scholarly journals Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

2019 ◽  
Vol 131 (3) ◽  
pp. 911-919 ◽  
Author(s):  
Ariel Kaen ◽  
Eugenio Cárdenas Ruiz-Valdepeñas ◽  
Alberto Di Somma ◽  
Francisco Esteban ◽  
Javier Márquez Rivas ◽  
...  
Keyword(s):  
Skull Base ◽  
Anatomical Study ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Anatomical Structures ◽  
Lateral Skull Base ◽  
Pharyngobasilar Fascia ◽  
Vidian Canal ◽  
Relationship Of

OBJECTIVEThe endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway.METHODSEight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed.RESULTSThe endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym—VELPPHA—to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach.CONCLUSIONSThe VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the endoscopic endonasal transpterygoid approach expanded to the lateral aspect of the skull base, especially when treating patients with poorly pneumatized sphenoid sinuses.

Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks

2007 ◽  
Vol 106 (1) ◽  
pp. 157-163 ◽  
Author(s):  
Domenico Solari ◽  
Francesco Magro ◽  
Paolo Cappabianca ◽  
Luigi M. Cavallo ◽  
Amir Samii ◽  
...  
Keyword(s):  
Skull Base ◽  
Anatomical Study ◽  
Spatial Relations ◽  
Pterygopalatine Fossa ◽  
Direct Access ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Invasive Approach

Object The pterygopalatine fossa is an area that lies deep within the skull base. The recent extensive use of the endoscopic endonasal approach has provided neurosurgeons with a method to reach various areas of the skull base through a less invasive approach than traditional transcranial or transfacial approaches. This study aims to provide neurosurgeons with new data concerning direct endoscopic measurements and precise anatomical topography features of the pterygopalatine fossa. Methods An anatomical dissection of six fixed cadaver heads (12 pterygopalatine fossae) was performed to analyze spatial relationships and distances between the most important neurovascular structures in this region, and to estimate the size of the endoscopic surgical field for operations in this area. The endoscopic endonasal approach offers direct access to the pterygopalatine fossa through its anteromedial walls. Conclusions Using an endoscopic endonasal approach makes it possible to identify all of the anatomical landmarks of the pterygopalatine fossa and almost all of the contiguous skull base areas.

Anatomical study of occipital triangles: the ‘inferior’ suboccipital triangle, a useful vertebral artery landmark for safe postero-lateral skull base surgery

2017 ◽  
Vol 159 (10) ◽  
pp. 1887-1891 ◽  
Author(s):  
Giuseppe La Rocca ◽  
Roberto Altieri ◽  
Luca Ricciardi ◽  
Alessandro Olivi ◽  
Giuseppe Maria Della Pepa
Keyword(s):  
Vertebral Artery ◽  
Skull Base ◽  
Skull Base Surgery ◽  
Anatomical Study ◽  
Lateral Skull Base

Radiographic Analysis of the Vidian Canal and Its Utility in Petrous Internal Carotid Artery Localization

2018 ◽  
Vol 15 (5) ◽  
pp. 577-583 ◽  
Author(s):  
Eric C Mason ◽  
Patricia A Hudgins ◽  
Gustavo Pradilla ◽  
Nelson M Oyesiku ◽  
C Arturo Solares
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Expert Knowledge ◽  
Average Distance ◽  
Surgical Approaches ◽  
Endoscopic Endonasal ◽  
Computed Tomographic ◽  
Vidian Canal

Abstract BACKGROUND Endoscopic endonasal surgery of the skull base requires expert knowledge of the anatomy and a systematic approach. The vidian canal is regarded as a reliable landmark to localize the petrous internal carotid artery (pICA) near the second genu, which can be used for orientation in deep skull base approaches. There is controversy about the relationship between the vidian canal and the pICA. OBJECTIVE To further establish the vertical relationship between the vidian canal and the pICA to aid in surgical approaches to the skull base. METHODS We utilized a collection of institutional review board-approved computed tomographic (CT) angiograms (CTAs). Fifty CTAs were studied bilaterally for 100 total sides. The vidian canal was visualized radiographically to determine whether it terminates below, at, or above the level of the pICA. RESULTS Sixty-six of 100 vidian canals terminated inferior to the pICA (66%), which was the most common relationship observed. The average distance inferior to the pICA was 1.01 mm on the right, 1.18 mm on the left, and 1.09 mm of the total 66 sides. Less commonly, the vidian canal terminated at the level of the pICA canal in 34 sides (34%). The vidian canal was not observed to terminate superior to the pICA in any of the 50 CTAs studied. CONCLUSION The vidian canal terminates inferior to the pICA most commonly, but often terminates at the level of the pICA. Careful drilling clockwise inferior to superior around the vidian canal should allow for safe pICA localization in most cases.

