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
1 王若雅 . 颞骨岩部胆脂瘤外科手术治疗及面神经功能保护的临床研究[D]. 北京： 中国人民解放军医学院, 2014.
2 汪照炎，王武庆 . 耳内镜外科学[M]. 西安：世界图书出版西安有限公司, 2018： 345-347.
3 Marchioni D , Alicandri-Ciufelli M , Pothier DD , et al . The round window region and contiguous areas: endoscopic anatomy and surgical implications[J]. Eur Arch Otorhinolaryngol, 2015, 272(5): 1103-1112. doi:10. 1007/s00405-014-2923-8 .
doi: 10. 1007/s00405-014-2923-8
4 Thomassin JM , Korchia D , Doris JM . Endoscopic-guided otosurgery in the prevention of residual cholesteatomas[J]. Laryngoscope, 1993, 103(8): 939-943. doi:10. 1288/00005537-199308000-00021 .
doi: 10. 1288/00005537-199308000-00021
5 Sanna M , Zini C , Gamoletti R , et al . Petrous bone cholesteatoma[J]. Skull Base Surg, 1993, 3(4): 201-213. PMID: 17170912doi:101055/s-2008-1060585
6 Sanna M , Pandya Y , Mancini F , et al . Petrous bone cholesteatoma: classification, management and review of the literature[J]. Audiol Neurootol, 2011, 16(2): 124-136. doi:10.1159/000315900 .
doi: 10.1159/000315900
7 田广永, 徐达传, 黄德亮, 等 . 经迷路下径路切除岩尖病变显微解剖学[J]. 中国耳鼻咽喉头颈外科, 2008, 15(1): 37-39. doi:10.3969/j.issn.1672-7002.2008.01.013 .
doi: 10.3969/j.issn.1672-7002.2008.01.013
TIAN Guangyong , XU Dachuan , HUANG Deliang , et al . Anatomy of the infralabyrinthine approach to the petrous apex[J]. Chinese Archiver of Otolaryngology-Head and Neck Surgery, 2008, 15(1): 37-39. doi:10.3969/j.issn.1672-7002.2008.01.013 .
doi: 10.3969/j.issn.1672-7002.2008.01.013
8 Leung R , Samy RN , Leach JL , et al . Radiographic anatomy of the infracochlear approach to the petrous apex for computer-assisted surgery[J]. Otol Neurotol, 2010, 31(3): 419-423. doi:10.1097/MAO.0b013e3181c99524 .
doi: 10.1097/MAO.0b013e3181c99524
9 Scopel TF , Fernandez-Miranda JC , Pinheiro-Neto CD , et al . Petrous apex cholesterol granulomas: endonasal versus infracochlear approach[J]. Laryngoscope, 2012, 122(4): 751-761. doi:10.1002/lary.22448 .
doi: 10.1002/lary.22448
10 Marchioni D , Alicandri-Ciufelli M , Rubini A , et al . Endoscopic transcanal corridors to the lateral skull base: Initial experiences[J]. Laryngoscope, 2015, 125(Suppl 5): S1-13. doi:10.1002/lary.25203 .
doi: 10.1002/lary.25203
11 朱琳, 张德军, 管国芳, 等 . 显微镜联合耳内镜手术治疗岩尖巨大胆脂瘤一例[J]. 山东大学耳鼻喉眼学报, 2016, 30(6): 101-103,106. doi:10.6040/j.issn.1673-3770.0.2016.345 .
doi: 10.6040/j.issn.1673-3770.0.2016.345
ZHU Lin , ZHANG Dejun , GUAN Guofang , et al . Treatment of huge cholesteatoma in the petrous apex by microscope combined with otoendoscope: report of 1 case[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2016, 30(6): 101-103,106. doi:10.6040/j.issn.1673-3770.0.2016.345 .
doi: 10.6040/j.issn.1673-3770.0.2016.345
12 Wick CC , Hansen AR , Kutz JW Jr , et al . Endoscopic infracochlear approach for drainage of petrous apex cholesterol granulomas: a case series[J]. Otol Neurotol, 2017, 38(6): 876-881. doi:10.1097/MAO.0000000000001422.
doi: 10.1097/MAO.0000000000001422.
13 Anschuetz L , Presutti L , Schneider D , et al . Quantitative analysis of surgical freedom and area of exposure in minimal-invasive transcanal approaches to the lateral skull base[J]. Otol Neurotol, 2018, 39(6): 785-790. doi:10.1097/MAO.0000000000001827 .
doi: 10.1097/MAO.0000000000001827
14 Kempfle JS , Fiorillo B , Kanumuri VV , et al . Quantitative imaging analysis of transcanal endoscopic Infracochlear approach to the internal auditory canal[J]. Am J Otolaryngol, 2017, 38(5): 518-520. doi:10.1016/j.amjoto.2017.03.01 .
doi: 10.1016/j.amjoto.2017.03.01
15 Trakimas DR , Kempfle JS , Reinshagen KL , et al . Transcanal endoscopic infracochlear vestibular neurectomy: A pilot cadaveric study[J]. Am J Otolaryngol, 2018, 39(6): 731-736. doi:10.1016/j.amjoto. 2018. 07. 024 .
doi: 10.1016/j.amjoto. 2018. 07. 024
16 Jacob CE , Rupa V . Infralabyrinthine approach to the petrous apex[J]. Clin Anat, 2005, 18(6): 423-427. doi:10.1002/ca.20156 .
doi: 10.1002/ca.20156
17 Marchioni D , Alicandri-Ciufelli M , Piccinini A , et al . Inferior retrotympanum revisited: an endoscopic anatomic study[J]. Laryngoscope, 2010, 120(9): 1880-1886. doi:10.1002/lary.20995 .
doi: 10.1002/lary.20995
18 Marchioni D , Alicandri-Ciufelli M , Grammatica A , et al . Pyramidal eminence and subpyramidal space: an endoscopic anatomical study[J]. Laryngoscope, 2010, 120(3): 557-564. doi:10.1002/lary.20748 .
doi: 10.1002/lary.20748
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