Glossopharyngeal Research Articles

GLOSSOPHARYNGEAL NERVE AS A SOURCE OF OROFACIAL PAIN - DIAGNOSTIC AND THERAPEUTIC CHALLENGES.

Chronic neuropathic orofacial pain along with physical suffering can cause emotional, psychological and social difficulties, which significantly affects the quality of life of patients. Pain in the area of glossopharyngeal nerve innervation, especially chronic neuropathic, is relatively rare, but is significant because of the great suffering it causes to sufferers. It can be life threatening, due to the cardiac arrhythmia, syncope or convulsions it can cause. Drug treatment is often of limited effectiveness and can be fraught with side effects. It is necessary to look for the etiology of the underlying disease, and if possible, to take adequate causal treatment. This review article discusses the etiology, clinical features, differential diagnosis, and treatment modalities of neuropathic pain in the area of glossopharyngeal nerve innervation.

Comparative anatomical studies on the cranial nerves of the fully formed embryos of the Nile tilapia Oreochromis niloticus (Ostiechthyes-Cichlidae). I. Nervus glossopharyngeus.

The organization of the roots, ganglia and the peripheral distribution of the cranial nerves of the fully formed embryos of Oreochromis niloticus are examined in the transverse serial sections. These nerves carry fibers, which were also analyzed. The results of this study demonstrated that the glossopharyngeal nerve originates by means of only one root, which leaves the cranium through the glossopharyngeal foramen. This nerve gives fibers (visceromotor) to the first internal and external levator arcus branchialis muscles. There is a single epibranchial (petrosal) ganglion located extracranially. Nervus glossopharyngeus has three rami; pharyngeus, pretramticus and posttrematicus. The ramus pharyngeus carries only viscerosensory fibers; general for the pharyngeal epithelium and special ones for the pseudobranch. General viscerosensory fibers are also carried by rami pretrematicus and posttrematicus for the pharyngeal epithelial lining. The special sensory fibers are carried by the ramus pretrematicus for the taste buds and by ramus posttrematicus for the gill filaments. The ramus pretrematicus also carries visceromotor fibers for the first adductor arcus branchialis and to the first obliquus ventralis muscles.

Lower Cranial Nerve Palsy due to Prevertebral Tuberculosis Infection

Prevertebral tuberculosis is a rare infectious disease that often affects immunocompromised patients in developing countries. We present the case of a patient who complained of headache, dysarthria, and dysphagia. Neurological examination revealed multiple cranial nerve palsies, including the hypoglossal, glossopharyngeal, and vagus nerves. Brain magnetic resonance imaging demonstrated an infiltrative lesion in the prevertebral space, and the biopsy revealed chronic inflammation. On suspicion of immune-mediated inflammation, the patient was treated with intravenous dexamethasone and oral prednisolone, with minimal response. Eleven months after the initial diagnosis, the patient’s neurological symptoms were aggravated, and we detected newly developed pulmonary tuberculosis. After the treatment of pulmonary tuberculosis, his neurological symptoms improved, and the imaging study demonstrated improvements. Although we lacked positive laboratory or biopsy results for tuberculosis, we suspect that the lesions were distant tuberculosis infections. Tuberculosis should be considered in patients with unknown infiltrative mass-like lesions in the prevertebral spaces.

Surgical treatment of glossopharyngeal nerve schwannomas: Results of two-center study (14 patients included) and literature review

