Enuuscupie Cadaver )ssectien tor leaching Anterior Shull ase Suagery Table of Contents 1.0. Introduction 2.0 Anatomic Dissection of the Laerimal Sac” 21 Endoscopic Anatomy 2.2. Anatomic Dissection 2.0 Identification of the Sphunopatatine Artery a1 Anatomy 3.2 Anatomic Dissection 4.0 Endonasal Dissection Approach to the Sellar and Parasellar Region 4.1 Anatomy 42 Anatomic Dissection of the Sollar Region Diroet Endonasal Transsphenoidal Approach Endonasad Transelhmeidal-tranesphenoldal Approach ‘Transsphenoidal Approach to the Sellar Region (Standard Approach) 4.3 Dissection of the Parasollar Region 5.0 Endoscopic Ethmoid Dissection Using a Cenuipetal Technique 7 6.0. Endonasaf Dissection of the Pterigupataline Fossa G1 Anatamy 6.2 Anatomic Dissection 7. Dissection for Endonasal Modiat Maxillectomy 8.0 Disseetion for Endonasal Orbital and Optic Nerve Decompression Anatomy, Anatomic Dissection Orbital Decompression Decompression of the Optic Nerve. Anatomic Cndonasal Dissection of the Frontal Sinus, Anatomy Anatomic Dissection Nasotrontal Approach, Fype | Nasofrontal Apprarch, Type I Nasotrontal Approach, Type II+ IV 10.0 Anatomic Dissectinn for CSF Fistula Repai Fistula Repair of the Anterior Skull Base 11.0 Identification of the Anterior and Posterior Ethmoid Arteries — External Approach 11.4 Anatomy 11.2 Dissection 10 un we 44 16 18 19 2 26 30 at 2 43. M4 Instrument Set for Endoscopic Cadaver Dissection for Anturiur Skull Base Surgery Extracts fram the following catalogs: ENDOSCOPES AND INSTRUMENTS FOR ENT and TELEPRESENCE, IMAGING SYSTEMS, DOCUMENTATION — ILLUMINATIONFig. (Osteclogy ofthe facial skull viewed from ‘A = nasal process of the frontal bone: B = nasal bone C= trontal process of the maxilla D = lacrimal bone Fig.2 Macroscopic cadaver specimen ofthe fa cial skul (Coronal section) {A= insertion ofthe right middle turbinate B = superior margin of the right lacrimal sac posteror margin ofthe right lacrimal sac middie turbine T= inforior turbinate ‘= nasal septum Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 1.0 Introduction Detailed knowiedge of nasal and para- rasal anatomy, including the anterior and middle skull base, is a fundamental requirement for surgical treatment of pathologies involving these anatomical areas. Cadaver dissection assisted by endoscopy is a valid approach for ac: uiring a true three-dimensional mental Image rather than schematic anatomic knowledge. In this way, the trainees are able to acquire the appropriate practical skills that serve as a basis for mastering sophisticated surgical techniques. ‘The purpose of training in anatomic dis- section is to enable the participants to familiarize themselves with both the en- doscopic and macroscopic anatomic topography. The major risk surgeons are faced with during endoscopy is dis Crrientation. It must be emphasized that endoscopic techniques provide good vision of sinonasal structures, but only in two dimensions. Repeated compari- son between endoscopic and macro- scopic anatomy during dissection al- lows trainees to improve the sense of epth, to identify anatomic landmarks and sites at risk, and to avoid iatrogenic damage. The main requirement for the surgeon, therefore, is always to know the exact operative position: continual compari- son between the two views - macro- scopic and endoscopic - helps to achieve this goal Another crucial prerequisite for master- ing the most complex surgical situa- tions is knowledge of the neighboring anatomical structures of the sinonasal complex. Proficiency in craniofacial re- section techniques is indispensable for the successful treatment of pathologies inthis anatomical area. It is therefore fundamental to ac- quire knowledge of the ‘@ endoscopic anatomy of the nose and paranasal sinuses ‘e anatomy of the walls delimiting the sinonasal structures (orbit, anterior and middle skull base) ‘¢ sellar and paraseliar region Another fundamental point in endoscop- ic surgical training is to build anatomic knowledge by studying CT scans and repeatedly comparing them with endo- ‘scopic and macroscopic dissection im- ages. This comparative method makes it possible to maintain optimal surgical ori entation and, above all, to apply the skills acquired during training sessions to in-vivo surgical conditions, where CT images will be the most faithful anatom- ic guide to the ethmoid labyrinth of each patient. Consequently, optimum leaning conditions for training in endoscopic sinonasal and skull base surgery on ca- daver specimens require the trainee to be able to apply profound anatomic knowledge to CT images and to use the comparative method described above. To implement this program, the cadaver dissection laboratory must ensure avail- ablity of suitable anatomical specimens for macroscopic anatomic dissections as well as those needed for endoscopic- assisted training sessions. In addition, participants in the training courses should be provided with CT images in three different planes (coronal, axial and sagittal). To optimize training, it is also important to involve radiologists who, in this way, are made duly aware of the needs of surgeons and may improve the quality of their own professional skils.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 2.0 Anatomical Dissection of the Lacrimal Sac 2.1 Endoscopic Anatomy The lacrimal sac is located in the later- ‘al nasal wall (Fig. 1), anterior to the in. sertion of the middle turbinate. The upper margin of the sac extends above the attachment of the middle turbinate while the posterior margin is ated inferiorly (Fig. 2). From an en- doscopic point of view, the maxillary ine is an important topographical landmark for identification of the ante- rior margin of the lacrimal sac. This line forms a curvilinear prominence, that stretches between the insertion points of the middle turbinate and the Fig. 5 Coronal dacryo-CT scan ofthe nasolacrim: stom. Note the poor pneumatiza- tion of the agger nasi cell that does not bscure the lacrimal sac modialy SL= lacrimal sac AN = agger nasi TM = middle turbinate SM = maxillary snus inferior turbinate, and corresponds with the endonasal projection of the nasolacrimal duct (Fig. 3). Pneuma- tized cells of the ethmoid may develop in the anterior part of the ascending branch of the maxillary sinus. In these cases, the agger nasi cells are situat- ed between the lacrimal sac and the lateral nasal wall (Figs. 4 and §). Due to anatomic variability, the anterior margin of the uncinate process shows different points of insertion; it articu- lates with the frontal process of the maxillary sinus or with the lacrimal bone (Figs. 6 and 7) Fig. 4» Coronal CT scan of the facial bones. Note th hypodense areas of the pnoumatized ger nasi cells that medially obscure the yt lacremal sac incompletely. ‘AN = right agger nasi; SL = right lacrimal sac: TM = middie turbinate T1= inferior tuinate r/0-CT scan of the nasolacrimal system. The contrast agent accumu lates in the left nasolacrimal duct, grving the structure a hypodense appearance; the anterior margin of the uneinate process originates trom the frontal maxilary process. PFOM = frontal maxillary process; DNL = nasolacrimal duct; PU = uncinate process; TM = middle turbinate Fig. Endescopic view d-mm telescope, 0 S = nasal septum; TM = middle turbinate; [AN = agger nasi, PU = uncinate process; the lft nasal cavity Fig. 7 ‘Axial dacryo-CT scan of the nasolacrimal duct system. Right note the anterior margin fof the Uneinate process that originates from 1 lacrimal bone, L = lacrimal sac: PU = uncinate process OL = lacrimal bone; SM = maxillary sinus ‘TM = middle turbinate; S$ = spnenoic sinus BE = bulla ethmoidalsFig.8 Osteology of the facial skull ‘A= nasal bone 1B = frontal process of the maxila C= colored Plasticine introduced into the imal ducts from the lacrimal sac to the imal ostium of the Inferior meatus; T= inferior turbinate; S = nasal septum Fig. 11 ternal view; @ fiber-optic light probe is inserted into the left inferior le optic light probe I= infenor lacrimal punctum mal duct Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Fig.9 Endoscopic view of the left n mm telescope, 0 5 - nasal septum TM = middle turoinate; T MI= inferior meatus cavity, inferior turbinate The lower portion of the lacrimal sac narrows to become the origin of the rasolacrimal duct that passes through an osseous channel embedded in the lacrimal bone, the maxillary bone and the inferior turbinate (Fig. 8). The naso. lacrimal duct passes below and is lo cated about 10 mm anterior to the nat ural maxillary ostium, travelling through an osseous channel about 12 mm in length and continues below the inferior Fig. 12 Endoscopic view of the let nasal cavity (¢-mm fiberscope, direction of view 30°, 'S= nasal septum TM = middie turinate SL = transiluminated aspect, prominence of he lacrimal sac on the lateral wal of the nasal ty dorsally to the maxilary line and lateral y tothe sagittal portion of the middle turbi fale; LM = maxilary ine Fig. 10 Endoscopic view of the left nasal cavity, (4mm telescope, 30°, T= inferior turbinate MI-= inferior meatus; VH = Hasner’s valve turbinate as a membranous duct for another 5 mm before it opens out into the inferior meatus. The orifice of the uct lies at the junction between the anterior and the medial third of the rasal meatus, about 8 mm posterior of the head of the inferior turbinate. This orifice is often covered by a mucous membrane, - the so-called Hasne’s valve that prevents reflux of nasal se cretions (Figs. 9 and 10) 2.2. Anatomical Dissection Endonasal anatomical identification of the lacrimal sac is facilitated by intro- ducing a fiber optic light probe through the lower canaliculus for transillumina tion of the lateral nasal wall in the area of the lacrimal sac (Figs. 11 and 12) The area of maximum brightness does rot correspond with the anterior part of the lacrimal sac but rather with its pos teromedial portion, where the overiying cortical bone is thinner (lacrimal bone). At times, the sac is not readily visible because of the interposition of the ag: ger nasi cells On dissection, a circular-shaped mu: cosal flap of about 1 cm is removed along the maxillary line (Fig. 13)Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 13 Endoscopic aspect of the dissected left hasal cavity using a 4-mm telescope, 30 $= nasal septurr; TM = middie turbinate LM = maxillary ine: SL - medial bony wall ofthe lacrimal sac The exposed bone is resected by use of a diamond burr until the medial wall of the lacrimal sac is reached (Fig. 14), Resection of the bony wall may in- clude the anterior margin of the unci- nate process, thereby allowing for an assessment of the variable thickness of the cortical bone that covers the lacrimal sac in the anteroposterior di Fig. 15 Endoscopy nasal cavity using a 4 mm-telescope, 30° aspect of the dissected left ‘The medial wal of the lacrimal sac is per forated with a ball-tioped probe that i in serted through the lower canaliculi. TM — middle turbinate SL=leh Fig. 14 Endoscopic aspect of the dissected lett nasal cavity using a 4-mm telescope, 30 ‘The medial bony portion overiying t lacrimal sac is removed with a diamond burr S = nasal septum: TM = middle turbinate SL = medial bony wall ofthe lacrimal sac rection. If the agger nasi forms a dis- tinct bulge anteriorly, the structure needs to be resected to gain to the lacrimal sac. The lacrimal sac is incised by using a round-tipped knife, distally angled at 45°. Once the gap is inspected, the breach is enlarged with forceps distally angled at 45° (Figs. 15 and 16) or by use of a shaver. Caution: Iatrogenic lesion of the lamina papyracea Fig. 16 Endoscopic aspect (¢ mm-telescope, 20°) of the dissected left nasal cavity. Once re- moval of the medial wall ofthe lacrimal sac is complete, the lateral and dorsal walls come into view TM = mide turbinate LP = lamina papyracea SL = lacrimal sacOsteotogy ofthe facial bones with staining the arterial branches. FIT = infratempora ‘ossa, AMI = internal maxilary artery FPM ~ pterygomaxllary fissure ASP = sphenopalatine artery Fig. 18 Osteology ofthe facial skull: aspect, (4 mm-telescope, 459) ofthe lft rasal cavity withthe sphenopal men (FSP), ‘TM ~ middle turbinate; OS = sphenoid bone: OOP = orbital process of the palatine bone [BSOP = spheroidal process ofthe palatine bone Fig. 21 Endoscopic aspect ofthe left nasal cavity (4 mm- telescope, 0°. Anatomic c Saver specimen ofthe lft pterygomaxilary Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 3.0 Identification of the Sphenopalatine Artery 3.1 Anatomy ‘The ephenopalatine artery is a terminal branch of the internal maxillary artery It originates in the pterygopaiatine fos sa and reaches the nasal cavi through the sphenopalatine foramen (Fig. 17), located posterior to the rear fend of the middle turbinate. In its lower section the sphenopalatine foramen is. made up of the vertical process of the palatine bone, the cranial margin of which divides into a posterior-iocated short sphenoidal process and an ante~ riorlocated wide orbital process that fuses with the maxillary bone (Fig. 18) Fig. 19 Endoscopic aspect ofthe lft nasal cavity (4 mm-telescope, 0". Note the rounded knife angled 45" used for the mucoper incision to expose the sphenopalatine artery ‘TM ~ mide turbinate: TI = inferior turbinat: AF = fontanelle area $ = nasal septur 3.2 Anatomical Dissection Using a knife with an angulated tip, the mucosa of the conchal wall is incised under endoscopic vision (4-mm tele: scope, 0°, about 1 cm anteriorly to the rear end of the middle turbinate (Fig. 19). The flap is elevated subpe riosteally by use of a Cottle Elevator (KARL STORZ 479100) as far as the sphenopalatine foramen immediately 4 Note the completely exposed sphencid Sinus and cavernous sinus, ‘TM = middie turbinate; T= inferior turbi- nate; S = nasal septum: AMI = internal ‘maxilary artery, ASP = sphenopalatine fartery (A-At = nasopalatine artery B= postenior nasal artery The roof of the sphenopalatine fora- men is made up of the body of the sphenoid bone that rests on the two processes of the palatine bone. On reaching the nasal cavity, the spheno- palatine artery spreads forward with two branches, The medial branch is called the nasopalatine artery that pro ceeds as far as the nasal septum close to the anterior palatine canal. The later. al one is called the posterior nasal artery, which vascularizes the turbi- nates and anastomoses with the eth: moid arteries (branches of the oph- thalmic artery) Fig. 20 Endoscopic view of the left nasal cavity (4 mm-telescope, 0"). Note the exposed sphenopalatine artery (turbinal branch) and sphenopalatine nerve [ASP ~ sphenopalatine artery (urbinal be NSP = spnenopalatine nerve (turbinal branct) Arrow = bony landmark ‘Ths inferior turbinate dorsal to the rear end of the middle turbinate. Slightly in front of this fora- men, there is a small bony spine that serves as a landmark for the foramen, itself (Fig. 20). Once the terminal branches of the sphenopalatine artery come into view, they are exposed up to the insertion of the rear ends of the turbinates and as far as the upper rim of the choana (Fig. 21). lO = infraorbital nerve; AIO = infraorbital artery; AAS = upper alveolar artery ‘ACI intracavernous internal carotid fatery, partion C4; SS = sphenoid sinus; [AF = descending pharyngeal arteryEndoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 22 ‘Macroscopic aspect ofa skull proparation in sagittal section. SS = sphenoid sinus: TS = superior {urbinate; TM = middle turbinat; ‘T= inferor turoinate; © = optic chiasm: al = aderohypophysis; nl = neurohypo- hye: DS * claphragma selae; tubal torus, Fig. 23 ‘Macroscopic aspect of a skull preparation in sagittal section. ‘A= diaphragma sellae (dural membrane BB = periosteal dura (dural mambrane I) = pituitary capsule (dural membrane I); al = adenchypophysis; nl = neurohypo- physis; ons Sinus; ING ACP = posterior cerebral artery 4.0 Endonasal Dissection Approach to the Sellar and Parasellar Regions 4. Anatomy The oval-shaped hypophysis, or pitu- itary gland, has an average transverse diameter of about 15 mm, a sagittal diameter of 7-10 mm, and a vertical diameter of about 5 mm. It weighs ‘about 0.6 g and is made up essential- ly of two lobes covered with a mem- brane related to the dura mater: the adenohypophysis and the neuro- hypophysis. It is attached to the median eminence of the tuber cinereum of the hypotha- lamus through the infundibular stalk, ‘hich is inserted only in the neurohy- ophysis and lodged in the sella turci ‘ca of the sphenoid sinus, below the diaphragma selize (Fig. 22). The dia- phragma sellae Is a quadriateral lamella tautened above the sella turci- ca of the sphenoid, which extends from the posterior margin of the optic cchiasm to the upper margin of the quadrilateral amelia (Fig. 23). Itthen proceeds, on each side to make Up the upper wall of the cavernous si- nus of the dura mater. The diaphrag- ma sellae has a small central hiatus through which the infundibular stalk passes. The cavernous sinus is a multiseptat- ‘ed venous channel located laterally of the sphenoid body, interconnected by nearly circular-shaped sinuses, named Intercavernous sinuses, which are situ ated anterior and posterior to the pituitary gland (anterior, posterior and inferior sinus circularis, according to Winslow) (Fig. 24) ‘The following pass through it: the in- ‘ternal carotid artery (IGA) with its in- tracavernous branches, the abducens nerve (VI en.) and the fibers of the sympathetic nerve lining the ICA (Figs. 25 and 26). 1” ‘Macroscopic aspect of skull preparation in sagittal section $= ephenoid sinus Fig. 25 ‘Macroscopic anatomical aspect ofa skull preparation in sagittal section. Note the course o the internal carotid artery i its intracavernous portion. G1 = posterior vertical section: C2 = posterior curve; C3 = horizontal sec tion; €4 = anterior curve; CB = anterior Vertical section; SS = sphenoid sinus: EP = posterior ethmoid; NO = optic nerve Fig. 26 Osteology of the skull with staining of the arterial beanches. Note the internal catia artery and Wilis' polygon,2 The oculomotor nerve (i e.n.), the trochlear nerve (IV cn), the ophthalmic (V1) and maxillary branch (V2) of the V. Cranial nerve, on the other hand, pass through its lateral wall in a dural spit. ‘Schematic interpretation of this region will involve descriptive study of the topographic relationships with bone, vein, artery and nerve compartments Fig. 27. ‘Topographic relationships with bony structures: medially, with the sphenoid body; anteriorly with the lesser wings of the sphenoid; inferiorly, with the greater wings of the sphenoid; and posteriorly, with the apex of the petrous portion of the temporal bone. ‘The sella occupies the central part of the sphenoid body and lies between the two cavernous sinuses, The carotid channel, a bony groove where the intracavernous ICA passes, is located laterally to the sphenoid body, and medially to the foramina ovale and rotundum, and to the superior orbital fissure. The foramen rotundum is locat- ed at the junction between the greater wing and the sphenoid body. The foramina ovale and spinosum are locat- ‘ed along the posterior margin of the ‘greater wing. The foramen lacerum is located between the posterior wall of the carotid groove and the petrosal ‘apex. ‘The anterior clinoid process makes up the terminal intracranial section of the ‘optic channel. The middle clinoid process is located laterally to the tuber- culum selize and medially to the carotid groove, The posterior clinoid process is located at the superolateral margin of the dorsum sellae. At times, a bony bridge may be ob- served between the anterior and middle (or posterior) clinoid process, trans- forming the carotid groove into a carotid-clinoid foramen. In some cases, the foramen of the sphenoid canaliculus may be observed on the greater wing of the sphenoid medially to the foramen ovale. This allows passage of a vein system linking the venous sinus with the pterygoid venous plexus Relationships Of the venous plexus are as follows: Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 27 ‘Schematic ilustration of the cavernous sinus in axial section. CH = optic chiasm; ‘al = neuronypophysis a 8s wu the cavernous sinus, in relation to the ICA, has four venous spaces, medial, lateral, anteroinferior and posterosupe- rior. Every cavernous sinus communi- ‘cates anteriorly with the spheno-parie- tal sinus, the superior ophthalmic vein and the superficial Sylvian vein; laterally with the sinus accompanying the mid- die meningeal artery and posteriorly the basal sinus (on the posterior surface of the dorsum sellae). The latter is the most important connection be- tween the two sides and communicates with the upper and lower petrosal sinus- es. The cavernous sinuses are intercon- nected with the intercavernous sinuses that eross the median line of the sella Topographic relationships of the arterial plexus: exiting from the anterior fora- men lacerum the ICA enters the pos- teroinferior wall of the cavernous sinus and extends through it for about 18 mm. The intracavernous portion is divided into five segments: ‘© posterior vertical ‘© posterior curve ‘¢ horizontal ‘© anterior curve ‘© anterior vertical .denohypophysis; AGI = internal intracavernous carotid artery: phenord sinus; il = 3rd cranial nerve (oculomotor; IV = 4th cranial nerve (trochleay) ophthalmic nerve; V2 = maxilary nerve; Vi = 6° cranial nerve (abducens). ‘The main branches of the intracav- ‘ernous ICA are the meningohypophy- ‘seal artery and the artery of the lower cavernous sinus. The _meningo- hypophyseal artery originates from the inferior curve and terminates in three branches. The inferior hypophyseal artery that travels medially to the pitu- itary gland, and the dorsal meningeal artery leading to the dura of the supe- rior clivus. The artery of the inferior cavernous sinus begins at the hori- zontal segment and in most cases passes above the VI. c.n. (abducens). Anatomical relationships with nerve structures: the oculomotor nerve Ill c.n)), the trochlear nerve (IV e.n), and the first (V4) and the second (V2) branch of the trigeminal nerve (V c.n.) travel between two dural membranes (the external membrane is thicker) that form the lateral wall of the cavernous sinus. The Ill c.n. perforates the roof of the sinus laterally to the anterior cli- noid process then enters the superior orbital fissure. The IV c.n. enters the roof of the sinus posterolaterally to the lil c.n., below and medially to the free ‘edge of the cerebellar tentorium.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery V1 and V2 enter the lowest part of the lateral wall and pass obliquely upward to enter the superior orbital fissure. The VI can. enters the cavernous sinus through Dorello’s canal. This is an oste- fibrous duct between the apex of the trous portion and petrosphenoidal ligament (Gruber's ligament). Above the petrosal apex, the nerve changes direction and reaches the ICA and then tums forward to reach the superior or- bital fissure. The nerve inside Dorello's canal is firmly embedded in the endost ‘eum and is associated with the dorsal ‘meningeal artery in 80% of cases. The lateral wall of the ICA passes inside the sinus and, at times, may present several branches. 4.2 Anatomic Dissection of the Sellar Region There are two endoscopic pathways to the sphenoid and in turn to the sel lar region. The natural ostium of the Fig. 29 Endoscopic view of the left nasal cavity {4 mm-telescope, 0). Dect intranasal rans: phenoidal approach using a circular-cutting bone punch. OSS = sp) TM midi = choana, ethmoid recess tirbnate sphenoid sinus may be reached at the ssphenosthmoid recess by a direct intra nasal transsphenoidal approach or an intranasal transethmoidal-transsphen- oidal approach, Direct intranasal Transsphenoidal ‘Approach This is the preferred approach to the sellar region (Fig. 28). The straight-forward telescope is di- rected tangentially to the nasal sept: um and medially to the middie turbinate. Initially, the upper margin of the choana (Fig. 28) is identified, fo- lowed by the inferior margins of the superior (Fig. 90) and supreme turbinates (Fig. 31). The sphenoid os- tium lies superomedially and dorsally to the dorsal end of the superior turbinate or medially to the dorsal end of the supreme turbinate, if present at all Fig. 30 Endoscopic view of the left nasal cavity (4 mm-telescope, 0). Direct intranasal trans sphenoidal approach, $= nasal sepium TM = midale turbinate TS = superior tubinate 13 Fig. 28 Macroscopic aspect in axial section. The resection margins of 1 ethmoid and sphenoid sinuses are highlighted in red. Rermoval of the outlined areas creates optimum free space for the direct intranasal transpheroidal appros FO = fiber-optic light probe; TM = middle turbinate; TS = superior turbinate. SS = sphenoid sinus; S = nasal septum: [ACI = Internal cavernous carotid artery Fig. 31 Endoscopic view of the lat nas (4-mm telescope, 0". Direct intranasal transsphenoidal approach $= nasal septum SE = sphenosthmoid recess OSS = natural ostium of the sphenoid sinus TSP = supreme turbinate14 Fig. 92 ‘Macroscopic aspect of a skull preparation inaxial secton. Transethmoidel approach, The ethmoid and spheroid bone portions, righlighted in ed, are resected to provide ‘optimum apen space forthe transathmoida- transphenoidal approach. Note, how this second technique provides improved v Sual control ofthe lateral wall of tha sphe- noid sinus and, in particular, ofthe cavern us sinus region. FO = fiber optic ight probe: TM = middle turbinate: S = nasal Septum; $$ - sphenoid sinus; ACI = intern- alintracavernous carotid artery Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery pie aspect ofa skull preparation ‘section, Note the anatomic con: tomie preparation exhibits pronaunced hy pertropie degeneration of the middle turbinate, particulary in the sagittal porto with turbinate-septal contact and a right Convexly deviated nasal septum forming the hape of a fat curve. S = nasal septu TM = maddie turbinate; TI = inferior turb nate; PU = uncinate proces: Intranasal Transethmoidal-Trans- ‘sphenoidal Approach I @ direct approach to the spheno: ethmoid recess is not feasible for anatomic reasons, the transethmoidal approach must be chosen (Fig. 32) The following must be considered: a medially enlarged insertion of the mid- dle turbinate (Fig. 33), the presence of a deviated septum, or a septal crest may impede access to the spheno ethmoid recess. As a first step in the transethmoidal approach the basal lamella of the mid dle turbinate Is fenestrated. Uncinec tomy and resection of the anterior eth maid bulla are performed in relation to the medial insertion of the middle turbinate and the uncinate process. A sharp, spoon-shaped curette is used for this step in dissection, The pene- tration site of the instrument must be htly superolateral to the conver- gence point of the three portions of the middle turbinate (Figs. 34-36) The basal lamella of the middle turbinate (middle third) is totally re sected (Figs. 37 and 38) Fig. 34 Endoscopic view ofthe right nasal cavity (4 mm-telescope, 0°. 5 = nasal septum: TM1 = midcle turbinate antenor third, sagittal) {TM ~ middle turbinate (posterior thie, horizontal), TI = inferior turbinato PU uncinate process Fig. 25, Endoscopic view of the right nasal cavity (@mmtetescope, 0 Transethomoldal approact PU = uncinate process BE = ethmosd bulla TM2 = middle turbnate (ride thir, ‘TNH = midlle turbinate (anterior thira sagittal contal) Fig. 96 Endoscopic view ofthe right nasal cavity (@mm-telescope, 09. Transethmoidal approach. Note the target site where a ‘Spoon-shaped curette is used to fenestrate the basal lamella between the second and third portion of the middle turbinate, a safe site for gaining access to the posterior ethmoid PU = uncinate process; BE = ethmoid bulla ‘TM3 ~ midale turbinate (posterior third, horizontal); TM2 = middle turbinate (m third, frontal; TM = middie turbinate (anterior third, sagittal) ‘daleEndoscopic Gadaver Dissection for Teaching Anterior Skull Ba In a second step, the free margin of the superior turbinate is identified (Fig. 39). The spoon-shaped curette is used to carry dissection along the cranial face of the posterior third of the middle turbinate and to elevate the inferior margin of the superior turbi nate. The superior concha is gently medialized, taking extreme care not to fracture the basal lamella of the turbinates. Using a straight through ‘cutting RHINOFORCE* forceps (Fig. 40), the fenestration is enlarged until the exposed natural ostium of the sphe: noid sinus comes into view (Fig. 41) 10 Surgery Fig. 37 Endoscopic view of the right nasal cavity (4mm telescope, 0°). Transetnmoidal ‘approach. Resection of the middie third of the middle turbinate using a through-cutting nasal forceps with 45° upturned jaws PU = uncinate process; BE = ethvmoid bula: TMS = middle turbinate (posterior third, horizontal); TM2 = miele turbinate (mv thir, frontal): TMT = midleturbinate {anterior third, sagittal Fig. 38 Endosc ic view of the right nasal cavity (4 mmtelescope, 0°). Transethmoidal approach, Subtotal resection of the middle thir of the middle turbinate exposing the posterior ethmoid in posterior location and the superior turbinate, ‘TS = superior turbinate; EP roid; TM2 = middle turbinate frontal posterior eth- (middle third Fig. 39 Endoscopic view ofthe right nasal (4 mm-telescope, 0°). Transelhynoidal 3ppr0ach. The (roe edge of the superior turbinate is medialized by use of a sharp spoon-shaped curette to gain access to and ‘sa control ofthe sphenoethmoid recess. ‘Asmall polyp (P) can be seen that origi- nates from the olfactory ceft and projects to the sphenoethmoid recess, superior turbinate; RSE ~ spheno- sthmoid recess; TM2 = middle turbinate (riddle third, trontad; EP = posteror ethmoid Fig. 40 Endoscopic view of the right nasal cavity (4'mm-telescope, 0°). Dissection of the Superior turbinate while preserving the al lamella of the nasal turbinates 6 to the sphenoethmoia recess basal lamella ‘ain EP = posterior athmoid: LC ofthe nasal turbinates; RSE = spheno- ethmoid recess: § = nasal septum: TSP = superior turbinate Fig. 44 copie View of the right nasal cavity En (4 mm-telescope, 0"). Final aspect of the transethmoidal phass to gain access to the ssphenoid cavity with exposure of the natural BE = cthrioid bula: TM2 ~ middle turbinate (middie third, frontal; TMS = Middle turbnate iposterior thin, horizontal); RSE = spheno: sthmoid recess: OSS ~ osthum of the pheno sinusFig. 