Mandibular subluxation for high carotid exposure

Abstract

Twenty-four patients with internal carotid artery lesions extending above the second cervical vertebra underwent mandibular subluxation for additional exposure. The original technique of bilateral arch bar wiring requiring 90 minutes for application has evolved into a circummandibular/transnasal wiring technique requiring approximately 10 minutes. Subluxation of the mandibular condyle 10 to 15 mm anteriorly results in displacement of the mandibular ramus 20 to 30 mm anteriorly. This technique provides a marked increase in exposure of the internal carotid artery up to the base of the skull by transforming a triangular operating field into a rectangular field. The technique is quick, easy to perform, and not associated with objective or subjective temporomandibular joint dysfunction.

Efficacy of Mandibular Subluxation for Carotid Endarterectomy with Combined Fixation Using Interdental Wire and Putty

“…The present study objectively demonstrated the efficacy of MS, which was previously only subjectively reported to increase ICA exposure by 5.5-20 mm to the cranial side [3][4][5][7][8][9][10][11]. We found that MS increased mastoid-mandible distance by 5.7 ± 3.1 mm and MIM angle by 13.3 ± 7.9º, and that wire fixation with interdental insertion of Coltoflax ® putty was the most effective technique.…”

“…Moreover, use of an intraluminal shunt requires more distal exposure of the ICA. Various techniques used for CEA in cases of cephalic location of the lesions have been reported, including the retrojugular approach [13], dissection and ligation of the adjacent structures (sternocleidomastoid artery, occipital artery and vein [14,15], ansa cervicalis [14], and posterior belly of the digastric muscle [14,16]), nasotracheal intubation [17], mandibular osteotomy [18,19], elevation of the hypoglossal nerve [1,15,16], and MS [3][4][5][6][7][8][9][10][11]20].…”

“…If a higher approach is taken (above the mastoid-mandibular line, which extends from the tip of the mastoid process to the angle of the mandible), an operative space cephalic to the mastoid-mandibular line is required [3]. Mandibular subluxation (MS) for CEA has been proposed to access such a cephalic location of the bifurcation [3][4][5][6][7][8][9][10][11][12]. However, only the subjective effects of MS have been reported, so the objective effects are still unclear.…”

Head and Neck Extension-Fixation With a Head Frame for Exposure of the Distal Internal Carotid Artery in Carotid Endarterectomy-Technical Note-

“…The major obstacle to access to the distal ICA is the mandibular ramus. Various techniques have been described to improve exposure of the ICA, such as anterior subluxation of the mandible [5][6][7]12) and mandibular osteotomy. 1,2,8,9) However, these techniques are complicated and associated with a high incidence of morbidity.…”

“…Access to the internal carotid artery (ICA) above the C-2 can be challenging during carotid endarterectomy (CEA), even for experienced surgeons. Improving access to the distal ICA often requires a maneuver such as nasotracheal intubation, 13) extended skin incision, 14) anterior subluxation of the mandible, [5][6][7]12) mandibular osteotomy, 1,2,8,9) retraction or division of the posterior belly of the digastric muscle, 3,4) or division of the styloid process and styloid group of muscles. 11) These techniques may increase exposure, but are time consuming, complicated, and associated with a high incidence of morbidity.…”