J Neurol Surg B Skull Base 2023; 84(01): 079-088
DOI: 10.1055/a-1723-1675
Original Article

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit

Laura Salgado-Lopez
1   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
2   Department of Neuroscience and Experimental Therapeutics, Northeast Skull Base Dissection Laboratory, Albany Medical Center, Albany, New York, United States
,
Luciano C. P. C. Leonel 
1   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
2   Department of Neuroscience and Experimental Therapeutics, Northeast Skull Base Dissection Laboratory, Albany Medical Center, Albany, New York, United States
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
4   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Michael O'brien
1   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
2   Department of Neuroscience and Experimental Therapeutics, Northeast Skull Base Dissection Laboratory, Albany Medical Center, Albany, New York, United States
,
Adedamola Adepoju
1   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
,
Christopher S. Graffeo
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
,
Lucas P. Carlstrom 
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
,
Michael J. Link
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
4   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
5   Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, United States
,
Carlos D. Pinheiro-Neto
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
4   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
5   Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, United States
,
Maria Peris-Celda
1   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
2   Department of Neuroscience and Experimental Therapeutics, Northeast Skull Base Dissection Laboratory, Albany Medical Center, Albany, New York, United States
3   Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
4   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
5   Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, United States
› Author Affiliations
Funding The laboratory received support from a NREF grant awarded to M.P.-C., laboratory grants from Medtronic and Storz.
› Further Information
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Abstract

Introduction Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking.

Methods Six sides of three formalin-fixed, color latex–injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed.

Results EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor.

Conclusion EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Keywords

antrostomy - education - lamina papyracea - medial maxillectomy - orbital floor - transethmoidal sphenoidotomy - uncinectomy

Note

The manuscript has been presented as a poster presentation at the North American Skull Base Society Meeting, February 2021.




Publication History

Received: 03 April 2021

Accepted: 13 December 2021

Accepted Manuscript online:
16 December 2021

Article published online:
31 January 2022

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