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Omura K, Kimple AJ, Senior BA, Nomura K, Norris M, Zeatoun AL, Klatt-Cromwell C, Ebert CS, Otori N, Thorp BD. Minimally Invasive Transnasal Approach to the Anteromedial Temporal Fossa and Lateral Sphenoid Using a Novel Landmark between Periorbita and Periosteum of the Pterygopalatine Fossa: A Cadaveric Study. J Neurol Surg B Skull Base 2024; 85:465-469. [PMID: 39228880 PMCID: PMC11368456 DOI: 10.1055/a-2101-9910] [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: 03/22/2023] [Accepted: 05/18/2023] [Indexed: 09/05/2024] Open
Abstract
The anteromedial temporal region and the lateral wall of the sphenoid can be the site of an array of pathology including trigeminal schwannoma, encephalocele, cholesterol granuloma of the petrous apex, malignancy, infection, and sellar pathology extending to the lateral cavernous sinus. Approaches to this region are technically challenging and the existing approach requires sacrifice of all of the turbinates including the nasolacrimal duct, which can cause postoperative complications. We describe a novel anatomical landmark between the periorbita and the periosteum of the pterygopalatine fossa (which is located at the inferolateral periorbital periosteal line [ILPPL]). The posterior one-third of the incision line lies between the foramen rotundum and the superior orbital fissure, which is proximal to the maxillary strut. A 1.5-cm incision can divide the orbital and pterygoid contents and lead us to the posterior inferolateral orbital region, anteromedial temporal region, lateral wall of the sphenoid sinus, and lateral wall of the cavernous sinus. A combined multiangled approach to the ILPPL will enable us to preserve all of the turbinates and the septum, and the nasolacrimal duct, allowing for the preservation of the physiological function and pedicled flaps, such as the middle turbinate, inferior turbinate, and septal membrane flap. The ILPPL is a simple, effective, and novel landmark for the minimally invasive approach to the anteromedial temporal fossa.
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Affiliation(s)
- Kazuhiro Omura
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Adam J. Kimple
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Brent A. Senior
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Kazuhiro Nomura
- Department of Otolaryngology, Tohoku Kosai Hospital, Miyagi, Japan
| | - Meghan Norris
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Abdullah L. Zeatoun
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Cristine Klatt-Cromwell
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Charles S. Ebert
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Nobuyoshi Otori
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Brian D. Thorp
- Department of Otolaryngology, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
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Ferres A, Tercero-Uribe AI, Matas J, Alcubierre R, Codes M, Tafuto R, Camós-Carreras A, Muñoz-Lopetegi A, Tercero J, Alobid I, Sanchez-Dalmau B, Di Somma A, Enseñat J. Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration. Oper Neurosurg (Hagerstown) 2024; 27:287-294. [PMID: 38578710 DOI: 10.1227/ons.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/25/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES. METHODS A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES). RESULTS In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected. CONCLUSION The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.
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Affiliation(s)
- Abel Ferres
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Ana Isabel Tercero-Uribe
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Jessica Matas
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Rafel Alcubierre
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Marta Codes
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Roberto Tafuto
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Anna Camós-Carreras
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Amaia Muñoz-Lopetegi
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Javier Tercero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Isam Alobid
- Department of Otorhinolaryngology, Institut Clinic d'Especialitats Mèdiques i Quirúrgiques (ICEMEQ), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Bernardo Sanchez-Dalmau
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Alberto Di Somma
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona , Spain
