Transoral & Transorbital approaches of skull base

14-8-201612.26 pm

Great teachers – All this is their work . I am just the reader of their books .

Prof. Paolo castelnuovo

Prof. Aldo Stamm Prof. Mario Sanna

Prof. Magnan

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Infratemporal fossa anatomy

IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial pterygoid muscle , LPM = lateral pterygoid muscle

Different layers of muscles & aponeurosis protecting

great vessels in infratemporal fossa –

Main protectors are medial & lateral pterygoid mucles

& temporalis muscle - great vessels are posterior

to these 3 muscles –

small contribution of protection of great vessels

are done by tensor veli palatini & styloid muscles

& stylopharyngeal aponeurosis

IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial pterygoid muscle , LPM = lateral pterygoid muscle

TVPM is triangular muscle , LVPM is cylindrical muscle

SPM attached to superior constrictor ,

SGM attached to tongue ,

SHM attached to lesser cornu of hyoid bone

After drilling LPP & MPP longissmus capitis & superior constrictor seen .

Trans - Oral approach to Infratemporal fossa

STEP 1 = Incision : anterior to anterior to anterior pillar of tonsil for “Trans - Oral approach to infratemporal fossa”

STEP 2 = Seperation of deep tissue identification of palato pharyngeus and palato glossus and superior consrictor muscles above medially below medial

pterygoid and ramus of mandible identification of triangles identification of ascending palatine and ascending pharyngeal ( resident friend) artery

STEP 3 = finally identification of our friends ica and jugular and vagus in the upper triangle formed by s c m stylopharyngeus

and stylo glossusmusclesTriangle between SPM & SGM & Superior constrictor Left side

Transoral approach to SUPERO-MEDIAL Parapharyngeal tumors – incision anterior to anterior pillar of tonsil

Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli

palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar of tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below

diagrams MPM reflected back for understanding purpose

MPM is reflected back – which shows the structures seen in trans-oral approach of ITF – incision anterior to anterior pillar of tonsil

Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli

palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar of tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below diagrams

MPM reflected back for understanding purpose

1. Each styloid muscle accompanied by one nerve – SPM by 9th nerve , SGM by lingual nerve , SHM by 12th nerve

2. SPM & SGM protects ICA whereas SHM protects both ECA & ICA – that is the reasonwhy wheen you dissect a plane over posterior belly of diagastric & SHM , you won’t get vital structures

3. ECA & ICA & CCA are like tuning fork – caricature diagram

Each styloid muscle accompanied by one nerve – SPM by 9th nerve , SGM by lingual nerve , SHM by 12th nerve

Note the 9th nerve accompanying Stylopharyngeus

The SPM runs inferiorly on the lateral aspect of the ICAp. The SHM is lateral to the ECA. The SGM passes lateral to the ICAp, medially to the ECA. The stylomandibular ligament is a condensation of the deep layer of the parotid fascia. It connects the styloid process with the angle of the mandible.

DMpb posterior belly of the digastric muscle, FA facial artery, ICAp parapharyngeal portion ofthe internal carotid artery, IJV internal jugular vein, SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, VIIcn facial nerve, Xcn vagus nerve, XIcn accessory nerve, XIIcn hypoglossal nerve, black asterisk glossopharyngealnerve at the skull base

MPM is reflected back – which shows the structures seen in trans-oral approach of ITF – incision anterior to anterior pillar of tonsil

ApaA ascending palatine artery, BFP buccal fat pad, BM buccinator muscle, ICAp parapharyngealportion of the internal carotid artery, IJV internal jugular vein, LN lingual nerve, MPM

medial pterygoid muscle, PG parotid gland, PP pharyngeal plexus, SCM superior constrictormuscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, IXcn

glossopharyngeal nerve, Xcn vagus nerve, black asterisk stylomandibular ligament

Transoral endoscopic view of the parapharyngeal regionApaA ascending palatine artery, ICAp parapharyngeal portion of the internal carotid artery, LCapM longus capitis muscle, PP pharyngeal plexus, SCM superior constrictor muscle, SGM styloglossus muscle, SPM stylopharyngeus muscle, white arrows glossopharyngeal nerve

The external carotid artery passes deeply to the digastric and stylohyoid muscles, but super fi cially tothe stylopharyngeus and styloglossal muscle when running toward the parotid gland (Janfaza et al.2001 ) . With a transoral window it is possible to control the space between the medial pterygoidmuscle laterally and the superior constrictor muscle medially. The stylopharyngeus and styloglossusmuscles are critical landmarks, being usually placed anterior to the great vessels (Dallan et al. 2011 ).Note that the presence of kinking or looping of the ICAp could make this statement untrue.

