Journal of Otolaryngology and Ophthalmology of Shandong University ›› 2019, Vol. 33 ›› Issue (5): 62-68.doi: 10.6040/j.issn.1673-3770.0.2019.177

• Original Article • Previous Articles     Next Articles

Applied anatomy of endoscopic resection of the petrous apex through the transcanal infracochlear approach

Feiyan LU,Yongtian LU(),Junwei ZHOU,Yuan LIU   

  1. Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Shenzhen University，Shenzhen Second People′s Hospital, Shenzhen 518035, Guangdong, China
  • Received:2019-04-08 Revised:2019-06-01 Online:2019-09-20 Published:2019-10-15
  • Contact: Yongtian LU E-mail:luyongtian@263.net

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Abstract: Objective

To explore endoscopic transcanal infracochlear approach for resection of the petrous apex and observe structures of the middle ear. The study also aimed to identify anatomical landmarks for locating the infracochlear corridor as well as quantify the corridor under three-dimensional reconstruction of high-resolution CT(HRCT) of temporal bone. The purpose is to provide a constant anatomical landmark and imaging basis for surgical intervention.

Methods

1.Ten (20 sides) fresh frozen adult cadaver heads were used. Preoperative temporal bone CT was used to measure the vertical distance between the basal turn of the cochlea and angle between the internal carotid artery and jugular bulb, as well as the distance between the basal turn of the cochlea and jugular vein bulb. 2. Retrospective analysis of high-resolution CT(HRCT) of the temporal bone in 85 patients (170 sides) was performed to record and summarize the imaging characteristics between the infracochlear corridor and cells of the petrous apex.

 Results

1. CT measurements of temporal bones of 20 sides in the frozen cadavers and 170 sides in patients showed that vertical distance between the basal turn of the cochlea and angle between the internal carotid artery and jugular bulb were (6.46 ±1.02) mm and (6.83 ±1.50) mm, respectively, and that between the basal turn of the cochlea and jugular bulb were (3.67±0.58) mm and (3.82±1.29) mm, respectively. Among them, the vertical distance between the pneumatized petrous apices were (6.79 ± 0.60) mm and (7.19 ± 1.44) mm, and that between the non-pneumatized apices were (6.28 ± 1.17) mm and (6.68 ± 1.50) mm, respectively. The distances from the basal turn of the cochlea to the jugular bulb with respect to the pneumatized petrous apices were (4.06 ± 0.36) mm and (4.06 ± 1.42) mm, respectively; and that of the non-pneumatized portions were (3.45 ± 0.58) mm and (3.74 ± 1.22) mm, respectively. 2. Results of CT classification of the infracochlear corridor and petrous apex of the temporal bone were as follows: Type A, pneumatized type 31.18% (53 ears); Type B, marrow type 57.65% (98 ears), and Type C, sclerosed type 11.18% (19 ears).

 Conclusion

High-resolution CT (HRCT) may be considered an important pre-operative reference tool for endoscopic transcanal infracochlear approach for resection of the petrous apex. From an anatomical point of view, endoscopic resection of lesions in the petrous apex is feasible using the transcanal infracochlear approach as it can avoid damage to the internal auditory canal, cochlea, and labyrinth, and preserve hearing. The technique can be considered one of the important surgical methods for treatment of minor lesions in the posterior and inferior aspects of the upper petrous apex.

Key words: Endoscopy, Transcanal, Infracochlear approach, Petrous apex, Finiculus, Fustis, Anatomy

CLC Number: 

  • R764.1

Fig. 1

Imaging measurements of the infracochlear passage after three-dimensional reconstruction with high-resolution CT (1 mm slice thickness). a, axial, locating the basal turn of the cochlea; b, coronal view, the infracochlear corridor and petrous gas chamber below the internal auditory canal are visible (the area depicted by the yellow arrow is the infracochlear corridor); c, three-dimensional reconstruction shows the relationship between the cochlear base, internal carotid artery, and jugular bulb; d, quantification of the infracochlear corridor, visible pneumatized type of the petrous apex."

Fig. 2

The subtypes of the infracochlear passage and petrous apex of the temporal bone by CT: A, B, and C. pr, promontory; su, subiculum; fu, fustis; f, finiculus"

Fig. 3

Anatomy of the posterior tympanum and the structure around the window (0° endoscope). The area depicted by the blue arrow is the infracochlear passage, leading to the petrous apex. a, Endoscopic tympanogram of the middle ear; b, Anatomy of the posterior tympanum and subtympanicus; c, Anatomy of the structure around the round window; d, Anatomy of the structure around the round windowma, malleus; in, incus; et, eustachian tube; cp, cochleariform process; ct, chorda tympani nerve; pe, pyramidal eminence; p, ponticulus; su, subiculum; pr, promontory; rw, round window; te, tegmen of round window niche; st, sinus tympani; fu, fustis; f, finiculus; sty, styloid complex; pts, posterior tympanic sinus; ss, sinus subtympanicus; ap, anterior pillar; pp, posterior pillar; t, tunnel of subcochlear canaliculus; ac, area concamerata."

Fig. 4

The infracochlear passage is exposed by endoscopy at 0 degrees. Among them, the blue triangle area is the gas chamber of the infracochlear passage leading to the petrous apex, which is of the pneumatized type. ma, malleus; in, incus; et, eustachian tube; p, ponticulus; su, subiculum; pr, promontory; rw, round window; st, sinus tympani; f, finiculus; fu, fustis; ICA, internal carotid artery; jb, jugular bulb."

Fig. 5

Endoscopic transcanal infracochlear approach（0 ° endoscope）. The area depicted by the blue arrow is the infracochlear corridor，leading to the petrous apex; the blue triangle area is the gas chamber of the infracochlear passage leading to the petrous apex, which is of pneumatized type.ma, malleus; in, incus; et, eustachian tube; ct, chorda tympani nerve; pr, promontory; su, subiculum; rw, round window; fu, fustis; f, finiculus; t, tunnel of subcochlear canaliculus；ICA, internal carotid artery; jb, jugular bulb."

Table1

The distances between the cochlear base and internal carotid artery,jugular bulb angle,and jugular bulb were measured on CT of the temporal bone in 10(20 sides )cadaveric specimens and 85 patients (170 sides).(mm, x ˉ ± s )"

研究对象

测量

指标

 最小值（min） 最大值（max） 距离（mm） t F P
10具标本颞骨CT a 4.3 7.8 6.46±1.02 10.654 0.514 ＜0.001
b 2.6 4.5 3.67±0.58
85例患者颞骨CT a 3.2 11.1 6.83±1.50 19.776 2.964 ＜0.001
b 1.3 8.1 3.82±1.29

Table 2

The distances between the cochlear base and internal carotid artery, jugular bulb angle, and jugular bulb were measured in 10 (20 sides) temporal bone specimens and 85 patients (170 sides) of the pneumatized and non- pneumatized petrous apex（mm, x ˉ ± s ）"

研究对象 测量指标 气化型岩尖 非气化型岩尖 t F P
10具标本颞骨CT a 6.79±0.60 6.28±1.17 1.050 0.616 0.15
b 4.06±0.36 3.45±0.58 2.495 2.003 0.01
85例患者颞骨CT a 7.19±1.44 6.68±1.50 2.093 0.025 0.019
b 4.06±1.42 3.74±1.22 1.534 3.109 0.06
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