1Department of ENT, All India Institute of Medical Sciences, Patna, Bihar, India.
3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio.
Neurosurg Focus. 2024 Apr;56(4):E10. doi: 10.3171/2024.1.FOCUS23863.
Minimally invasive endoscopic endonasal multiport approaches create additional visualization angles to treat skull base pathologies. The sublabial contralateral transmaxillary (CTM) approach and superior eyelid lateral transorbital approach, frequently used nowadays, have been referred to as the "third port" when used alongside the endoscopic endonasal approach (EEA). The endoscopic precaruncular contralateral medial transorbital (cMTO) corridor, on the other hand, is an underrecognized but unique port that has been used to repair CSF rhinorrhea originating from the lateral sphenoid sinus recess. However, no anatomical feasibility studies or clinical experience exists to assess its benefits and demonstrate its potential role in multiport endoscopic access to the other contralateral skull base areas. In this study, the authors explored the application and potential utility of multiport EEA combined with the endoscopic cMTO approach (EEA/cMTO) to three target areas of the contralateral skull base: lateral recess of sphenoid sinus (LRSS), petrous apex (PA) and petroclival region, and retrocarotid clinoidocavernous space (CCS).
Ten cadaveric specimens (20 sides) were dissected bilaterally under stereotactic navigation guidance to access contralateral LRSS via EEA/cMTO. The PA and petroclival region and retrocarotid CCS were exposed via EEA alone, EEA/cMTO, and EEA combined with the sublabial CTM approach (EEA/CTM). Qualitative and quantitative assessments, including working distance and visualization angle to the PA, were recorded. Clinical application of EEA/cMTO is demonstrated in a lateral sphenoid sinus CSF leak repair.
During the qualitative assessment, multiport EEA/cMTO provides superior visualization from a high vantage point and better instrument maneuverability than multiport EEA/CTM for the PA and retrocarotid CCS, while maintaining a similar lateral trajectory. The cMTO approach has significantly shorter working distances to all three target areas compared with the CTM approach and EEA. The mean distances to the LRSS, PA, and retrocarotid CCS were 50.69 ± 4.28 mm (p < 0.05), 67.11 ± 5.05 mm (p < 0.001), and 50.32 ± 3.6 mm (p < 0.001), respectively. The mean visualization angles to the PA obtained by multiport EEA/cMTO and EEA/CTM were 28.4° ± 3.27° and 24.42° ± 5.02° (p < 0.005), respectively.
Multiport EEA/cMTO to the contralateral LRSS offers the advantage of preserving the pterygopalatine fossa contents and the vidian nerve, which are frequently sacrificed during a transpterygoid approach. This approach also offers superior visualization and better instrument maneuverability compared with EEA/CTM for targeting the petroclival region and retrocarotid CCS.
微创内镜经鼻内多端口入路可创造更多的可视化角度来治疗颅底病变。现今经常使用的经唇下对侧经上颌（CTM）入路和外侧眼睑经眶外侧入路，当与内镜经鼻内入路（EEA）联合使用时，被称为“第三端口”。另一方面，内镜滑车旁对侧内侧经眶（cMTO）通道是一种尚未被充分认识但独特的入路，已被用于修复源自外侧蝶窦隐窝的 CSF 鼻漏。然而，目前还没有解剖可行性研究或临床经验来评估其益处，并证明其在多端口内镜进入对侧颅底其他区域方面的潜在作用。在这项研究中，作者探讨了多端口 EEA 联合内镜 cMTO 入路（EEA/cMTO）在三个对侧颅底靶区的应用和潜在用途：蝶窦外侧隐窝（LRSS）、岩尖（PA）和岩斜区，以及颈内动脉海绵窦间隙（CCS）。
在立体定向导航引导下，对 10 具尸体标本（20 侧）进行双侧解剖，通过 EEA/cMTO 进入对侧 LRSS。通过 EEA 单独、EEA/cMTO 和 EEA 联合经唇下 CTM 入路（EEA/CTM）暴露 PA 和岩斜区以及颈内动脉海绵窦间隙。记录包括到达 PA 的工作距离和可视化角度在内的定性和定量评估。展示了 EEA/cMTO 在外侧蝶窦 CSF 漏修复中的临床应用。
在定性评估中，多端口 EEA/cMTO 提供了从高角度的卓越可视化效果和更好的器械操作能力，优于多端口 EEA/CTM 用于 PA 和颈内动脉海绵窦间隙，同时保持相似的外侧轨迹。与 CTM 入路和 EEA 相比，cMTO 入路到达所有三个靶区的工作距离明显更短。LRSS、PA 和颈内动脉海绵窦间隙的平均距离分别为 50.69 ± 4.28mm（p<0.05）、67.11 ± 5.05mm（p<0.001）和 50.32 ± 3.6mm（p<0.001）。多端口 EEA/cMTO 和 EEA/CTM 到达 PA 的平均可视化角度分别为 28.4°±3.27°和 24.42°±5.02°（p<0.005）。
多端口 EEA/cMTO 到达对侧 LRSS 具有优势，可保留翼腭窝内容物和 vidian 神经，这些结构在经翼突入路时经常被牺牲。与 EEA/CTM 相比，该入路在针对岩斜区和颈内动脉海绵窦间隙时提供了更好的可视化效果和更好的器械操作能力。
