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Endoscopic Endonasal Approach to Intrapetrous Carotid Artery
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cICA
VN
pICA
ET
Fig. 17.5 Transpterygoid infrapetrous approach to
the petrous apex. cICA, paraclival portion of the ICA; ET,
eustachian tube; pa, petrous apex; pICA, petrous portion of the
ICA; VN, vidian nerve.
pa
palatine artery are transected. In such a way, the pterygopalatine soft tissues are elevated in a medial to lateral direction to expose the medial and lateral pterygoid
plates (LPPs). Following a subperiosteal plane, the foramen rotundum containing V2 is seen superolaterally to
the VN. The periosteal plane behind the maxillary antrum is then opened and the first structure that comes
into view is the fat pad of the ITF that continues with
the Bichat’s fat pad. Lying on the fat pad, the internal
maxillary artery (IMA) and its terminal branches are
visible (Fig. 17.7). A clip is positioned on the lateral-
ION
NP
MS
Fig. 17.6 Endoscopic endonasal maxillectomy with removal
of the pyriform aperture (right side). ION, infraorbital nerve;
MS, maxillary sinus; NP, nasopharynx.
5
aspect of the IMA to avoid bleeding.
After the fat pad is
removed, the two heads of the lateral pterygoid muscle
(LPM) inserting on the LPP come into view, bordered
laterally by the deep portion of the temporalis muscle
(sphenomandibular muscle). The LPM is detached from
its medial insertion.
• A transpterygoid approach is then performed
(Fig. 17.8). The root of the pterygoid is drilled out following the VN, as far as the medial genu of the ICA.
Then, the medial pterygoid plate (MPP) is drilled out,
showing the medial aspect of the cartilaginous ET. In
this phase, the insertion of the medial pterygoid muscle
is distinguished and detached from the lateral aspect of
the MPP, showing the tensor veli palatini muscle and,
behind, the levator veli palatini muscle. Remarkably,
the superior edge of the LPP can be a useful landmark
TM
MS
Fig. 17.7 Transmaxillary approach with exposure of the
infratemporal fossa content. DPA, descending palatine artery;
LPM, lateral pterygoid muscle; MA, maxillary artery; MS,
maxillary sinus (lateral wall); TM, temporal muscle; V2, second
branch of the trigeminal nerve.
MA
V2
LPM
DPA
CS
V2
PP
Fig. 17.8 Transpterygoid approach with removal of base of
the pterygoid plates. cICA, paraclival portion of the ICA; CS,
cavernous sinus (medial wall); NP, nasopharynx; PP, pterygoid
plates; V2, second branch of the trigeminal nerve.
cICA
NP
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Endoscopic Endonasal Approach to Intrapetrous Carotid Artery
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for identifying V3: by drilling out this bone, the surgeon can find and cut V3 emerging from the foramen
ovale (FO) and lying on the upper part of the cartilaginous ET (Fig. 17.9). Moving in a posterolateral direction
at the level of the bony skull base, the middle meningeal artery, passing through the foramen spinosum (FS),
is detected and cut. Just behind the FS, the spine of the
sphenoid bone is exposed.
4
• The cartilaginous ET is resected as far as the bony
tube, which is a critical landmark for identifying the
junction between the intrapetrous and the parapharyngeal segment of the ICA (posterior genu)
cICA
VN
V3
ET
LPM
ppICA
(Fig. 17.10). From an anterior to posterior viewpoint,
an anatomic sequence can be utilized to localize the
carotid foramen: FO, FS, spine of the sphenoid bone,
and bony tube. In such a way, the surgeon can localize
and safely skeletonize the distal portion of the petrous
ICA and the upper portion of the parapharyngeal ICA.
