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Endoscopic transnasal or transorbital approach for lesions in the petrous apex

 Last Update: 2023-02-03
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 Author: User

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Recently, Won Jae Lee et al.
of the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea, analyzed the efficacy of endoscopic transnasal or orbital resection in patients with lesions in the petrous apical area, and the results were published online in J Neurosurg in August 2021
.

- Excerpted from the article chapter

【Ref: Lee WJ, et al.
J Neurosurg.
2021 Aug 20; 136(2):431-440.
doi: 10.
3171/2021.
2.
JNS203867.
Print 2022 Feb 1.
】

Research background

The Petrousapex (PA) area is one of the
most difficult areas for skull base surgery.

Microscopic anterior petrosis approach is an ideal way
to treat skull base lesions in the focal point area.

Recently, Won Jae Lee et al.
of the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea, analyzed the efficacy of endoscopic transnasal (EEA) or transorbital approach (TOA) resection in patients with lesions in the rock apex area, and the results were published online in J Neurosurg in August 2021
.

Research methods

The researchers divided the apex into three regions: Zone 1 is the upper part of the petrous segment of the internal carotid artery (p-ICA); Zone 2 is the posterior part of the petrous bone segment of the internal carotid artery and the lower part of the petrous bone segment of the internal carotid artery in Region 3 (Fig.
1).

A retrospective analysis was performed on the clinical data
of 19 patients with lesions in the petoliscopic area (excluding meningioma in the petrous oblique area) at Samsung Medical Center between May 2015 and December 2019.

Among the 19 patients, 10 had malignant tumors (including chondrosarcoma, chordoma and osteosarcoma); 6 cases of benign tumors (including schwannomas, Cushing's disease and teratomas); Three cases of
encephalocele in the apical area of the rock.

There were 13 cases of endoscopic transnasal approach, 5 cases of endoscopic transorbital approach, and 1 case of endoscopic transnasal joint transorbital approach
.

Among the 16 tumor patients, 13 (81.
3%) had complete or near-total resection of the lesion; Patients with encephalocele are completely repaired (Figure 2).

Postoperative complications: 2 cases of cerebrospinal fluid leakage, 1 case of postoperative diplopia, 1 case of internal carotid artery injury and 1 death
.

Typical case descriptions are shown in Figure 3
.

Figure 1.
3D CT reconstruction image
of the rock tip area.

PA is divided into three regions: A.
Upper part of the p-ICA (Zone 1, orange).

B.
posterior p-ICA (Zone 2, green).

Zone 1 is excised to reveal zone
2.

C.
Lower part of p-ICA (Zone 3, purple).

Figure 2: 3D reconstruction image of MRI or CT of different skull base lesions in the apical region
.

A1-4: Slope chordoma involving zones 1 and 2; A5-6: Postoperative MRI shows subtotal resection
of lesions in the apical area.

B1-4: affects three areas of chondrosarcoma; B5-6: Postoperative MRI shows total resection
of lesions in the apical area.

C1-4: Middle skull base teratoma affecting zone 1; C5-6: postoperative MR shows total resection
of lesions.

D1: MRI-T2 weighted encephalocele in bilateral apex region; D2-4: right-sided symptomatic lesion involving zones 1 and 2; D5-6: Postoperative MRI-T1-weighted repair showing autologous abdominal fat tamponade
.

E1-4: trigeminal schwannoma involving regions 1 and 3 extending into the inferior temporal fossa; E5-6: postoperative MRI shows total incision
.

Figure 3.
Preoperative and postoperative endoscopic imaging of two patients with endoscopic nasal approach
.

Above: 1 case of cavernous sinus schwannoma invading the apical area, MRI showed uniformly strengthened mass in the left cavernous sinus and the floor of the middle cranial fossa (A1-2); Sagittal CT shows that the tumor invades regions 1 and 3 (A3)
of the apex.

Postoperative image after total resection of lesion via pterygoid approach (A4-5).

Endoscopic photograph (A6)
6 months after surgery.

Below: Preoperative and postoperative MRI images and endoscopic imaging in one patient with recurrent adrenocorticotropic hormone-type pituitary adenoma
.

MRI-T1 coronal (B1) and axial (B2) enhancements show tumor invasion of three areas of the rock apex (black arrow), and tumor covering the ruptured foramen segment of the internal carotid artery (white arrow).

The paraslope segment and rupture foramen segment of internal carotid artery displacement expose the medial portion of zone 3 (B3).

Zones 1 and 2 are accessed through the posterior window of the internal carotid artery (B4
).

* indicates exposed rock tips
.

MRI coronal (B5) and axial (B6) images
after total resection of lesions.

Study results

Finally, the authors note that endoscopic transnasal approaches can reach three areas of the rock tip to treat lesions
.

It is especially suitable for slope tumors
that extend from the inside to the tip of the rock.

The endoscopic transorbital approach provides access to the upper part of the rock tip (zone 1), which is suitable for cystic lesions
in this area.

The surgical approach to the orifice area should be individualized
according to the origin of the lesion and the extent of invasion.

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