Endoscopic Endonasal Access to the Jugular Foramen: Defining the Surgical Approach

Abstract

Introduction The endoscopic endonasal approach to the parapharyngeal space (PPS) and jugular foramen is not well defined. We sought to systematically define the important landmarks and limitations of this new surgical technique using an endoscopic transmaxillary transpterygoid corridor. Methods Endoscopic dissection was performed in both sides of two latex-injected cadaver heads. Left-sided dissections were facilitated by the addition of a sublabial maxillary antrostomy. The pterygopalatine fossa, infratemporal fossa, and PPS were sequentially dissected and the endoscopic perspective was examined. Measurements were obtained from the surgical orifices to the upper cervical internal carotid artery (ICA) and internal jugular vein (IJV). Results Successful access to the PPS and jugular foramen was achieved in each dissection. The lateral pterygoid plate, mandibular branch of the trigeminal nerve, middle meningeal artery, levator veli palatini muscle, Eustachian tube, and stylopharyngeal fascia were identified as landmarks for the upper cervical ICA and the IJV. The mean distance from the nasal sill was markedly greater than from an ipsilateral sublabial antrostomy. Conclusion The endoscopic endonasal approach can provide adequate access to the PPS, carotid sheath, and jugular foramen. Multiple landmarks are useful to guide the dissection within these deep spaces and may facilitate the clinical application of this approach.

Comparison of lateral microsurgical preauricular and anterior endoscopic approaches to the jugular foramen

“…The vaginal process has received little attention as a landmark in the endoscopic approach to the jugular foramen. 1,2,4 However, it proved to be a useful landmark in this study. The fascia attached to the vaginal process protects the major neuromuscular structures, and opening it exposes the ICA, IJV and cranial nerve IX.…”

“…1,2,4,5,7 The infratemporal fossa is a complicated area. Surgical approaches to this deep region may be associated with bleeding and injury of nerves.…”

“…[1][2][3][4][5][6][7] The traditional lateral microsurgical approaches to the jugular foramen and infratemporal fossa include Fisch's type C infratemporal fossa approach and the preauricular subtemporal infratemporal fossa approach. 3,5 The preauricular approach, as compared with Fisch's approach, has the advantage of minimising risk to facial nerve function and avoiding sacrifice of the middle and inner ear.…”

Surgical approaches to jugular foramen schwannomas: An anatomic study

“…An endoscopic transnasal/transmaxillary transpterygoid approach may be considered for tumors that extend to the infratemporal fossa and along the petrous portion of the internal carotid artery through the eustachian tube, or to the cancellous portion of the petrous apex. However, the application of this approach is limited and should be considered only if the tumor occupies the infratemporal fossa and creates a surgical corridor by displacing the carotid artery and internal jugular vein posteriorly, and only minimum dissection of the pterygoid muscles is required . Foraminal and intracranial tumors with anterior extension are difficult to approach.…”

“…Ten hemicrania from formalin‐perfused adult cadaveric heads in which the arteries and veins were injected with red or blue silicone rubber (Dow Corning, Midland, MI), Thinner 200 (Dow Corning), and RTV catalyst (Dow Corning), were dissected using ×3 to ×40 magnifications of the surgical microscope and a 0°, 18‐cm Hopkins endoscope (Karl Storz GmbH, KG, Tottlingen, Germany) connected to a xenon light source and a high‐definition camera. The lateral suboccipital, far lateral, postauricular transtemporal, preauricular subtemporal infratemporal fossa, and endoscopic transnasal/transmaxillary transpterygoid approaches were performed to open the jugular foramen from a variety of angles.…”