• At the end of the anatomic dissection, the petrous tract
of the ICA can be transected and displaced down to expose completely the carotid canal, from the sphenoidal
lingula back to the carotid foramen (Fig. 17.11). In this
way, the horizontal shape of the canal and its anteromedial direction become evident.
cICA
V2
VN
V3
LPM
6
ppICA
4
Fig. 17.9 Relationship between the cartilaginous eustachian
tube, vidian nerve, and ICA. cICA, paraclival tract of the ICA;
ET, cartilaginous portion of the eustachian tube; LPM, lateral
pterygoid muscle; ppICA, parapharyngeal segment of the ICA;
VN, vidian nerve; V3, mandibular nerve.
cICA
CC
CC
SpL
a bc
Fig. 17.11 (a) Lateralization of the paraclival ICA with exposure of the sphenoidal lingula. (b) Transection of the petrous ICA. (c)
Carotid canal exposure. BA, basilar artery; CC, carotid canal; cICA, paraclival tract of the ICA; PG, pituitary gland; pICA, petrous portion
of the ICA; SpL, sphenoidal lingula.
pICA
Fig. 17.10 Exposure of the upper parapharyngeal spaces with
the resection of the cartilaginous eustachian tube and complete
dissection of the ICA (paraclival, petrous, and parapharyngeal
segments). cICA, paraclival tract of the ICA; LPM, lateral
pterygoid muscle; ppICA, parapharyngeal segment of the ICA;
VN, vidian nerve; V2, maxillary nerve; V3, mandibular nerve.
The yellow dotted line points out the bony ET.
cICA
cICA
PG
BA
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17.4 Case Examples
17.4.1 Case 1
A 67-year-old woman presented with headache on the
right side and diplopia. A head CT and contrast-enhanced
MR scans demonstrated an expansile lesion of the right
petrous apex abutting in the sphenoid sinus, compatible
with a cholesterol granuloma (Fig. 17.12a). The patient
underwent an endoscopic endonasal marsupialization
of the cystic lesion, under control of the paraclival and
petrous segments of the ICA (medial aspect). Wide communication with the cystic cavity is achieved following
evacuation of the content. An ipsilateral nasoseptal flap
is harvested and placed inside the cystic cavity to prevent restenosis (Fig. 17.13). The symptoms of the patient
were solved after surgery and the 1-year post-op MR scan
shows the patency of the surgical cavity (Fig. 17.12b).
17.4.2 Case 2
A 41-year-old man, previously treated with radiochemotherapy for undifferentiated carcinoma of nasopharyngeal type (WHO type III), presented with a persistence
of disease involving the left nasopharynx and extended
to the UPPS. However, no encasement of the ICA was observed on the pre-op MR scan (Fig. 17.14a). The tumor
was staged as yrT4N0M0. The patient underwent an endoscopic endonasal nasopharyngectomy type III with resection of the ITF and UPPS. The petrous portion of the
ICA was fully exposed as far as the carotid foramen and
the upper part of the parapharyngeal ICA was visualized
as well (Fig. 17.15). The 1-year post-op MR scan excluded
persistence or recurrences of disease (Fig. 17.14b).
17.5 Complications
Injuring the ICA is arguably the most frightened and
debilitating complication of endoscopic endonasal cranial base surgery. Furthermore, the fear of injuring the
ICA may limit and, hence, jeopardize the extent of resection. Being able to accurately predict the location of
the vessel intraoperatively before actually visualizing it
is crucial for performing safe and effective approaches. Two means by which the ICA may be injured during
endoscopic surgery involve the unexpected absence of
overlying protective bone or an unexpected changed
position of the artery itself.7 In a recent study, the rates
of ICA injury during transnasal procedures varied from
0.4% for experienced surgeons to 1.4% for surgeons with
less experience.
Other minor complications and sequelae that may
occur during these approaches are as follows: the dry
eye syndrome, subsequently to the vidian bundle resection; the numbness of the hard palate ipsilateral to
the surgical resection, due to the sacrifice of palatine
nerves (greater and lesser); temporary or permanent
paresthesia of the cheek secondary to an injury of the
maxillary nerve (V2); persistent glue ear with disabling
conductive hearing loss, as a result of cartilaginous ET
resection; temporary postoperative masticatory impairment; and/or trismus in case of expanded approaches
including the cutting or disarticulation of the LPM and/
or temporal muscle.
