Combined Endoscopic Transoral and Endonasal approach to the Jugular Foramen: a Multiportal Expanded Access to the Clivus

• Published in: World neurosurgery Vol. 95; pp. 62 - 70
• Main Authors: Zhang, Xin, MD, PhD, Tabani, Halima, MD, El-Sayed, Ivan, MD, Tayebi Meybodi, Ali, MD, Griswold, Dylan, Mummaneni, Praveen, MD, Benet, Arnau, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2016
• Subjects: Cadaver; Cranial Fossa, Posterior - surgery; Dissection - methods; Expanded endoscopic endonasal approach; Far-medial approach; Humans; Jugular foramen; Mouth; Natural Orifice Endoscopic Surgery - methods; Neuroendoscopy - methods; Neurosurgery; Nose; Occipital Bone; Petrous Bone; Skull Base; Transoral approach; PCS; Internal Carotid Artery; expanded endoscopic endonasal approach; FL; Pharyngeal segment of the Internal Carotid Artery; far-medial approach; ICA ph; endoscopic endonasal “far medial” approach; EEFMA; AICA; cerebellopontine angle; Hypoglossal Canal; EEEA; CC; Carotid Canal; jugular foramen; ICA; Foramen Lacerum; skull base; Petroclival Suture; Posterior Inferior Cerebellar Artery; PICA; CPA; Rectus capitis anterior muscle; Anterior Inferior Cerebellar Artery; HC; RCAM; JF; transoral approach; Expanded endoscopic endonasal approach; Transoral approach; Skull base; Jugular foramen; CN; Far-medial approach
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2016.07.073

Abstract Background The expanded endoscopic endonasal (“far medial”) approach to the inferior clivus provides a unique surgical corridor to the ventral surface of the ponto- and cervico-medullary junctions. However, exposing neoplasms involving the jugular foramen (JF) through this approach requires extensive nasopharyngeal resection and lateral dissection beyond the boundaries of the endonasal corridor, limiting the extent of resection and its application to expert surgeons. Objectives To describe a multiportal endoscopic transoral and endonasal approach to maximize surgical access to the JF and clivus. Methods A multiportal endoscopic transoral and endoscopic approach to JF and lower clivus was simulated in eight specimens. A transoral corridor was created through a soft palate incision.JF and parapharyngeal space were dissected through the transoral trajectory under endoscopic endonasal view. The length of the corridor of the transnasal and transoral trajectories was measured. Results The JF was exposed intra- and extra-cranially. The exposure extended superiorly to the sphenoid floor, inferiorly to the anterior atlanto-occipital space and laterally to the internal acoustic meatus and parapharyngeal space. Cisternal part of CN VII-XII and C1 nerve bundles were accessible. Exposure of JF contents and parapharyngeal space was possible using straight scopes and without Eustachian tube resection. The working corridor to JF was significantly shorter through the mouth than through the nose (p<0.0001). Conclusions This approach provides access to JF from a ventromedial trajectory, enabling panoramic views and outlines an expanded surgical exposure (superolateral intradural and inferolateral extracranial). It may provide optimal access for resection of dumbbell-shaped lesions of the JF.