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Corvino S, Kassam A, Piazza A, Corrivetti F, Esposito F, Iaconetta G, de Notaris M. Navigating the Intersection Between the Orbit and the Skull Base: The "Mirror" McCarty Keyhole During Transorbital Approach: An Anatomic Study With Surgical Implications. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01247. [PMID: 38995028 DOI: 10.1227/ons.0000000000001274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/21/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES McCarty keyhole (MCK) is the most important entry point during orbitocranial and cranio-orbital approaches; nevertheless, its anatomic coordinates have never been detailedly described from transorbital perspective. To provide the spatial coordinates for intraorbital projection of the "mirror" MCK by using the well-established main anatomic-surgical bony landmarks met along transorbital corridor. METHODS MCK was identified in 15 adult dry skulls (30 sides) on exocranial surface of pterional region based on the well-defined external bony landmarks: on the frontosphenoid suture, 5 to 6 mm behind the joining point (JP) of frontozygomatic suture (FZS), frontosphenoid suture (FSS), and sphenozygomatic suture (SZS). A 1-mm burr hole was performed and progressively enlarged to identify the intracranial and intraorbital compartments. Exit site of the intraorbital part of burr hole was referenced to the FZS on the orbital rim, the superior orbital fissure, and the inferior orbital fissure and to the JP of FZS, FSS, and SZS. To electronically validate the results, 3-dimensional photorealistic and interactive models were reconstructed with photogrammetry. Finally, for a further validation, McCarty mirror keyhole was also exposed, based on results achieved, through endoscopic transorbital approach in 10 head specimens (20 sides). RESULTS Intraorbital projection of MCK was identified on the FSS on intraorbital surface, 1.5 ± 0.5 mm posterior to JP, 11.5 ± 1.1 mm posterior to the FZS on orbital rim following the suture, 13.0 ± 1.2 mm from most anterior end of superior orbital fissure, 15.5 ± 1.4 mm from the most anterior end of the inferior orbital fissure in vertical line, on measurements under direct macroscopic visualization (mean ± SD). These values were electronically confirmed on the photogrammetric models with mean difference within 1 mm. CONCLUSION To be aware of exact position of intraorbital projection of MCK during an early stage of transorbital approaches provides several surgical, clinical, and aesthetic advantages.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
- European Biomedical Research Institute of Salerno (EBRIS) Foundation, Salerno, Italy
| | - Amin Kassam
- Department of Neurosciences, Intent Medical Group, Northshore University Neurosciences Institute, Arlington Heights, Illinois, USA
| | - Amedeo Piazza
- European Biomedical Research Institute of Salerno (EBRIS) Foundation, Salerno, Italy
- Department of Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Corrivetti
- European Biomedical Research Institute of Salerno (EBRIS) Foundation, Salerno, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giorgio Iaconetta
- Division of Neurosurgery, AOU "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Matteo de Notaris
- European Biomedical Research Institute of Salerno (EBRIS) Foundation, Salerno, Italy
- Division of Neurosurgery, AOU "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
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Mongkolkul K, Salem EH, Alsavaf MB, Prevedello DM, Vankoevering K, Kelly K, Carrau RL. Advantages and caveats of endoscopic to the infratemporal fossa as isolated and combined techniques. Laryngoscope Investig Otolaryngol 2024; 9:e1242. [PMID: 38736945 PMCID: PMC11081421 DOI: 10.1002/lio2.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/07/2024] [Accepted: 03/16/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Identify the benefits and caveats of combining minimal access approaches to the infratemporal fossa (ITF), such as the endoscopic transnasal, endoscopic transorbital, endoscopic transoral, and endoscopic sublabial transmaxillary approaches to address extensive lesions not amenable to a single approach. The study provides anatomical metrics including area of exposure and degree of surgical freedom. Methods Five human cadaveric specimens (10 sides) were dissected to expose and methodically analyze the anatomical intricacies of the ITF using the following minimal access approaches: endoscopic transnasal transpterygoid (EETA), endoscopic sublabial transmaxillary, endoscopic transorbital via infraorbital foramen, and endoscopic transoral techniques. Area of exposure at the pterygopalatine fossa and surgical freedom at the ITF were obtained for each approach. Results The endoscopic sublabial transmaxillary sinus and the combined approach afford a significantly greater exposure than an isolated EETA. The difference in exposure (mean) between the endoscopic sublabial transmaxillary and EETA was 1.62 ± 0.85 cm2 (p < 0.001), and the difference between the combined approach and EETA was 4.25 ± 0.85 cm2 (p < 0.001). Conclusions Combining minimal access endoscopic approaches to the ITF can provide significantly greater exposure than an isolated EETA; thus, providing enhanced access to address lesions with extensive involvement of the ITF, especially those with superolateral and inferolateral extensions. In addition, some approaches may have an adjunctive role to the resection, such as the endoscopic transoral approach offering the potential for early control of the internal maxillary artery and its branches, some of which may be supplying the tumor in the ITF; or the endoscopic transorbital approach yielding a direct line of sight to the superior ITF and middle cranial fossa. Level of Evidence NA.