8
Fig. 17.12 (a) Preoperative T1-weighted contrast-enhanced MR scan showing a cholesterol granuloma of the right petrous apex
(black asterisk), extended behind the paraclival tract of the ICA (red arrowheads). (b) Postoperative MR scan. The white arrows point
out the ipsilateral nasoseptal fl ap placed to resurface the petrous apex, maintaining the patency of the surgical cavity.
ba
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Endoscopic Endonasal Approach to Intrapetrous Carotid Artery
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V2
cICA
pICA
VN
*
ab
cICA
PA
pICA
C
C
V2
cICA
pICA
VN
NSF
PA
C
PA
cd
Fig. 17.13 Endoscopic transnasal management of a right petrous apex cholesterol granuloma. (a) After a wide sphenoidotomy with
the removal of the intersinus septum and the drilling out of the basisphenoid, the paraclival and petrous segments of the ICA were
identifi ed. The black asterisk indicates the petrous apex region. (b) The petrous apex was addressed transnasally. (c) The content
of the cyst was evacuated. (d) Permanent drainage pathway was created by inserting an ipsilateral nasoseptal fl ap to resurface the
cavity. C, clivus; cICA, paraclival tract of the ICA; NSF, nasoseptal fl ap; PA, petrous apex; pICA, petrous portion of the ICA; VN, vidian
nerve; V2, maxillary nerve.
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Endoscopic Endonasal Approach to Intrapetrous Carotid Artery
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ba
Fig. 17.14 (a) Preoperative T1-weighted contrast-enhanced MR scan showing an undiff erentiated carcinoma of nasopharyngeal type
(UCNT, WHO type III) aff ecting the left nasopharynx and extended to the upper parapharyngeal space. The white arrow indicates the
left internal carotid artery. (b) Postoperative MR scan confi rming the radical resection of the lesion through the transnasal approach.
The white arrow indicates the left internal carotid artery.
VN
V3
MMA
pICA
pICA
V3
ET
SpS
ppICA
a
b
Fig. 17.15 Intraoperative landmarks useful for the expanded endoscopic endonasal nasopharyngectomy (left side). (a) Resection of
the lesion at the level of the skull base. (b) The resection was extended laterally and inferiorly in the upper parapharyngeal space. ET,
eustachian tube (bony portion); MMA, middle meningeal artery; pICA, petrous portion of the ICA; ppICA, parapharyngeal tract of the
ICA; SpS, spine of the sphenoid bone; VN, vidian nerve; V3, third branch of the trigeminal nerve.
References
1. Castelnuovo P, Dallan I, Tschabitscher M. Surgical Anatomy of the
Internal Carotid Artery: An Atlas for Skull Base Surgeons. Berlin:
Springer-Verlag Gmbh; 2013
2. Mason E, Gurrola J II, Reyes C, Brown JJ, Figueroa R, Solares CA.
Analysis of the petrous portion of the internal carotid artery:
landmarks for an endoscopic endonasal approach. Laryngoscope
2014;124(9):1988–1994
3. Labib MA, Prevedello DM, Carrau R, et al. A road map to the internal
carotid artery in expanded endoscopic endonasal approaches to
the ventral cranial base. Neurosurgery 2014;10(Suppl 3):448–471,
discussion 471
4. Castelnuovo P, Nicolai P, Turri-Zanoni M, et al. Endoscopic endonasal nasopharyngectomy in selected cancers. Otolaryngol Head
Neck Surg 2013;149(3):424–430
5. Battaglia P, Turri-Zanoni M, Dallan I, et al. Endoscopic endonasal
transpterygoid transmaxillary approach to the infratemporal
and upper parapharyngeal tumors. Otolaryngol Head Neck Surg
2014;150(4):696–702
6. Bolzoni Villaret A, Battaglia P, Tschabitscher M, et al. A 3-dimensional transnasal endoscopic journey through the paranasal sinuses and
adjacent skull base: a practical and surgery-oriented perspective.
