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
Also available at
    Permissions and Reprints

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

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Norris JL, Cleasby GW. Endoscopic orbital surgery. Am J Ophthalmol 1981; 91 (02) 249-252
    CrossrefPubMedGoogle Scholar
  • 2 Castelnuovo P, Turri-Zanoni M, Battaglia P, Locatelli D, Dallan I. Endoscopic endonasal management of orbital pathologies. Neurosurg Clin N Am 2015; 26 (03) 463-472
    CrossrefPubMedGoogle Scholar
  • 3 Lenzi R, Bleier BS, Felisati G, Muscatello L. Purely endoscopic trans-nasal management of orbital intraconal cavernous haemangiomas: a systematic review of the literature. Eur Arch Otorhinolaryngol 2016; 273 (09) 2319-2322
    CrossrefPubMedGoogle Scholar
  • 4 McKinney KA, Snyderman CH, Carrau RL. et al. Seeing the light: endoscopic endonasal intraconal orbital tumor surgery. Otolaryngol Head Neck Surg 2010; 143 (05) 699-701
    Google Scholar
  • 5 Kasemsiri P, Carrau RL, Ditzel Filho LF. et al. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg 2014; 82 (6, suppl) S12-S21
    CrossrefPubMedGoogle Scholar
  • 6 Leonel L, Carlstrom L, Graffeo C. et al. Foundations of advanced neuroanatomy: technical guidelines for specimen preparation, dissection, and 3D-photodocumentation in a surgical anatomy laboratory. J Neurol Surg B Skull Base 2019
    PubMedGoogle Scholar
  • 7 Engle RD, Chaskes M, Wladis E, Pinheiro-Neto CD. Feasibility study for transnasal endoscopic repair of orbital floor fracture with alloplastic implant. Ann Otol Rhinol Laryngol 2016; 125 (12) 970-975
    CrossrefPubMedGoogle Scholar
  • 8 Norris JL, Stewart WB. Bimanual endoscopic orbital biopsy. An emerging technique. Ophthalmology 1985; 92 (01) 34-38
    CrossrefPubMedGoogle Scholar
  • 9 Bleier BS, Castelnuovo P, Battaglia P. et al. Endoscopic endonasal orbital cavernous hemangioma resection: global experience in techniques and outcomes. Int Forum Allergy Rhinol 2016; 6 (02) 156-161
    Google Scholar
  • 10 Melder K, Zwagerman N, Gardner PA, Wang EW. Endoscopic endonasal approach for intra- and extraconal orbital pathologies. J Neurol Surg B Skull Base 2020; 81 (04) 442-449
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Kuppersmith RB, Alford EL, Patrinely JR, Lee AG, Parke RB, Holds JB. Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy. Laryngoscope 1997; 107 (03) 311-315
    CrossrefPubMedGoogle Scholar
  • 12 Pham AM, Strong EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 2006; 14 (04) 234-241
    CrossrefPubMedGoogle Scholar
  • 13 Kasperbauer JL, Hinkley L. Endoscopic orbital decompression for Graves' ophthalmopathy. Am J Rhinol 2005; 19 (06) 603-606
    CrossrefPubMedGoogle Scholar
  • 14 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005; 19 (01) E3
    CrossrefPubMedGoogle Scholar
  • 15 Maroon JC, Kennerdell JS. Surgical approaches to the orbit. Indications and techniques. J Neurosurg 1984; 60 (06) 1226-1235
    CrossrefPubMedGoogle Scholar
  • 16 Murchison AP, Rosen MR, Evans JJ, Bilyk JR. Endoscopic approach to the orbital apex and periorbital skull base. Laryngoscope 2011; 121 (03) 463-467
    CrossrefPubMedGoogle Scholar
  • 17 Graham SM, Thomas RD, Carter KD, Nerad JA. The transcaruncular approach to the medial orbital wall. Laryngoscope 2002; 112 (06) 986-989
    CrossrefPubMedGoogle Scholar
  • 18 Rivkin MA, Turtz AR, Morgenstern KE. Transorbital endoscopic removal of posterior lateral orbital mass. Laryngoscope 2013; 123 (12) 3001-3004
    CrossrefPubMedGoogle Scholar
  • 19 Schaefer SD, Soliemanzadeh P, Della Rocca DA. et al. Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression. Laryngoscope 2003; 113 (03) 508-513
    CrossrefPubMedGoogle Scholar
  • 20 Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity following endoscopic endonasal skull base surgery. Clin Neurol Neurosurg 2015; 130: 162-167
    CrossrefPubMedGoogle Scholar
  • 21 White WA, White WL, Shapiro PE. Combined endoscopic medial and inferior orbital decompression with transcutaneous lateral orbital decompression in Graves' orbitopathy. Ophthalmology 2003; 110 (09) 1827-1832
    CrossrefPubMedGoogle Scholar
  • 22 Bejjani GK, Cockerham KP, Kennerdel JS, Maroon JC. A reappraisal of surgery for orbital tumors. Part I: extraorbital approaches. Neurosurg Focus 2001; 10 (05) E2
    CrossrefPubMedGoogle Scholar
  • 23 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 (06) 393-398
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Snyderman CH, Pant H, Carrau RL, Prevedello D, Gardner P, Kassam AB. What are the limits of endoscopic sinus surgery?: the expanded endonasal approach to the skull base. Keio J Med 2009; 58 (03) 152-160
    CrossrefPubMedGoogle Scholar
  • 25 Asal N, Bayar Muluk N, Inal M, Şahan MH, Doğan A, Arıkan OK. Carotid canal and optic canal at sphenoid sinus. Neurosurg Rev 2019; 42 (02) 519-529
    CrossrefPubMedGoogle Scholar
  • 26 Shin JH, Kim SW, Hong YK. et al. The Onodi cell: an obstacle to sellar lesions with a transsphenoidal approach. Otolaryngol Head Neck Surg 2011; 145 (06) 1040-1042
    CrossrefPubMedGoogle Scholar
  • 27 Gauba V, Saleh GM, Dua G, Agarwal S, Ell S, Vize C. Radiological classification of anterior skull base anatomy prior to performing medial orbital wall decompression. Orbit 2006; 25 (02) 93-96
    CrossrefPubMedGoogle Scholar
  • 28 Chhabra N, Healy DY, Freitag SK, Bleier BS. The nasoseptal flap for reconstruction of the medial and inferior orbit. Int Forum Allergy Rhinol 2014; 4 (09) 763-766
    Google Scholar
  • 29 Zinreich SJ, Mattox DE, Kennedy DW, Chisholm HL, Diffley DM, Rosenbaum AE. Concha bullosa: CT evaluation. J Comput Assist Tomogr 1988; 12 (05) 778-784
    CrossrefPubMedGoogle Scholar
  • 30 Cannon CR. Endoscopic management of concha bullosa. Otolaryngol Head Neck Surg 1994; 110 (04) 449-454
    CrossrefPubMedGoogle Scholar
  • 31 Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991; 101 (1 pt. 1): 56-64
    CrossrefPubMedGoogle Scholar
  • 32 Cohen NA, Antunes MB, Morgenstern KE. Prevention and management of lacrimal duct injury. Otolaryngol Clin North Am 2010; 43 (04) 781-788
    CrossrefPubMedGoogle Scholar
  • 33 Metson R, Samaha M. Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique. Laryngoscope 2002; 112 (10) 1753-1757
    CrossrefPubMedGoogle Scholar