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Affiliation(s)
- Kittichai Mongkolkul
- Excellence Center in Otolaryngology Head & Neck SurgeryRajavithi HospitalBangkokThailand
- Rangsit University College of MedicineMueang Pathum ThaniThailand
| | - Eman H. Salem
- Otorhinolaryngology‐Head and Neck SurgeryMansoura University HospitalsMansouraEgypt
| | - Mohammad Bilal Alsavaf
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | | | - Kathleen Kelly
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Ricardo L. Carrau
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Tong JY, Sung J, Psaltis AJ, Selva D. Inferior orbital fissure release to access the inferolateral orbital apex. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00007-3. [PMID: 38359895 DOI: 10.1016/j.jcjo.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To describe release of the inferior orbital fissure (IOF) as a novel surgical technique that will improve access to the inferior and inferolateral orbital apex. DESIGN Laboratory investigation. PARTICIPANTS Human cadaver heads. METHODS Cadaveric dissection study whereby the technique of an IOF release was performed. A swinging eyelid preseptal approach was used to enable a subperiosteal dissection to the orbital floor without obstruction from orbital fat prolapse. A plane was dissected between periorbita and Muller's muscle, the smooth muscle that overlies the entire length of the IOF. Measurements were taken in the sagittal plane from a point on the inferior orbital rim directly above the infraorbital foramen to the most posterior aspect of the orbital floor. RESULTS Fifteen orbits from 8 cadaver heads were dissected with the aid of a rigid 0-degree endoscope and microsurgical instruments. This study demonstrated that an additional 10.93 ± 2.10 mm of access to the orbital apex was gained after the release of periorbita from the IOF. CONCLUSION We propose that the IOF release can be adopted as an adjunctive technique to orbital surgery of the inferior and inferolateral orbital apex.
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Affiliation(s)
- Jessica Y Tong
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia.
| | - Jeffrey Sung
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Alkis J Psaltis
- Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Locatelli D, Veiceschi P, Arosio AD, Agosti E, Peris-Celda M, Castelnuovo P. 360 Degrees Endoscopic Access to and Through the Orbit. Adv Tech Stand Neurosurg 2024; 50:231-275. [PMID: 38592533 DOI: 10.1007/978-3-031-53578-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.
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Affiliation(s)
- Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
| | - Pierlorenzo Veiceschi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Unit of Neurosurgery, Spedali Civili Hospital, Brescia, Italy
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paolo Castelnuovo
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
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de Notaris M, Sacco M, Corrivetti F, Grasso M, Corvino S, Piazza A, Kong DS, Iaconetta G. The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles. J Clin Med 2023; 12:6484. [PMID: 37892624 PMCID: PMC10607762 DOI: 10.3390/jcm12206484] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations.
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Affiliation(s)
- Matteo de Notaris
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, 82100 Benevento, Italy
| | - Matteo Sacco
- Department of Neurosurgery, University of Foggia, 71122 Foggia, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
| | - Michele Grasso
- Department of Surgery, Otorhinolaryngology Operative Unit, “San Pio” Hospital, 82100 Benevento, Italy
| | - Sergio Corvino
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, 80055 Naples, Italy
| | - Amedeo Piazza
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neurosurgery, Sapienza University, 00185 Rome, Italy
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06531, Republic of Korea
| | - Giorgio Iaconetta
- Unit of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, 84084 Salerno, Italy
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Nakagawa M, Toyooka T, Takeuchi S, Yoshiura T, Tomiyama A, Omura T, Otsuka Y, Higashi T, Kobayashi Y, Wada K. Cadaver investigation of the usefulness of the transstyloid diaphragm approach for high-position plaque carotid endarterectomy. Clin Neurol Neurosurg 2023; 233:107948. [PMID: 37657129 DOI: 10.1016/j.clineuro.2023.107948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/29/2023] [Accepted: 08/16/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Patients sometimes present with high cervical internal carotid artery (ICA) stenosis. This study demonstrates the usefulness of the transstyloid approach to expose the distal ICA by dissection of the styloid diaphragm covering the distal cervical ICA for carotid endarterectomy (CEA). In particular, the possible exposure length achieved by this approach was investigated using cadaveric heads. METHODS The procedure of the transstyloid diaphragm approach was confirmed in 10 cadaveric heads (20 sides). After the carotid triangle was opened, both the posterior belly of the digastric muscle (PBDM) and the stylohyoid muscle could be divided. Then, the carotid sheath was dissected, and the glossopharyngeal nerve was identified crossing over the distal ICA. The revealed length of the ICA was measured with or without dissection of both the PBDM and the stylohyoid muscle. The specimens were dissected under the surgical microscope. RESULTS The transstyloid diaphragm approach was achieved successfully in all specimens. The revealed lengths of the ICA with and without dissection of the styloid diaphragm were 53.7 ± 5.9 mm and 38.8 ± 2.9 mm (mean ± standard deviation), respectively. Therefore, the revealed length of the distal ICA was 14.9 ± 4.5 mm greater using the transstyloid diaphragm approach compared to the regular CEA approach. CONCLUSIONS More of the ICA can be revealed by dissection of both the PBDM and the stylohyoid muscle. The transstyloid diaphragm approach might be helpful to reveal the distal ICA in cases of high cervical ICA stenosis.