Objective: This study is aimed to analyze the outcomes of surgical treatment of glossopharyngeal schwannomas based on pre- and postoperative neurological status assessment. Materials and methods: This paper is a retrospective analysis of examination and surgical treatment of 14 patients who were operated on in two large clinics from 2018 to 2021 inclusive. When analyzing the collected data, gender, age, disease symptoms, tumor size and location, surgical approach, tumor to cranial nerves (CN) ratio, jugular foramen (JF) condition, and tumor removal volume were taken into account. All tumors were divided into groups depending on tumor location relative to the JF. Particular attention was paid to assessing cranial nerves functions. Facial nerve function was assessed as per House-Brackmann Scale (HBS), hearing function as per Gardner-Robertson Scale (GRS). Results: 3 (21.4%) patients had total tumor removal: 2 patients had type A tumors and one had type B tumor. Subtotal resection took place in 7 (50%) cases. In 4 cases, a tumor was partially removed: 3 patients had type D tumors and one had type B tumor. 3 (21.4%) patients had preoperative FN deficit (HBS Grade II) and mild dysfunction. 5 (35.7%) patients had postoperative facial nerve deficit: HBS ІІ, 2; ІІІ, 1; V, 2. Preoperative sensorineural type hearing impairment on the affected side was diagnosed in 13 (92.6%) patients. Before surgery, 6 patients had non-serviceable hearing, which remained at the same level after surgery. None of the patients with grade I or II hearing before surgery had any hearing impairment postoperatively. In 2 (14.3%) cases, hearing improved from grade V to grade III after surgery. 6 (42.9%) patients developed new neurological deficit in the caudal group CN. Postoperative deficit of the caudal group CN occurred in type D tumors in 3 patients, type A tumors 2 patients, and type B tumors one patient. Conclusions: Applying a retrosigmoid approach only makes it possible to achieve total tumor removal in case of type A tumors. To remove other tumor types, it is necessary to select approaches that enable access to the jugular foramen and infratemporal fossa. Intraoperative neurophysiological monitoring is an extremely important tool in glossopharyngeal schwannoma surgery. The most common postoperative complication is a developed or increased deficit of the caudal CN group, which can lead to persistent impairments in the patients’ quality of life. Preservation of the CN VII and VIII function in most cases is a feasible task and shall be ensured as a standard for this pathology.

A Case of Ramsay Hunt-Like Syndrome Advanced to Multiple Cranial Neuropathy

Ramsay Hunt syndrome (RHS) is a neurologic disorder with symptoms of ear blisters and facial nerve paralysis caused by varicella zoster virus (VZV). We report a case of a 74-year-old male who had symptoms similar to RHS, but was tested positive for herpes simplex virus instead of VZV, which could be defined as Ramsay Hunt-like syndrome. The patient’s symptoms advanced to multiple cranial neuropathy including glossopharyngeal nerve palsy and vagus nerve palsy. (J Clinical Otolaryngol 2021;32:251-255)

A long-term survival case with proton beam therapy for advanced sphenoid sinus cancer with hypopituitarism

Sphenoid sinus malignancies are rare diseases. Secondary hypopituitarism associated with sphenoid sinus malignancy is not well known. A 41-year-old male complained of right ptosis. Neurological findings revealed right oculomotor, trochlear and glossopharyngeal nerve palsy. Imaging diagnosis suggested a tumor that had spread bilaterally from the sphenoid sinus to the ethmoid sinus, nasopharynx and posterior pharyngeal space. Biopsy revealed squamous cell carcinoma (SCC). Based on these findings, a clinical diagnosis of SCC of the sphenoid sinus was made. Removal of the tumor without damaging nearby organs would have been difficult because the tumor extended to the bilateral optic nerves, optic chiasma and internal carotid artery, and surgeons, therefore, recommended proton beam therapy (PBT). Before PBT, the hypopituitarism occurred in the patient and we administered hydrocortisone and levothyroxine. During treating for hypopituitarism, we performed PBT with nedaplatin and 5-fluorouracil. The daily PBT fractions were 2.2 relative biological effectiveness (RBE) for the tumor received total dose of 81.4 Gy RBE. The acute side effect of grade 2 dermatitis according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Occurred after PBT. The patient needs to take hydrocortisone and levothyroxine, but he remains in complete remission 8 years after treatment without surgery or chemotherapy. Visual function is gradually declining, but there is no evidence of severe radiation-induced optic neuropathy.

Microvascular decompression for a unique case of glossopharyngeal neuralgia with provokable symptomatic bradycardia: 2-Dimensional operative video

Background: Glossopharyngeal neuralgia is a rare neurovascular compression syndrome that can lead to paroxysmal craniofacial pain and sometimes cardiovascular symptoms.[1,2] The characteristic pathology involves a vessel (commonly a branch/loop of PICA) compressing the nerve at the root entry/exit zone at the brainstem.[1] Microvascular decompression is a commonly used treatment approach for patients that have failed conservative measures.[2]Case Description: A 72-year-old male presented to the ED following four episodes of syncope. The patient had a multi-year history of right-sided burning/stabbing pain involving the submandibular area and posterior throat. His syncope was related to symptomatic bradycardia that would occur during episodes of pain. His pain was exacerbated by speaking and swallowing and could be triggered by placing his finger in the right external auditory meatus. Interestingly, this maneuver would also trigger his bradycardia. The patient had failed previous pharmacotherapy, and a pacemaker had been placed to protect him from periods of hypotension. MRI/MRA of the brain and cervical spine were unremarkable. Due to his profoundly symptomatic status, the patient was offered a right retrosigmoid craniotomy for microvascular decompression of the right glossopharyngeal nerve. The patient had complete resolution of his pain and bradycardia immediately post-operatively. He was discharged on the second postoperative day and his pacemaker was ultimately removed. The patient continues to be pain free and off medication.Conclusion: Here we present a video case report of microvascular decompression with favorable outcome for an interesting presentation of glossopharyngeal neuralgia. The patient gave informed consent for surgery and video recording.

