The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Landmarks for Endoscopic Approach to the Parapharyngeal Internal Carotid Artery: A Radiographic and Cadaveric Study Brian Ho, MD; David W. Jang, MD; Jason Van Rompaey, MD; Ramon Figueroa, MD; Jimmy J. Brown, DDS, MD; Ricardo L. Carrau, MD; C. Arturo Solares, MD Objectives/Hypothesis: To define transnasal endoscopic surgical landmarks for the parapharyngeal segment of the internal carotid artery (ppICA) using radiographic analysis and cadaveric dissection. Study Design: Cadaveric and radiographic study. Methods: One hundred seventy-nine computed tomography angiography studies of the head and neck were analyzed using Osirix third-party software (Pixmeo, Geneva, Switzerland). Dissection of a cadaveric specimen was used as a correlate to radiographic findings. The posterior aspect of the lateral pterygoid process and posterior border of the mandibular ramus were used as bony landmarks for the ppICA. Results: At the level of the nasal floor, the distance from the ppICA to the posterolateral pterygoid process and to the posterior mandibular ramus was 2.36 cm and 1.94 cm, respectively, in males, and 2.37 cm and 1.99 cm, respectively, in females. At the level of the skull base, the distance from the ppICA to the posterolateral pterygoid process and to the posterior mandible was 2.33 cm and 1.49 cm, respectively, in males, and 2.20 cm and 1.57 cm, respectively, in females. Cadaver dissection demonstrated the utility of identifying these landmarks. Conclusions: The posterior border of the mandibular ramus and the posterolateral aspect of the pterygoid process may serve as consistent bony landmarks for identification of the ppICA. Key Words: Parapharyngeal internal carotid artery, endoscopic skull base surgery, three-dimensional volume rendering, three-dimensional anatomic rendering. Level of Evidence: NA Laryngoscope, 124:1995–2001, 2014
INTRODUCTION Transnasal endoscopic approaches to the skull base are an alternative to more traditional open approaches. Although they require specialized surgical skills and instrumentation, they have the potential to minimize postoperative morbidity. Recently, endoscopic access to the parapharyngeal space and infratemporal fossa has been described.1–6 What is crucial in these approaches is the anatomy of the internal carotid
From the Department of Otolaryngology (B.H., J.J.B., C.A.S.), Center for Skull Base Surgery (J.V.R., C.A.S.), and Department of Radiology (R.F.), Georgia Regents University, Augusta, Georgia; Department of Otolaryngology–Head & Neck Surgery (R.L.C.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Division of Otolaryngology (D.W.J.), Duke University, Durham, North Carolina, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 7, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Brian Ho, MD, and David W. Jang, MD, contributed equally to this work. Additional Supporting Information may be found in the online version of this article. Send correspondence to C. Arturo Solares, MD, Associate Professor, Head and Neck/Skull Base Surgery, Neurosurgery, Co-Director, Center for Skull Base Surgery, Georgia Regents University, 1120 15th Street, BP 4109, Augusta, GA 30912. E-mail: [email protected] DOI: 10.1002/lary.24601
Laryngoscope 124: September 2014
artery, which takes a complicated, tortuous course through this area. Very few reports have specifically described the transnasal endoscopic anatomy for management of the parapharyngeal segment of the internal carotid artery (ppICA).1,2 Using information obtained from computed tomography (CT) angiographic studies and cadaveric dissection, we sought to define bony landmarks that could potentially aid in the identification of the ppICA. This knowledge would allow for increased familiarity of its anatomy, which should translate to safer dissection and minimal morbidity for patients.
MATERIALS AND METHODS After approval by the institutional review board at Georgia Regents University, 222 normal CT angiography scans performed between October 2011 and December 2012 were analyzed. Forty-three studies were excluded due to poor quality, incompleteness, or age
Rhinological and Otological Society, Inc.
Landmarks for Endoscopic Approach to the Parapharyngeal Internal Carotid Artery: A Radiographic and Cadaveric Study Brian Ho, MD; David W. Jang, MD; Jason Van Rompaey, MD; Ramon Figueroa, MD; Jimmy J. Brown, DDS, MD; Ricardo L. Carrau, MD; C. Arturo Solares, MD Objectives/Hypothesis: To define transnasal endoscopic surgical landmarks for the parapharyngeal segment of the internal carotid artery (ppICA) using radiographic analysis and cadaveric dissection. Study Design: Cadaveric and radiographic study. Methods: One hundred seventy-nine computed tomography angiography studies of the head and neck were analyzed using Osirix third-party software (Pixmeo, Geneva, Switzerland). Dissection of a cadaveric specimen was used as a correlate to radiographic findings. The posterior aspect of the lateral pterygoid process and posterior border of the mandibular ramus were used as bony landmarks for the ppICA. Results: At the level of the nasal floor, the distance from the ppICA to the posterolateral pterygoid process and to the posterior mandibular ramus was 2.36 cm and 1.94 cm, respectively, in males, and 2.37 cm and 1.99 cm, respectively, in females. At the level of the skull base, the distance from the ppICA to the posterolateral pterygoid process and to the posterior mandible was 2.33 cm and 1.49 cm, respectively, in males, and 2.20 cm and 1.57 cm, respectively, in females. Cadaver dissection demonstrated the utility of identifying these landmarks. Conclusions: The posterior border of the mandibular ramus and the posterolateral aspect of the pterygoid process may serve as consistent bony landmarks for identification of the ppICA. Key Words: Parapharyngeal internal carotid artery, endoscopic skull base surgery, three-dimensional volume rendering, three-dimensional anatomic rendering. Level of Evidence: NA Laryngoscope, 124:1995–2001, 2014
INTRODUCTION Transnasal endoscopic approaches to the skull base are an alternative to more traditional open approaches. Although they require specialized surgical skills and instrumentation, they have the potential to minimize postoperative morbidity. Recently, endoscopic access to the parapharyngeal space and infratemporal fossa has been described.1–6 What is crucial in these approaches is the anatomy of the internal carotid
From the Department of Otolaryngology (B.H., J.J.B., C.A.S.), Center for Skull Base Surgery (J.V.R., C.A.S.), and Department of Radiology (R.F.), Georgia Regents University, Augusta, Georgia; Department of Otolaryngology–Head & Neck Surgery (R.L.C.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Division of Otolaryngology (D.W.J.), Duke University, Durham, North Carolina, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 7, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Brian Ho, MD, and David W. Jang, MD, contributed equally to this work. Additional Supporting Information may be found in the online version of this article. Send correspondence to C. Arturo Solares, MD, Associate Professor, Head and Neck/Skull Base Surgery, Neurosurgery, Co-Director, Center for Skull Base Surgery, Georgia Regents University, 1120 15th Street, BP 4109, Augusta, GA 30912. E-mail: [email protected] DOI: 10.1002/lary.24601
Laryngoscope 124: September 2014
artery, which takes a complicated, tortuous course through this area. Very few reports have specifically described the transnasal endoscopic anatomy for management of the parapharyngeal segment of the internal carotid artery (ppICA).1,2 Using information obtained from computed tomography (CT) angiographic studies and cadaveric dissection, we sought to define bony landmarks that could potentially aid in the identification of the ppICA. This knowledge would allow for increased familiarity of its anatomy, which should translate to safer dissection and minimal morbidity for patients.
MATERIALS AND METHODS After approval by the institutional review board at Georgia Regents University, 222 normal CT angiography scans performed between October 2011 and December 2012 were analyzed. Forty-three studies were excluded due to poor quality, incompleteness, or age
