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Tong JY, Sung J, Chan W, Valentine R, Psaltis AJ, Selva D. Transorbital Endoscopic Approach to the Foramen Rotundum for Infraorbital Nerve Stripping. Ophthalmic Plast Reconstr Surg 2024; 40:321-325. [PMID: 38215465 DOI: 10.1097/iop.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
PURPOSE To develop and evaluate a transorbital endoscopic approach to the foramen rotundum to excise the maxillary nerve and infraorbital nerve branch. METHODS Cadaveric dissection study of 10 cadaver heads (20 orbits). This technique is predicated upon 1) an inferior orbital fissure release to facilitate access to the orbital apex and 2) the removal of the posterior maxillary wall to enter the pterygopalatine fossa (PPF). Angulations along the infraorbital nerve were quantified as follows: the first angulation was measured between the orbitomaxillary segment within the orbital floor and the pterygopalatine segment suspended within the PPF, while the second angulation was taken between the pterygopalatine segment and maxillary nerve as it exited the foramen rotundum. With refinement of the technique, the minimum amount of posterior maxillary wall removal was quantified in the final 5 cadaver heads (10 orbits). RESULTS The mean distance from the inferior orbital rim to the foramen rotundum was 45.55 ± 3.24 mm. The first angulation of the infraorbital nerve was 133.10 ± 16.28 degrees, and the second angulation was 124.95 ± 18.01 degrees. The minimum posterior maxillary wall removal to reach the PPF was 11.10 ± 2.56 mm (vertical) and 11.10 ± 2.08 mm (horizontal). CONCLUSIONS The transorbital endoscopic approach to an en bloc resection of the infraorbital nerve branch up to its maxillary nerve origin provides a pathway to the PPF. This is relevant for nerve stripping in the context of perineural spread. Other applications include access to the superior portion of the PPF in selective biopsy cases or in concurrent orbital pathology.
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Affiliation(s)
- Jessica Y Tong
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeffrey Sung
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - WengOnn Chan
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rowan Valentine
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Surgery-Otolaryngology, Head and Neck Surgery University of Adelaide Adelaide South Australia Australia
| | - Alkis J Psaltis
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Surgery-Otolaryngology, Head and Neck Surgery University of Adelaide Adelaide South Australia Australia
| | - Dinesh Selva
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Machado A, Simmen D, Schuknecht B, Briner HR. Greater Palatine Canal: Computed Tomography-Based Anatomic Analysis And Clinical Significance for the Sinus and Skull Base Surgeon. EAR, NOSE & THROAT JOURNAL 2022:1455613221111063. [PMID: 36073506 DOI: 10.1177/01455613221111063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Our aim is to describe the location and course of the greater palatine canal (GPC) by analyzing its relationship with anatomical landmarks that can be used during endoscopic sinus surgery. This information might help prevent injury to the neurovascular bundle. METHODS A retrospective evaluation of paranasal sinus CT scans of 100 consecutive random patients, 200 sides, was performed. Five measurements related to the course of the GPC were conducted, from cranial to caudal. The anatomical landmarks were the inferior bony border of the sphenopalatine foramen to the cranial entrance of the GPC, the distance from the most dorsal, and inferior bony insertion of the middle turbinate and the inferior turbinate bones to the anterior margin of the GPC. The angle between the horizontal palatine bone and the GPC, its length, and the prevalence of osteophytes in GPC was also assessed. RESULTS The mean distance of the inferior border of the sphenopalatine foramen to the cranial entrance of the GPC was 9.39 ± 1.72 mm. The mean distance of the dorsal insertion of the middle turbinate to the anterior margin of the GPC was 3.89 ± 0.93 mm. The distance of the dorsal insertion of the inferior turbinate to the anterior margin of the GPC was 3.16 ± 0.81 mm. The mean angle between the horizontal palatine bone and the GPC was 114.33 ± 10.92º and the mean length of the GPC was 30.23 ± 3.74 mm. None of the measurements showed a significant difference between the two sides. CONCLUSIONS The landmarks used are easy to locate and assess on CT scans. These findings may help to make dissection safer in pathologies related to the pterygopalatine fossa, lateral sphenoid sinus or adjacent skull base.