Effectiveness and Toxicity of Fractionated Proton Beam Radiotherapy for Cranial Nerve Schwannoma Unsuitable for Stereotactic Radiosurgery.

PurposeIn this benign tumor entity, preservation of cranial nerve function is of special importance. Due to its advantageous physical properties, proton beam radiotherapy (PRT) is a promising approach that spares healthy tissue. Could PRT go along with satisfactory preservation rates for cranial nerve function without compromising tumor control in patients with cranial nerve schwannoma unsuitable for stereotactic radiosurgery?MethodsWe analyzed 45 patients with cranial nerve schwannomas who underwent PRT between 2012 and 2020 at our institution. Response assessment was performed by MRI according to RECIST 1.1, and toxicity was graded following CTCAE 5.0.ResultsThe most common schwannoma origin was the vestibulocochlear nerve with 82.2%, followed by the trigeminal nerve with 8.9% and the glossopharyngeal nerve as well as the vagal nerve, both with each 4.4%. At radiotherapy start, 58% of cranial nerve schwannomas were progressive and 95.6% were symptomatic. Patients were treated with a median total dose of 54 Gy RBE in 1.8 Gy RBE per fraction. MRI during the median follow-up period of 42 months (IQR 26–61) revealed stable disease in 93.3% of the patients and partial regression in 6.7%. There was no case of progressive disease. New or worsening cranial nerve dysfunction was found in 20.0% of all patients, but always graded as CTCAE °I-II. In seven cases (16%), radiation-induced contrast enhancements (RICE) were detected after a median time of 14 months (range 2–26 months). RICE were asymptomatic (71%) or transient symptomatic (CTCAE °II; 29%). No CTCAE °III/IV toxicities were observed. Lesions regressed during the follow-up period in three of the seven cases, and no lesion progressed during the follow-up period.ConclusionThese data demonstrate excellent effectiveness with 100% local control in a median follow-up period of 3.6 years with a promising cranial nerve functional protection rate of 80%. RICE occurred in 16% of the patients after PRT and were not or only mildly symptomatic.

Transcutaneous vagus nerve stimulation (tVNS) as a potential therapeutic application for neurodegenerative disorders - A focus on dysautonomia in Parkinson's disease.

The understandings of pathogenic processes in major neurodegenerative diseases has significantly advanced in recent years, with evidence showing pathological spread of intraneuronal proteinaceous inclusions as a fundamental factor. In Parkinson's disease (PD), the culprit protein has been identified as α-synuclein as the main component for mediating progressive neurodegeneration. With severe pathology evident in the autonomic nervous system prior to clinical manifestations of PD, pathogenic spread can occur from the peripheral nervous system through key nuclei, such as the anterior olfactory nucleus and dorsal motor nucleus of the glossopharyngeal and vagal nerves, gradually reaching the brainstem, midbrain and cerebral cortex. With this understanding and the proposed involvement of the vagus nerve in disease progression in PD, notably occurring prior to characterized clinical motor features, it raises intriguing questions as to whether vagal nerve pathology can be accurately detected, and importantly used as a reliable marker for determining early neurodegeneration. Along with this is the potential use of vagus nerve neuromodulation for treatment of early disease symptoms like dysautonomia, for modulating sympatho-vagal imbalances and easing severe comorbidities of the disease. In this article, we take a closer look at the pathogenic transmission processes in neurodegenerative disorders that impact the vagus nerve, and how vagus nerve neuromodulation can be potentially applied as a therapeutic approach for major neurodegenerative disorders.

