonel LCPC, Van Gompel JJ, Peris-Celda M, Choby G. Three-hundred and sixty degrees of surgical approaches to the maxillary sinus. World J Otorhinolaryngol Head Neck Surg 2022; 8 (01) 42-53
33 Labib M, Prevedello D, Fernandez-Miranda J, Carrau R, Kassam A. The roadmap for the internal carotid artery in expanded endoscopic endonasal approaches. Skull Base 2011;21(S 01)
34 Li L, London Jr NR, Prevedello DM, Carrau RL. Role of resection of torus tubarius to maximize the endonasal exposure of the inferior petrous apex and petroclival area. Head Neck 2021; 43 (02) 725-732
35 Eloy JA, Murray KP, Friedel ME, Tessema B, Liu JK. Graduated endoscopic multiangle approach for access to the infratemporal fossa: a cadaveric study with clinical correlates. Otolaryngol Head Neck Surg 2012; 147 (02) 369-378
36 Martinez-Perez R, Aref M, Ramakhrisnan V, Youssef AS. Combined biportal unilateral endoscopic endonasal and endoscopic anterior transmaxillary approach for resection of lesions involving the infratemporal fossa. Acta Neurochir (Wien) 2021; 163 (12) 3439-3445
37 Cohen-Cohen S, Carlstrom LP, Janus JR, Van Gompel JJ. Combined anterior transmaxillary (Caldwell-Luc) with an endoscopic endonasal transpterygoid approach for resection of a large juvenile nasopharyngeal angiofibroma: 2-dimensional operative video. Oper Neurosurg (Hagerstown) 2021; 20 (03) E227-E228
38 Parkinson D. A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 1965; 23 (05) 474-483
39 Dolenc V. Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 1983; 58 (06) 824-831
40 Isolan GR, Braga FLS, Campero A. et al. Microsurgical and endoscopic anatomy of the cavernous sinus. Arq Bras Neurocir Brazilian Neurosurg 2020; 43: 211-218
41 Scopel TF, Fernandez-Miranda JC, Pinheiro-Neto CD. et al. Petrous apex cholesterol granulomas: endonasal versus infracochlear approach. Laryngoscope 2012; 122 (04) 751-761
42 Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009; 119 (01) 19-25
43 Karligkiotis A, Bignami M, Terranova P. et al. Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex. Int Forum Allergy Rhinol 2015; 5 (08) 747-753
44 Ravisankar M, Khatri D, Gosal JS, Arulalan M, Jaiswal AK, Das KK. Surgical excision of trigeminal (V3) schwannoma through endoscopic transpterygoid approach. Surg Neurol Int 2019; 10: 259
45 Yang L, Hu L, Zhao W, Zhang H, Liu Q, Wang D. Endoscopic endonasal approach for trigeminal schwannomas: our experience of 39 patients in 10 years. Eur Arch Otorhinolaryngol 2018; 275 (03) 735-741
46 Raza SM, Donaldson AM, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Surgical management of trigeminal schwannomas: defining the role for endoscopic endonasal approaches. Neurosurg Focus 2014; 37 (04) E17
47 Ramina R, Mattei TA, Sória MG. et al. Surgical management of trigeminal schwannomas. Neurosurg Focus 2008; 25 (06) E6 , discussion E6
48 Samadian M, Akbari Dilmaghani N, Ahmady Roozbahany N, Farzin N, Bahadoram M. Endoscopic transnasal approach for cholesterol granuloma of the petrous apex. Case Rep Neurol Med 2015; 2015: 481231
49 Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol 2002; 23 (04) 529-533
50 Caballero N, Welch K, Lininger L. Complications associated with a transpterygoid approach to meningoencephalocele repair. J Neurol Surg B Skull Base 2012; 73: A121
51 Bozkurt G, Turri-Zanoni M, Coden E. et al. Endoscopic endonasal transpterygoid approach to sphenoid sinus lateral recess defects. J Neurol Surg B Skull Base 2020; 81 (05) 553-561