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Affiliation(s)
- André Machado
- Otolaryngology, Head & Neck surgery Department of Centro Hospitalar Universitário do Porto, Porto, Portugal
- Faculdade de Ciências da Saúde - Universidade da Beira Interior, Covilhã, Portugal
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Loymak T, Belykh E, Abramov I, Tungsanga S, Sarris CE, Little AS, Preul MC. Comparative Analysis of Surgical Exposure among Endoscopic Endonasal Approaches to Petrosectomy: An Experimental Study in Cadavers. J Neurol Surg B Skull Base 2022; 83:526-535. [PMID: 36097500 PMCID: PMC9462962 DOI: 10.1055/s-0041-1741067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 11/12/2021] [Indexed: 01/16/2023] Open
Abstract
Objectives Endoscopic endonasal approaches (EEAs) for petrosectomies are evolving to reduce perioperative brain injuries and complications. Surgical terminology, techniques, landmarks, advantages, and limitations of these approaches remain ill defined. We quantitatively analyzed the anatomical relationships and differences between EEA exposures for medial, inferior, and inferomedial petrosectomies. Design This study presents anatomical dissection and quantitative analysis. Setting Cadaveric heads were used for dissection. EEAs were performed using the medial petrosectomy (MP), the inferior petrosectomy (IP), and the inferomedial petrosectomy (IMP) techniques. Participants Six cadaver heads (12 sides, total) were dissected; each technique was performed on four sides. Main Outcomes and Measures Outcomes included the area of exposure, visible distances, angles of attack, and bone resection volume. Results The IMP technique provided a greater area of exposure ( p < 0.01) and bone resection volume ( p < 0.01) when compared with the MP and IP techniques. The IMP technique had a longer working length of the abducens nerve (cranial nerve [CN] VI) than the MP technique ( p < 0.01). The IMP technique demonstrated higher angles of attack to specific neurovascular structures when compared with the MP (midpons [ p = 0.04], anterior inferior cerebellar artery [ p < 0.01], proximal part of the cisternal CN VI segment [ p = 0.02]) and IP (flocculus [ p = 0.02] and the proximal [ p = 0.02] and distal parts [ p = 0.02] of the CN VII/VIII complex) techniques. Conclusion Each of these approaches offers varying degrees of access to the petroclival region, and the surgical approach should be appropriately tailored to the pathology. Overall, the IMP technique provides greater EEA surgical exposure to vital neurovascular structures than the MP and the IP techniques.
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Affiliation(s)
- Thanapong Loymak
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christina E. Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S. Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Address for correspondence Mark C. Preul, MD c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center350 West Thomas Road, Phoenix, Arizona 85013
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Li L, London NR, Prevedello DM, Carrau RL. Endoscopic prelacrimal approach to lateral recess of sphenoid sinus: feasibility study. Int Forum Allergy Rhinol 2019; 10:103-109. [PMID: 31834678 DOI: 10.1002/alr.22455] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/13/2019] [Accepted: 09/17/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Various pathologies, including cerebrospinal fluid leaks and meningoencephaloceles, may arise in the lateral recess of the sphenoid sinus (LRSS), which may be accessed via an endonasal transpterygoid approach. The objective of this study was to evaluate the feasibility of accessing the LRSS via an endoscopic prelacrimal approach. Furthermore, we hypothesized that this approach may protect the pterygopalatine ganglion and vidian nerve. METHODS Five cadaveric heads (9 sides) with a well-pneumatized LRSS were identified and an endonasal prelacrimal approach was performed. The infraorbital nerve, at the orbital floor, served as a critical landmark. After identification of the foramen rotundum at the pterygoid base, the vascular compartment of the pterygopalatine fossa and the pterygopalatine ganglion were displaced inferomedially and superomedially, respectively. Drilling of the bone inferomedial to the foramen rotundum allowed entry into the LRSS. RESULTS The average distances from the prelacrimal window to the pterygoid base and the posterior wall of the LRSS were 6.22 ± 0.39 cm and 7.16 ± 0.50 cm, respectively. The average areas of the bony prelacrimal window and pterygoid base window were 4.33 ± 0.32 cm2 and 0.73 ± 0.10 cm2 , respectively. The LRSS could be accessed using a 0-degree endoscope, and pterygopalatine neurovascular structures, including the pterygopalatine ganglion and vidian nerve, could be preserved on all 9 sides. CONCLUSION Our findings suggest that an endonasal prelacrimal approach provides a reasonable alternative to access the LRSS while preserving the vidian nerve and pterygopalatine ganglion.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head & Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China.,Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD.,National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center, The Ohio State University, Columbus, OH
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The pterygopalatine fossa: morphometric CT study with clinical implications. Surg Radiol Anat 2018; 41:161-168. [DOI: 10.1007/s00276-018-2136-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/16/2018] [Indexed: 11/27/2022]
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Anatomical landmarks for maxillary nerve block in the pterygopalatine fossa: A radiological study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:90-94. [PMID: 28345519 DOI: 10.1016/j.jormas.2016.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/13/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed. METHODS This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route. RESULTS No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°. DISCUSSION With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block.