Vector 3D Reconstruction of the Nerves of the Ventral Region of the Neck from Anatomical Sections of Korean Visible Human at the Laboratory of Digital Anatomy of Paris Descartes

Objective: To carry out a 3D vector reconstruction of the nerves of the ventral region of the neck from anatomical sections of the “Korean Visible Human” for educational purposes. Materials and Methods: The anatomical subject was a 33-year-old Korean man who died of leukemia. He was 164cm tall and weighed 55kgs. A cryomacrotome sectioned the frozen body into 5960 sections. Sections numbered 1500 to 2000 were used for this study. A segmentation by manual contouring of each nervous anatomical element of the ventral region of the neck was done using Winsurf version 3.5 software on a laptop PC running Windows 10 equipped with an 8 gigabyte RAM. Results: Our vector 3D model of nerves in the ventral neck region includes the brachial plexuses, vagus nerves, inferior and superior laryngeal nerves, glossopharyngeal nerves, hypoglossal nerves and spinal nerves. This vector model has been integrated into the Diva3d virtual dissection table. It was also uploaded to the Sketchfab website and 3D printed using an ENDER 3 printer. Conclusion: Our 3D reconstruction of the nerves of the ventral region of the neck is an educational tool for learning the nerves of the ventral region of the neck and can also serve as a 3D atlas for simulation purposes for training in therapeutic gestures.

An anatomical study of the pharyngeal plexus: Application to avoiding postoperative dysphagia following anterior approaches to the cervical spine.

We aimed to localize the pharyngeal branches of the pharyngeal plexus to preclude postoperative complications such as dysphagia resulting from injury to those branches. Cranial nerves IX and X and the sympathetic trunk were dissected on 10 sides in the necks of embalmed adult cadavers of European descent to identify the pharyngeal branches so that anatomical landmarks could be identified and injury thereby avoided. In all sides, the pharyngeal branches originated from the glossopharyngeal and vagus nerves and the superior cervical ganglion and entered the posterior pharyngeal wall at the C2-C4 levels within 10 mm medial to the greater horn of the hyoid bone. All pharyngeal branches were anterior to the alar fascia. Based on our anatomical study, vagus nerve branches to the pharyngeal muscles enter at the C3/C4 vertebral levels. Such knowledge might help decrease or allow surgeons to predict which patients are more likely to develop dysphagia after cervical spine surgery.

Eversion carotid endarterectomy with nerve-sparing component in a case of high location of common carotid artery bifurcation

We performed carotid endarterectomy on a patient with 75% stenosis of the left internal carotid artery (ICA), 70% stenosis of the left common carotid artery (CCA), 60% stenosis of the right ICA and 55% stenosis of the right CCA after a transient ischaemic attack on the premises of the surgical unit of Russian Railways Hospital–Medicine (Samara), which is the clinical site for the care of surgical diseases at Samara State Medical University. During the preoperative evaluation and physical examination, we determined that the chance of high CCA bifurcation was high because the patient had a brachymorphic physique and his neck was short and broad. In fact, during the surgical exploration of the carotid triangle area, the CCA bifurcation was identified 7 ± 0.5 cm higher than the shield-like cartilage rim; thus the CCA bifurcation area crossed the stems of the glossopharyngeal (IX), vagus (X) and hypoglossal (XII) nerves, which precluded classic carotid endarterectomy. We then decided to perform carotid endarterectomy, using the eversion method and transposing the ICA above the rami of the cranial nerves. Through this method, we minimised traction and nerve stem trauma during the process of reconstructing brachiocephalic trunk arteries, prevented morbidities involving the cranial nerves during postsurgical period, accelerated the patient’s recovery and improved the patient’s quality of life. With further patient monitoring during the early and late postoperative periods, no abnormalities of peripheral innervation occurred.Received 26 March 2021. Revised 6 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

English

Obstructive sleep apnoea (OSA) is a sleep associated breathing disorder and it affects the health and quality of life of individuals suffering from it. Orthodontists should be well aware of the symptoms of this disorder and competent enough to recognize its signs and symptoms. Orthodontics is well suited for the treatment of OSA patients due to their expertise and knowledge regarding growth and development of orofacial and dentofacial structures as well as orthopaedic, orthodontic, and surgical correction of the jaws and other supporting tissues. There are basically two types of sleep apnoea- Central sleep apnoea and obstructive sleep apnoea where obstructive sleep apnoea is the more common one. This disorder can be life threatening as the oxygen supply to various parts of the body is substantially reduced. Obstructive sleep apnoea is caused by an interplay between a variety of factors, including sleep related loss of muscle tone in the tissues supplied by the glossopharyngeal nerve, anatomical obstruction of the nasal passages, large tonsils, large tongue, a retrognathic mandible, obesity, alcohol, sedative medication, and allergies. Sleep apnoea can be caused due to many factors and many treatment modalities have been employed to correct this disorder including mandibular advancement appliances, polysomnographs, and surgical intervention. It can be treated using surgery, continuous positive airway pressure and oral appliances therapy. This article highlights the role the orthodontist plays in the diagnosis and treatment planning of OSA patients. KEY WORDS Orthodontics, Obstructive Sleep Apnoea, Sleep, Snoring

