Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2024; 85(06): 575-586
DOI: 10.1055/s-0043-1775754

Original Article

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Anterior Cranial Fossa

Edoardo Agosti

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

³Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

,

A. Yohan Alexander

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Luciano C. P. C. Leonel

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Stephen Graepel

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Carlos D. Pinheiro-Neto

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

,

Maria Peris Celda

¹Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States

²Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States

⁴Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States

› Author Affiliations

Abstract

Introduction The development of endoscopic techniques has made endoscopic endonasal approaches (EEAs) to the anterior cranial fossa (ACF) increasingly popular. Still, the steps and nuances involved in the approach may be difficult to understand for trainees. Thus, we aim to didactically describe the EEAs to the ACF in an anatomically based, step-by-step manner with supplementary clinical cases.

Methods Six cadaveric head specimens were dissected. Endoscopic endonasal Draf I, IIA, IIB, and III frontal sinusotomies, endoscopic endonasal superior ethmoidectomy, and endoscopic endonasal transcribriform and transplanum approaches were modularly performed. The specimens were photodocumented with endoscopic techniques.

Results Draf I frontal sinusotomy started with the complete removal of the anteromedial portion of the agger nasi cell, exposing the medial orbital wall, cranial base, and anterior cribriform plate. Draf II frontal sinusotomy proceeded with the removal of the floor of the frontal sinus between the lamina papyracea and the middle turbinate (IIa), and the nasal septum (IIb) until the first olfactory filaments were exposed. Draf III proceeded by creating a superior septal window just below the floor of the frontal sinus. The bone of the ACF bounded by the limbus sphenoidale posteriorly, frontal sinus anteriorly, and the medial orbital walls bilaterally was removed; the cribriform plate was removed; and the crista galli was dissected free from the dural leaflets of the falx cerebri and removed.

Conclusion We provide a step-by-step dissection describing basic surgical steps and anatomy of the EEAs to the ACF to facilitate the learning process for skull base surgery trainees.

Keywords

Keywords

step-by-step dissection - anatomical details - skull base surgery - endonasal approaches - anterior cranial fossa - transcribriform - transtuberculum-transplanum - draf frontal sinusotomies

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