Contralateral Transmaxillary and Ipsilateral Transpterygoid Approaches: A Balanced Evaluation for Enhanced Endoscopic Petrosectomy Safety
Bibliographic record
Abstract
Introduction: Traditional approaches to addressing the intricate regions of the petrous apex (PA) and petroclival region have predominantly relied on transtemporal and middle fossa transpetrosal strategies. The endoscopic endonasal approach, bolstered by advancements in endoscopic techniques, has proven effective in reaching lesions within this segment of the skull base. While the medial petrous apex presents lesser challenges, accessing the posterior and superior PA segments requires lateral mobilization of the paraclival segment of the internal carotid artery (ICA), a maneuver elevating the risk of arterial injury. The ipsilateral transpterygoid (ITP) approach is commonly utilized; however, while previous studies have advocated for the use of a contralateral transmaxillary (CTM. Corridor to minimize ICA mobilization, direct qualitative and quantitative anatomical comparisons between the two approaches remain limited. This study aims to precisely delineate the boundaries of endoscopic petrosectomy, comparing the visualization, angle of attack, reach and safety of the ITP and CTM approaches. Methods: Using image-guidance alongside 0° and 30° rigid endoscopes, ITP and CTM approaches were implemented bilaterally on three cadaveric specimens. We evaluated and recorded the visualization, and reach into the defined petrous bone segments—lateral petrous apex anteriorly (LPAA), lateral petrous apex posteriorly (LPAP), and inferior petrous apex (IPA). Thereafter, a consensus between two experienced endoscopic surgeons ensured a pragmatic safety analysis of drilling these segments, primarily focusing on the traction on the paraclival carotid. Quantitative analysis of the attack angles from the axis of the petrous segment of the ICA was performed using the GNU Image Manipulation Program (GIMP). Results: The ITP facilitated drilling reach into the LPAA, LPAP, and IPA in 5, 5, and 6 out of 6 petrosectomies, with “safe” drilling being affirmed in 1, 4, and 6 out of 6 instances, respectively. Conversely, the CTM approach consistently allowed “safe” drilling in all segments during every petrosectomy. Visualization comparisons using a 0° endoscope favored CTM for LPAP (6/6 vs. 3/6 in ITP) and showed no significant difference in LPAA and IPA visualization. The employment of a 30° endoscope nullified visualization differences between the approaches. Quantitative findings highlighted a reduced angle of attack for CTM (20.8° ± 1.5°) as against ITP (41.4° ± 2.3°). Conclusions: Both ITP and CTM approaches demonstrated extensive reach into the delineated petrous bone compartments, showcasing equivalent visualization capabilities with a 30° endoscope. The CTM approach availed a perceived heightened safety in LPAA drilling, situated posterior to the paraclival ICA, presumably due to a reduced angle of attack and less retraction on the paraclival carotid. The CTM emerges as a potentially favorable strategy when engaging with hard lesions behind the paraclival carotid where simple curettage is inadequate. The selection between ITP and CTM is nuanced, potentially hinging on intraoperative assessments of lesion consistency and its adherence to the carotid, rather than preoperative imaging alone. This underscores the imperative for a dynamic, intraoperative decision-making strategy to optimize outcomes in PA and petroclival region surgeries. Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.007 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".