[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Original Article Anatomic study and clinical significance of extended endonasal anterior skull base surgery
Shousen Wang*, Jian Lv1*, Liang Xue*, Zhiyu Xi, Heping Zheng2, Rumi Wang
Department of Neurosurgery, 2Research Center of Clinical Anatomy, Fuzhou General Hospital, Fujian Medical University, Fuzhou, 1Department of Rehabilitation, Laiwu Steel Hospital, Taishan Medical University, Laiwu, People's Republic of China *The authors named Shousen Wang, Jian Lv and Liang Xue contributed equally to this work.
Abstract
Objective: This study is to investigate the anatomical relationship of endonasal approach for anterior skull base surgery, and to determine the boundaries between anterior basicranial craniotomy and the security of operative techniques. Materials and Methods: A total of 10 adult dry skulls and 13 adult cadaveric heads processed by formalin were examined under operating microscope. The micro‑anatomic structures of the turbinate, sphenoid sinus, ethmoid sinus, anterior ethmoidal artery, posterior ethmoidal artery and anterior skull base were observed. Artificial anatomy was performed and the deep‑seated regions of the surgical approach were observed under operating microscope and endoscope. Results: Examined from the intracranial and intranasal aspects, it was found that the middle turbinate, uncinate process, ethmoid bulla, lamina papyracea, anterior ethmoid canal, posterior ethmoid canal, prominence of the optic canal and opticocarotid recess were all important anatomic landmarks for surgery. The horizontal distances between medial orbital wall on both sides at the level of crista galli, anterior ethmoid canal, and posterior ethmoid Address for correspondence: Pro. Shousen Wang, canal were (22.31 ± 3.08) mm, (23 ± 2.93) mm, and (26.25 ± 2.88) mm, respectively. Department of Neurosurgery, Fuzhou The distance between the double optic canal cranial opening was (14.67 ± 3.82) mm. General Hospital, Fujian Medical Conclusions: During the endonasal approach for anterior skull base surgery, full advantage University, No. 156, Xi’erhuanbei Road, of the surgical corridor made by the middle turbinate resection should be taken. To control Fuzhou - 350 025, People's Republic of intraoperative bleeding, it is critical to identify anterior and posterior ethmoidal artery. China. Identification and protection of medial orbital wall and the optic nerve, and controlling E‑mail: [email protected] the ranges of anterior basicranial craniotomy are of great importance for surgical safety. Received : 16‑06‑2014 Review completed : 25‑08‑2014 Key words: Anterior skull base, endonasal approach, ethmoidal artery, microsurgery Accepted : 05‑10‑2014 surgical anatomy
Introduction endonasal approaches, skull base surgery has increased probabilities of resection of a variety of skull base lesions. Over the last decade, with the development of extended In 1987, endonasal and transsphenoidal surgery for pituitary adenoma was introduced by Griffith.[1] Since Access this article online then, a number of pioneers of endonasal skull base surgeries subsequently emerged and the endonasal Quick Response Code: Website: www.neurologyindia.com approach has greatly developed. For example, the practice of endonasal approach for resection of PMID: *** ethmoidal labyrinths has lasted for one century, and there is certain understanding of anatomical relations DOI: about this approach.[2] When using endonasal approach 10.4103/0028-3886.144451 for anterior skull base surgery, the lamina cribrosa
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Wang, et al.: Anatomy of anterior skull base surgery
planum sphenoidale or tuberculum sellae is opened. Instruments The endonasal approach is mainly used to remove Common surgical instruments were provided by the olfactory groove meningiomas and tuberculum sellae hospital. The other instruments include: Microscope meningiomas. Compared with craniotomy, endonasal (Zhongtian Optical Instrument Co., Ltd. Zhenjiang, approach avoids brain retraction and greatly reduces China), endoscope (Pv 430 Aesclup Neuroendoscopy, direct injury to intracranial nerves and blood vessels. In AESCULAP, Inc. ‑Berlin, Germany), FinePix S5600 recent years, with the continuous progresses of ethmoid digital camera (FUJIFILM Corporation Tokyo, Japan), sinus anatomy and operation equipment, the researches vernier calipers with a precision of 0.02 mm (Ningbo on expanded endonasal approach for anterior skull base Great Wall Precision Industrial Co., Ltd Ningbo, China). surgery are developing rapidly. According to Casiano et al.,[3] nasal endoscope assisted endonasal approach Dry skull anatomy surgery can be used to safely handle most cases of The anterior ethmoid sinus, posterior ethmoid sinus, olfactory neuroblastoma that invaded anterior skull and anterior basicranial bone were opened. Anatomical base. And, the resection area of nasal endoscope‑assisted relationship between anterior ethmoid canal, posterior endonasal approach is not less than that of the ethmoid canal, sphenoid sinus, ethmoid sinus, and cranio‑facial combined approach. Fernandez Miranda lamina cribrosa were observed. et al., and Liu et al.,applied this approach in the treatment of olfactory groove meningiomas.