transoral endoscopic views of the tongue base and parapharyngeal regions

APA ascending pharyngeal artery, ApaA ascending palatine artery, DM digastric muscle, FAfacial artery, HGM hyoglossus muscle, IAN inferior alveolar nerve, ICAp parapharyngeal portionof the internal carotid artery, IJV internal jugular vein, LA lingual artery, LN lingual nerve,M mandible, MPM medial pterygoid muscle, SCM superior constrictor muscle, SGM styloglossusmuscle, SPM stylopharyngeus muscle, TB tongue base, XIIcn hypoglossal nerve, black arrowsglossopharyngeal nerve

Lateral vision of the upper cervical and lower parapharyngeal regions. The vertical branchof the mandible has been removed

DM digastric muscle, ECA external carotid artery, FA facial artery, ICAp parapharyngeal portionof the internal carotid artery, IJV internal jugular vein, LFVT linguofacial venous trunk,LN lingual nerve, MPM medial pterygoid muscle, OA occipital artery, SCM superior constrictormuscle, SGM styloglossus muscle, SHM stylohyoid muscle, SMG submandibular gland, SPMstylopharyngeus muscle, IXcn glossopharyngeal nerve, XIcn accessory nerve, XIIcn hypoglossalnerve, yellow arrow ansa cervicalis profunda

Transoral endoscopic view of the parapharyngeal regionAPA ascending pharyngeal artery, ApaA ascending palatine artery, ICAp parapharyngeal portionof the internal carotid artery, IJV internal jugular vein, LN lingual nerve, M mandible,SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeusmuscle, TB tongue base, white arrow hypoglossal nerve, black arrows glossopharyngealnerve, blue arrows lingual nerve

Sree ram murthy sir dissection in Italy Dear surgeons today we did cadavèric dissection to endoscopic transoral approach to parapharyngeal space The indications are 1. removal of small tumours of parapharyngeal space 2. biopsy of growths 3. to enter in to infratemporal space 4. para mandibular approaches to mid cranial fossa

The dissection was done by us with dr Dallan Of Pisa medical university of PISA ITALY

5. Incision over soft palate above anterior pillar 6. Seperation of deep tissue identification of palato pharyngeus and palato glossus and

superior consrictor muscles above medially below medial pterygoid and ramus of mandible identification of triangles identification of ascending palatine and ascending pharyngeal ( resident friend) artery

7. Finally identification of our friends ica and jugular and vagus in the upper triangle formed by s c m stylopharyngeus and stylo glossusmuscles inferiorly mtm and mandible v3 branches entering infra temporal space are important things.

Trans oral endoscopy of pps is gaining popularity now a days a new procedure hence friends just pass deeper to tonsil we see wonders The video is thrilling to see It is a anatomical feast

finally identification of our friends ica and jugular andvagus in the upper triangle formed by s c m stylopharyngeus and stylo

glossusmuscles

Dear surgeons it is trans oral endoscopic pic of parapharyngeal space to show ascending pharyngeal artery and other structures of neck

1ascending palatine artery 2 ascending pharyngeal artery 3 ica 4 ij v 5 stylo pharyngeus muscle

ARTERY OF TROUBLE ARTERY OF TROUBLE: The inferior tympanic artery which supplies medial wall of middle ear. Normally it is a small branch of ascending pharyngeal artery a middle terminal twig along with anterior pharyngeal branch and posterior neuro meningeal branch. In 50% cases, it is visible But in glomous tumours the major blood supply to the tumour is from this artery. In glomous tumours it is engorged more than 8 times Inferior tympanic artery enter the floor of middle ear through tympanic canaliculus at crotch along with jocobsons nerve. Finiculus island mark to this artery entry.

Surgical implications:• 1) In glomus tympanicus tumours initial coagulation of this vessel at the

region of finiculus reduces bleeding• 2) It can have anastomoses with petrous segment of ICA so glomous

tumour may be supplied by EAC and ICA

1 Inferior tympanic artery 2 anterior crus of stapes 3 long process of incus 4 malleus

1 Inferior tympanic artery 2 anterior crus of stapes 3 long process of incus 4 malleus

Paraphayrngeal JNA removal by Endoscopic trans-oral approach by Dr.Janakiram

Another case of MUCOEPIDERMOID TUMOR – OPERATED TWICE BEFORE.. ENDOSCOPIC TRANSORAL EXCISION by Dr.Janakiram –

Click

https://www.facebook.com/narayanan.janakiram/media_set?set=a.862837223808213.1073741939.100002458306921&type=3

Trans-Oral approach to CVJ [ cranio-vertebral junction ]

Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palatewas excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally.

D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebralbody and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica:

anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis

muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil,saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.

Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palatewas excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally.

D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebralbody and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica:

anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis

muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil,saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.