Neurosurgery 2014;10(Suppl 1):116–120, discussion 120
7. Karligkiotis A, Bignami M, Terranova P, et al. Use of the pedicled
nasoseptal flap in the endoscopic management of cholesterol
granulomas of the petrous apex. Int Forum Allergy Rhinol
2015;5(8):747–753
8. Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of
transsphenoidal surgery: results of a national survey, review
of the literature, and personal experience. Neurosurgery
1997;40(2):225–236, discussion 236–237
MMA
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Chapter 18
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18.1 Indications 192
Anterior Endoscopic
Petrosectomy
18.2 Surgical Steps 192
18.3 Complications 194
18.4 Tips and Tricks 194
18.5 Case Example 195
8
Anterior Endoscopic Petrosectomy
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18 Anterior Endoscopic Petrosectomy
Jun Muto, Ricardo L. Carrau, Ricardo Dolci, Pornthep Kasemsiri, Bradley A. Otto, Daniel M. Prevedello
Introduction
The endoscopic endonasal approaches (EEAs) to remove
lesions of the petrous apex include the transpterygoid
infrapetrous approach with or without vidian nerve
transposition and partial clivectomy via a transsphenoidal
approach with or without internal carotid artery (ICA)
lateralization. The selection of the safest surgical approach
depends on the position of the lesion relative to the ICA,
degree of tumor extension, and pathology. The EEAs
are ideal for lesions that abut the lateral recesses of the
sphenoid sinus. Advantages over the transcranial
approaches include less operative time, no craniotomy, easy
follow-up at the clinic, and faster recovery. This chapter
provides stepwise descriptions of both surgical approaches.
18.1 Indications
• Cystic tumor: cholesterol granuloma, dermoid tumor,
mucocele.
• Solid tumor: chordoma, chondrosarcoma, suspected
metastatic tumor, etc.
• Others: petrous apicitis, etc.
18.2 Surgical Steps
EEAs to remove lesions of the petrous apex include a
transpterygoid infrapetrous approach, with or without
vidian nerve transposition, and a partial clivectomy via a
transsphenoidal approach, with or without ICA lateralization. This chapter provides stepwise descriptions of these
surgical approaches.
The petrous apex is located in the petrous temporal
bone, a pyramidal-shaped bone located at the confluence
of the greater wing of the sphenoid and basilar portion of
the occipital bones (Fig. 18.1a–c). Several techniques for
accessing the petrous apex region have been proposed,
including the anterior transpetrosal,
1,2
transsphenoidal,
and translabyrinthine (in the case of hearing loss)
approaches.
niques beginning after completion of total ethmoidectomies and wide sphenoidotomies.
3
Herein, we offer a description of the tech-
18.2.1 Medial Transsphenoidal
Approach
If the petrous apex lesion expands into the sphenoid
sinus, a medial transsphenoidal approach can be performed. Anatomic landmarks in the sphenoid sinus are
shown in Fig. 18.2a. After ethmoidectomies and wide
sphenoidotomies (Fig. 18.2a), the floor of the sphenoid
sinus is drilled posteriorly, using a high-speed drill with a
3-mm coarse diamond burr, until it is flush with the clivus; then a partial clivectomy is performed. Once the medial aspect of the paraclival ICA and the lesion is opened,
the thin, small pieces of bone are removed with a 1- or
2-mm Kerrison rongeur to avoid injuring the dura mater,
and the cyst is drained into the sphenoid sinus and nasopharynx (Fig. 18.2b, c). Angled suction tips facilitate the
removal of all granuloma contents as well as the irrigation of the cavity. We advocate inserting a silicone stent
into the cavity (e.g., 6–7 mm tracheal T-tube customized
in the fashion of a tympanostomy T-tube), draining it into
the sinonasal tract, and maintaining the marsupialization
of the granuloma for 3 to 6 months.
Lesions that are mainly located posterior to the ICA or that
are hard to access because of poor pneumatization require a
medial transsphenoidal approach with ICA lateralization. A
transpterygoid approach is used to identify the vidian nerve
and artery, and to follow them to the anterior genu of the
ICA. The posterior nasal and sphenopalatine arteries are
dissected and transected, and the pterygopalatine ganglion
is exposed. The soft tissues are dissected laterally until the
vidian artery and nerve can be visualized exiting their canal
(Fig. 18.2d). The vidian canal can be identified running on
the floor of the sphenoid sinus from medial to lateral in the
② Lateral
approach
a
192
Carotid
canal
① Medial approach
Petrosal apex
Fig. 18.1 Petrous apex in skull
bone model. (a) Front view of the
occipital bone and temporal bone.