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Affiliation(s)
- Masaya Nakagawa
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyooka
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Satoru Takeuchi
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Toru Yoshiura
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Arata Tomiyama
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Tomoko Omura
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yohei Otsuka
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Takahito Higashi
- Departments of Anatomy and Neurobiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yasushi Kobayashi
- Departments of Anatomy and Neurobiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kojiro Wada
- Departments of Neurosurgery and National Defense Medical College, Tokorozawa, Saitama, Japan.
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Zoia C, Mantovani G, Müther M, Suero Molina E, Scerrati A, De Bonis P, Cornelius J, Roche P, Tatagiba M, Jouanneau E, Manet R, Schroeder H, Cavallo L, Kasper E, Meling T, Mazzatenta D, Daniel R, Messerer M, Visocchi M, Froelich S, Bruneau M, Spena G. Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section. BRAIN & SPINE 2023; 3:102669. [PMID: 37720459 PMCID: PMC10500473 DOI: 10.1016/j.bas.2023.102669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/16/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
Introduction Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods A PRISMA based literature search was performed to select the most relevant papers on the topic. Results Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.
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Affiliation(s)
- C. Zoia
- UOC Neurochirurgia, Ospedale Moriggia Pelascini, Gravedona e Uniti, Italy
| | - G. Mantovani
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - M. Müther
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - E. Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - A. Scerrati
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - P. De Bonis
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - J.F. Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - P.H. Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - M. Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - E. Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - R. Manet
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - H.W.S. Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Germany
| | - L.M. Cavallo
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
| | - E.M. Kasper
- Department of Neurosurgery, Steward Medical Group, Brighton, USA
| | - T.R. Meling
- Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark
| | - D. Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - R.T. Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Messerer
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - S. Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - M. Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - G. Spena
- Neurosurgery Unit, IRCSS San Matteo Hospital, Pavia, Italy
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10
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Câmara B, Fava A, Matano F, Okano A, Ronconi D, Silva Costa B, Gadelha Figueiredo E, Chassoux F, Devaux B, Froelich S. Transuncal Selective Amygdalohippocampectomy by an Inferolateral Preseptal Endoscopic Approach Through Inferior Eyelid Conjunctival Incision: An Anatomic Study. Oper Neurosurg (Hagerstown) 2023; 25:199-208. [PMID: 37133253 DOI: 10.1227/ons.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/23/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Transorbital endoscopic approaches have been described for pathologies of anterior and middle fossae. Standard lateral orbitotomy gives access to mesial temporal lobe, but the axis of work is partially obscured by the temporal pole and working corridor is limited. OBJECTIVE To evaluate the usefulness of an inferolateral orbitotomy to provide a more direct corridor to perform a transuncal selective amygdalohippocampectomy. METHODS Three adult cadaveric specimens were used for a total of 6 dissections. A step-by-step description and illustration of the transuncal corridor for a selective amygdalohippocampectomy were performed using the inferolateral orbitotomy through an inferior eyelid conjunctival incision. The anatomic landmarks were demonstrated in detail. Orbitotomies and angles of work were measured from computed tomography scans, and the area of resection was illustrated by postdissection MRI. RESULTS Inferior eyelid conjunctival incision was made for exposure of the inferior orbital rim. Inferolateral transorbital approach was performed to access the transuncal corridor. Endoscopic selective amygdalohippocampectomy was performed through the entorhinal cortex without damage to the temporal neocortex or Meyer's loop. The mean horizontal diameter of the osteotomy was 14.4 mm, and the vertical one was 13.6 mm. The mean angles of work were 65° and 35.5° in the axial and sagittal planes, respectively. Complete amygdalohippocampectomy was achieved in all 6 dissections. CONCLUSION Transuncal selective amygdalohippocampectomy was feasible in cadaveric specimens using the inferolateral transorbital endoscopic approach avoiding damage to the temporal neocortex and Meyer's loop. The inferior eyelid conjunctival incision may result in an excellent cosmetic outcome.