TRANSORBITAL ENDOSCOPICAPPROACHES TO THE ANTERIOR

CRANIAL FOSSA

Updated soon

Read Chapter 15 TRANSORBITAL ENDOSCOPICAPPROACHES TO THE ANTERIOR

CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y

Sree ram murthy sir dissection in italy Dear surgeons to day we dissected Transorbital approach to infratemporal fossa on cadaver under guidence of pro Sellari franchisco of PISA italy He is expert for this approaches So far he has done 1980 cases through approach The main indications are

1 orbital decompression 2 clenoid meningiomas and other tumours of anterior cranial fossa 3cavernous sinus pathologies 4 meckles cave tumours 5 infratemporal fossa pathologies 6 this one approach is for all pathologies of anterior middle cranial and infra temporal fossa

superior lid incision sub periosteal elivation of globe identification of sof and meningo orbital artery drillng of greater wing of sphenoid for mid fossa alittle inferior for itf frotal bone for acf and incision of dura finally visualisation of structures are steps these are some pics

Dr. Sree ram murthy & Pro Sellari franchisco of PISA italy

TRANSORBITAL ENDOSCOPICAPPROACHES TO THE MIDDLE

CRANIAL FOSSA

Orbital apex

ORBIT

• 1. Two Ice cream cones in orbit -mnemonic - SOF & IOF - superior orbital fissure & inferior orbital fissure.

• 2. Bone between OC ( optic canal ) & SOF is optic strut ( OS)

• 3. Bone between SOF & V2 ( foramen rotundum ) is MS ( maxillary strut ) - front door of cavernous sinus

• 4. So SOF is presents between two struts - OS & MS• 5. Bone above SOF is LWS ( leader wing of

sphenoid )• 6. Bone between SOF & IOF is GWS ( greater wing

of sphenoid )• 7. Four semilunar lines 1, 2, 3, 4 are - orbital surface

of frontal bone , orbital surface of zygomatic none , orbital surface of maxillary none , laminae papyracea resp.

• 8. Medial wall of SOF is nothing but nasal surface of SOF which is just anterior to cavernous sinus

ORBITAL APEX [ SOF = ALSC + Orbital apex]

Extraconal & intraconal compartmements

A - trajectory leads to middle cranial fossa B - trajectory leads to infra-temporal fossa

GWS=Greater wing of sphenoid LWS = Lesser wing of sphenoid

Updated soon

Read Chapter 34 TRANSORBITAL ENDOSCOPICAPPROACHES TO THE MIDDLE

CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y

Six handed technique ??

Read Chapter 34 TRANSORBITAL ENDOSCOPICAPPROACHES TO THE MIDDLE

CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y

TRANS ORBITAL APPROACH cadaveric approach to middle cranial fossa In future it will be good easy approach for ent surgeons It is devised by pro castelneuvo with my friends Dallan and Battaglea

There are 3 approaches to ent surgeons for cavernous sinus 1 trans sellar approach 2 transpterygoid approach 3 trans orbital approach - this approach is easy .

The trans orbital approach steps are 1 upper lid incision 2 subperiosteal dissection of globe and identification superior orbital fissure and meningo orbital artery 3 identification of c s 4 seperation of two walls of c s 4 identification of structures 5 incision of mid cranial fossa dura 6 meckles cave visualisation along with other structures - small incision , no injury to eye , entrance of cv in between two layers , no much bleeding , no csf leaks are advantages .

TRANSORBITAL ENDOSCOPICAPPROACHES TO THE MIDDLE

CRANIAL FOSSA – cadaver study

meningo orbital artery

endoscopic endonasal cadaveric ORBITAL TRANSPOSITION

Murali Chand Nallamothu: What are indications of orbital transposition.

Sree Ram Murthy Dr Vizak ENT: Now a days it is important part the indications 1. removal of infections lateral to mid pupillary level 2. lateral osteomas of frontal sinuses 3. trans orbital approaches to middle cranial tumours 4. exposure of cavernous sinus trans orbitally

I think 1 & 2 indications can be done by external approaches by brow or bicoronal incisions

Sree Ram Murthy Dr : Dear surgeons it is a endoscopic endonasal cadaveric ORBITAL TRANSPOSITION technique

The steps follows

1 complete exposure of anterior skull base2 identification of septal branch of a e a and 1st olfactory fibre3 removal of lamina papyracea4 identification of aea and pea 5 cutting of both arteries and release the globe 6 gentle lateralization globe along with periorbita up to mid pupillary point7 complete exposure of medial orbital roof and further according to pathology

1 septal branch of a e a

2 orbital roof4 posterior ethmoidal groove

3 first olfactory fibre

For Other powerpoint presentatioins of “ Skull base 360° ”

I will update continuosly with date tag at the end as I am getting more & more information

click

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