Elsevier

World Neurosurgery

Volume 95, November 2016, Pages 62-70
World Neurosurgery

Original Article
Combined Endoscopic Transoral and Endonasal Approach to the Jugular Foramen: A Multiportal Expanded Access to the Clivus

https://doi.org/10.1016/j.wneu.2016.07.073Get rights and content

Background

The expanded endoscopic endonasal (“far medial”) approach to the inferior clivus provides a unique surgical corridor to the ventral surface of the pontomedullary and cervicomedullary junctions. However, exposing neoplasms involving the jugular foramen (JF) through this approach requires extensive nasopharyngeal resection and lateral dissection beyond the boundaries of the endonasal corridor, limiting the extent of resection and restricting to use of this approach to expert surgeons. Here we describe a multiportal endoscopic transoral and endonasal approach to maximize surgical access to the JF and clivus.

Methods

A multiportal endoscopic transoral and endoscopic approach to the JF and lower clivus was simulated in 8 specimens. A transoral corridor was created through a soft palate incision. The JF and parapharyngeal space were dissected through the transoral trajectory under endoscopic endonasal view. The length of the corridor of the transnasal and transoral trajectories was measured.

Results

The JF was exposed intracranially and extracranially. The exposure extended superiorly to the sphenoid floor, inferiorly to the anterior atlanto-occipital space, and laterally to the internal acoustic meatus and parapharyngeal space. The cisternal parts of the cranial nerves VII–XII and C1 nerve bundles were accessible. Exposure of the JF contents and parapharyngeal space was possible using straight scopes, without Eustachian tube resection. The working corridor to the JF was significantly shorter through the mouth than through the nose (P < 0.0001).

Conclusions

This approach provides access to the JF from a ventromedial trajectory, enabling panoramic views, and outlines an expanded surgical exposure (superolateral intradural and inferolateral extracranial). It may provide optimal access for resection of dumbbell-shaped lesions of the JF.

Section snippets

Methods

Eight adult cadaveric specimens were prepared for dissection at the University of California San Francisco's Skull Base and Cerebrovascular Laboratory, following our protocol for surgical simulation.25 The endoscopic transoral and endonasal corridors were used simultaneously in each procedure.

After an oral retractor was placed, a 1.5-cm incision was made in the soft palate in the midline, beginning from the posterior edge of the hard palate (hard-to-soft palate intersection) (Figure 1A). A

Results

The extracranial, foraminal, and intradural parts of the JF were exposed in all specimens using straight endoscopic instruments. During dissection, the RCAM, carotid ridge, supracondylar groove, and alar ligament served as safety landmarks. The extent of bone resection is shown in Figure 5.

Discussion

The evidence provided in this study shows that a combined simultaneous endoscopic transoral and endonasal approach allows exposure and dissection of the intradural, foraminal, and extradural parts of the JF using straight endoscopic instrumentation while reducing resection of nasopharyngeal structures (e.g., Eustachian tube). The surgical dissections demonstrate that the anterior wall of the internal acoustic meatus in the petrous bone, the carotid sheath in the parapharyngeal space, and the

Conclusion

The simultaneous use of the endoscopic transoral and endonasal corridors, as reported in this work, allows access to the most lateral aspect of the lower clivus and is especially advantageous for exposing the ventral skull base and carotid sheath. The proposed technique compares favorably with its transcranial counterparts for lesions in the ventromedial compartment of the posterior fossa, because it does not require cerebellar retraction, transposition of CNs or the jugular tubercle, avoids a

Acknowledgments

We thank the body donors and their families, who through their altruism contributed to making this project possible.

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