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Affiliation(s)
- Breno Câmara
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arianna Fava
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fumihiro Matano
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Atsushi Okano
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Ronconi
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Silva Costa
- Hospital Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | | | - Francine Chassoux
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Bertrand Devaux
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Sébastien Froelich
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
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11
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Mongkolkul K, Alsavaf MB, Salem EH, VanKoevering KK, Kelly K, Hardesty DA, Prevedello DM, Carrau RL. Endoscopic Multiport Approach for Exenteration of the Infratemporal Fossa. Laryngoscope 2023; 133:1367-1374. [PMID: 36752574 DOI: 10.1002/lary.30611] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To demonstrate anatomic relationships pertinent to the endoscopic multiport approach to the infratemporal fossa (ITF). Discuss advantages and limitations of each individual approach. STUDY DESIGN Cadaveric study. METHODS Endoscopic and endoscopic-assisted endonasal transpterygoid, sublabial transmaxillary, endoscopic transorbital, and endoscopic transoral approaches to accessing the ITF were completed in five silicone-injected fresh cadaveric specimens (10 sides) with the assistance of 0, 30, and 450 rods-lens endoscopes. Image guidance was used to confirm and document the anatomical relationships encountered in each approach. RESULTS The endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure to median structures. Endoscopic-assisted sublabial transmaxillary approach enhances the field of exposure, angle of attack, and ease of instrumentation to the lateral part of the ITF. Endoscopic-assisted transorbital approach via the inferior orbital fissure provided cephalic and anterior access. Endoscopic-assisted transoral approach complements the access to lesions extending inferior to the hard palate or far lateral to the mandibular condyle. CONCLUSIONS A combination of minimal access infratemporal approaches can provide adequate exposure of the entire ITF while avoiding some of the morbidity associated with open approaches. LEVEL OF EVIDENCE NA Laryngoscope, 2023.
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Affiliation(s)
- Kittichai Mongkolkul
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Excellence Center in Otolaryngology-Head & Neck Surgery Rajavithi Hospital, Bangkok, Thailand.,Department of Otolaryngology-Head & Neck Surgery, Rangsit University College of Medicine, Bangkok, Thailand
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Eman H Salem
- Department of Otolaryngology-Head & Neck Surgery, Mansoura University Hospitals, Mansoura, Egypt
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Kathleen Kelly
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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12
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Lee WJ, Kim YH, Hong SD, Rho TH, Kim YH, Dho YS, Hong CK, Kong DS. Development of 3-dimensional printed simulation surgical training models for endoscopic endonasal and transorbital surgery. Front Oncol 2022; 12:966051. [PMID: 35992880 PMCID: PMC9389537 DOI: 10.3389/fonc.2022.966051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEndoscopic skull base surgery (ESBS) is complex, requiring methodical and unremitting surgical training. Herein, we describe the development and evaluation of a novel three-dimensional (3D) printed simulation model for ESBS. We further validate the efficacy of this model as educational support in neurosurgical training.MethodsA patient-specific 3D printed simulation model using living human imaging data was established and evaluated in a task-based hands-on dissection program. Endoscopic endonasal and transorbital procedures were simulated on the model by neurosurgeons and otorhinolaryngology surgeons of varying experience. All procedures were recorded using a high-definition camera coupled with digital video recorder system. The participants were asked to complete a post-procedure questionnaire to validate the efficacy of the model.ResultsFourteen experts and 22 trainees participated in simulations, and the 32 participants completed the post-procedure survey. The anatomical realism was scored as 4.0/5.0. The participants rated the model as helpful in hand-eye coordination training (4.7/5.0) and improving surgical skills (4.6/5.0) for ESBS. All participants believed that the model was useful as educational support for trainees (4.7 [ ± 0.5]). However, the color (3.6/5.0) and soft tissue feedback parameters (2.8/5) scored low.ConclusionThis study shows that high-resolution 3D printed skull base models for ESBS can be generated with high anatomical accuracy and acceptable haptic feedback. The simulation program of ESBS using this model may be supplemental or provide an alternative training platform to cadaveric dissection.