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Peris-Celda M, Pinheiro-Neto CD, Scopel TF, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Endoscopic endonasal approach to the infraorbital nerve with nasolacrimal duct preservation. J Neurol Surg B Skull Base 2013; 74:393-8. [PMID: 24436942 DOI: 10.1055/s-0033-1347372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 03/10/2013] [Indexed: 10/26/2022] Open
Abstract
Objectives Infraorbital nerve (ION) decompression, excision to remove intrinsic tumors, and resection with oncological margins in malignancies with perineural invasion or dissemination are usually accomplished with an open approach. The objective is to describe the surgical anatomy, technique, and indications of the endonasal endoscopic approach (EEA) to the ION with nasolacrimal duct preservation. Design Eleven sides of formalin-fixed specimens were dissected. An anterior maxillary antrostomy was performed. The length of the ION prominence within the sinus and anatomic features of the covering bone were studied. A 45-degree endoscope visualized the infraorbital prominence endonasally. An angled dissector and dural blade allowed for dissection and resection of the ION ipsilaterally and contralaterally. Results The bone features of the ION prominence allowed for ipsilateral dissection in 10 out of 11 sides. In one case with the ION surrounded by thick cortical bone, the dissection could only be started by drilling contralaterally. The 45-degree endoscope visualized 92.2% and 100% of the length of the nerve using the ipsilateral and contralateral nostrils, respectively. Ipsilaterally, 83% of its length was resected, and 96.3% was resected contralaterally. Conclusion The ION can be approached using an ipsilateral EEA with nasolacrimal duct preservation in most cases. The contralateral approach provides a wider angle to access the ION. This technique is primarily indicated in cases where the EEA can be used for tumor resection and oncological margins within the ION.
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Affiliation(s)
- Maria Peris-Celda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carlos D Pinheiro-Neto
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Tiago F Scopel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Feng GD, Gao ZQ, Jiang H, Zha Y, Shen P, Lv W. A novel method for three-dimensional analysis of endoscopic spatial relationships of pterygopalatine fossa structures and associated regions. ORL J Otorhinolaryngol Relat Spec 2012; 74:220-7. [PMID: 22907168 DOI: 10.1159/000340045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 06/06/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The spatial orientation rules of the important skull base structures are essential for performing endoscopic surgery. However, there is no satisfactory three-dimensional (3-D) anatomy study available to the surgeon at present. The aims of this study are to construct a new method to learn the spatial orientation of anatomical features under endoscopy and to help the surgeon establish a 3-D image of skull base structures in his mind. METHODS A modified MicronTracker navigation system was used to measure the pitch angle, direction angle and distance from the reference points to various anatomical landmarks of the pterygopalatine fossa and related structures (PPFRS) at the skull base in 10 fresh cadavers (20 sides). RESULTS The location data of the positions of the major landmarks were acquired and a digital model of the anatomical structures of the PPFRS was built, which can be moved, whirled or demonstrated easily. CONCLUSION It is practical to measure the positions of the anatomical structures of the PPFRS with a modified binocular vision-based MicronTracker navigation system. It is a valuable exploration tool to help the surgeon establish the orientation of surgical landmarks in his mind by the 3-D parameters and model.
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Affiliation(s)
- Guo-Dong Feng
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Gangata H. A mental hook for learning the three-dimensional anatomy of the sphenoid bone: an angelic resemblance. Br J Oral Maxillofac Surg 2010; 48:e27-8. [PMID: 20472332 DOI: 10.1016/j.bjoms.2010.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 04/15/2010] [Indexed: 11/16/2022]
Abstract
The sphenoid bone seems to resemble a biblical angel. The angel had six wings, and used two to cover the eyes (lesser wings with optic canal representing the eyes), two to fly (greater wings), and two (broad lateral pterygoid plates) to cover the feet (medial pterygoid plates with hamulus). This illustration may help surgical trainees to conceptualise and understand the clinical implications of this wide-ranging bone.
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Affiliation(s)
- Hope Gangata
- Anatomy Division, Floor 2 of MED Building, School of Medicine, Health Policy and Practice, Faculty of Health Sciences, University of East Anglia, Norwich NR4 7TJ, Norfolk, United Kingdom.
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