Pure Endoscopic Lateral Orbitotomy Approach to the Cavernous Sinus, Posterior, and Infratemporal Fossae: Anatomic Study (original) (raw)
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The Annals of otology, rhinology, and laryngology, 2018
A transcranial extradural approach to the middle cranial fossa (MCF) requires separation of the dural layers of the lateral wall of the cavernous sinus. The authors tested the feasibility of an endonasal approach for this separation. A cadaveric feasibility study was conducted on the sides of 14 dry skulls and 10 fresh cadaveric heads. An endonasal, transsphenoidal, transpterygoid approach was taken to the MCF. The maxillary struts and medial greater wing of the sphenoid below the superior orbital fissure were drilled with transposition of the maxillary nerve. The lateral cavernous dural layers were split at the maxillary nerve with separation of the temporal lobe dura and exposure of the MCF bony base. The integrity of the cranial nerves and inner and outer dural layers of the lateral cavernous wall was checked. Different measurements of bony landmarks were obtained. The integrity of the dural layers of the lateral cavernous wall and the cranial nerves were preserved in 10 heads. T...
Journal of Neurological Surgery Part B: Skull Base, 2017
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Lateral orbital wall approach to the cavernous sinus
Journal of Neurosurgery, 2012
Object Lesions of the cavernous sinus remain a technical challenge. The most common surgical approaches involve some variation of the standard frontotemporal craniotomy. Here, the authors describe a surgical approach to access the cavernous sinus that involves the removal of the lateral orbital wall. Methods To achieve exposure of the cavernous sinus, a lateral canthal incision is performed, and the lateral orbital rim and anterior lateral wall are removed, for later replacement at closure. The posterior lateral orbital wall is removed to the region of the superior and inferior orbital fissures. With reflection of the dural covering of the lateral cavernous sinus and removal of the anterior clinoid process, the cavernous sinus is exposed. Results Exposure and details of the procedure were derived from anatomical study in cadavers. After the approach, with removal of the anterior clinoid process, the entire cavernous sinus from the superior orbital fissure anteriorly to the Meckel ca...
Endoscopic Transnasal Approach to the Cavernous Sinus versus Transcranial Route: Anatomic Study
Operative Neurosurgery, 2005
OBJECTIVE: The aim of the present study was to compare the anatomy of the cavernous sinus via an endoscopic transnasal route with the anatomy of the same region explored by the transcranial route. The purpose was to identify and correlate the corresponding anatomic landmarks both through the endoscopic transnasal transsphenoidal and the microscopic transcranial views. METHODS: Five fresh injected heads (10 specimens) were dissected by the endoscopic transnasal and microsurgical transcranial approaches. A comparison of different microsurgical corridors of the cavernous sinus with the corresponding endoscopic transnasal ones was performed. RESULTS: Through the endoscopic transnasal approach, it is possible to explore only some of the parasellar and middle cranial fossa subregions. Because of the complex multilevel architecture of the cavernous sinus, there is not always a correspondence between the surgical corridors bounded through the transcranial route and those exposed through the...
E XPANDED endoscopic surgery is a standard option in the armamentarium for skull base approaches to address numerous pathologies. 2,4,13,16,27 Technical improvements over the past decade have made endoscopy a viable alternative to conventional microscopic or open procedures. 10,31 Expanded endoscopic endonasal approaches have been used to access lesions in the clivus, 17,20 posterior fossa, 18,29 craniovertebral junction, 5,24 and anterior fossa. 29 One such expanded endoscopic approach, the endoscopic transmaxillary approach (ETMA), is used to access le-sions within the maxillary sinus, lateral sphenoid sinus, cavernous sinus, and anterolateral skull base. 1,8,14,23,25,32,34 The transmaxillary corridor is most commonly accessed through an endonasal approach and a medial maxillec-tomy or through a sublabial incision and a direct anterior maxillectomy (i.e., Caldwell-Luc approach). 8,23,25 Endoscopic approaches to the anterolateral skull base are challenging for neurosurgeons because of the unfamil-abbreviations ETMA = endoscopic transmaxillary approach; ICA = internal carotid artery; IOA = infraorbital artery; ION = infraorbital nerve. obJective Endoscopic transmaxillary approaches (ETMAs) address pathology of the anterolateral skull base, including the cavernous sinus, pterygopalatine fossa, and infratemporal fossa. This anatomically complex region contains branches of the trigeminal nerve and external carotid artery and is in proximity to the internal carotid artery. The authors postulated, on the basis of intraoperative observations, that the infraorbital nerve (ION) is a useful surgical landmark for navigating this region; therefore, they studied the anatomy of the ION and its relationships to critical neurovascular structures and the maxillary nerve (V2) encountered in ETMAs. methods Endoscopic anatomical dissections were performed bilaterally in 5 silicone-injected, formalin-fixed cadav-eric heads (10 sides). Endonasal transmaxillary and direct transmaxillary (Caldwell-Luc) approaches were performed, and anatomical correlations were analyzed and documented. Stereotactic imaging of each specimen was performed to correlate landmarks and enable precise measurement of each segment. results The ION was readily identified in the roof of the maxillary sinus at the beginning of the surgical procedure in all specimens. Anatomical dissections of the ION and the maxillary branch of the trigeminal nerve (V2) to the cavernous sinus suggested that the ION/V2 complex has 4 distinct segments that may have implications in endoscopic approaches: 1) Segment I, the cutaneous segment of the ION and its terminal branches (5-11 branches) to the face, distal to the in-fraorbital foramen; 2) Segment II, the orbitomaxillary segment of the ION within the infraorbital canal from the infraorbital foramen along the infraorbital groove (length 12 ± 3.2 mm); 3) Segment III, the pterygopalatine segment within the ptery-gopalatine fossa, which starts at the infraorbital groove to the foramen rotundum (13 ± 2.5 mm); and 4) Segment IV, the cavernous segment from the foramen rotundum to the trigeminal ganglion (15 ± 4.1 mm), which passes in the lateral wall of the cavernous sinus. The relationship of the ION/V2 complex to the contents of the cavernous sinus, carotid artery, and pterygopalatine fossa is described in the text. conclusions The ION/V2 complex is an easily identifiable and potentially useful surgical landmark to the foramen rotundum, cavernous sinus, carotid artery, pterygopalatine fossa, and anterolateral skull base during ETMAs.