[4,5] Padhye et al.,[6] Antiseptic cadaveric cranial anatomy successfully removed anterior cranial fossa meningiomas The craniums of 10 cadaveric heads were sawed away by using this endoscopic endonasal approach. Kassam along the l. 0 cm horizontal lines between superciliary et al.,[7,8] managed lesions in midline anterior skull base ridge and superior margin of the external occipital in children. Patel et al.,[9] performed a resection of a huge protuberance, succeeded by removal of brain tissues. osteoblastoma with nasal endoscope assisted endonasal The location of anterior ethmoidal artery and posterior approach surgery. Lee et al.,[10] treated tumors in the ethmoidal artery throughout the anterior skull base orbital apex with this approach. Faggin et al.[11] used and their relationship with the duramater and lamina endoscopic microsurgery‑combined transethmoid cribrosa were observed from intracranial aspect. The operation to treat children with pituitary lesions and anterior basicranial bone was moved with the opening achieved good operation effects. They pointed that of the anterior and posterior ethmoid sinus. The adjacent compared to traditional craniotomy, endonasal approach relationship of ethmoid sinus and optic canal was had distinct advantages of less complications and short investigated and the distance was measured. Anterior hospitalization time. and posterior ethmoidal arteries were identified and the anatomical relations of their courses to ethmoid roof and The anatomical relation of endonasal approach for the lamina papyracea were observed. The relationship anterior skull base surgery is complicated and the between anterior ethmoid artery, posterior ethmoidal operation is hard to be managed. As a result, a series of artery, and ophthalmic artery was detected. Observation basic scientific observations have been focused on the of lateral boundary of operation field was taken from applied anatomy.[12‑14] However, prevention of bleeding intranasal aspects and intracranial aspects. The lateral during surgery and delayed postoperative bleeding is wall of ethmoid sinus and sphenoid sinus was confirmed, rarely studied.[6] Identification of anatomical landmarks and the distance between medial orbital wall and optic and their relations during endonasal approach is canal was measured. important for bleeding control. Thus, in this study, we have performed endonasal approach in skull and Simulation of expanded endonasal approach for cadaveric head specimens. The microanatomic structures anterior skull base surgery were examined. The other three antiseptic cadaveric heads were fixed on the autopsy table to imitate the endoscopic endonasal Materials and Methods transsphenoidal approach. The structures of middle turbinate, uncinate process and sphenoethmoidal recess Specimens were identified under microscope. Sphenoid sinus A total of 10 dry skulls (20 sides) and 13 cadaveric ostium was identified and the internal structures of the heads (26 sides) processed by formalin were enrolled sphenoid sinus were observed by using endoscope. in this study. The specimens were all of adults Anterior ethmoidal artery was exposed after removing (age 20-70 years) of Han from South China. They died the middle turbinate, uncinate process and anterior wall of other reasons but not with brain diseases, and no of ethmoid bulla. Anterior ethmoid sinus was cleaned obvious abnormalities were detected. The study plan backward along the lamina cribrosa. Basal lamellae of was approved by the medical ethics committee of Fuzhou the middle turbinate were removed, and then posterior General Hospital, Fujian Medical University, China. ethmoidal artery was revealed by opening of posterior
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Wang, et al.: Anatomy of anterior skull base surgery
ethmoid sinus backward along the ethmoid roof. of the specimens. Two sides of skull specimens in this Prominence of the optic canal and the prominence study were without posterior ethmoid canal. Posterior of internal carotid artery were searched backward. ethmoid sinus could be divided into four types Lamina cribrosa and anterior basicranial bone were according to the relationship between the positions opened upward and the olfactory nerve was found of ethmoid sinus back wall and optic canal. These and isolated from lamina cribiosa. The region around four types and the frequency of each type were as midline anterior skull base was exposed and observed follows: Anterocanal type (20%), semicanal type (45%), subsequently. whole‑canal type (20%), and sella turcica type (15%). Identical pneumatization on both sides accounted for Results 60%, while diverse pneumatization accounted for 40%.
