Labib Mohamed A, Abramov Irakliy, Houlihan Lena Mary, Srinivasan Visish M, Scherschinski Lea, Prevedello Daniel M, Carrau Ricardo L, Abou-Al-Shaar Hussam, Preul Mark C, Lawton Michael T
1Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.
2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
J Neurosurg. 2023 Mar 31;139(4):992-1001. doi: 10.3171/2023.1.JNS221854. Print 2023 Oct 1.
The eustachian tube (ET) limits endoscopic endonasal access to the infrapetrous region. Transecting or mobilizing the ET may result in morbidities. This study presents a novel approach in which a subtarsal contralateral transmaxillary (ST-CTM) corridor is coupled with the standard endonasal approach to facilitate access behind the intact ET.
Eight cadaveric head specimens were dissected. Endoscopic endonasal approaches (EEAs) (i.e., transpterygoid and inferior transclival) were performed on one side, followed by ST-CTM and sublabial contralateral transmaxillary (SL-CTM) approaches on the opposite side, along with different ET mobilization techniques on the original side. Seven comparative groups were generated. The length of the cranial nerves, areas of exposure, and volume of surgical freedom (VSF) in the infrapetrous regions were measured and compared.
Without ET mobilization, the combined ST-CTM/EEA approach provided greater exposure than EEA alone (mean ± SD 288.9 ± 40.66 mm2 vs 91.7 ± 49.9 mm2; p = 0.001). The VSFs at the ventral jugular foramen (JF), entrance to the petrous internal carotid artery (ICA), and lateral to the parapharyngeal ICA were also greater in ST-CTM/EEA than in EEA alone (p = 0.002, p = 0.002, and p < 0.001, respectively). EEA alone, however, provided greater VSF at the hypoglossal canal (HGC) than did ST-CTM/EEA (p = 0.01). The SL-CTM approach did not increase the EEA exposure (p = 0.48). The ST-CTM/EEA approach provided greater exposure than EEA with extended inferolateral (EIL) or anterolateral (AL) ET mobilization (p = 0.001 and p = 0.02, respectively). The ST-CTM/EEA also increased the VSF lateral to the parapharyngeal ICA in comparison with EEA/EIL ET mobilization (p < 0.001) but not with EEA/AL ET mobilization (p = 0.36). Finally, the VSFs at the HGC and JF were greater in EEA/AL ET mobilization than in ST-CTM/EEA without ET mobilization (p = 0.002 and p = 0.004, respectively).
Combining the EEA with the more laterally and superiorly originating ST-CTM approach allows greater exposure of the infrapetrous and ventral JF regions while obviating the need for mobilizing the ET. The surgical freedom afforded by the combined approaches is greater than that obtained by EEA alone.
咽鼓管（ET）限制了经鼻内镜进入颞下区。横断或移动ET可能会导致并发症。本研究提出了一种新方法，即联合跗下对侧经上颌（ST-CTM）通道与标准经鼻内镜入路，以便在完整ET后方实现更好的显露。
解剖8个尸体头部标本。在一侧进行经鼻内镜入路（EEA）（即经翼突和经斜坡下部），然后在对侧进行ST-CTM和唇下对侧经上颌（SL-CTM）入路，并在原侧采用不同的ET移动技术。形成7个比较组。测量并比较颞下区颅神经的长度、暴露面积和手术自由度（VSF）。
在不移动ET的情况下，联合ST-CTM/EEA入路比单独EEA提供了更大的暴露面积（均值±标准差 288.9±40.66mm² 对 91.7±49.9mm²；p = 0.001）。在颈静脉孔（JF）腹侧、岩骨段颈内动脉（ICA）入口处以及咽旁ICA外侧的VSF，ST-CTM/EEA也比单独EEA更大（分别为p = 0.002、p = 0.002和p < 0.001）。然而，单独EEA在舌下神经管（HGC）处提供的VSF比ST-CTM/EEA更大（p = 0.01）。SL-CTM入路未增加EEA的暴露面积（p = 0.48）。ST-CTM/EEA入路比采用ET下外侧延长（EIL）或前外侧（AL）移动的EEA提供了更大的暴露面积（分别为p = 0.001和p = 0.02）。与EEA/EIL移动ET相比，ST-CTM/EEA也增加了咽旁ICA外侧的VSF（p < 0.001），但与EEA/AL移动ET相比未增加（p = 0.36）。最后，EEA/AL移动ET在HGC和JF处的VSF比未移动ET的ST-CTM/EEA更大（分别为p = 0.002和p = 0.004）。
将EEA与起源更偏外侧和上方的ST-CTM入路相结合，可在避免移动ET的情况下，更好地暴露颞下区和颈静脉孔腹侧区域。联合入路提供的手术自由度大于单独EEA所获得的手术自由度。