TMC4 is a novel chloride channel involved in high-concentration salt taste sensation

“Salty taste” sensation is evoked when sodium and chloride ions are present together in the oral cavity. The presence of an epithelial cation channel that receives Na+ has previously been reported. However, no molecular entity involving Cl− receptors has been elucidated. We report the strong expression of transmembrane channel-like 4 (TMC4) in the circumvallate and foliate papillae projected to the glossopharyngeal nerve, mediating a high-concentration of NaCl. Electrophysiological analysis using HEK293T cells revealed that TMC4 was a voltage-dependent Cl− channel and the consequent currents were completely inhibited by NPPB, an anion channel blocker. TMC4 allowed permeation of organic anions including gluconate, but their current amplitudes at positive potentials were less than that of Cl−. Tmc4-deficient mice showed significantly weaker glossopharyngeal nerve response to high-concentration of NaCl than the wild-type littermates. These results indicated that TMC4 is a novel chloride channel that responds to high-concentration of NaCl.

Neurovascular Compression in Arterial Hypertension: Correlation of Clinical Data to 3D-Visualizations of MRI-Findings

Aims: In this study, we attempted to identify clinical parameters predicting the absence or presence of Neurovascular Compression (NVC) at the Ventrolateral Medulla (VLM) in arterial hypertension (HTN) in MRI findings. Background: Cardiovascular and pulmonary afferences are transmitted through the left vagus and glossopharyngeal nerve to the brain stem and vasoactive centers. Evidence supports the association between HTN and NVC at the left VLM. Several independent studies indicate a reduction of HTN after Microvascular Decompression (MVD) of the left. Several independent studies indicate a reduction of HTN after Microvascular Decompression (MVD) of the left VLM. Image processing of MRI provides comprehensible detection of NVC. HTN affects hemodynamic parameters and organs. Objective: This study analyzes and correlates clinical data and MRI findings in patients with and without NVC at the VLM in treatment resistant HTN to obtain possible selection criteria for neurogenic hypertension. Methods: In 44 patients with treatment resistant HTN, we compared MRI findings of neurovascular imaging to demographic, clinical and lifestyle data, office and 24-hour ambulatory Blood Pressure (BP), and cardiovascular imaging and parameters. Results: Twenty-nine (66%) patients had evidence of NVC at the VLM in MRI. Sixteen patients (36%) had unilateral NVC on the left side, 7 (16%) unilateral right and 6 (14%) bilateral NVC. Fifteen (34%) had no evidence of NVC at the VLM. Patients with left sided NVC were significantly younger, than those without NVC (p=0.034). They showed a statistically significant variance in daytime (p=0.020) and nighttime diastolic BP (p<0.001) as the mean arterial pressure (p=0.020). Other measured parameters did not show significant differences between the two groups. Conclusion: We suggest to examine young adults with treatment resistant HTN for the presence of NVC at VLM, before signs of permanent organ damage appear. Clinical and hemodynamic parameters did not emerge as selection criteria to predict NVC. MVD as a surgical treatment of NVC in HTN is not routine yet as a surgical treatment of NVC in HTN is not routine yet. Detection of NVC by imaging and image processing remains the only criteria to suggest MVD, which should be indicated on an individual decision.

WS7.6. Approach to US of tongue and cranial nerves

Bulbar muscle (including the tongue muscle) ultrasound is used as an alternative tool for detecting fasciculations in the diagnosis of ALS because the judgment of the presence of fasciculation potentials in needle EMG examination is always difficult in the tongue muscle. Also, bulbar muscle ultrasound is useful for the assessment of bulbar dysfunction and dysphagia. Nerve ultrasound can detect some cranial nerves. Sonographic optic nerve sheath assessment may be useful in the diagnosis of intracranial hypertension and optic neuritis. Sonographic facial nerve enlargement can be observed in patients with Bell’s palsy. Sonographic identification of glossopharyngeal nerve is useful for glossopharyngeal nerve block. Vagus nerve hypertrophy is seen in immune-mediated neuropathy and atrophy is observed in Parkinson’s disease. The spinal accessory nerve also can be detected by nerve ultrasound. Cranial nerve imaging by ultrasound can be a supplementary tool in the diagnosis and assessment of some neurological diseases.