42 Endoscopic view ofthe right nasal cavity (4 mm-telescope, 0°). Note the sphenoid Sinus ostium enlarged by use of a circular cutting punch: UC = basal lamella of the turbinates; O88 = ostium of the sphenoid sinus; EP = posterior ethmoid: $ = nasal septum. Transsphenoidal Approach To The Sellar Region (Standard Approach) (Once the natural ostium of the sphe- noid sinus comes into view, the os- tium is enlarged, initially using a circu- lar-cutting STAMMBERGER punch (Fig. 42) and subsequently with a McKENTY bone punch (KARL STORZ} If the direct pathway to the sphenoid sinus ostium is obstructed by anatomic structures, access to the natural os: tium can be gained by using a diamond: Fig. 45 Endoscopic view of the sphenoid sinus (Close-up view of the posterior wal of the Ssphenoid sinus and opticocarotid recess, NO = optic nerve: RIOC - opticocarotia recess, ACI = internal carotid artery Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 43 Endoscopic view of the let nasal cavity ‘4 mm-telescope, 0°), Intranasal tanssphe: noidal approach. Once the sphenoid sinus ‘ostium is enlarged using a diamond-lipped burr the intersphenoid septum is removed. ‘S= nasal septum ‘Sedx = right spheroid hemi-sinus ‘Sex = left sphenoid homi-sinus tipped burr for resection of the sphe- noid rostrum. In this way, the entire anterior wall of the sphenoid sinus is removed to visualize the anterior mar- gin of the intersphenoid septum. The intersphenoid septum is taken down by use of an intranasal drill with a diamond-tipped burr (Fig. 43). Re- moval of the septum is completed us- ing through-cutting instruments, such as GRUNWALD forceps (Fig. 44). Endoscopic intersphenoid view (4 mm-tele- scope, 0", Saddle-shaped sphenoid sinus, ‘extensively pnoumatized with clearly visible fanatome landmarks. SIS = intersphenoi septum; ACI = internal intracavernous carotid artery (portion C1 vertical, posterior); PS = sellar oor, RIOG = opticocarotid recess. Fig. 44 Endoscopic view (¢ mm-telescope, 0”, Removal ofthe itersphenoig septum by Use ofa through-cutting nasal forceps. SIS = interspnenoid septum ‘Ssdx = right sphenoid hemi-sinus ‘Sex = left sphenoid hemi-sinus During this maneuver, it is important that any torsion or leverage on the septum be avoided to prevent fract: ures at the junction between the inter- sphenoid septum and the posterior ssphenoid wall, because at times, the septum originates from the bone por- tion that overlies the internal carotid artery or the optic nerve. Having cre- ated a single sphenoid cavity, a 45° telescope is used to identify the land- marks on the lateral walls, The upper landmark is the optic nerve, the lower one is the internal carotid artery These two prominences are separated by a groove, very pronounced at times, named the opticocarotid recess. (Fig. 45). The manifestation of this groove depends on the degree of neumatization of the anterior clinoid process and the sphenoid sinus itsett. The bony sellar floor, in median posi tion, may be very thin and, owing to the underlying sellar contents (Fig. 46) may take on a bluish tint.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 47 Endoscopic view (4 mn-telescope, 0° ACI = prominence of the right internal cavern: us carotid artery: PS — sll floor After repositioning the 0° telescope, the anterior wall of the sella is ap: proached exactly on the median line using an intranasal drill with diamond: tipped burr (Fig. 47). The opening cre- ated is widened in a circular fashion. It is recommended that the fenestration bbe large enough to extend from one ‘cavernous sinus to the other and, in a vertical direction, from the floor to the circular sinus. The opening of the sell ar floor is then widened as far as the ‘medial margin of the cavernous sinus (Fig. 48). The pituitary gland is cover- ed at this level by two dural layers: the periosteal dura externally, and the connective tissue capsule of the pitu itary gland, internally (Fig. 49). A sickle-shaped knife is used to make a cross-shaped incision in the pe- riosteal dura to expose the sellar con- tents (Fig. 50). The incision is enlarged laterally with a micro-dissector, distal ly angled at 45°, and, if necessary, with angulated micro-forceps. (Once the T-shaped dura incision (hori zontal and vertical incisions) is com: plete, the pituitary parenchyma is ex: posed. Ring-shaped curettes with an- Qulated distal ends of various sizes or basket-shaped suction cure be used to evacuate the intraseliar contents, tes may Fig. 48 Endoscopic view removal ofthe se rmm-telescope, 09. After ar flor, the fst dural mem: brane (periosteum) of the sellar cavity is ex- DPS = dura ofthe solar oor [ACL = prominence othe internal cavernous IOC = opticocarotid recess Intrasollar endoscopic navigation is the elective technique for completing evacuation of sellar contents. This in- volves using an irrigation pump to which a specially designed irrigation sheath is connected for intra-opera- tive rinsing of the distal telescope lens (KARL_STORZ CLEARVISION™ sys tem). Cleansing and evacuation of de- brs Is performed under constant im- mersion enabling determination of the various intrasellar components. The intrasellar maneuver may be per- formed using a “three-hand tech nique” once a suction tube is intro- duced through the free nostril con tralateral to the one through which the first surgeon operates. Finally, the suction tube is advanced through the sphenoid sinus ostium. In sollar surgery, this maneuver is per fomed almost in contact with the parenchyma under constant immer sion in an “operating cavity” filed with transparent fluid, which facilitates de- tection of any debris trapped in hid den spaces. The continuous flow of the irrigation liquid causes tumoral fragments to be cleansed of blood and, as a result of outflow pressure building up inside the seliar cavity, to be evacuated. Fig. 49 Endoscopic view (4 mm-telescope, sive exposure ofthe sellar cavity an ra. Note the pit the periosteal wih rs capsule [ACI = intemal intracavernous carotid arte RIOG - opticocarotd recess IPO = pituitary oland isphenoid endoscopic close-up viow (4 mm-telescope, 0°. Following removal of the bony wall ofthe sellar floor, a sickle- shaped knife is used to incise the perost feal membrane and the capsule of the pit itary dura, ACI = internal cavernous carotid anery DIPO = tissue capsule overtying the pit This technique meets the require- ments of minimally invasive surgery and provides ergonomic working con- ditions, even in critical situations when complications related to limited space for handling the instruments arise from tumoral bleeding, size or consis- tency of the tumor.18 Fig. 81 Infrasellar endoscopic view (4 mm-tle scope, 0°) Note the pituitary gland in the Center Centrally, the Glaphragma seliae (OS) cranial, the optic chiasma (Ch) and the in fundibular stak (I). Laterally, the lower hypophyseal artery (All) and the internat intracavernous carotid artery (ACI) Fig. 54 Endoscopic dissection of the cavernous si rus (4-mm telescope, 0°). Removal of the Posterior and lateral walls of the sphencid Sinus and the periosteal dura results in ‘mediolateral exposure of the pituitary gland APO), the inferior hypophyseal artery (Al. the internal carotid artery inthe entire ca vernous section and, laterally to this, the = this cranial nerve (oculomotey IV= fourth cranial nerve (trochiear Vi = sixth cranial nerve (abducens) (e2 = posterior curve, internal intracay fernous carotid artery 163 = horizontal section: (04 = anterior curver (05 = vertical anterior se Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 52 Intrasphenoid endoscopic close-up view. Note the extensively resected sella oor ‘and the bony wall veriying the cavernous Sinus. The intemal intracavernous carctis artery and pituitary gland are clearly ex posed, Partial removal of the parietal dura, ‘Semonstrating the lateral topographic rela tionships ofthe internal cavernous carotid| and the pituitary gland. IPO = pitutary gland; ACI = internal intra cavernous carotid artery; C3 = horizontal section of the intracavernous ACI: G4 = an terior curve of the intracavernous ACI; 5 = vertical anterior section ofthe intra cavernous ACI: GLI = elvus During dissection, it is preferable to leave the pituitary gland in situ in order to study the topographic relationships to neighboring structures (Fig. 51), Laterally, the cavernous sinus and its contents; medially and below, the infe ior hypophyseal arteries; posteriorly the clivus; and superiorly, the infun- dibular stalk and its vascularization (superior hypophyseal arteries) and the diaphragma sellae. Caution: latrogenic lesion of the optic nerve, lesion of the internal carotid artery, ural lesion and lesion of the VI. c.n. 4.3 Dissection Of The Parasellar Region Following fenestration of the sellar floor, dissection of the posterolateral bony wall of the sphenoid sinus is continued, starting from the bony prominence of the internal carotid artery (ICA) in its in- tracavernous segment, upward to the optic nerve, which travels in its channel in a cranial direction. (Fig. 52). Access. Fig. 83 Endoscopic view of itrasphenoid dissection [4 mmetelescope, 0). Following complete re ‘moval ofthe posterior wal of the sphenoid Shus, the intereavernous sinuses and the Cavernous sinus enclosing the cavity around the sella are exposed and marked by intra \asal staining. At the top, nate the optic nefve and the optic chiasma, below, the ACI ‘and the cranial Gura mater. INO = optic nerve: SC = cavernous snus; SIC = intracavernous sinus; CH = optic ‘chiasma: AGI = internal inracavernous Carotid artery to the cavemous sinus is accomplished by removal of the bony wall of the opticocarotid recess with a diamond- tipped burr and subsequent dissection of the periosteal dura, If the dura mater remains intact and on- ly the bony component is removed, the venous plexus through which the two cavernous sinuses communicate be- comes translucent and may be visual ized after injection of colored sub- stances into the respective ‘compartment (Fig. 53). Once the peri steal dural layer is removed, the intern. al carotid artery may be visualized throughout its intracavernous course. The bone underlying the pituitary gland is the upper portion of the clivus. Later: ally to the vertical segment of the inter ral carotid artery, the abducens nerve ccan be identified at its insertion into the cavernous sinus; medially to this, the sympathetic plexus of the ICA comes into view. The meningohypophyseal artery originates medially from the intra- cavernous segment of the ICA that ram- fies to form the lower hypophyseal ar- teries (Fig. 54)Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 55. Endoscopic close-up view (4 mm-telescope, 0* after dissection of the clus, AB = basilar artry, I= thre pal carotid artery, posterior vert cal section (G1); ACP = posterior cerebral tary; ACOP = posterior communicating artery, ACES = superior cerebellar artery P= pituitary infuneibulum, (On continuing dissection, the course of the Ill and IV oculomotor nerves con- tained in the dural duplication of the lateral wall of the cavernous sinus and, less readily, the nerve branches that f rally make up the Il and Il division of the V cranial nerve can be observed, (Once abrasion of the elival bone and the orifice of the cranial dura mater is complete, the basilar artery, the poste rior cerebral arteries and the superior cerebellar artery can be seen, Laterally to the pituitary gland and medially to the ICA, the posterior communicating arteries can be visualized (Fig. 5), while dorsally to the C1 section of the intracavernous ICA the dural ring formed by Dorello's channel and the in: sertion of the VI cranial nerve into the cavernous sinus come into view. Upon removal of the bony wall, be- tween the two optic nerves and the sellar contents, the dura of the planum sphenoidale is seen, which continues to form the roof of the sella. Resection of the latter structure exposes the in- fundibular stalk and the superior hy- pophyseal arteries, the optic chiasma and the origin of the ophthalmic artery from the internal carotid artery, the an- terior cerebral artery and the anterior communicating artery (Figs. 56 and 57). AGA = anterior c ‘Af = anterior corobral {2 = anterior cerebral ar ing artery ry (rst section Y [second saction) 5.0 Ethmoid Endosco| Fig. 57 Endoscopic dissection (¢ mm-telescope, 0°, Detal of tne paraselar region. ‘optic nerve; AO - ophtnalmic artery 1PO = pituitary gland; ACI = internal intra cavernous carotid artery. anterior curve ( and anterior vertical section (c5}; Ill = thre ‘ania nerve (eculomaton: IV = fourth cran ial nerve (tochiear; Vi = sixth cranial nerve (abducens) Dissection Using The Centripetal Technique Ethmoid dissection by use of the cen- tripetal technique aims at en-biock re- section of mucosal and bony contents (ethmoid cells and bony turbinates), elevation of a muco-periosteal flap Gescribing a semicircle that cavers the lateral nasal wall (from the maxillary line to the orbital apex), the ethmoid roof, the olfactory cleft and the cranial Portion of the nasal septum. The dis- section margins at the end of this step are defined as follows: laterally, the lamina papyracea; posteriorly, the an- terior wall of the sphenoid sinus; cra- nially, the ethmoid roof and the olfac- tory cleft, and medially, the nasal sept- um. Dissection may also involve re ‘moval of the anterior wall of the sphe: noid and