Abstract
Background
The petrous apex is one of the most challenging areas of the skull base to access.
Method
We present a case of residual petrous apex chordoma posterolateral to the paraclival segment of the internal carotid artery (ICA) resected with combined endoscopic endonasal and contralateral transmaxillary (CTM) approaches, without lateralization of the ICA.
Conclusion
This case demonstrates the value of the CTM corridor in resecting petrous apex lesions that are posterolateral to the paraclival segment of the ICA.
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Funding
This study was sponsored by CAMS Innovation Fund for Medical Sciences (CIFMS, 2019-I2M-5–008)。
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Key points
1. Chondromatous tumors, including chordomas and chondrosarcomas, are the most common in the petrous apex.
2. The epidural anterior petrosectomy (Kawase approach) directly accesses the petrous apex lesions from the lateral aspect. Although it still carries a minor potential risk of brain edema and seizure, it might be the number one strategy for many skull base neurosurgeons.
3. The routine endoscopic endonasal approach (EEA) to petrous apex lesions that are posterolateral to the paraclival segment of the internal carotid artery (ICA) requires lateralization of the paraclival segment of the ICA, carries an unignorable risk of vascular injury.
4. The contralateral transmaxillay (CTM) approach is suitable for petrous apex lesions posterolateral to the paraclival and horizontal petrous segment of the ICA, without the need to manipulate the ICA or the Eustachian tube.
5. The combined endoscopic endonasal and CTM approaches take advantage of multiport approaches with enhanced surgical freedom and provide more options in case of a vascular injury.
6. The CTM approach does not appear to add significant morbidity. The most common risks are infraorbital nerve hypesthesia and an oral-antral fistula.
7. Identification and preservation of the infraorbital nerve decrease the risk of infraorbital nerve hypesthesia.
8. A clear cut and good suture of the sublabial incision decreases the risk of oral-antral fistula.
9. The neuronavigation, mini-Doppler ultrasound, and extraocular EMG monitoring help identify critical anatomical and neurovascular structures in the petrous apex area.
10. The CTM corridor is longer than a transnasal corridor at its utmost reach. The extended drill bits or ultrasonic bone curettes should be prepared.
This article is part of the Topical Collection on Brain Tumors
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Shen, M., Shou, X., Zhao, Y. et al. How I do it? Resection of residual petrous apex chordoma with combined endoscopic endonasal and contralateral transmaxillary approaches. Acta Neurochir 164, 1967–1972 (2022). https://doi.org/10.1007/s00701-022-05243-5
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DOI: https://doi.org/10.1007/s00701-022-05243-5