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Affiliation(s)
- Won-Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University School of Medicine, Seoul, South Korea
| | - Sang-Duk Hong
- Department of Otorhinolaryngology—Head & Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae-Hoon Rho
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea
| | - Young Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Doo-Sik Kong, /
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13
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Dallan I, Cristofani-Mencacci L, Fiacchini G, Turri-Zanoni M, van Furth W, de Notaris M, Picariello M, Alexandre E, Georgalas C, Bruschini L. Endoscopic-assisted transorbital surgery: Where do we stand on the scott’s parabola? personal considerations after a 10-year experience. Front Oncol 2022; 12:937818. [PMID: 35912254 PMCID: PMC9334664 DOI: 10.3389/fonc.2022.937818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their “new” trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment.
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Affiliation(s)
- Iacopo Dallan
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Lodovica Cristofani-Mencacci
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
- *Correspondence: Lodovica Cristofani-Mencacci,
| | - Giacomo Fiacchini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Mario Turri-Zanoni
- ENT Unit, Department of Biotechnology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Wouter van Furth
- Neurosurgery Unit, Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Matteo de Notaris
- Neurosurgery Operative Unit, Department of Neuroscience, “San Pio” Hospital, Benevento, Italy
| | - Miriana Picariello
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Enrico Alexandre
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | | | - Luca Bruschini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
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14
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Lee WJ, Hong SD, Woo KI, Seol HJ, Choi JW, Lee JI, Nam DH, Kong DS. Combined endoscopic endonasal and transorbital multiportal approach for complex skull base lesions involving multiple compartments. Acta Neurochir (Wien) 2022; 164:1911-1922. [PMID: 35488013 DOI: 10.1007/s00701-022-05203-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/30/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE This study defines the specific areas that connect the surgical corridors of the endoscopic endonasal (EEA) and transorbital approach (TOA) to identify adequate clinical applications and perspectives of this combined multiportal approach. METHODS Consecutive patients who underwent combined EEA and TOA procedures for various pathologies involving multiple compartments of the skull base were enrolled. RESULTS A total of eight patients (2 chondrosarcomas, 2 meningiomas, 2 schwannomas, 1 glioma, and 1 traumatic optic neuropathy) were included between August 2016 and April 2021. The cavernous sinus (CS) was targeted as the connection area of the combined approach in four patients with tumors infiltrating the middle cranial fossa (MCF) and central skull base through the CS. For two patients with MCF tumors extending into the infratemporal fossa (ITF), the horizontal portion of the greater sphenoid wing and the foramen ovale were utilized as the connection area. In the remaining 2 patients, connection was achieved through the optic canal (OC). Gross total and near total resection was achieved in 5 patients with tumors, and circumferential removal of bone composing the OC was performed in one patient with traumatic compressive optic neuropathy. Postoperative complications included one cardiac arrest due to underlying cardiovascular disease and one case of oculomotor nerve palsy. CONCLUSIONS The combined EEA and TOA procedure is a useful strategy for complex lesions involving multiple compartments of the skull base. Herein, we identified the specific areas connecting the two surgical approaches, allowing a common path for EEA and TOA procedures.
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15
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Waqar M, Chadwick A, Kersey J, Horner D, Kearney T, Karabatsou K, Gnanalingham KK, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery. Pituitary 2022; 25:267-274. [PMID: 34843070 PMCID: PMC8894148 DOI: 10.1007/s11102-021-01195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. METHODS Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. RESULTS 651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99). CONCLUSIONS Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - James Kersey
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Konstantina Karabatsou
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Kanna K Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK.
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK.