Hitting a Wall: An Ambiguous Case of Wallenberg Syndrome

Wallenberg syndrome is the most common stroke of the posterior circulation. Diagnosis of Wallenberg syndrome is often overlooked as initial MRI may show no visible lesion. We present an atypical case of Wallenberg syndrome in which the initial MRI of the brain was normal.Our patient is a 65-year-old male who was brought in by emergency medical services complaining of right-sided facial droop, slurred speech, and left-sided weakness for one day. Physical examination showed decreased left arm and leg strength compared to the right side, decreased left facial temperature sensations, decreased left arm and leg temperature sensations, and difficulty sitting upright with an associated leaning towards the left side. An initial magnetic resonance imaging (MRI) of the brain with and without contrast revealed no abnormality. In light of such a high suspicion for stroke based on the patient’s neurologic deficits, a repeat MRI of the brain was performed three days later and exposed a small focus of bright signal (hyperintensity) on T2-weighted fluid-attenuated inversion recovery and diffusion-weighted imaging (DWI) in the left posterior medulla.Wallenberg syndrome, also known as lateral medullary syndrome or posterior inferior cerebellar artery syndrome, is a constellation of symptoms caused by posterior vascular accidents. The neurological deficits associated with this disease are due to damage of the lateral medulla, inferior cerebellar peduncle, nucleus of trigeminal nerve, nucleus and fibers of vagus and glossopharyngeal nerves, descending sympathetic tract, spinothalamic tract, and/or vestibular nuclei. MRI with DWI is the gold standard to confirm the diagnosis.Wallenberg syndrome has the potential to leave patients extremely debilitated. Early detection, management, and rehabilitation are critical for improving post-stroke recovery.

Sublingual Nitroglycerin spray versus normal saline spray in attenuating pressor response to extubation: Changes in heart rate

The sympathetic response involves polysynaptic pathway with Glossopharyngeal and Vagus nerve forming afferent arc to the sympathetic nervous system via brain stem and spinal cord. This causes firing of adrenergic mediators such as norepinephrine and epinephrine which leads to increase in HR and blood pressure. Parasympathetic reflex is monosynaptic and is more common in children. Approval from ethical committee and written informed consent was obtained. A total of 60 patients undergoing surgery under general anaesthesia with endotracheal intubation were included in the study. After having met inclusion and exclusion criteria and having obtained informed consent, patients were randomized based on computer generated randomization table into one of the two groups. Hemodynamic response to extubation increases HR, BP which in turn increases myocardial oxygen demand. Activation of sympathetic nervous system during extubation causes coronary vasoconstriction which in turn reduces coronary blood flow. NTG dilates coronary vessels thereby increases blood flow of coronaries and thus improving oxygen delivery to myocardium which is an added advantage.

Ultrasound-guided glossopharyngeal nerve block: Description of a new technique.

Ultrasound-guided glossopharyngeal nerve block: Description of a new technique.

Endonasal access to lower cranial nerves: From foramina to upper parapharyngeal space.

Lesions arising from the upper parapharyngeal space (UPPS) often involved the jugular foramen region (JFR), occasionally extending into the posterior cranial fossa. This study aims to investigate the surgical anatomy of the JFR and UPPS from the perspective of an expanded endoscopic approach (EEA), tracing the lower cranial nerves from their extracranial foramina to the UPPS. Six cadaveric specimens (12 sides) underwent a transpterygoid EEA to expose the JFR and UPPS. Distances from the medial pterygoid plate (MPP) to the internal carotid artery (ICA), hypoglossal canal (HC), and jugular tubercle (JT) were measured on anonymized Computed tomography angiography images previously obtained from 30 patients with pulsatile tinnitus. Full access to the JFR, and its medial, superior, and anterior aspects, could be adequately achieved via an EEA. Upon exiting the jugular foramen, the glossopharyngeal nerve courses posterior to the ICA, traveling inferiorly into the UPPS between ICA and IJV. The vagus nerve is in close proximity to the hypoglossal nerve traveling posterior to the ICA. The accessory nerve courses lateral to the vagus nerve, running posterior to the IJV. The minimal distances from the MPP to ICA, HC, and JT were 2.52 ± 0.34, 2.86 ± 0.36, and 3.18 ± 0.33 cm, respectively. This anatomical study strongly suggests the feasibility of using an EEA to access to the medial, superior, and anterior aspects of the jugular foramen and the adjacent UPPS.