Managing Cerebrospinal Fluid Rhinorrhea after Lateral Skull Base Surgery via Endoscopic Endonasal Eustachian Tube Closure

2015 ◽  
Vol 29 (3) ◽  
pp. 207-210 ◽  
Author(s):  
Lori A. Lemonnier ◽  
Belachew Tessema ◽  
Arjuna B. Kuperan ◽  
Deya N. Jourdy ◽  
Fred F. Telischi ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Eustachian Tube ◽  
Skull Base Surgery ◽  
Endoscopic Endonasal ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Lateral Skull Base ◽  
Tube Closure

Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations

2005 ◽  
Vol 19 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Luigi M. Cavallo ◽  
Andrea Messina ◽  
Paul Gardner ◽  
Felice Esposito ◽  
Amin B. Kassam ◽  
...  
Keyword(s):  
Skull Base ◽  
Anatomical Study ◽  
Pterygopalatine Fossa ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Anatomical Dissection ◽  
Clinical Considerations ◽  
Functional Surgery ◽  
Safe Approach

Object The pterygopalatine fossa is an area located deep in the skull base. The microsurgical transmaxillary–transantral route is usually chosen to remove lesions in this region. The increasing use of the endoscope in sinonasal functional surgery has more recently led to the advent of the endoscope for the treatment of tumors located in the pterygopalatine fossa as well. Methods An anatomical dissection of three fresh cadaveric heads (six pterygopalatine fossas) and three dried skull base specimens was performed to evaluate the feasibility of the approach and to illustrate the surgical landmarks that are useful for operations in this complex region. The endoscopic endonasal approach allows a wide exposure of the pterygopalatine fossa. Furthermore, with the same access (that is, through the nostril) it is possible to expose regions contiguous with the pterygopalatine fossa, either to visualize more surgical landmarks or to accomplish a better lesion removal. Conclusions In this anatomical study the endoscopic endonasal approach to the pterygopalatine fossa has been found to be a safe approach for the removal of lesions in this region. The approach could be proposed as an alternative to the standard microsurgical transmaxillary–transantral route.

scholarly journals The use of an O-arm in endonasal endoscopic operations of the skull base

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Vlastimil Novák ◽  
Lumír Hrabálek ◽  
Jan Valošek ◽  
Jakub Jablonský ◽  
Jiří Hoza ◽  
...  
Keyword(s):  
Skull Base ◽  
Ct Scans ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
X Ray ◽  
Mean Error ◽  
Neuronavigation System ◽  
Hypophyseal Adenoma ◽  
The Mean ◽  
Ct And Mri

Abstract Background Endoscopic endonasal transsphenoidal approaches are broadly used nowadays for a vast spectrum of pathologies sited in the anterior and middle cranial fossa. The usage of neuronavigation systems (neuronavigation) in these surgeries is crucial for improving orientations deeply inside the skull and increasing patient safety. Methods The aim of this study was to assess the use of optical neuronavigation, together with an intraoperative O-arm O2 imaging system, in a group of patients with hypophyseal adenoma that underwent a transnasal transsphenoidal surgery, and correlate the accuracy and its deviation during the navigational process against the use of conventional neuronavigation that uses preoperative MRI and CT scans. The overall group consisted of six patients, between 39 and 78 years old, with a diagnosis of hypophyseal adenoma. Patients were treated with an endoscopic transsphenoidal technique and all of them underwent preoperative MRI and CT scans of the brain. These images were used in the neuronavigation system StealthStation S7® during the surgery, where we defined two bony anatomical landmarks, such as a vomer or the origin of an intrasphenoidal septum, in each operated patient. The tip of the navigational instrument, under endoscopic control, pointed to these landmarks and the distance between the tip and the bony structure was measured on the neuronavigation system. Afterwards, intraoperative 3D x-ray imaging was performed via the mobile system O-arm O2® system with automatic transfer into the navigational system. Under endoscopic guidance, we localized the identical bony anatomical landmarks used in the previous measurement and re-measured the distance between the tip and bony landmark in images acquired by the O-arm. The results of both measurements were statistically compared. Results The mean error of accuracy during conventional neuronavigation with usage of preoperative CT and MRI scans was 2.65 mm. During the neuronavigation, with utilization of intraoperative 3D O-arm images, the mean error of accuracy 0 mm. These mean errors of accuracy (both measurement methods were compared by nonparametric Wilcoxon test) had a statistically significant difference (p = 0.043). Conclusions Based on this preliminary clinical study, we conclude that the O-arm is capable of providing intraoperative x-ray 3D images in sufficient spatial resolution in a clinically feasible acquisition. The mean error of accuracy during intraoperative navigation, based on 3D O-arm scans at the skull base, is significantly lower compared to the usage of navigation using conventional presurgical CT and MRI images. This suggests the suitability of this method for utilization during endoscopic endonasal skull base approaches.