elevation of the mucoperiost- ‘eum of the sphenoid cavity. The bony walls should be totally denuded of the overlying mucoperiosteum via centr petal technique, At this point, dissection provides two Options. The first includes the removal of the entire ethmoid contents, as al ready described, with the medial mar- gin involving resection of the basal lamella of the nasal turbinates. The second option extends the technique to the removal of the olfactory cleft and the upper third of the nasal sept- um, and dorsally to the nasopharynx.20 Endoscopic Cadaver Dissection Base Surgery Teaching Anterior : Fig. 68 Fig. 59 ioscopic view of the i Endoscopic view of the right nie view of the right nasal cavity ‘mim-telescope, 0), Ar mm-telescope, 0}. The ines escope, 0"). The mucoperiosteal i Used to cary the mucoperiosteal incision further and elevation ofthe mucoperiost D's elevated from the lateral nasal wall downwara beginning atthe level of the tap begins. axilary line: LMP = mucoperiost manila PU process; TM = middle p: PU = uncinate process; BE = ethmoid S = nasal septum; TM = middie turbinate; _turbinate; BE ~ ethrnoid bul $ bulla; TM1 = sagittal portion of the mille UM = maxilar line septum. urbinate; TM3 = horizontal portion of ‘middle turbinate; S = nasal septum The following applies to the dissecting its anterior margin (Fig. 60) advanced technique: The technique proceeds by identifying subperiosteal layer at the level of ateral wall of the ethmoid infundibulun ymina papyracea) (Fig. 61) and elevat g the flap anteroposteriory in the sub- periosteal incision is made at the periosteal plane as far as the apex of maxillary level with the round-tipped — the orbit (Fig. 62). During this maneu knife (Figs. 58 and 9). An olovator is remove the bony ethmoid septa that used for the mucoperiosteal flap and originate from the lamina papy: the uncinate process is medialized after til skeletonization is complete, Dissection commen der endo: scopic vision using the straight-forward 1m diameter, 0°). The mu: Fig, 62 nasal cavity Endo of the left nasal cavity 5 ofthe left nasal cavit scope, 09. Note the prominence (4 mm-telescope, 0). ‘or nasal artery, a branch of the ASP-RS - sphenopalatine artery, septal ‘artery (ASP) and the branch (nacopaiating), TM = midi na turbinate: AFD = descending pharyngeal artery; ASP-RT ~ sphenopalatine aren turbinal branch No ap is elevated from the lamina papyracea. of the LP — lamina papayracea: LMP = muco Sphenopal renee of the sphenopalati the arrow indicates to the borEndoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 64 Endoscopic closo-up view ofthe rg cavity (4 mm-telescope, 09. Note th ough-eutting instrument used to ‘lamina papyracea fragment. PO = peror bita; LP = lamina papyracea; AEA = anter ethmad artery Ventrally to the rear of the middle turbinate, the sphenopalatine foramen 's identified by the artery of the same name that ramifies into two main branches (Fig. 63). The artery is dis- sected with straight forceps and sub- periosteal elevation proceeds as far as the upper margin of the choana. A dis: on modification may be the re- moval of the lamina papyracea, care- fully preserving the periorbit that deter- mines the level of elevation (Fig. 64). In ‘another modification, dissection may extend to the olfactory cleft, to the me- dian septal portion and to the roof of the nasopharynx. These anatomic structures are always dissected subpe- rigsteally. The preliminary horseshoe: shaped incision, which commences anteriorly, 's carried toward the other incision of the maxillary line, thereby passing dorsally to the upper nasal spine and reaching the corresponding septal portion (Figs. 65 and 66). Cranially, the flap is elevated in an an- teroposterior direction, gradually ex- posing the olfactory filaments by dis- section. In the course of this step, the basal lamella of the turbinates (Fig. 67) is incised as far as the upper rim of the natural sphenoid sinus ostium.The mu: coperiosteal flap is then elevated Fig. 65 Endoscopic view of the right nasal (@ mmtelescope, 0°. Upper starting Of the horse-shoo-shaped incision vation of the mucopenastea! flap, LM maxilary ine: SNS = superior nasal 'S = nasal septum; TM = middie lose-up view of the ight nasal telescope, O°) showing the ipper portion of the elevated mucoperiost al lap with the ethrnoid roof and the olfac- tory cleft. Using the scissors to dissect the cavity (4 me basal lamella of the turbinates in a ven trodersal direction (LC) LP = lamina papyracea, AEA = anterior ethmoid artery; FO = olfactory cet fio = olfactory filaments: § = nasal septurr downward from the ethmoid roof Fig. 68). Endoscopic dissection (4 mm-telescope, 45°) of the mucosa of the ethmoid roof is completed with a 45° upturned Strimpel-Voss forceps or 30° upturned Blakesley-Weil forceps. Fig, 66 Endoscopic view of the right nasal cavity (4 mntelescope, 0°). Completion ofthe ‘shoe-shaped incision for elevation of periosteal flap. 11 o'clock positon: note the frontal sinusotomy type Il (Oral type Mb drainage) 'S = nasal Septum; TM = mice turbinate: PU = uncinale process; BE = ethmoid bulla ‘SF = frontal sinus. Fig. 68. Endoscopic view of the right nasal cavity 4 mm-tolescope, 45°). The mucoperiosteal flap is elevated from the ethmod root LP = lamina papyracea; OSF = frontal sinus ostium; AEA = anterior ethmois LMP = mucoperiostea! flapFig. 69 Endoscopic view ofthe right nasal cavity (4 mm-telescope, 0°). Note the longitudinal mucoperiesteal incision in the nasal sept Um extending as far as the choanal rim. 5 = nasal septum; LMP = mucoperiostea flap; €O = choana Fig. 72 ‘Osteology ofthe facial bones. Endoscor View (4 mm-tolescope, 0"). Lateral view of the left pterygopalatine fossa (FOPP). FSP = sphenopaiatine foramen FOI = inferior orbital fissure Ma = maxilary prominence PP = pterygoid process Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Endoscopic view of the right nasal cavity (4 mm-toiesc ‘same mucopeti- ‘steal incision at the ievel ofthe lator fasal wall runs from the posterior fontan- tlle area to the nasopharynx, thereby, passing over the tubal prominence (TT) TTT = torus tubarus; TM = docsal end of the middle turbinate; TV = inferior turbi nate: RSE = sphenoethmod recess; S—nasal septum At the septum level, a longitudinal in- cision is carried as far as the dorsal rim of the vomer (Fig. 69). Continue the incision in the nasopharyngeal roof as far as the posterior wall of the nasopharynx where it joins a similar controlateral incision. This incision ex- lends the mucoperiosteal elevation to the fontanelle area and, keeping to the supraturbinal level, reaches the posterior walls of the nasopharynx (Fig. 70). All tissues dissected in this way are shifted en-biock toward the central portion of the nasal cavity (centripetal technique) and then, passing beyond the choana, directed towards the nasopharynx from where they are extracted transorally. In this way, the entire contents of the upper two thirds of the nasal cavity that are firmly connected to the roof of the na- sopharynx are removed transorally in the subperiosteal plane while preserv ing the mucosa of the inferior septum, the nasal floor, the inferior turbinate and the Eustachian tube (Fig. 71). Fig. 71 Endoscopic view of the right nasal cavity (4 mm-telescope, 0%). Final aspect of the mucoperiosteal flap after en-block removal Of the contents of the ethmoid coll. Note, how the procedure has arrived at the post erior wall ofthe nasopharynx, preserving the tubal prominence (T7), the inferior turbinate (TP) and the lovier haf of the nasal septum (8) 6.0 Endonasal Dissection of the Pterygopalatine Fossa 6.1 Anatomy The plerygopalatine fossa is a pyra~ mid-shaped cavity with a superior floor, open laterally toward the in: fratemporal fossa, which communi cates with the nasal cavity through the sphenopalatine foramen and with the orbit through the inferior orbital fis: sure. In its lower fourths, the anten- or wall is made up by the maxillary prominence and in the superior fifth by the orbital process of the palatine bone. The upper wall corresponds with the cranial plane of the greater wing of the sphenoid and the anterior sphenoid sinus wall The medial wall of the pterygopalatine fossa (Fig. 72) comprises the vertical lamella of the palatine bone, articulat ed forward with the maxillary bone and. backwards with the pterygoid process. At the top, the lamella that separates the pterygopalatine fossa from the corresponding nasal cavity divides into two lamellar processes with anterior (or orbital) and posterior (or sphenoid) locations.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base S. Fig. 74 logy of the facial bones. Intranasal _ Endoscopic dissection of the left nasal ‘ew of the left nasal cavity avity telescope, 0"). Note th mm-tolescope, 45°) Ch sphenopalatine foramen with the promi the sphenopalatine nenees of the sphenopalatine artery (ASP) sphenoidale, poOP and the posterior nasal nerve (NP) Palatine bone; psOP = sphenoid G = choana; TM = middle turbinate Palatine bone: FO fiber optic ight fiber’ SM - manilary sinus, protruding from the anterior lacerated foramer The first process is the most volumin. ous and litle pneumatized; it f with the maxillary bone to form the su- peromedial aspect of the maxillary antrum and is also joined to the eth: moid and the sphenoid sinuses; the second process is smaller and thinner, and forms the pterygopalatine canal together with the pterygoid canal. The sphenopalatine artery and the posteri- or nasal nerves travel through the ‘sphenopalatine foramen in the corres- ponding nasal cavity (Figs. 73 and 74) Fig. 75a and b 75a Endoscopic aspect of the left nasal avity 4 ‘domo sirating the ilar artery inthe infraterp and sphenopalatine cavity after ‘oval of the posterior maxilary sin wall and evacuation ofthe int zontal section above the pterygod (MP), APS = superior poste- The maxillary artery, which travels Fig. 76 Ter siachet atten SD = name he ay ater travels Eetook aepect ofthe right nasal cavty nares GBP = aptenopaa neve along the anterior margin of the lateral (4'mm telescope, 0°). The image shows Genter; APD = descending palatine fossa (Fig. 76a) roaches the ptery- (AMI wih is terminal branches AiO” ntact erry gepalatine fossa through the ptengo- Stary "APD.s Gesconcoy pane atery; avy (mm escape demon maxillary fissure. This artery follows a NPD = descending palalite nerve. trating the course of the spheno- twisted and variable path but is al palin artery inthe ptorygomaxilan ways in the anterior position to the =e ao - ‘Sa ree nerves inside the fossa. The maxillary Cua antry initially follows a vertical course, 6 choana:§ = nasal septum then turns medially, crossing the fossa FS = septal branch rascpaatine horizontally, and forms the major ter is urbinel branch poster sal minal branch of the sphenopaiatine tery ofthe sprenopalaine arte anery Fig. 75) and the descending ASP = Spheropalaire artery AMI = internal manilary artery APD = descending palatine arery NiO = intraorbital ner TM = mice turbinate palatine arteries (Fig, 76).24 Fig. 7 Endoscopic aspect of the right nasal cavity (4 mm-telescope, 0°) NiO = infraoroltal nerve; AMI = internal maxillary artery; AIO = infraorbstal artery ASD = sphnencalatine artery ‘APD = descending palatine artery [AAPS = posterosuperior alveolar artery, Fig. 78 Endoscopic aspect ofthe right nasal cavity (4 mm-telescope, 09, NiO’ The maxillary nerve, the second ramification of the trigemin- «al nerve, reaches the pterygopalatine fossa through the fora- men rotundum and emerges through the inferior orbital fis- sure. Running on an S-shaped course, it reaches the infra: orbital channel. Reaching the pterygopalatine fossa it gives off four collateral branches: the middle meningeal, the post- erior alveolar, the zigomatic and the sphenopalatine nerves. ‘The nerve of the pterygoid canal (or Vidian nerve) is made up of preganglionic parasympathetic fibers that originate from the superior salivatory nucleus (of CN Vil), described by Yagita, located at the pons Varolii of the brainstem. These fibers reach the geniculate ganglion through the facial nerve and join the greater superficial petrosal nerve. This nerve in- cludes post-ganglionic orthosympathetic fibers arising from the upper cervical ganglion and a somatic sensitive bundle of nerves originating from the geniculate ganglion, At the anterior foramen lacerum, before entering the ptery- Qoid canal, the greater superficial petrosal nerve joins the deep petrosal nerve to form the Vidian nerve. (Fig. 79) ifraorbial nerve: AAPS = postero- Superior alveolar artery; AIO = iafraoroital Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery On entering the pterygomaxillary fis sure, the sphenopalatine artery gives off two collaterals, the posterosuperior alveolar branch (Fig. 77) that has small dimensions, and the infraorbital branch, which travels with the infraor- bital nerve in the foramen of the same name (Fig. 78) Because the sphenopalatine artery is located superior and medial to the fossa of the same name it may be masked at times by the orbital apo- physis of the palatine. On reaching the nasal cavity posteriorly to the rear end of the middle turbinate, the spheno- palatine artery gives off two branches; ‘one medial called the nasopalatine artery travels to the septum, and the other lateral, named the posterior nasal artery, reaches the dorsal end of the turbinates. The lateral wall is made Up of the pterygomaxillary fissure that connects the infra-temporal and the pterygopalatine fossae. Fig. 79 ‘Schematic depiction of the nerve of the pterygoid canal (or Vidian 1erve). Red: orthosympathetic nuclei and fibers; blue: parasym- pathetic fibers; NPP = deep petrosal nerve; NGPS = greater su- Perficial petrosal nerve; NV = Vidian nerve; GSP = sphenopalatine ‘ganglion; NY = Yagita ganglion; GSG = cervical superior ganglionEndoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Endoscopic aspect of the right nasal cavi- ty (6 mm-telescope, 07) NO = infraorbital nerve: AFD = descend: ing pharyngeal artery; ASP = sphenopala- tine artery; AV = artery ofthe nerve of Dlerygosd canal; AMI — intemal maxilary atery; GSP = sphenopalatine ganglion: ANPA = nasopaiatine artery The sphenopalatine or Meckel’s gan- glion (Fig. 80) is a distribution center for ortho/parasympathetic bundles, aniving through the Vidian nerve and through sensitive somatic fibers origin ating at the maxillary nerve. Overlying the opening of the pterygoid canal, it takes on an oblong or lenticular shape, grey-reddish color, and is about 2 mm in diameter. It receives two afferent branches, the Vidian nerve and the sphenopalatine nerve, and gives rise to five efferent branches respectively: orbital, posterior superior nasal, nasopalatine, pterygopalatine and descending palatine nerves. 