Transnasal approach to the orbital apex and cavernous sinus
The Annals of otology, rhinology, and laryngology
The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency. One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative. There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (resolv...
Multiportal Endoscopic Approaches to the Central Skull Base: A Cadaveric Study
World Neurosurgery, 2010
Ⅲ CONCLUSIONS: The precaruncular transorbital approach provided rapid, direct, coplanar access to the clivus, sella, and suprasellar/parasellar regions. The supraorbital minicraniotomy augmented access to the planum sphenoidale, sella, tuberculum sella, and suprasellar regions. These approaches provided shorter working distances, improved visualization, and working angles that offer more direct access to the pituitary gland, suprasellar region, clivus, medial and lateral cavernous sinus than the endoscopic transnasal approach alone. The combination of endoscopic approaches to the central anterior skull base significantly improved instrument access, particularly to lateral targets, as well as better visualization of the vital structures in these regions. These ports provide the surgeon with a more expansive surgical field and improved the ability to perform two-handed microsurgical dissections.
Anatomy of the Inferior Orbital Fissure: Implications for Endoscopic Cranial Base Surgery
Journal of Neurological Surgery Part B: Skull Base, 2012
The development of endonasal, endoscopic cranial base surgery has permitted access to the anterior and inferior aspects of the skull base using various surgical corridors. 1-12 Endoscopic transmaxillary, transethmoidal, and transsphenoidal approaches often rely on the collaboration between specialists in the fields of otolaryngology and neurosurgery. Many approaches to the skull base either confront or come in close proximity to the inferior orbital fissure (IOF). Nevertheless, the IOF (also called the sphenomaxillary fissure) has been neglected as an endoscopic surgical landmark. The IOF lies in the orbital floor in proximity to the superior orbital fissure (SOF), foramen rotundum, pterygopalatine fossa, infratemporal fossa, and temporal fossa. Because trauma, tumor, and/or infection can affect all of these structures or regions, understanding the anatomical detail of the IOF is essential. 22-27 Its anatomy was previously described in relation to an orbitozygomatic osteotomy, 28-31 yet its comprehensive three-dimensional (3D) anatomical relationships have not been described from an endoscopic perspective.
Journal of Neurosurgery, 2021
OBJECTIVE The anteromedial triangle (AMT) is the triangle formed by the ophthalmic (V1) and maxillary (V2) nerves. Opening of this bony space offers a limited access to the sphenoid sinus (SphS). This study aims to demonstrate the utility of the orbitopterygopalatine corridor (OPC), obtained by enlarging the AMT and transposing the contents of the pterygopalatine fossa (PPF) and V2, as an entrance to the SphS, maxillary sinus (MaxS), and nasal cavity. METHODS Five formalin-injected cadaveric specimens were used for this study (10 approaches). A classic pterional approach was performed. An OPC was created through the inferior orbital fissure, between the orbit and the PPF, by transposing the PPF inferiorly. The extent of the OPC was measured using neuronavigation and manual measurements. Two illustrative cases using the OPC to access skull base tumors are presented in the body of the article. RESULTS Via the OPC, the SphS, MaxS, ethmoid sinus (EthS), and nasal cavity could be accesse...
European Archives of Oto-Rhino-Laryngology, 2013
The posterior sino-orbito-cranial interface is a critical area in the skull base since it represents a gateway to deeper vital regions. Quantification of the surgical freedom for any given point/area is an objective method for comparing in a reproducible way different surgical approaches. Three freshly injected cadaver heads (six sides) were dissected under the magnetic navigation control system. The surgical freedom (SF) and the angle of attack of fixed target points were determined from the ipsilateral nasal fossa, from the contralateral nasal fossa (after posterior septectomy), and after an anteromedial maxillotomy (according to the Denker procedure). The mean pre-operative SF value resulted to be 403.07 ± 102.73 mm 2 for the ipsilateral nostril, increasing by 126.97 % for the binostril approach, by 118.45 % for the monolateral nostril approach after anteromedial maxillotomy, and by 310.48 % for the binostril approach after bilateral anteromedial maxillotomy. Laterally extended lesions require an anteromedial maxillotomy, while more medially located lesions can be managed by means of a posterior septectomy. When addressing the posterior sinoorbito-cranial interface, the transnasal binostril approach and anteromedial maxillotomy both increase the SF. The choice between them depends on exact position, relationship and clinical behaviour of the lesion to treat. Keywords Endoscopic endonasal Á Orbit Á Skull base Á Denker approach Á Binostril approach Abbreviations SF Surgical freedom LOCR Lateral optic-carotid recess MS Maxillary strut IRM Inferior rectus muscle MRM Medial rectus muscle PEA Posterior ethmoidal artery