Multiportal Transnasal and Transcranial Combined Approach to Para-Jugular Foramen Lesions: Comparison of Six Approaches and Clinical Cases

Background: Although most skull base lesions are benign tumors, in many cases a gross total resection is preferred to reduce the risk of tumor progression; including in clival chordomas, chondrosarcomas, and jugular foramen tumors. Achieving total resection is technically challenging in many of these complex tumors.

Conventionally, posterior petrosectomy, transsigmoid, transjugular approach have used for in these lesions. Recently, the transnasal endoscopic approach has been developed and extended transnasal approach provides wide visualization and other possibilities of resection of the clivus lesions.

Objective: We propose the following six approaches to medial jugular complex lesions with using endoscopic-assisted multiportal transnasal or transcranial approaches: (1) transmastoid w/o transjugular approach, (2) extended transnasal lower and lateral clivus approach, (3) anterolateral approach, (4) extended far lateral transcondylar approach, (5) extended anterior petrosectomy approach, (6) extended retrosigmoid inframeatal approach

Method: We reviewed our recent experience with surgical treatment of clival chordomas, chondrosarcoma, and jugular foramen schwannomas operated on through these approaches during which there was a need for endoscopic assistance. Our surgical strategy was to obtain maximal safe resection with conventional microscopic techniques and then, when tumor consistency and location were favorable, complete the resection under endoscopic visualization. The selection of the approaches depends on tumor size, tumor extension, tumor axis, pathology, origin of tumors, sinus occlusion, sinus dominancy, and patient’s symptom.

Results: Six cases underwent different transcranial approaches or endoscopic transnasal approach for resection of complex lesions of the medial jugular lesions and during which endoscopic assistance was useful in maximizing tumor resection. These approaches were chosen carefully depends on the tumor location and extension. The endoscope provided better exposure of portions of the tumor extending medially, anteriorly, superiorly or inferiorly to the JF, the jugular bulb (JB) and to the hypoglossal canal. In all cases, the tumor was soft and easily aspirated in an intra-capsular fashion. We performed maximum tumor resection with preserving of both the sigmoid sinus/JB and lower cranial nerves. Near-total resection (≥90%), as documented by postoperative MRI, was achieved in all cases. Postoperative outcome was favorable in all cases with no new cranial neuropathy.

Conclusion: Surgical approaches to deep-seated tumors of the craniovertebral junction should be tailored to each lesion’s specific location and extensions. Use of the endoscope may increase the transcranial corridor and allow for more radial resection of chordomas, chondrosarcomas and jugular foramen schwannomas safely.