6.2 Anatomic Dissection Access to the pterygopalatine fossa is accomplished by complete resection of the fontanelles. Dissection begins with partial uncinectomy to expose the natural ostium of the maxillary sinus. The ostium is then enlarged dorsally, proceeding with removal of the fontanelle area. This eventually provides complete exposure of the posterior wall of the maxillary sinus, which is the first anatomic landmark. Dissecting the periosteum of the Fig. 81 Endoscopic aspect of the right nasal cavity nm-telescope, 0°) demonstrating the 18@ of a blunt hook to remove the posterior wall of the maxillary sinus, PSM = posterior wal, maxillary sinus ‘APD = descending palatine art [ASP = sphenopalatine artery [AFD = descending pharyngeal artery ANP = posterior nasal artery. residual fontanelle area inferiorly and ventrally to the rear of the middie turbinate enables identification of the second landmark, which is the turbinal branch of the sphenopalatine artery. In the next stage, the posterior wall of the maxillary sinus is removed with a sharp spoon-shaped curette or a Citelli punch, first with straight, and then with angled jaws The bony resection margins are: medially, the perpendicular plate of the palatine bone and, laterally, the angle between the posterior and later al walls of the maxillary sinus (Fig. 81) The orbital process of the palatine ‘bone is then removed, thus transform: ing the sphenopalatine foramen into a groove and allowing the common trunk of the sphenopalatine artery and its septal branch to come into view. ‘An incision is made in the fascia covering the pterygomaxillary fissure and the fatty contents inside the fis sure are removed (Fig. 82). The maxil- lary artery is the first vessel to be iden- tified and exposed, lying on a superfic- lal plane, Fig, 82 Endoscopic aspect of the eft nasal (0), Foreground: nasal forceps evacuating the fatty content of the (4 mm-telescoy pterygomanillay fissure. AM AF = descer sphenopalatine artery posterior nasal artery: choana; AIO = infraorbital artery infraorbital nerve AAPS = posterosuperior al internal maxillary artery: ing pharyngeal artery olar artery. ity26 Fig. 63 Endoscopic aspect of the right nasal cavi ty (4 mm-telescope, 0°). Incision of the ‘idle third ofthe inferior turbinate con- tinuing the incision of the maxillary li While retaining integnty of the head of the T1= infercor turbinate: S = nasal septum. Fig. 86 Endoscopic aspect of the ight nasal cavity (4 mm-telescope, 0°). A diamond-tioped burr is used to remove the Bony floor of the medial wall of the maxillary sinus. PN = nasal floor; TI = inferior turbinate: PMSM = medial wall of the maxillary sinus, Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 84 Endoscopic aspect of the right nasal cavity (4 mm-telescope, 0°. The incision is made dorsally to the head of the inferior turbinate Ti= inferior turbinate: $ = nat {TI = head of inferior turbinate 5 sept 7.0 Endonasal Dissection Medial Maxillectomy This stage of dissection first involves identification of the lateral nasal wall Then, the latter structure or, better, the medial wall of the maxillary sinus is re- sected by en bloc-technique. To com: plete removal of the lateral nasal wall the procedure may be combined with the centripetal technique. There are three modifications of the procedure, each providing a better control of the dissection, either via the lateral wall of the maxillary sinus (type I) or its ante- rior wall (type Type | dissection involves removal of the medial wall of the maxillary sinus while preserving the integrity of the anterior third of the inferior turbinate and the nasolacrimal duct. This type of dissection provides good contro! of the posterior and upper walls (incom- plete in the anterior portion) of the maxillary sinus. ‘A mucosal incision is made under en: doscopic vision (4 mm-telescope, 0°) using a round knife with a 45° angled tip at the floor of the inferior meatus. The exact site of the incision corre- sponds with the protruding posterior Fig. 85 Endoscopic aspect ofthe right nasal cavity (4: mm-telescope, 0°). A lengthy mucosal Incision is made at the tloor of the inferior meatus; the mucoperiosteal flap is elevat ed at the level of the maxillary sinus. MI — inferior meatus; TH~ intenor turbinate; PMSM ~ medial maxillary sinus wall; PN = nasal floor margin of the Hasner valve, located about 1.3 cm dorsally to the head of the turbinate. The mucosal incision is carried to the lateral wall, posteriorly to the Hasner valve and the endo: meatal face of the inferior turbinate. At the lower margin of the inferior turbinate, the knife is reversed and moved upward along its medial line to reach (cranially) the anterior margin of the uncinate process or, more anteri- rly, the protrusion of the nasolacrimal uct (maxillary ine) (Fig. 83). A suber steal flap is created above the inferi- or turbinate and an uncinectomy is performed, thus enabling the natural maxillary sinus ostium and the eth- moid infundibulum to be identified. The inferior turbinate is dissected at the site of the previously made inci sion using turbinate forceps with con- vex blades curved into the nasal cavi ty (Fig. 84). At the floor of the inferior meatus (Fig. 85), the mucosal incision is carried as far as its dorsal margin. The bony base of the medial maxillary sinus wall is dissected using a straight ‘osteotome (width of the tip, 2-3 mm) or the long intranasal drill (Figs. 86ndoscopic Cadaver Dissection for Teachi Fig. 87 Endoscopic aspect of the rg applied to the med PMSM = medial wal, m PN = nasal floor; SM = maxilry sinus MSM = medial wall ofthe maxillary sinus SM = maxillary sinus T= inferior turbinate and 87). Ventrally to the perpendicular plate of the palatine bone, the de scending palatine branch of the sphenopalatine artery can be identi fied and dissected. After this maneuver, the medial wall of the maxillary sinus is medialized Fig. 88), including the fontanell followed by dissection of the mucope- riosteun of the maxillary sinus, Com monty, elevation of the mucope steal flap is initiated at the lateral wall, the roof and floor of the maxillary sinus. Dissection of the posterior por tion of the maxillary sinus normally does not pose any problems (Figs. 89 and 90); however, it is not feasible to extend anteriorly into the cavity itself E sen, SUS: PLM = lateral wal, maxilary sinus Once this step of dissection is com- Sus, PLSM = lateral wal, maxilary si plete, the maxillary mucoperiosteal NiO = infraorbital nerve flap is medialized (Fig. 91) in that it is transferred into the nasal cavity to gether with the previously medialized medial wall of the maxillary cavity. sinus; PPSM 9 Anterior Skull Base Surgery Fig. 88 yy Endoscoy The intranasal ils ty ope, O°). Note the 8 cted portion of Fig. 90 doscopic aspect of the right nasal cavity mm-telescope, 45°) LMPSM = mucoperosteal fap, maxillary posterior wall, maxillary pect of the right nasal cavi PSSM PPSM periosteal flap proved to be the ideal ap- proach for the posterior wall, howe Option is limited to the posterior third of the Superior wall only, and may a'so be applied PPSM = posterior wal, maxillay sinus PSSM = superior wail, maxillary sinus PLSM = lateral wall, maxillary sinus Fig. 91 -Adoscopic aspect of the right mm telescope, 0°). Elevation of mucoperiosteal flap of the maxilary sinus {and mediaization of the medial maxilary Sinus wall together withthe inferior turbinate PLSM = iateral wall, maxilary sinus PSSM = superior wall, maxilary sinus LMPSM = mucoperiosteal flap, maxiliary sinus; PMSM = superior wall, mani Sinus, TI = inferior tubinate28 Fig. 92 Endoscopic aspect of Fig. 95 Endos (4 mm-telesc head of S = nasal s TM = middle Mi = inferior jescope, noethmoid recess; TT ‘ope im: TH inate; S teal opic aspect of the right nasal cavity Dissection of the inforior turbinate Fig. 93, th = nead of inferior turbinate PMSM = medial wall, maxillary sinus $= nasal septum: TI = inferior turbinat speriosteal di Fig. 92) and dis- section is extended as far as the bony dorsal margin of the maxillectomy, in: cluding the anterior portion of the pendicular plate of the palatine bone. Once these steps are accomplished, dissected tissue is via sal or transoral pathway (Fig. 93 and 94). At the end of this lateral nasal wall is completely ex posed, with the following structures spared: anterior third of the inferior turbinate, nasolacrimal duct, ethmoid bulla and middle turbinate. T maxillary sinus cavity is also readily visible Elevation of the mu Type II dissection involves removal of the medial wall of the maxillary sinus, loss of the inferior turbinate and dis: 4 Fig. 96 ndoscopic aspect of the rig y ‘mv err Cadaver Dissection for Teaching Ante or Skull Base Surgery Fig. 94 Env spect ofthe right nasal cavity sagavenc tissue dissected “en Block TMPSM — mucoperiosteal flap, maxilla sinus; PMSM = upper wall, maxillary si 3: TI = inferior turbinat. rection of the nasolacrimal duct be: low the lacrimal sac, as well a en block-removal the muco perior and most of the inferior maxil This technique provides good visual control of the posterior, superior and lateral walls, and parts of the inferio In addition to type the type Il tech: nique also omplete di tion of the inferior turbinate and re moval of its head (Fig. 95), exposure of the nasolacrimal duct along the na somaxillary line (Fig. 96) by use of dia- mond tipped burr, dissection inferior to the Fig. 97), and re- erior portion of lacrimal sac moval of the aEndoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 98 Endoscopic aspect of the right nasal cavity (4 mm-telescope, The incision is VN = nasal vestibulum and vibrissae; PLAP = lateral wall, piriform aperture ried through mucosa medial wall of the maxillary sinus in- feroanterior to the outlet of the naso- lacrimal duct. ‘Type Ill dissection involves removal of the medial wall of the maxillary si nus, loss of the inferior turbinate, inci- sion of the nasolacrimal duct, removal of the lateral portion of the piriform aperture and en block-resection of a mucoperiosteal flap of the maxillary sinus cavity. The technique provides good visual control of all maxillary walls. In addition to type I, it includes elevation of the cutis and mucosa of the lateral margin of the piriform aper- ture (Fig. 98) and removal of its lateral bony portion by use of a diamond tipped burr (Fig. 99). In this way, dis ‘section is carried further in the antero: lateral direction, which provides much better visual control of the anterior maxilary sinus wall (Fig. 100), so that subperiosteal exposure and en block- resection of the entire maxillary sinus cavity can be extended (Figs. 101 and 102, Fig. 99 Endoscopic aspect ofthe right nasal cavity d-mm telescope, 45°), Removal ofthe feral margin of the pintorm PLA Fig. 101 Endoscopic aspect of 1 right nasal cavity telesc PASM = anterior PLSM = lateral wal, maxillary Sinus PPSM = posterior wall, maxillary sinus PSSM = superior wall, maxilary st DNL = nasolacrimal duct LP = lamina papyracea PVOP = vertical plato, palatine bone Fig. 102 » Endoscopic aspect of the right nasal cavity (4 mm-telescope, 0 SM = maxillary sinus; $ = nasa ACI = internal carotid artery ‘SS = sphenaid sinus; R= nasopharynx. Endoscopic aspect of the right nasal cavity30 These three techniques and the cen- ipetal technique require the use of telescopes with a 45° direction of view junction with sophisticated in: strumentation. In fact, the use of curved sheath-instruments of only ‘one angulation (45° or 90°) cannot provide access to the lateral margins of the maxillary sinus because the curved section is too short. Instru- ments with an elongated curved sec tion are difficult or even impossible to. insert in the nasal cavity. To overcome these instru chnical_challeng: featuring double have been developed. Double re ensures easier insertion into the nasal cavity and, under endoscop- Ol, provides access to all max lary sinus walls, including the anterior wall The use of double curvature-instru ments in conjunction with telescopes of more than 0° direction of view al- lows the tip of the instrument to be kept centered in the field of view (Fig, 103) It must be emphasized that the dis- section steps mentioned above may only be conducted effectively with telescopes with more than a 0° direc tion of view if double curvature-instru- ments are used to ensure that both the target site and distal end of the in strument can be kept in the tele- scope's field of vision, Caution: Iatrogenic lesion of the sphenopalatine artery, descending palatine artery, perforation of the hhard palate, and lesion of the naso- lacrimal duct. Endoscopic Cadaver Dissection for Teaching Anterior Skull Base 8.0 Endonasal Dissection: Decompression of the Orbit and the Optic Nerve 8.1 Anatomy The lateral wal of the ethmoid sinus is formed by the lamina papyracea which is extremely thin at its posterior third so that, at times, itis possible to 800 the periorbit through it. The poste- rior ethmoid artery originates from the ophthalmic artery inside the orbit and traverses the roof of the posterior eth- moid where the bony lamina of the su: perior turbinate is into the lamina papyracea, 3-8 mm anterior to the frontal wall of the sphenoid sinus. The junction between the posterior ‘ethmoid and the sphenoid sinus is al- 0 the site of the optic ring, the narrow est point of the optic canal because of the adherences of the dura m: riosteum and Zinn's circle, as well as the origin of the straight medial and su- Perior muscles. Zinn's circle is the bbrous ring where the tendons 0 traocular muscles merge at the the orbit. The optic canal is deli by the roots of the lesser wings of the sphenoid sinus; its dimensions are ex tremely variable, being 5.5-11.5 mm in length and 4-9.5 mm in dia Fig. 103 The operating position of 45*-telescope. The curved shat of the the field of vision The channel has an elliptic cross-sec- tion, and its maximum width is on t horizontal axis. A fold - the transverse or falciform crest ~ forms the roof of the channel, marking the junction between the intracranial and the intracanalicular segments. The bone overiying the optic canal be- comes progressively thicker and denser, running from the intracranial segment to the optic ring, located at the junction between the posterior eth: moid and the sphenoid si t the tarting point of the optic canal, the ophthalmic artery traverses on the in: ferolateral surface of cases and ‘on the inferior surface in the remaining 45%. Proceeding in the channel, it has an inferomedial