Endoscopic transoral - medial pterygomandibular fold approach anatomic study for jugular foramen

doi:10.3969/j.issn.1672-6731.2023.07.005

Abstract

Abstract:

Objective: To investigate the endoscopic transoral-medial pterygomandibular fold approach anatomic procedures for jugular foramen, and to analyze the clinical feasibility of this approach. Methods and Results: In the anatomical laboratory of the Surgical Treatment Technology Innovation Unit of Nasal Skull Base Tumor in Eye & ENT Hospital of Fudan University, a total of 5 specimens of necroheads (10 sides) were taken as research objects to simulate the anatomical steps of entering the jugular foramina and its adjacent structures through the oral pterygomandibular fold medial approach, and observe and describe important anatomical markers. 1) Anatomical procedures of the jugular foramen: firstly, the soft palate mucosa and suprapharyngeal retractive muscle were cut through the medial incision of pterygomandibular fold to enter anterior parapharyngeal space, the adipose tissue in the space was removed, and the stylopharyngeal fascia and stylopharyngeal muscle group were exposed. After the stylopharyngeal fascia was removed, the internal carotid artery (ICA) was further exposed and the jugular foramen was exposed. 2) The jugular foramen and its adjacent anatomical structures: the upper boundary of the jugular foramen was jugular bulbous fossa, the anterior was ICA, the anterolateral lateral was styloid process, the posterolateral boundary was the lateral rectus of head and transverse process of atlas, the medial boundary was the hypoglossal nerve and medial of occipital condyle, and the lateral boundary was the mastoid, digastric and facial nerves. Conclusions: Endoscopic transoral-medial pterygomandibular fold approach for jugular foramen has better visual field, wider exposure range and shorter path.

Key words: Jugular foramina, Parapharyngeal space, Endoscopy, Autopsy

摘要：

目的: 探讨内镜下经口翼下颌皱襞内侧入路进入颈静脉孔区的解剖步骤，分析其临床施行之可行性。方法与结果: 于复旦大学附属眼耳鼻喉科医院鼻颅底肿瘤外科治疗技术创新单元解剖实验室以5具(10侧)尸头标本作为研究对象，模拟经口翼下颌皱襞内侧入路进入颈静脉孔区及其相邻结构的解剖步骤，观察并描述重要解剖标志。(1)颈静脉孔区解剖步骤：首先通过翼下颌皱襞内侧切口切开软腭黏膜、咽上缩肌进入咽旁前间隙，剔除间隙内脂肪组织，显露茎突咽筋膜和茎突肌群，切除茎突咽筋膜后进入咽旁后间隙，进一步显露颈内动脉并进入颈静脉孔区。(2)颈静脉孔及其毗邻解剖结构：颈静脉孔上界为颈静脉球窝，前方为颈内动脉，前外侧为茎突前外侧，后方为头外侧直肌、寰椎横突，内侧为舌下神经和枕髁内侧，外侧为乳突、二腹肌和面神经。结论: 经口翼下颌皱襞内侧入路进入颈静脉孔区视野良好，显露范围广泛，路径更短。

关键词: 颈静脉孔, 咽旁间隙, 内窥镜检查, 尸体解剖

Jing LI, Huan-kang ZHANG, Quan LIU, Ye GU, Kai XUE, Xi-cai SUN, Hong-meng YU. Endoscopic transoral - medial pterygomandibular fold approach anatomic study for jugular foramen[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2023, 23(7): 591-598.

李静, 张焕康, 刘全, 顾晔, 薛凯, 孙希才, 余洪猛. 内镜下经口翼下颌皱襞内侧入路颈静脉孔区解剖学研究[J]. 中国现代神经疾病杂志, 2023, 23(7): 591-598.

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URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2023.07.005

https://journal11.magtechjournal.com/cjcnn/EN/Y2023/V23/I7/591

Figures/Tables 4

Figure 1 View of bone structures in the jugular foramen. Front view (Panel 1a). Right lateral view (Panel 1b).