The cochlear aqueduct: An important landmark in lateral skull base surgery

1998 ◽  
Vol 118 (4) ◽  
pp. 532-536
Author(s):  
Asim Aslan ◽  
Maurizio Falcioni ◽  
Fatih Ridvan Balyan ◽  
Giuseppe De Donato ◽  
Abdelkader Taibah ◽  
...  
Keyword(s):  
Skull Base ◽  
Sagittal Plane ◽  
Skull Base Surgery ◽  
Cranial Nerves ◽  
Close Relation ◽  
Cochlear Aqueduct ◽  
Lateral Skull Base ◽  
Important Landmark ◽  
Temporal Bones ◽  
Relationship Of

The cochlear aqueduct (CA) is used as a landmark in lateral skull base surgery. In this study anatomic relationships between the CA and adjacent neurovascular structures were examined by dissecting 32 temporal bones. Observations of the relationship of the external opening (EO) of the CA with the ninth, tenth, and eleventh cranial nerves, inferior petrosal sinus (IPS), and intrapetrous carotid artery (ICA) were noted. In addition to the distance of the EO of the CA to the vertical portion of the ICA, the entire length of the CA and the width of the EO were also measured. The ninth nerve was the only structure lodged at the EO of the CA in 34.4% of bones. However, in 40.6% of bones only the IPS crossed the EO of the CA, although the ninth nerve was situated just anteroinferiorly in the vicinity of the EO. In 15.6% of bones it was possible to observe both the ninth nerve and the IPS crossing the EO. In 9.4% of bones the EO of the CA was found to be occupied by the tenth and eleventh nerves. It was also observed that the ICA was located anteriorly on the same sagittal plane with the EO in 15.6% of bones. It was concluded that although in 90% of cases the EO of the CA was in close relation with the ninth nerve, other structures such as the IPS, the tenth and eleventh cranial nerves, and the ICA were also at risk during drilling in this area because of their intimate relationships with the EO of the CA.

scholarly journals Osteological studies of skull base neurovascular area in reference to infratemporal approach to skull basec

2021 ◽  
Vol 4 (3) ◽  
pp. 89-93
Author(s):  
Harsh Sharma
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Relative Size ◽  
Jugular Foramen ◽  
Surgical Approaches ◽  
Carotid Canal ◽  
Stylomastoid Foramen ◽  
Lateral Skull Base ◽  
Infratemporal Approach ◽  
Relationship Of

Surgical approaches to the lateral skull base often lead to tearing of vessels and piecemeal removal of the tumour. This study is aimed to delineate exact relationship of the various foramina at the lateral skull base. The coronal dimensions of the jugular foramina are larger as compared to sagittal with right sided dominance also noticed in the case of carotid canal. The width of “Keel” separating the carotid and jugular foramina normally varies from 0.4 to1.4 centimetres and may not always suggest the erosion of the foramen of skull base scans, unless the erosion is associated with irregularity or demineralization the thickness of this keel really depends upon relative size of the vessels and location of foramina. Area between stylomastoid foramen, carotid canal and jugular foramen is roughly wedge shaped. The angle subtended by carotid and jugular at the stylomastoid foramen is about 36.84whereas the location of stylomastoid foramen and internal carotid axis pose an angle of 83:16. The angle subtended by stylomastoid and jugular at carotid on an average 59:31. The space between these structures is measured to be 0.642centimetres which can be verified on tomograms. By using these measurements, the precise location of the upper end of the vessels could be predicted, whereas the superior stump could be clamped with minimal exposure of the skull base and identification and location of the last four cranial nerves is found out. This could avoid injuries and subsequent morbidity while carrying out surgery in this region.

scholarly journals Expanded Endoscopic Endonasal Approach to Anterior and Ventral Skull Base: An Evolving Paradigm

2013 ◽  
Vol 2013 ◽  
pp. 1-11 ◽  
Author(s):  
Balwant Singh Gendeh
Keyword(s):  
Skull Base ◽  
Cranial Base ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Perioperative Morbidity ◽  
Number Of Patients ◽  
Cranial Base Surgery ◽  
Long Term Impact ◽  
Ventral Skull Base

The transition from external approaches to an endonasal corridor has seen a significant decline in patient morbidity and inpatient care. Our Rhinology and Cranial Base Surgery Group has been able to focus on the management of certain pathologies, endoscopic access to various areas in the skull base, reconstruction of the defect, ensuring that clear anatomical landmarks can be identified during the surgery, and improving the quality of life/function after treatment. The focus on surgical treatment is always to control disease and cure patients by not only reducing recovery time and perioperative morbidity, but also decreasing the long-term impact of having a tumour removed. With a dedicated combined operating theater setting with updated instrumentation, the Neuro-ENT team is able to continue to expand and develop endoscopic care for a greater number of patients and wider range of pathologies. The collaborative Neuro-ENT to work closely via the nose using the two-hole and four-hand technique when performing the operation simultaneously is of added advantage in the diverse and expanding field of cranial base surgery. Our skull base team is joined by expert radiation and medical oncologists who provide essential adjunctive care in the multidisciplinary management of these patients.

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