orientation in 60% of cases, it follows an inferior course in 30%, and an inferolateral course in on: ly 10%. This aspect must be kept i mind when, after subjecting the optic canal to driling, a dural incision is made. To prevent iatrogenic rupture of ophtalmic artery, the "jaws of the forcens is centered in the field of vision of the 'asal fore 1 allows the jaws to always be kept inEndoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 104 Endoscopic aspect of the left nasal cavity (4mm telescope, 0°. The inraocbital nerve is dissected atthe level ofthe superior maxillary sinus wall (PSSM), PPSM = posterior wall, maxillary sinus: PLM = lateral wall, maxilary sinus; IO = infraorbital nerve. should be made as close as possible to the roof of the optic canal The artery and nerve are lined by two dural layers: the external forms the periorbit, while the internal follws the nerve to the bulb. 8.2 Anatomic Dissection 82.1. Orbital Decompression Endoscopic-guided cadaver dissec- tion starts with identification of the nat- ural maxillary sinus ostium, its enlarge ment and en block resection of the fontanalies to dorsally gain access to the posterior maxillary sinus wall, ven- trally the nasolacrimal duct, cranially the orbital floor and caudally the supe- flor margin of the inferior turbinate This step provides good exposure of the orbital floor and allows visualization of the course of the infraorbital nerve at the roof of the paranasal sinuses (Fig. 104). Anteroposterior ethmoidectomy and sphenoidectomy are conducted, including complete removal of the an- ofthe let nasal cavity imm telescope, 0°) folowing ethmoidec- tomy/sphenoidectomy. Resection of the lamina papyraces TM = anterior third of the middle turbinate TM3 = medial third (horizontal portion) of the middle turbinate; PSM = posterior third of the middle turbinato: SS = sphenoid sinus; LP = lamina papyra cea, PO = periorbit; AEA = anterior ethmoid artery, SF = frontal sinus, terior wall of the sphenoid sinus. The trainee should bear in mind that the middle turbinate must remain intact unless removal of the latter is required to optimize fenestration of the medial wallof the orbit. The lamina papyracea is carefully fragmented so that it can be removed without causing damage to the underlying periorbit. Resection continues superiorly up to the margin of the ethmoid roof and is carried pos- teriorly toward the apex of the orbit, stopping about 2 mm anterior to the henoid sinus wall, close to the bony thickening where the common annular tendon is located below (Fig. 105). This point is the posterior dissection mar. gin. The anterior margin is defined by he junction of the lamina papyracea with the lacrimal bone. The fascia of the lacrimal sac may be exposed but not opened. Next, the medial portion of the orbital floor is re- sected (Fig. 106). It is important not to transgress the lateral margin demar- cated by the infraorbital nerve. 3 Fig. 106 Endoscopic aspect ofthe lft nasal cay (4 mm-telescope, 0°) following resection of 1e medial portion of the orbital floor as far {as the infraorbital nerve, = inferior turbinate; PPSM = posterior Wall, maxillary sinus; PO = periorbtt PaO = orbital floor; NIO = infraorbital nerve PLSM = lateral wail, maxillary sinus.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 107 Endoscopic aspect of the left nasal cavity (4 mm-telescope, 0°) following ethmoidec- tomy / sphenoldectomy: incision of the per orbit after complete resection of the lamina papyraces co shoana; § = nasal septum; CL = clus; IPO = pituitary gland; ACI = internal intra- ‘cavernous carotid artery: NO = optic nerve, PO = penorbit Fig. 110 Endoscopic aspect ofthe left nasal cavity (@ mm-telescope, 0°) folowing resection of he periorbit and orbital fatty tissue. Note the venter of the medial ractus muscie (MRM), GLO = bulbus ocul NO = optic nerve; AGI = internal intracavern- ous carotid artery At this stage, the periorbit may be in- cised. Initially, a lateral incision is made at the orbital floor followed by a medial incision made at the medial or- bital wall. Then, two lengthy incisions and a series of transverse incisions are applied. The first have posteroan: terior orientation to avoid prolapse of Periorbital fat impeding vision of pos- terior structures, One superior incision is placed at the roof of the ethmoid, the inferior one is made at the orbital Fig. 108 Endoscopic aspect of the left nasal cavity (4 mm-telescope, 0° following ethmoidec- tomy / sphenoidectomy: orbital fat die charging after incision of the periorbt €O = choana; § = nasal septum; IPO = pituitary gland; ACI = internal intra Cavernous caroiid artery, GPO = orbital fat; PPSM = posterior wall, maxillary sin floor. The transverse incisions are made to fragment the periorbit (Fig. 107). Once access is accomp: lished, prolapse of the periorbital fat inside the ethmoid and maxillary sinus can be observed (Fig. 108) It is advisable that a residual part of the lamina papyracea be kept intact at the level of the cranial and ventral angle, to prevent protrusion of fat into this site, which might obstruct the natural frontal sinus ostium, 8.2.2. Optic Nerve Decompression This step comprises both anteroposte- rior ethmoidectomy and sphenoidec- tomy. The natural sphenoid ostium is enlarged and the anteroir wall resect- ed to such an extent that the optico- carotid space becomes visible at the junction between the lateral and pos- terior walls of the sphenoid sinus. This space is located between two bulges, ‘one produced by the optic canal above, and the second arising from the intracavernous internal carotid artery below. The opticocarotid space is distinctly visible in extensively pneumatized sphenoid sinuses (sellar type), generally still evident, albeit at times with some difficulty in less pneumatized sinuses (presellar type) and may not at all be identified in Fig. 109 Endoscopic aspect of the left nasal cavity (4 mm-telescope, 0° folowing ethmoidec tomy/sphenoidectorny: optic nerve de- compression. PS = cellar floor; oN AO = apax of the orbit sinuses with low-grade pneumatiza- tion (conchal type) Dissection proceeds with fragmenta- tion and removal of the lamina pa: pyracea at the orbital apex. Through this procedure, identification of the starting point of the nerve chan: nel at the common annular tendon (Circle of Zinn) is improved. Dissection proceeds with fragmentation and re: moval of the lamina papyracea at the orbital apex. Decompression of the optic canal is initiated using a long intranasal drill with a diamond-tipped burr at the bony junction between the ethmoid and sphenoid sinuses overlying the common annular tendon (Fig. 109) The anterior margin of decompression is demarcated by the medial rectus muscle fibers. At this stage, dissection proceeds posteriorly along the wall of the sphenoid sinus. ‘The optic canal is dissected step-by- step in the anterior-to-posterior direc: tion. At the site where the canal be- comes particularly thin, proceed with curette of appropriate size. Expo: sure of the nerve on its medial plane must be at least 180° in circumter- ence from the apex of orbit to the op-Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery tic chiasma. A sickle-shaped knife is used to make a lengthy incision in the optic nerve dural sheath starting at the common annular tendon and pro- ceeding in a ventrodorsal direction as far as the median portion of the poste- rior sphenoid sinus wall. At times, cerebrospinal fluid outflow may be ob- served after puncture of the the dural sheath. During this step of dissection it is im- portant to identify and expose the ophthalmic artery, bearing in mind the anatomic variations as compared to the nerve of the same name, along the course of the artery from the endocra- rium to the orbit. Caution: latrogenic lesion of the medial rec- tus muscle (Fig. 110), lesion of the optic nerve, lesion of the intemal ‘carotid artery, lesion of the ethmoid arteries, cerebrospinal fluid fistula, ‘The greatest risk during incision of the optical canal dural sheath (dupli- ‘cation of the dura mater}: lesion of the ophthalmic artery (OA) (Fig. 111). ‘This may occur in rare cases where the OA courses in a median position relative to the nerve itself (15%). 33 9.0 Endonasal Anatomic Dissection of the Frontal Sinus 9.1 Anatomy ‘The frontal sinus is an air-filled cavity that lies between two bony walls known by the same name. The frontal sinus cavity may be described as a pyramidal-shaped cavity with a medial or inferior base. The four internal walls are the medial wall or the intersinus septum, the anterior wall, the posteri- or wall, and the inferior or orbital-eth- moid-nasal wall. Its dimensions vary from 6x 4 x 10 mm to 77 x 30 x 74 mm, respectively, in width, depth and height. As arule, the medial wall is a slender septum dividing the two sinuses but it may also be extremely thick and have spongiosa, particularly in the pres- ence of small-sized sinuses. It usually has median orientation and is located on the same plane as the internal frontal crest. Owing to predominance of one sinus over the other, the medial wall may be shifted laterally or slant- ed, especially in its upper portion. The anterior or frontal wall is made of cortical bone at the superciliary arch while the rest consists of thin spongiosa lying between two slender lameliae of cortical bone. Its thickness varies between 1 and 12 mm in in- verse relationship with the internal width of the frontal sinus. The posterior or cranial wall has 2 vertical and a horizontal portion that fare almost perpendicular to each other, thus forming a 90° angle open to the posterior. Both are made up of the internal wall of the frontal sinus. This cortical bone is about 1 mm in thickness, susceptible to fracture and partially dehiscent. The anterior intra- cavitary lamella of the cranial wall has 4 Fig. 111 Endoscopic aspect of the lett nasal cavity (4 mm-telescope, 0° with close-up view of the paraseliar region. IPO = pituitary gland; ‘ACI = internal intracavernous carotid artery, Il = horizontal segment, IV = anterior curve, V = anterior vertical ‘segment; NO = optic nerve; AO = ophthalrnic anery, a mucosal lining. The posterior lamella is covered by the dura mater, which firmly adheres centrally to the bony wall The inferior or orbital-ethmoid-nasal wall comprises an orbital and an eth- moidonasal section, both lying in the horizontal plane but on different lev. els. The orbital section is made up of a slender lamella of cortical bone, at times papyraceous, concave below and convex above, surmounting the orbit. It is delimited anteriorly by the superior orbital rim (the internal third of which has a base or outlet where the supraorbital nerve inserts), poste- riorly by the insertion of the posterior wall of the frontal sinus, and medially by the superior margin of the lacrimal bone and the lamina papyracea (junc tion between the frontal and ethmoid sinus, the frontal and lacrimal sinus, re- spectively). The superior intracavitary wall has a mucosal lining and is delim- ited medially by the wall of the intersi- nus septum, anteriorly and posteriorly by the anterior and posterior walls of the frontal sinus, laterally joining seamlessly into the orbital section The external wall is lined by the orbital periosteum that separates it from the orbital contents, ‘The ethmoidonasal section is located on a lower level as compared to the orbital section. It is made up of a quadrilateral lamella of sturdy, cortical bone, of average thickness 1-5 mm, sized 5-10 x 15-20 mm in width and depth, respectively. The inferior plane is fused with the lateral portion of the cribriform plate that, in turn, at the an- gulation with its horizontal portion forms the insertion of the basal lamel- la of the middle turbinate. This promi: nent part is not considered a predilec- tion area for perforation since the frontal bone is very thick and sturdy, except for its medial portion. The me- dial portion of the ethmoid roof isFig. 112 Schematic depiction be ‘coronal plane, ‘of the ethmoid root: the vertically directed lateral lamelia of the chibriform plate is of reduced lenath. ‘The ethmoid roof is totally mace up of the frontal sinus and, thus, is significantly less susceptible to iatrogenic injury MRM - medial rectus muscle: LP =lamina apyracea: TM = middle turbinate. ed on a modifieg formed by the lateral lamella of the ccribriform plate that, owing to its mini mal thickness and fragility, is the site of greatest risk for iatrogenic cere: brospinal fluid leakage. It may present significant anatomic variations: it may be longer or shorter, may be vertical or more slanted laterally and may also show anatomical asymmetries in its h and course on both sides. The point of insertion of the anterior eth: moid artery traversing from the eth- moid into the anterior cranial fossa is the most vulnerable site of the entire ethmoid labyrinth. In this area, the thickness of the bone decreases on average to just 0.05 mm; its level of strength is about 1/10th that of the ethmoid roof, The highest point of the cethmoid roof, corresponding with the frontal ostium, may surpass the eribri- form plate extensively, with limit val- ues of 17 mm. These anatomic structures subdivide an anatomical entity into a slender medial wall, that corresponds to the anterior margin of the roof of the nasal cavity (starting point of the oifactory Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 113, ‘Schematic depiction based on a modified ‘sean, coronal plane. Configuration type i of the ethmoid root the lateral lamella of the eribriform plate has an increased length and lies in an in ined plane. In the lateral half of its exten Sion, the ethmoid roof merges with the frontal sinus, while the medial half of the ‘oot made Up of thin Ethmoid bone (LCP), This anatomic configuration is at higher risk for iatrogenic injury. MRM ~ medial rectus muscle: LP papyracea; TM = middle turbinate, Cleft), and a wider lateral portion, that forms the roof of the anterior ethmoid cells. The relationship between these two structures, the fovea ethmoidalis (of the frontal sinus) and the cribriform plate (lateral portion) ~ varies in rela- tion to the medial development of the frontal sinus and may be classified in three types. Type I: (Fig. 112) ‘Type II: intermediate fovea (Fig. 113). ‘Type lil: short fovea (Fig. 114). long fovea ethmoidalis Dimensions and outer shape of the eth- moidonasal section depend on bot! the spatial extension of the sinus and the degree of pneumatization of the un- derlying ethmoid cells, which at times may develop to the level of the orbital section (frontal bulla), or transform it in to a slender