1, transsphenoidal medial approach;
2, lateral transpterygoid infrapetrous
b
c
approach. ICA in the petrous part runs
through the petrosal bone (red circle).
Black circle marks the petrous apex.
(b) The view of the petrous apex from
the superior, occipital, and temporal
bones. (c) The view of the petrous
apex from the inferior.
Cv
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Anterior Endoscopic Petrosectomy
OnOn
LOCR
S
ICA
ICA
ICA
Dura of
clivus
ICA
FL
Vn
Dura of
clivus
PG
ICA
SA
Vn
PA
FL
ICA
ICA
Vn
PG
SA
Vn
Vx
c
P
f
Dura of
clivus
i
FL
a
ICA
PG
d
ICA
Vn
g
Fig. 18.2 Stepwise transsphenoidal approach to the petrous apex using EEA. (a) A wide sphenoidotomy and ethmoidectomy
with a posterior septectomy. (b) Direct access to the medial part of the lesions in the case of a small tumor. (c) Close-up view of
bone removal in the clivus. (d) In the case of a large lesion, the overlaying mucosa is stripped to expose of vidian nerve and the
pterygopalatine ganglion is identifi ed. (e) The pterygoid bone is partially drilled. (f) The vidian nerve is transected to clearly identify
the anterior genu of the ICA. (g) The exposure of the paraclival ICA. (h) The exposure of the clivus dura and the entire paraclival ICA.
(i) Close-up view of the petrosal apex and paraclival ICA (30-degree-angled scope). Cv, clivus; FL, fl oor of the sphenoid sinus; ICA,
internal carotid artery; LOCR, lateral opticocarotid recess; On, optic nerve; P, palatine bone; PA, petrous apex; PG, pterygopalatine
ganglion; S, sella; SA, sphenopalatine artery; Vn, vidian nerve; Vx, venous plexus surrounding the ICA.
b
e
h
P
30˚
anteroposterior sagittal plane (Fig. 18.2e). The region medial and inferior to the vidian canal is skeletonized with a highspeed drill from anterior to posterior to reach the cartilage
of the foramen lacerum (Fig. 18.2f). This landmark becomes
crucial in avoiding damage to the ICA at this level. The bone
over the carotid artery is thinned with the high-speed drill
and carefully removed with a combination of drilling and
elevation with Kerrison rongeurs, to expose the periosteum
that surrounds the vertical and horizontal segments of the
ICA (Fig. 18.2g). The dura of clivus and the entire medial
part of the paraclival ICA are exposed in a similar fashion
to provide adequate space to access the lesion (Fig. 18.2h,
i). Bleeding from the clival bone marrow and basilar plexus
can be copious but relatively easy to control with hemostatic paste. Removal of the midclivus and paraclival ICA canal
allows the lateralization of the vessel by several millimeters,
thus expanding the lateral access to the lesion.
18.2.2 Transpterygoid Infrapetrous
Approach
After performing bilateral wide sphenoidectomies
(Fig. 18.3a) and a wide antrostomy that allows visualization of the posterior wall of the maxillary sinus, the
posterior wall of the maxillary sinus is removed to expose
the contents of the pterygopalatine fossa. The sphenopalatine artery can be ligated, clipped, or cauterized at its
exit at the sphenopalatine foramen and then mobilized
with the soft tissues of the pterygopalatine fossa, inferiorly and laterally, to expose the pterygoid process and
identify the vidian canal and foramen. Drilling around
these structures is performed from anterior to posterior,
effectively removing the base of the pterygoid process
(Fig. 18.3c).