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16
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Jiang JY, Leu YS, Wang YP, Chan YK, Chen TY. A Giant Schwannoma Extending from Medial Portion of Middle Cranial Fossa to Parapharyngeal Space and Deep Parotid Space. EAR, NOSE & THROAT JOURNAL 2022:1455613221086031. [PMID: 35349782 DOI: 10.1177/01455613221086031] [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: 11/16/2022] Open
Abstract
Trigeminal schwannomas are rare tumours comprising 0.2% of all intracranial tumours and 0.5% of all head and neck tumours. Patients with trigeminal schwannomas presented with facial hypoesthesia and pain. We presented a case with left bulging oropharynx. The CT scan showed a 3.8x2.6x4.9cm left parapharyngeal tumour compressed to the oropharynx and middle cranial fossa. We performed 3 ways in two times of operation to excise the whole tumour. We chose the transoral approach for parapharyngeal space, trans-parotid approach for deep parotid part and the endoscopic endonasal trans-pterygoid approach and trans-maxillary with Canine fossa trephination for intracranial lesions. The pathology showed schwannoma. A huge schwannoma extended from intracranial to several spaces is difficult to resect just by one approach. We should separate the tumour to several parts by clinical image before the operation and design a plan to remove the whole tumour in different approach. The different space of tumour involvement had several ways to access. We needed to choose the less harm but with better surgical field.
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Affiliation(s)
- Jing-Yi Jiang
- Department of Otolaryngology-Head and Neck Surgery, 36897MacKay Memorial Hospital, Taiwan
| | - Yi-Shing Leu
- Department of Otolaryngology-Head and Neck Surgery, 36897MacKay Memorial Hospital, Taiwan
| | - Ying-Piao Wang
- Department of Otolaryngology-Head and Neck Surgery, 36897MacKay Memorial Hospital, Taiwan
- School of Medicine, MacKay Medical College, Taiwan
| | - Yun-Kai Chan
- Division of Neurosurgery, Department of Surgery, 36897MacKay Memorial Hospital, Taiwan
| | - Tung-Ying Chen
- Department of Pathology, 36897MacKay Memorial Hospital, Taiwan
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17
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Lee WJ, Hong SD, Woo KI, Seol HJ, Choi JW, Lee JI, Nam DH, Kong DS. Endoscopic endonasal and transorbital approaches to petrous apex lesions. J Neurosurg 2021; 136:431-440. [PMID: 34416715 DOI: 10.3171/2021.2.jns203867] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The petrous apex (PA) is one of the most challenging areas in skull base surgery because it is surrounded by numerous critical neurovascular structures. The authors analyzed the clinical outcomes of patients who underwent endoscopic endonasal approach (EEA) and transorbital approach (TOA) procedures for lesions involving PA to determine the perspectives and proper applications of these two approaches. METHODS The authors included patients younger than 80 years with lesions involving PA who were treated between May 2015 and December 2019 and had regular follow-up MR images available for analysis. Patients with meningioma involving petroclival regions were excluded. The authors classified PA into three regions: superior to the petrous segment of the internal carotid artery (p-ICA) (zone 1); posterior to p-ICA (zone 2); and inferior to p-ICA (zone 3). Demographic data, preoperative clinical and radiological findings, surgical outcomes, and morbidities were reviewed. RESULTS A total of 19 patients with lesions involving PA were included. Ten patients had malignant tumor (chondrosarcoma, chordoma, and osteosarcoma), and 6 had benign tumor (schwannoma, Cushing's disease, teratoma, etc.). Three patients had PA cephalocele (PAC). Thirteen patients underwent EEA, and 5 underwent TOA. Simultaneous combined EEA and TOA was performed on 1 patient. Thirteen of 16 patients (81.3%) had gross- or near-total resection. Tumors within PA were completely resected from 13 of 16 patients using a view limited to only the PA. Complete obliteration of PAC was achieved in all patients. Postoperative complications included 2 cases of CSF leak, 1 case of injury to ICA, 1 fatality due to sudden herniation of the brainstem, and 1 case of postoperative diplopia. CONCLUSIONS EEA is a versatile surgical approach for lesions involving all three zones of PA. Clival tumor spreading to PA in a medial-to-lateral direction is a good indication for EEA. TOA provided a direct surgical corridor to the superior portion of PA (zone 1). Patients with disease with cystic nature are good candidates for TOA. TOA may be a reasonable alternative surgical treatment for select pathologies involving PA.