transverse groove or a small funnel-shaped cavity. As a rule, the frontal sinus ostium is located at the ‘most slanted site of the ethmoidonasal section. The ostium may be round, oval or sickle-shaped with variable width of 2-8mm. Under certain ig. 114 ‘Schematic depiction based on a modified CT scan, coronal plane Gontiguration type ill of the ethmoid root the lateral lamella of the cribriform plate has an increased lenath and lies in an even more inclined plane, For most ofits spacial extension, the ethmoid roof is. made up of thin ethmoid bone (LLCP) ‘Tis anatomic configuration is associated with a higher risk for iatrogenic injury MAM - medial rectus muscle: LP papyracea; TM = middle turbinate anatomical conditions, an in the bony thickness of the anterior wal of the frontal sinus ostium may be en- countered. This increase in thickness may extend for a few millimeters cra- nially, creating a small duct with a frontal superior and an inferior ostium, also termed nasofrontal duct. The o: tium opens into the frontal recess. ‘The frontal recess is a space be- tween independent bony structures that define its boundaries, form and imensions. The frontal sinus ostium in the upper part of the frontal recess is located at the junction of the frontal sinus and the ethmoid sinus; the mar. ins of this ostium are made up of et moid components. As a rule, the me- dial wall of the frontal recess is made up of the lateral lamella of the cribr form plate, which is fused with the sagittal portion of the basal lamella of the middle turbinate. In case the cra: nial portion of the uncinate process articulates medially, merging with the sagittal portion of the basal lamina of the middle turbinate, the medial wall of the frontal recess may also consti-Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery i t 4 35 Fig. 115 Trwee-dimensional schematic depiction of the most favourable anatomic condition: direct endoscopic vision of the natural ‘ostium ofthe frontal sinus (blue). The three components ager nasi, uncinate process and anterior ethmoid bulla) of the anterior recess distinctly showing through the middle turbinate (highlighted In different colours) tute the lateral face of the uncinate Process itself. The lateral wall of the frontal recess is formed to a large ex- tent by the lamina papyracea. If the cranial portion of the uncinate process is laterally oriented toward the lamina papyracea, it may form part of the lat- eral wall of the frontal recess and may also contribute to the formation of its floor. The posterior wall may be formed by the anterior wall of the ethmoid bul- laiif it reaches the ethmoid roof. Be- cause the bulla rarely rises as far as the roof, the frontal recess communi- cates posteriorly with the lateral sinus. With regard to size, form and bound- ates, the frontal recess is subject to anatomic variations of the ager nasi The anterior wall of the frontal recess is formed by the posterior portion of the ager nasi cells and the frontal sinus. Well-pneumatized agger nasi calls may protrude posteriorly and in- duce stenosis of the frontal recess. Similarly, the three different variations of the superior insertion of the unci- nate process — on the lamina pa- pyracea, the ethmoid roof and the Fig. 116 ‘Three-dimensional schematic depiction demonstrating the anatomic condition where extensively pneumatized ager nasi cells (green) impede endoscopic vision and obstruct direct access to the frontal sinus ostium. sagittal portion of the middle turbinate - may radically modify the ostium of the frontal sinus, which may then open into the ethmoid infundibulum or di- rectly into the middle nasal meatus. In View of the proximity to particularly vulnerable structures, such as the lat- eral lamella of the cribriform plate, the lamina papyracea and the anterior ethmoid artery, intraoperative identii- cation of the variable and complex anatomic configuration of the frontal recess is quite difficult, particularly since many small ethmoid cells devel- 0p from the frontal recess tse. ‘The bony roof of the ethmoid is essen- tially made up of the frontal sinus. Access to the natural ostium of the frontal sinus is quite variable and is de- termined by the different degree of pneumatization of two structures on the sagittal plane: the agger nasi and the ethmoid bulla, and by a structure fon the coronal plane: the uncinate process. Extreme cases of such vari- ability are: hypopneumatization of the ‘ager nasi and the ethmoid bulla with Fig. 117 ‘Three-dimensional schematic depiction ‘demonstrating the anatomic condition where an extensively pneumatized ethmold bulla cell (yellow) impedes endoscopic vision and obstructs direct access to the {rontal sinus ostium. fan uncinate process that maintains lat- eral orientation and terminates at the lamina papyracea. Under these cir- ‘cumstances, introduction of a 45° tele- scope into the middle meatus can al- low for inspection of the frontal sinus ‘ostium and the intracavitary contents (Fig. 115). The opposite extreme of the ‘aforementioned condition may never- theless compromise visualization of the frontal sinus ostium with the same endoscopic approach. This may be caused by three variable conditions: in the sagittal plane by a progressive growth of pneumatized ager nasi cells in the anteroposterior direction (Fig. 116) or a growing degree of ‘pneumatization of the ethmoid bulla in the posteroanterior direction (Fig. 117) in a coronal direction by an increase of the curvature of the uncinate process. In this condition, the uncinate process. forms a circular arc reaching medially ‘the sagittal portion of the middle turbinate, then curving back on the ‘ethmoid roof and reaching the lamina Papyracea. Over this course, the unci- nate process completely obstructsFig. 118 Thvee-dimensional schematic depiction ilustraing the anatomic condition where a strongly curved or excessively pneumatiz~ 6d uncinate process (violet) impedes. Vision and, thus, obstructs access to the frontal sinus ostium. access to the frontal sinus ostium (Fig. 118). These ideas have been dis- cussed in detail in various publica- tions by Prof. Heinz Stammberger. Another predilection site for iatrogenic lesions Is the ethmoid roof, which pre- sents an upward convexity and a slanted impression in a median posi- tion, This anatomical variation is par- ticularly susceptible to iatrogenic trau- ma when there is a well-developed su- perior concavity of the anterior skull base in its median portion. In fact, considering the axis of endonasal in- ‘troduction of surgical instruments, an impression of the ethmoid roof at its ‘medial third can enhance the likeli- hood of iatrogenic trauma (Fig. 119) Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 9.2 Anatomic Dissection ‘The anatomic dissection technique of- fers various nasofrontal approaches. ‘The type | nasofrontal approach (NFA) involves dissection of the frontal re- cess following the endoscopic proced- ure defined by Stammberger, leaving intact the frontal sinus ostium or the frontal sinus floor. The nasofrontal ap- proaches of type Il, I and IV are mod- ifications of Loothrop's external osteo- plasty described by Drat. NFA type I (or Drat Ila) involves the removal of the frontal sinus fioor between the orbit and the insertion of the middle turbinate. NFA type III (or Draf IIb), on the other hand, adds to the removal of the frontal sinus floor the resection of Fig. 119 Macroscopic view of a cadaver dissection specimen in sagittal section: the surgical in~ Strument points to the most slanted impression of the skull base located at the junction Zone between the anterior and posterior ethmoid. This particular condition poses an ele- ated risk of farogenic injury at this site of the ethmoid roof. the area between the orbit and the nasal septum. Finally, NFA type IV (or Drat Ill involves dissection of the inte- rior wall of the frontal sinus traversing from the orbital portion on one side to the contralateral portion through a perforation made in the nasal septum. ‘The approach to the frontal recess is the most dificult and risky stage in all endoscopic surgery. The frontal recess is opened using a 4 mm-telescope, 45° (more rarely 30° or 70"), and in- struments angled at 45° or 90°, such 2s bal-tipped hooks, through-cutting HEUWIESER maxillary sinus forceps, curettes, BLAKESLEY-WEIL nasal for- cops, STAMMBERGER circular-cut- ting-punch, and angulated suction tubes for the frontal sinus.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 120 Fig. 121 Fig. 122 Endoscopic aspect of the left nasal cavity Endoscopic aspect of the left nasal cavity _Entioscopic aspect of the left nasal cavity (4mm-telescope, 45%), The frontal recess (4 mm-telescope, 45°). The frontal recess (4 mm-telescope. 45°). Close-up view of ‘pens into a wids lumen, allowing access opens into a wide lumen, allowing access the cranial portion of the frontal recess. to the frontal sinus. to the frontal sinus BE = ethmoid bulla; St = lateral nasal TM = middle turbinate; BE = ethmoid TM = middie turinate; BE = ethmoid bulla; LP = lamina papyracea; SF = frontal sinu PU = uncinate process. SL = lateral sinus; OSF = frontal sinus NFA Type | approach to the frontal sinus the preferred endoscopic-guided ana- tomic technique (according to Stamm: berger), and is suited to identifying and dissecting various structures. The key in implementing this technique is the anatomic dissection concept. The various structures must be identified (Figs. 120-124), localized and re- joved only after being dissected This approach does not involve drilling of bony structures. asa cavity spect of the le oid bulla -telescope, 45°) show BE = othmoid bulla; SL = lateral nasal wal; frontal recess with very con SF = frontal sinus: PU = cranial lamella of the frontal sinus owing to a strongly curve fe uncinate process; AN = caudal lamella _uncinate process that is in contact with the of the agger nasi cells sagittal-cranial portion of the middle turbinate. TM = middle turbinate, PU = uncinate process: BE = ethmoid bulla.38 Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 125 Endoscopic aspect of the let nasal cavity (4 mm-telescope, 45°) showing a narrowed frontal recess with very confined access to the frontal sinus caused by a strongly curved uncinate process that is in contact with the sagital-cranial portion of the mid- le turbinate. The anterior margin of the un. cinate process is incised. ‘TM = madle turbinate: PU = uncinate process; AN = agger nasi Fig. 128 Let nasal cavity (4 mm-telescope, 45°) The frontal recess after removal ofthe uncinate ‘process, The bony shell is opened and ex ised to gain access to the frontal sinus. TM = middie turbinate; SF = frontal sinus LP = lamina papyracea Prior to gaining access to the frontal re- cess, the lamina papyracea, considered to be a safe landmark, needs to be iden- tified. After partial inferior uncinectomy, the residual uncinate process may be medialized to assess its cranial insertion, the degree of pneumatization of the agger nasi and the ethmoid bulla (Figs.125- 128). Once the cranial portion of the un- cinate process is dissected using through-cutting nasal forceps, the bony lamella portion may be left intact, which Fi Endoscopic aspect of the left nasal cavity (4 mrr-telescope, 45 Close-up view of the cranial aspect of the Uncinate process (terminal recess) that forms a bony shell impeding access to the frontal sinus, PU = uncinate process: GO = bony shel incinate process; LP = lamina pa: of the Fig. 127 Endoscopic aspect of the left nasal cavity [A mm-telescopa, 45°) showing the frontal recess ater resection of the uncinate process, The most cranial aspect of the Uncinate process obstructing the frontal Sinus ostium remains intact ‘TM = middie turbinate; GO = bony shell of the uncinate process; LP = lamina papyra- Fig. 129 Three-dimensional schematic depiction (red arrow) of the meial-to-lateral motion of the tip of the currete which is used to remove the residual cranial portion ofthe uncinate pro- {cess to provide access tothe frontal sinus is formed by the dorsal portion of the ur cinate process and is attached to the lamina papyracea. In such cases, it is crucial to identify the medial residue of the bony lamella to allow precise distinc tion between the sagittal portion of the middle turbinate and the lateral portion of the cribriform plate. Before its com. plete removal, the medial residue of the tncinate process is first medialized with medio-lateral movements and then dis: sected by use of through-cutting forceps Fig. 190 Three-dimensional schematic depiction (red arrow) ilustrating the motion of the tip of we curete, which is used to remove the cranial aspect ofthe ethmoid bulla to pro- vide access to the frontal sinus. Fig. 129). This aids in preventing the very vulnerable oblique portion of the cribritorm plate from iatrogenic trauma and stripping of the mucosa, the latter being the most important cause of post: operative stenosis obstructing the frontal sinus estium ifthe ethmoid bulla fills the frontal recess due to high-grade anterior pneumatiza- tion, the surgeon must try to localize the anterior bony margin proceeding from anterior to posterior (Fig. 130)Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 131 ‘Tntee-dimensional schematic depiction (red arrow) of the motion ofthe tip ofthe curette used to remove the cranial aspect of the ag {ger nasi cell to provide access to the rontal = Fig. 134 ‘Schematic depiction of the position of the anterior ethmo artery (red dot) atthe level ofthe ethmoid root. Type Il configuration of the anterior skull base, The lateral sinus has developed as far as the frontal sinus; the Posterior wall of the frontal snus les in the Anteroposterior and dorsoventral plane: the rst fovea thmoidalis is in vertical position and merges with the posterior wall of the frontal sinus (red line) Hf the bony separation is made up of the posterior process of the agger nasi, the curette must be used in a posterior approach to remove the bony lamella in posterior-to-anterior direction (Fig. 131). After cutting off the bony lamella with the curette, it is always preferable to resect the bony margins with through- cutting forceps before removing them, Fig. 132 ‘Schematic depiction ofthe position of the anterior ethmoid artery (red dot) atthe level Of the ethmoid root. Type | configuration of the anterior skull base, The agger nasi cell has developed as far as the frontal sir the posteror wall of the frontal sinus lies in the posteror-anterior and dorsal-ventral plane; the first fovea ethmoidalis is wel ‘veloped and lies in the horizontal plane (red line Fig, 138 Endoscopic aspect of the left