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CA
ET
On
S
ICA
M
LOCR
PG
Vn
PG
P
b
PG
Vn
D
Dura of
Mn
Ca
e
clivus
ICA
c
SG
Mn
Ca
f
ICA
M
ET
On
S
ICA
a
d
Fig. 18.3 Stepwise lateral transpterygoid infrapetrous approach to the petrous apex using EEA. (a) A wide sphenoidectomy, the
same initial procedure as the medial approach. (b) The pterygoid bone is exposed and the pterygopalatine ganglion is identifi ed.
(c) Following the pterygopalatine ganglion posteriorly, the vidian nerve is identifi ed emerging from the vidian canal. Initially, the
inferior and medial half of the vidian canal is drilled and the vidian nerve is skeletonized. (d) Skeletonization of the vidian nerve up to
the cartilage of the foramen lacerum. The vidian nerve is followed posteriorly up to the cartilage. (e) The white circle is the trajectory
of the transpterygoid infrapetrous approach. The white dotted line shows the paraclival and petrous ICA. Infrapetrous access to the
petrous apex. (f) General view of the access by transpterygoid infrapetrous approach. The white dotted line shows the paraclival
and petrous ICA. The white line shows the mandibular nerve. The white circle is the trajectory. Whenever possible, we preserved the
vidian nerve as shown (30-degree-angled scope). Ca, cartilage part of the foramen lacerum; Cv, clivus; D, periosteum dural of middle
fossa; ET, eustachian tube; FL, fl oor of the sphenoid sinus; ICA, internal carotid artery; LOCR, lateral opticocarotid recess; M, mucosa
of posterior wall in the nasopharynx; Mn, mandibular nerve; On, optic nerve; P, palatine bone; PA, petrous apex; PG, pterygopalatine
ganglion; S, sella; Vn, vidian nerve; Vp, venous plexus; Vx, venous plexus surrounding the ICA.
Cv
The floor of
sphenoid sinus
PG
Vn
Ca
The pharyngobasilar fascia is dissected from the roof
of the choana (Fig. 18.3b), and the floor of the sphenoid
sinus is drilled posteriorly until flush with the clivus.
The vidian canal is skeletonized while drilling the base of
the pterygoid process. Thus, the vidian nerve is followed
posteriorly to reach the cartilage that shields the anterior face of the foramen lacerum and the anterior genu of
the ICA in its transition from the petrous to the paraclival
segments (Fig. 18.3d).
Drilling the pterygoid process further posterior and
lateral also exposes the medial part of the foramen ovale
and the proximal segment of the mandibular nerve anterior to the petrosal part of the ICA (Fig. 18.3e, f). Tumors
located in the petrous apex are most commonly epidural, and may compress surrounding nerves and arteries,
especially the ICA and mandibular nerve. In cases of a
cholesterol granuloma, a silicone stent is inserted into the
cavity as aforementioned.
18.3 Complications
Injury of the ICA is the most devastating complication of
the approach to the petrous apex, as lesions are intimately
associated with the posterior aspects of the vertical
(i.e., paraclival) and horizontal (i.e., petrosal) segments of
the ICA. The sixth cranial nerve runs through the cistern
194
and passes through the interdural space (located just
posterior to the petrous apex). Therefore, the periosteal dura is the only layer separating the sixth nerve and
the petrous apex before entering Dorello’s canal.
4
Tumors
arising in the petrous apex usually displace the sixth cranial nerve posteriorly.
Other potential complications include the following:
vidian nerve injury; injuries to the maxillary nerve, mandibular nerve, and basilar artery; and injury to clival
lesion dura. Injury to the vidian nerve may lead to a
5
dry eye.
18.4 Tips and Tricks
• The vidian nerve, vidian artery, and vidian canal are
important landmarks to avoid complications.
serve the vidian nerve as much as possible. In patients
at high-risk case for a vidian nerve injury, we use a vid-
ian nerve transposition.
5
The medial extension of the
cystic wall to cross the plane of the medial aspect of the
ICA reduces the chance of a carotid injury, as the vessel
does not need lateralization.
• Identification of important landmarks is easiest in
well-pneumatized sphenoid sinuses. In the case of
a not-so-well-pneumatized sinus, image guidance
becomes more critical.
6
We pre-
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