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. 2024 May 5;13(9):2713.
doi: 10.3390/jcm13092713.

Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications

Carmine Antonio Donofrio  1   2 , Francesco Corrivetti  3 , Lucia Riccio  1 , Sergio Corvino  3   4 , Iacopo Dallan  5 , Antonio Fioravanti  1 , Matteo de Notaris  3   4   5   6   7
Affiliations

Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications

Carmine Antonio Donofrio et al. J Clin Med. .

Abstract

The endoscopic contralateral transmaxillary (CTM) approach has been proposed as a potential route to widen the corridor posterolateral to the internal carotid artery (ICA). In this study, we first refined the surgical technique of a combined multiportal endoscopic endonasal transclival (EETC) and CTM approach to the petrous apex (PA) and petroclival synchondrosis (PCS) in the dissection laboratory, and then validated its applications in a preliminary surgical series. The combined EETC and CTM approach was performed on three cadaver specimens based on four surgical steps: (1) the nasal, (2) the clival, (3) the maxillary and (4) the petrosal phases. The CTM provided a "head-on trajectory" to the PA and PCS and a short distance to the surgical field considerably furthering surgical maneuverability. The best operative set-up was achieved by introducing angled optics via the endonasal route and operative instruments via the transmaxillary corridor exploiting the advantages of a non-coaxial multiportal surgery. Clinical applications of the combined EETC and CTM approach were reported in three cases, a clival chordoma and two giant pituitary adenomas. The present translational study explores the safety and feasibility of a combined multiportal EETC and CTM approach to access the petroclival region though different corridors.

Keywords: Caldwell–Luc; carotid artery; endoscopic; multiportal approach; petroclival fissure; skull base; transmaxillary.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Endonasal step. (a) Endoscopic view of the right nostril; (b) Middle turbinectomy; (c) Sphenoid sinus exposure. CP: clinoidal process; IT: inferior turbinate; LOCR: lateral optico-carotid recess; MT: middle turbinate; ON: optic nerve; pcICA: paraclival segment of the internal carotid artery; SSN: suprasellar notch; V: vomer.
Figure 2
Figure 2
Endonasal step. (a) Clivectomy. (b) Endoscopic intradural visualization. AICA: anteroinferior cerebellar artery; CP: clinoidal process; PCA: posterior cerebral artery; pcICA: paraclival segment of the internal carotid artery; SCA: superior cerebellar artery; SF: sellar floor.
Figure 3
Figure 3
Sublabial-transmaxillary approach. (a) Sublabial exposure of the canine fossa, acceding to the maxillary sinus drilling the anterior wall below the inferior orbital nerve. (b) Endoscopic view of the maxillary sinus. (c) Endoscopic view of the maxillary sinus after removal of the mucosa. ION: inferior orbital nerve; S: spatula.
Figure 4
Figure 4
Endoscopic endonsal transsphenoidal approach with extended exposure of the ventral skull base. (a) The clivus was completely drilled out and the paraclival segment of the internal carotid artery (pcICA) was exposed bilaterally. The medial petrous apex was drilled up to the foramen lacerum (FL) inferiorly, providing access to the petroclival synchondrosis (PCS). The clival dura was then removed to identify intradural landmarks. (b) Two straight surgical aspirators were inserted through the endonasal (+) and transmaxillary (*) corridor showing the different angles of attack toward the PCS; BA: basilar artery; FL: foramen lacerum; PCA: posterior cerebral artery; PCS: petroclival synchondrosis; PG: pituitary gland; pICA: paraclival segment of the internal carotid artery; SCA: superior cerebellar artery; VA: vertebral artery; VI: sixth cranial nerve.
Figure 5
Figure 5
Axial CT scan showing the angle of attack of the endoscopic endonasal (a) and contralateral transmaxillary (b) approaches. A line parallel to the axis of the petrous segment of the internal carotid artery is used as a reference to calculate the angles of attack. MS: maxillary sinus.
Figure 6
Figure 6
Case 1: preoperative and postoperative MRI scans of a large cranio-cervical junction chordoma, underwent first surgery through a retrosigmoid craniotomy, and then operated on by a combined EETC and CTM approach. (a) preoperative MRI scan, axial view. (b) preoperative MRI scan, coronal view. (c) postoperative MRI scan, axial view. (d) postoperative MRI scan, coronal view.
Figure 7
Figure 7
Case 2: preoperative and postoperative MRI scans of a recurrent giant non-secreting pituitary adenoma, previously operated through transcranial and then operated on by a combined EETC and CTM approach. (a) preoperative MRI scan, axial view. (b) preoperative MRI scan coronal view. (c) postoperative MRI scan, axial view. (d) postoperative MRI scan, coronal view.
Figure 8
Figure 8
Case 3: preoperative and postoperative MRI scans of a recurrent giant non-secreting pituitary adenoma, previously operated through transcranial and then operated on by a combined EETC and CTM approach. (a) preoperative MRI scan coronal view. (b) preoperative MRI scan, sagittal view. (c) postoperative MRI scan, coronal view. (d) postoperative MRI scan, sagittal view.
Figure 9
Figure 9
Bone CT scan comparing the trajectories and the area of exposure related to the endoscopic endonasal (grey) and the contralateral transmaxillary (yellow) approaches, showing that the endonansal corridor provides a good exposure of the medial clivus, while contralateral transmaxillary corridos allow reaching the lateral clivus and the petroclival synchondrosis.
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