nasal cavity (4 mm-telescope, 45°). Close-up view of the receding fst fovea ethmoidal's (type Ill), AEA = anterior ethroid artery SF = frontal sinus, in this way, dissection can proceed without affecting the morphological in- tegrity of the underlying structures, which otherwise occurs if a traction (tearing) technique is applied. The technique described above significant ly facilitates the recognition of various anatomic structures. Another predilec- tion site for iatrogenic injury is the ante- 39 Fig, 133. Endoscopic aspect of the eft nasal cavity (4 mm-telescope, 45°), Close-up view of athmoid roof in which the fist fovea ethmoidalis is of increased length and les inthe horizontal plane (type I AEA = antorior thmoid artery P= lamina papyracea, FFE = first fovea ethmoidals, CCF scan (coronal piane) of the anterior skul bbase. Note the clear asymmetry of the two sides of the ethrrid roof (type | and left. type Il, right). The lateral amelia of the cri form plate is cistincty longer and strongly deviated to the right. rior ethmoid artery. To avoid lesions, the anatomical landmarks are the nat- ural frontal sinus ostium, always fol lowed by the different types of foveae ethmoidales (Figs. 132-138, Figs. 137, 138 see p. 40)loft nasal ca ose-up view the ethmoid root TM = middle turbinate: AEA = anterior ethmoidal artery; FE = first fovea eth oidais: LP = lamina papyracea: SF = frontal sinus. Fig. 140 Endoscopic aspect of the. ty @ mmtelescope, 45 ttanasal dril the medi ight nasal cavi By use of the in portion of the ag- first stage in th rat la 199er nas} type Il nasofrontal appro. TM = middie turbinate; AN FO = olfactory cleft: S nasal As a rule, the anterior ethmoidal artery (AEA) is embedded in a bony canal passing from dorso-ventral to latero- nedial and, thus, may be identified by this specific topographical anatomic feature. The most vulnerable point of the cribriform plate is the insertion of e AEA into the olfactory cleft, an area where the dura mater is very thin and adheres to the bony lamella Fig. 198 Endoscopic aspect of (4 mm-telescope, 45°), close the ethmoid roof where a cerebrospinal fui fistula was deliberately created at the trance of the anterior eth middie turDinate: AEA = a moid artery; I FE = fist ethmoidal LP = lamina papyracea: $F = frontal si erior eth Fig. 141 Endoscopic aspect ofthe right nasal cavity (4 mm-telescope, 45°). Removal ofthe ft al sins floor by use of an TM = middle turbinate, AN = agger nasi; S = nasal septum intranasal dri NFA Type I This endonasal approach to the frontal sinus was defined by Prot. Draf (Type Ma). The landmark is the arch formed by he passage between the medial as- pect of the frontal maxillary process and the lateral aspect of the insertion of the middle turbinate (Fig. 139), in turn fused with the ethmoid sinus. Initially \doscopic Cadaver Dissection f Teaching Anterior Skull Base Surgery 139 scopic aspect of the right nasal cavity 4 mm-telescope, 45°) showing the anatom ic landmarks of the type II nasotrontal a riddle turbinate; AN = ager nas! asal soptum; PNF = nasolrontal Fig. 142 Endoscopic aspect of the right nasal cavity (4'mmtelescope, 45°). Removal of the frontal sinus oor. The blunt hook indicates the point of access to the frontal sinus (SF; niddie turbinate; PNF nasofrontal 3S = nasal septum, the mucosa overlying the aforemen- tioned anatomic area is removed under ‘endoscopic vision (4-mm telescope, 0 then a powered cutter and subsequent- ly an intranasal drill (Figs. 140 and 141) are used to remove the pneumatized agger nasi to such an extent that natural frontal sinus ostium can identified from the anterior frontal sinus floor. (Fig. 142)Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery ‘Anatomic depiction showing the resection ‘margins ina type-II nasofrontal approach (Draf ll) yellow area). Using ths toch. ‘nique, the frontal sinus floor is resected me- dilly rom the natural ostium to the inser- tion of the middle turbinate, A neo-ostium is Created that runs from the lamina papyra- ‘cea to the insertion of the middie turbinate, At this stage, the ostium is enlarged posteriorly by removing the anterior portion of the frontal sinus floor. This step of dissection is associated with the risk of iatrogenic trauma to the lacrimal bone and the lamina pa: pyracea, and the ensuing risk of perfo- rating the cranial and medial aspect of the lacrimal sac (Fig. 143) NFA Type Ill This approach, likewise defined by Prof. Draf (Type lib), is a systematic ex- tension of the aforementioned ap proach. Resection of the floor of the frontal sinus is carried as far as the nasal septum and includes the removal of the anterior insertion of the middle turbinate (Figs. 144 and 145). The anatomic landmark for medial enlarge ment of the fenestrated frontal sinus floor, the first olfactory nerve, is local- ized by elevating the mucoperiosteum from the roof of the nasal cavity medial- ly to the sagittal portion of the middle turbinate. This structure may serve as a landmark to avoid inadvertent contact with the olfactory cleft. In his original definition, Prof. Draf sug- gested extending the area of the mu: Cosal resection anteriorly to the middle Alle Fig. 144 ‘Anatomic depiction showing the resection ‘margins of a type-I nasotrontal approach (Draf I) (allow aroa). Using this toch nique the trontal sinus floor is resected me- ally from the natural ostium to the nasal ‘septum. Thus, a neo-ostium is created that runs from the lamina papyracea to the nasal ‘septum, The red line marks the frst olfacto rynerve, turbinate, to remove all agger nasi cells, {and then the bone to allow identifica tion of the lacrimal sac, This anatomical structure must be exposed cranial. Superomedial to the lacrimal sac, the bone of the nasofrontal process is re- moved by using a diamond burt. The lacrimal sac thus defines the anterior margin of the area of dissection NFA Type IV Defined by Prof. Draf (Type Il) 2s well this approach represents a further sys- ‘ematical extension of the previous ap. proaches. The anterolateral and dor- socranial landmarks that need to be identified before starting dissection are again the lacrimal sac and the first ol- factory nerve. These landmarks are the resection margins that must not be ex- ceeded to prevent perforation of the or bit and the anterior skull base, NFA ‘Type IV involves making a horizontal mucosal incision in the nasal septum, approximately 5 mm below the project ing inferior margin of the middie turbinate. The vertical mucosal incision in the nasal septum must be carried as far as the roof of the nasal cavity and fends 5 mm posterior to the projection of a cure that passes from the inser- Fig. 145 Endoscopic aspect of the right nasal cavity (4 mmetelescope, 45°) ‘Area of resection after completion of a type nasofrontal approach (Drat Ib), '$ = nasal soptum; TM = middie turbinat: SF = frontal sinus. tion of the middle turbinate to the frontal maxillary process. The musosa is elevated subperiosteally and is re- moved, ‘The exposed septum cartilage is re- moved either by use of the backward: cutting Gruenwald forceps or a dia- ‘mond bur.Fig. 146 Endoscopie aspect of the right nasal cav/ ty (4 mm-telescope, 45°), The tip of strument points to the anatomical si Serves as a landmark for identification of the frontal sinus floor PNF = nasofrontal process; $ = nasal sept um; TM = middle turbinate; BE = ethmoid bulla; PU = uncinate process. Fig. 149 Endoscopic aspect of the right nasal cavi ty 4 mmtelescope, 45°), Area of resectir after completion of a type-IV nasotront ‘approach (Oraf Il), clamond bur is used tor complete removal ofthe left frontal s ‘us floor. Creation of a drainage pathway inthe superior nasal septum via the right nasal cavity FO = olfactory cleft, right; $ = tum; SFdx = frontal sinus, rig Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery K Y WN Fig. 147 SSematic depiction ofthe aeas of sec tionin a type-lV navorontl approach (Ort Ih Yetow sea) Te technique involves the Jocton of portions tthe superior nasal Scpturn and ine inferior inorenus eeptum as far as ne cortralateral lamina papyracea, ection margins dekted digo of the ofactory cat de aod by the fst ofactory nerve (ed The main landmark is a triangular bony area, called the nasofrontal process (al so known as the “nasofrontal beak’ formed by the junction of the medial portion of the frontal maxillary process and the nasofrontal process (Figs. 146 and 147). Resection begins in the mid- ine at the sphenoid rostrum (also known as the “kee!”) that forms at the point where the perpendicular lamina of the ethmoid sinus merges with the na- sofrontal process. The dorsal margin is defined by the first olfactory nerve. Re- section using a diamond burr starts. a few millimeters anterior to the medially projecting arch of the insertion of the middle turbinate. This margin must ab- solutely not be exceeded posteriorly to prevent jatrogenic perforation of the anterior skull base. Following vitary inspection of the frontal sinus, the intersinus septum is fenestrated and the opening enlarged laterally as far as the lamina papyracea (Figs. 148-150) Fig. 148 Endoscopic aspect of the right nasal cavity (mmetelescope, 45°). Area of resection after n of a type IV nasofrontal ap- proac! ina cadaver specimen. A Giamond burr is used for complete removal of the night frontal sinus floor, including re- section of the superior nasal septum. Fen estration of the left frontal sinus has only just begun. A blunt ball-enc hook is insert into the left nasal cavity for assessment f patency of the right frontal sinus. TM = middle turbinate, right; FO = olfacto- ry clef: SF = frontal sinus, right; $ = nasal septu Fig. 150 Endoscopic aspect of the lett nasal cavity (4 mm-telescope, 45°). Area of resection following a type IV nasotrontal approach (Caf Il). Frontal sinus drainage on both sides; a diamond burt is used to remove the frontal sinus floor. The curved suction tube 's inserted in the left frontal sinus (Stsx) FO = olfactory cleft, left; S = nasal sept: tum: TM = middie turbinate, le; Stdx = frontal sinus, night,Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery 10. Anatomic Dissection: Repair of Cerebro- spinal Fluid Fistula of the Anterior Skull Base After complete exposure of the anterior skull base a cranial and dural lesion is created by a deliberate puncture at a preselected site (Fig. 151). The mucosa and the periosteum are then elevated in the circumference of the bone defect to at least 10 mm; ade- quate preparation of the implant bed is essential before placement of the graft. Prior to this step, the graft is harvested from autologous cartilage (quadrangu- lar cartilage, auricular concha) and trimmed to the required shape and size (Fig. 152); using the underlay tech- nique, the graft is implanted, overiap- ping the intracranial margins of the de- fect (Fig, 159). The leak is then covered with flaps of mucoperiosteum harvest ed from the nasal septum or the middle turbinate; the flaps are trimmed to size Fig. 151 Endoscopic aspect of the left nasal cavity after creation of a bony and dural defect medially to the ethmoid root and dorsally to the endocranial insertion of the anterior etmold artery (AEA) TFE = 1. Fovea ethmoidalis; FE = 2. Fovea ethmoidals. to fit the dimensions of the defect. For small leaks, a mucoperiosteal flap is harvested from the middle turbinate and detached from its bony compo- nent, The latter may be used as an al- ternative option to cartilage graft for re- pairing the bone defect (Figs. 154 and 155). A second type of flap may be a piece of mucoperichondrium harvested from the nasal septum. A third alterna- tive is temporal fascia or fascia lata. If the superior or lateral wall of the sphe- old sinus is the selected site of the de- fect, it is useful to gain experience in the use of an abdominal fat graft har: vested as a single piece. Prior to place- ment of the graft, the mucosa of the sphenoid sinus is resected at the site of the implant bed, Fig. 152 Cadaver specimen of a piece of quadran- ular cartilage used as a tree graft in the Simulation of a duraplasty of an intracran- lal detect. 43 Fig. 153 Endoscopic aspect of the left nasal cavity after creating a bony and dural defect me: dialy to the ethmoid roof and dorsally to the endocranial insertion of the anterior eth moid artery (AEA). Using a ball-tipped blunt hook, the graft of quadrangular cartilage is shifted into the bone defect. The duraplasty 's performed with an underlay technique. {FE = second fovea ethmoidalis: GQ = piece of quadrangular cartiage: PO = periorbit; SF = frontal sinus.Endoscopic Cadaver Dissection for Teaching Anterior Skull Base Surgery Fig. 154 1Goscopic view of the left nasal cavity after placement ofthe free graft (CQ, quad- ‘angular cartilage) using the underiay tech: rique ILFE = second fovea ethmoidalis CQ — piece of quadrangular cartilage PO = pariorbit; AEA = anterior ethroid anery, | FE = first fovea ethmoidals SF = frontal sinus. Fig. 155 Endoscopic view of the left nasal cavity af ter placement (underlay technique) of a {roe mucoperichondrium graft harvested from the nasal septum (LMP) PO = periorbit; SF = frontal sinus 11.0 Identification of the Anterior and Posterior Ethmoid Arteries via External Approach 141.1 Anatomy The ethmoid arteries originate inside the orbit from the terminal section of the ophthalmic artery - a collateral branch of the internal carotid artery ~ course through the ethmoid accom: panied by the ethmoid nerves, and di- vide at the cribriform plate of the eth- moid to supply small branches to the olfactory bulb, the meninges and the mucosa of the nasal cavity. The anteri- or ethmoid artery is the most well de- veloped and supplies the dura of the anterior cranial fossa via its terminal branch, the anterior meningeal artery. 11.2 Dissection ‘A curved incision is made with a No. 15 surgical knife, approx. 2 cm medially to the internal canthus, in the center between the internal canthus and the median nasal line. The inci sion is carried through the cutis and subcutis as far as the periosteum. The lacrimal sac is medialized to expose the lacrimal bone and, posteriorly, the lamina papyracea. The periorbit is ele- vated from the lamina papyracea with 1 Freer elevator for identification of the anterior ethmoid artery, located ap- prox. 15-2 om posteriorly to the lacrimal fossa. Periorbital elevation then proceeds to expose the posterior ethmoid artery, located approx. 1.5 cm orsally to the anterior ethmoid artery Caution: Iatrogenic lesion of the lamina papyracea, periorbital lesion, lesion of the medial rectus muscie, lesion of the superior oblique muscle, {and lesion of the lacrimal sac.