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Endoscopic endonasal and transorbital routes to the petrous apex: anatomic comparative study of two pathways

  • Original Article - Neurosurgical Anatomy
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Abstract

Background and objective

Surgical approaches to the petrous apex region are extremely challenging; while subtemporal approaches and variations represent the milestone of the surgical modules to reach such deep anatomical target, in a constant effort to develop minimally invasive neurosurgical routes, the endoscopic endonasal approach (EEA) has been tested to get a viable corridor to the petroclival junction. Lately, another ventral endoscopic minimally invasive route, i.e., the superior eyelid endoscopic transorbital approach, has been proposed to access the most lateral aspect of the skull base, including the petrous apex region. Our anatomic study aims to compare and combine such two endoscopic minimally invasive pathways to get full access to the petrous apex. Three-dimensional reconstructions and quantitative and morphometric data have been provided.

Material and methods

Five human cadaveric heads (10 sides) were dissected. The lab rehearsals were run as follows: (i) preliminary pre-operative CT scans of each specimen, (ii) pre-dissection planning of the petrous apex removal and its quantification, (iii) petrous apex removal via endoscopic endonasal route, (iv) post-operative CT scans, (v) petrous apex removal via endoscopic transorbital route, and (v) final post-operative CT scan with quantitative analysis. Neuronavigation was used to guide all dissections.

Results

The two endoscopic minimally invasive pathways allowed a different visualization and perspective of the petrous apex, and its surrounding neurovascular structures. After both corridors were completed, a communication between the surgical pathways was highlighted, in a so-called connection area, surrounded by the following important neurovascular structures: anteriorly, the internal carotid artery and the Gasserian ganglion; laterally, the internal acoustic canal; superiorly, the abducens nerve, the trigeminal root, and the tentorium cerebelli; inferomedially, the remaining clivus and the inferior petrosal sinus; and posteriorly, the exposed area of the brainstem. Used in a combined fashion, such multiportal approach provided a total of 97% of petrous apex removal. In particular, the transorbital route achieved a mean of 48.3% removal in the most superolateral portion of the petrous apex, whereas the endonasal approach provided a mean of 48.7% bone removal in the most inferomedial part. The difference between the two approaches was found to be not statistically significant (p = 0.67).

Conclusion

The multiportal combined endoscopic endonasal and transorbital approach to the petrous apex provides an overall bone removal volume of 97% off the petrous apex. In this paper, we highlighted that it was possible to uncover a common path between these two surgical pathways (endonasal and transorbital) in a so-called connection area. Potential indications of this multiportal approach may be lesions placed in or invading the petrous apex and petroclival regions that can be inadequately reached via transcranial paths or via an endonasal endoscopic route alone.

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Acknowledgments

The authors wish to thank Mayfield Clinic/Glia Media (Martha Headworth and Tonya Hines) for the precious Medical Illustration dedicated to this paper.

Funding

This project has been partially supported by grants from the “Instituto de Salud Carlos III (ISCIII)” (PI19/00592) and the “Fundació La Marató de TV3” (Reg. 95/210; Codi projecte 201914).

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Author notes

  1. Thomaz E. Topczewski and Alberto Di Somma contributed equally to this work.

Authors and Affiliations

  1. Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Carrer de Villaroel, 170, 08036, Barcelona, Spain

    Thomaz E. Topczewski, Alberto Di Somma, Abel Ferres, Jorge Torales, Luis Reyes, Ruben Morillas & Joaquim Enseñat

  2. Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universidad de Barcelona, Barcelona, Spain

    Alberto Di Somma, Jose Pineda & Alberto Prats-Galino

  3. Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy

    Domenico Solari, Luigi Maria Cavallo & Paolo Cappabianca

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  1. Thomaz E. Topczewski
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Correspondence to Alberto Di Somma.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

The material in this paper was elected as one of the best posters at the 68th Meeting of the Italian Society of Neurosurgery (SiNch), Rome, Italy, September 2019.

Comments

The authors describe a very nice anatomical study of a multi portal approach to the petrous apex.The article has the merit even if prior relatively similar studies have been published, but the quantitative analyses is of importance in this communication. After combined endonasal and endo-orbital endoscopic approach, the petrous apex was drilled for the volume of approximately 97%, and the transitional zone of the ICA, behind the foramen lacerum was reached through the orbital corridor. The orbital component exposes the superolateral part of the petrous apex while the endonasal transpterygoid approach exposes the inferomedial petrous apex. Anatomical landmarks: Abducens and trigeminal nerves origin superiorly, clivus medially, inner ear laterally and the inferior petrosal sinus inferomedially were identified. A limited portion of brainstem is exposed through this corridor. Skull base neurosurgeons should consider the orbit as an exposure venue for petrous apex in selected indications and should explore and gain experience in laboratory before implementing it in real practice. Neurosurgeons should use the orbit more than it is done currently as it opens variety of innovative approaches to skull base pathologies. Transorbital neurosurgery approaches (including trans-palpebral orbitofrontal craniotomy) are relatively safe and if it is done correctly, the morbidity is relatively minimal.

Amir Dehdashti

NY, USA

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Topczewski, T.E., Di Somma, A., Pineda, J. et al. Endoscopic endonasal and transorbital routes to the petrous apex: anatomic comparative study of two pathways. Acta Neurochir 162, 2097–2109 (2020). https://doi.org/10.1007/s00701-020-04451-1

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