Figure 2 Anatomy of anterior styloid space through transoral - medial pterygomandibular fold approach into the anterior parapharyngeal space The anatomical marks of the soft palate were uvula, palatopharyngeal arch, palatoglossus arch and pterygomandibular fold from the center line outward (Panel 2a). The internal mucosa was incised to reveal the suprapharyngeal retractor (Panel 2b). The suprapharyngeal retractor muscle was incised to reveal the internal muscle of lateral parapharyngeal space and the adipose tissue within the space (Panel 2c). After removing the adipose tissue in the anterior parapharyngeal space, it could be seen the upper outside of the parapharyngeal space was the tensor veli palatine muscle, and the upper medial side was the levator veli palatine muscle, the inner side was the superior pharyngeal constrictor muscle, the stylopharyngeal fascia was located in the triangular area between the styloid process muscle group and the superior pharyngeal constrictor muscle (Panel 2d). The posterior pharyngeal lymph nodes could be seen between the carotid sheath and the longus capitis. The lingual nerve was located in the anterior inferior limb of the medial pterygoid muscle and passes through the inferior temporal fossa into the tongue body (Panel 2e). The styloid septum thickened to form the styloid mandibular ligament, which was covered by the styloid hyoid muscle and some branches of the external carotid artery (Panel 2f).

Figure 3 Anatomy of the posterior styloid space through transoral- medial pterygomandibular fold into the anterior parapharyngeal space The stylopharyngeal fascia and stylopharyngeal septum were excised to reveal the ICA, internal jugular vein and posterior cranial nerve (Panel 3a). Pulling the ICA outside to see the rectus capitis lateralis, the C1 nerve, the medial posterior cranial nerve and the meningeal branch of the ascending pharyngeal artery behind the internal jugular vein (Panel 3b). The ICA was pushed aside, the posterior cranial nerve and the C1 nerve located on the surface of the lateral rectus capitalis muscle (Panel 3c). Under the petrous bone, the pharyngobasilar fascia attached to the inside and front of the ICA (Panel 3d). The styloid septum and the styloid mandibular ligament were removed between the styloid muscle group and the parotid gland, and the main ECA and the posterior mandibular vein running through the parotid gland were exposed one by one. The ECA branches and the occipital artery run inward and backward between the posterior abdomen of the digastric muscle and the lateral rectus of the head. The posterior auricular artery sent out the stylomastoid artery into the stylomastoid foramen to feed the facial nerve (Panel 3e).

Figure 4 Anatomy of the jugular foramen and adjacent anatomy through transoral- medial pterygomandibular fold approach After exposing the posterior parapharyngeal space, the longus capitis muscle was excised, and the ascending pharyngeal artery meningeal branch and the hypoglossal nerve emerged from the hypoglossal neural tube and passed through the atlanto - occipital ligament to descend posteriorly (Panel 4a). The anterior rectus capitis was resected to provide and access to the supracondylar groove, lateral mass of the atlas, and capsule of the atlanto - occipital joint (Panel 4b, 4c). Resecting the pharyngobasilar fascia, lateral atlanto - occipital ligament, exposing the petrous apex (Panel 4d). Between the ICA and the styloid muscles, the accessory nerve, the internal jugular vein, and the deep medial rectus capitis lateralis, and the digastric muscle laterally, the occipital artery runs from the inside to the outside between the the lateral rectus capitis and posterior belly of digastric muscles. And the accessory nerve crosses the surface of the lateral rectus capitis and runs to the outside (Panel 4e). Grinding away the bone of the jugular tubercle and occipital condyle, exposing the jugular tubercle and the hypoglossal canal, and further exposing the inferior petroclival vein in the petroclival fissure, which flows into the petrous vein confluence (Panel 4f). The inferior petrosal sinus and inferior petrooblique vein were mirror structures inside and outside the meninges, and they were merged into the petrosal venous confluence, and into the internal jugular vein between the glossopharyngeal nerve and the vagus nerve (Panel 4g). Grinding away part of the jugular process and part of the lateral rectus capitis attached to it, the sigmoid sinus can be seen to merge into the jugular bulb (Panel 4h). In the medial side of the transverse process foramen and the lateral rectus muscle, the epidural VA can be seen, and was upward and then penetrating the meninges (Panel 4i).

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