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Affiliation(s)
| | | | - Kyung In Woo
- 3Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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18
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Konuthula N, Abuzeid WM, Humphreys IM, Bly RA, Moe K. Endoscopic Paramaxillary Approach to the Infratemporal Fossa and Pterygomaxillary Space: Computer Modeling Analysis and Clinical Series. J Neurol Surg B Skull Base 2021; 83:e514-e520. [DOI: 10.1055/s-0041-1733919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective Several different open and endoscopic approaches for the pterygomaxillary space and infratemporal fossa have been described. Limitations to these approaches include restricted exposure of the infratemporal fossa and difficult surgical manipulation.
Study Design Consecutive clinical cases utilizing a novel approach to access lesions in the infratemporal fossa and pterygomaxillary space were reviewed. Data was collected on pathology, lesion location, and surgical approach(es) performed. Computer modeling was performed to analyze the full extent of surgical access provided by the paramaxillary approach to the range of target locations.
Results Ten consecutive cases met inclusion criteria. Surgical access to the target lesion was achieved in all cases. Computer modeling of the approach derived the anatomical boundaries of the paramaxillary approach. Wide access to the posterior maxilla, and lateral or medial to the mandibular condyle allows for variability in endoscopic angles and access to more medial pterygomaxillary space lesions. The lateral extent is limited proximally only by the extent of cheek/soft tissue retraction and by the zygomatic arch more superiorly. The superior limit of dissection is at the temporal line.
Conclusion The endoscopic paramaxillary approach is a transoral minimally disruptive approach to the ITF and PS that provides excellent surgical exposure for resection of lesions involving these areas. Compared with previously described endoscopic approaches, there are no external incisions; tumor manipulation is straightforward without angled endoscopy, and all areas of the infratemporal fossa and pterygomaxillary space can be accessed.
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Affiliation(s)
- Neeraja Konuthula
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, United States
| | - Waleed M. Abuzeid
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, United States
| | - Ian M. Humphreys
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, United States
| | - Randall A. Bly
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, United States
- Division of Pediatric Otolaryngology–Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, United States
| | - Kris Moe
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington, United States
- Otolaryngology–Head & Neck Surgery, Harborview Medical Center, Seattle, Washington, United States
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19
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Dallan I, Cristofani-Mencacci L, Fiacchini G, Caniglia M, Sellari-Franceschini S, Berrettini S. When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base. ACTA ACUST UNITED AC 2021; 41:S59-S66. [PMID: 34060521 PMCID: PMC8172113 DOI: 10.14639/0392-100x-suppl.1-41-2021-06] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/16/2021] [Indexed: 11/29/2022]
Abstract
The transorbital approaches are a group of surgical procedures performed passing through the orbital spaces and aimed to reach deeper areas. This kind of surgery has been proved to be safe and effective in the management of selected lesions of the anterior, middle and infratemporal fossa. The aim of the present study is to perform a review of the literature, in order to draw the reader’s attention on the main features of this kind of surgery, focusing on the anatomical background and the surgical setting; we will also summary the current indications and contraindications to this approach and find out the related complications and the possible alternatives. Even if we consider the transorbital approach as a promising route to the skull base, we underline that there is no better approach over another and the choice must always consider several elements. Furthermore, as for every skull base procedure, a multidisciplinary management is strongly advisable.
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Affiliation(s)
- Iacopo Dallan
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Lodovica Cristofani-Mencacci
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Giacomo Fiacchini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | | | - Stefano Sellari-Franceschini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Stefano Berrettini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
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20
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Lazar A, Brookes C. Case Report: Temporal Bone Lesion Extending Into Infratemporal Fossa. J Oral Maxillofac Surg 2020; 78:e17-e20. [PMID: 32229022 DOI: 10.1016/j.joms.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/24/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Ashley Lazar
- Resident (Postgraduate Year 1), Division of Oral and Maxillofacial Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Carolyn Brookes
- Assistant Professor, Chief, and Residency Program Director, Division of Oral and Maxillofacial Surgery, Medical College of Wisconsin, Milwaukee, WI.
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