2025 Proffered Presentations
S314: A COMPARATIVE ANALYSIS OF THE CONTRALATERAL ENDOSCOPIC CORRIDORS TO THE JUGULAR TUBERCLE AS A COMPLEMENT TO THE ENDONASAL APPROACH.
Chandrima Biswas, MD; Moataz D Abouammo, MD; Guilherme Mansur, MD; Ludovica Pasquini, MD; Mohammad Bilal Alsavaf, MD; Daniel M Prevedello, MD, MBA; Ricardo L Carrau, MD, MBA; The Ohio State University Wexner Medical Center
Introduction: The endoscopic endonasal approach (EEA) to tumors located around the jugular tubercle is challenging. Usually, it requires mobilization of the internal carotid artery (ICA), mobilization or transection of the eustachian tube (ET), and removal of the nasopharyngeal structures (nasopharyngeal mucosa, buccopharyngeal fascia, prevertebral muscles) to access the complete extent of the lesion. Recently sublabial contralateral transmaxillary (SL-CTM) corridor, as an adjunct to EEA was proposed to access the petrous apex, however, it has limited access to jugular tubercle (JT). Other corridors proposed as multiport to the EEA have been described including the contralateral medial transorbital (cMTO), contralateral nasofrontal trephination (CNT), and subtarsal contralateral transmaxillary (ST-CTM). In this cadaveric study, we have quantitatively evaluated each of these corridors to access the JT and studied their feasibility, anatomical constraints, and limitations.
Methods: Endoscopic endonasal transpterygoid transclival dissection of 20 sides (10 cadavers) was performed. This was followed by dissections for the 4 contralateral complementary approaches (cMTO, CNT, ST-CTM, SL-CTM). These corridors were used to reach the JT (if possible) and dissection was continued beyond this target to study the anatomical limits. Dissection was not continued beyond the occipital condyle inferiorly and internal acoustic meatus (IAM) laterally. The surgical exposure area (SEA), angle of attack (AoA) (mediolateral and craniocaudal), and the volume of surgical freedom (VSF) were measured for each approach and compared statistically. To access the JT through the EEA alone, additional maneuvers like mobilization of ICA or mobilization/transection of the ET and removal of the buccopharyngeal fascia and prevertebral muscles had to be performed and similar measurements were taken subsequently.
Results: The mean SEA around the JT was maximum for the ST-CTM (2.78 ± 0.05cm2), followed by cMTO (2.65 ± 0.04 cm2), EEA alone (2.22 ± 0.08 cm2), SL-CTM (2.12 ± 0.06 cm2) and least for the CNT (1.99 ± 0.11 cm2), p=0.012. Craniocaudal AoA was most favorable with the cMTO (15.7 ± 0.7o) and least for ST-CTM (5.2 ± 0.2o) (p=0.09). Medio-lateral AoA was most favorable for EEA (19.06 ± 0.09) and least for ST-CTM (7.4 ± 0.3) (p=0.04). The VSF was the maximum for EEA (1.72 ± 0.09cm3) followed by cMTO (1.47 ± 0.07cm3) and least for ST-CTM (0.23 ± 0.12cm3) (p=0.03).
Conclusion: While EEA provided the maximum maneuverability, it had limited exposure of the infra-petrous region, especially along the lateral aspect of the petrous. ST-CTM provided maximum exposure to the infrapetrous region, especially along the lateral petrous (and could reach the IAM), however, it had least maneuverability. CNT can provide inferior access beyond the occipital condyle; however, it was limited in its lateral exposure and smaller mediolateral maneuverability. SL-CTM was unable to reach the JT in a straight trajectory, although it provided good access laterally and reached the IAM. cMTO provided both a good maneuverability and exposure area including inferiorly to the occipital condyle and laterally to the IAM. Additionally, none of the contralateral approaches needed ET mobilization or transection, ICA lateralization or the removal of the nasopharyngeal structures which was required when EEA was used alone..