The ethmoid canals of the dry skulls The ethmoidal artery of cadaveric heads Ethmoid canal is a bony pipeline in the ethmoid Ophthalmic artery went forward along the orbit sinus with two portals at both ends. The swelled ends after passing through the orbital opening [Figure 2]. serve as anatomical landmarks for ethmoid canal and Ophthalmic artery branched into anterior and posterior facilitate the detection. Generally, anterior ethmoid ethmoidal arteries successively, which then entered the canal is distributed from the lamina papyracea toward corresponding ethmoidal foramen, respectively. As anteromedial part of ethmoid sinus while posterior observed from the superior aspect, ophthalmic artery ethmoid canal is distributed from the lamina papyracea together with the anterior and posterior ethmoidal artery toward the posteromedial part of ethmoid sinus. showed the shape of “F” in eight sides of specimens. In However, there were certain variations in the courses two sides of specimens, anterior and posterior ethmoidal of anterior and posterior ethmoid canals [Figure 1]. arteries were branched simultaneously from ophthalmic Anterior ethmoid canal might locate in the bony plate artery, and the three arteries showed the shape of “K”. of anterior ethmoid roof, between the bone plate and This “K”‑shaped distribution could be divided into ethmoid mucous membrane, or in anterior ethmoid three subtypes of K1 type, K2 type, and K3 type. In cells, as observed in six sides, 10 sides, and four sides K1 type, both the ethmoidal arteries were branched of the specimens. There were 2 sides with the middle simultaneously before the anterior ethmoidal foramen. ethmoid canal between the anterior and posterior In K2 type, ethmoidal arteries were branched between ethmoid canal. The course of this middle ethmoid the anterior and posterior ethmoidal foramen. In K3 type, canal was similar to that of posterior ethmoid canal. ethmoidal arteries were branched behind the posterior Posterior ethmoid canal located in the bony plate of ethmoidal foramen. There were two sides of specimens posterior ethmoid roof, between the bone plate and with K1 type, six sides with K2 type and four sides with ethmoid mucous membrane, or in posterior ethmoid K3 type. cells, as observed in six sides, 10 sides and two sides
Figure 2: Course of the ethmoidal artery in orbit. The brown line Figure 1: Schematics of position variation of the anterior and posterior represents the course of the anterior ethmoidal artery entering into the ethmoidal canal (Sagittal section). The anterior ethmoidal canal was ethmoid sinus through the anterior ethmoidal foramen. The orange line located in the bony plate of the anterior ethmoid roof (A), between the indicates the course of the middle ethmoidal artery entering into the anterior ethmoid roof and the ethmoid sinus mucosa (B), and in the ethmoid sinus through the middle ethmoidal foramen. The blue line anterior ethmoid cells (C). The posterior ethmoidal canal was located in represents the posterior ethmoidal artery entering into the ethmoid the bony plate of the posterior ethmoid roof (D), between the posterior sinus through the posterior ethmoidal foramen. PEF, posterior ethmoid ethmoid roof and the ethmoid sinus mucosa (E), and in the posterior foramen. AEF, anterior ethmoid foramen. MEF, middle ethmoid foramen. ethmoid cells (F) AE, anterior ethmoid sinus
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Wang, et al.: Anatomy of anterior skull base surgery
Anterior and posterior ethmoidal arteries were field of the anterior skull base is relatively broad located in the ethmoidal sinus after entering into in the front, quite broad in the middle while rather the corresponding ethmoid canal though anterior narrow in the back [Figure 4]. At the back of anterior and posterior ethmoidal foramen, respectively. The skull base, opticocarotid recess in the lateral wall anterior and posterior ethmoidal arteries entered the of sphenoid sinus was the anatomical landmark for nose via the corresponding ethmoid canal, supplied identifying the bilateral cranial opening of bilateral the ethmoidal sinuses, and entered the skull to supply optic canals [Figure 5]. This location represents the meninges. Anterior ethmoidal artery was divided pneumatized inner cavity of anterior clinoid process. into nasal septal branch, lateral nasal branch, nasal dorsal branch, dural branch and lamina cribrosa The findings of simulated endonasal anterior skull branch. Posterior ethmoidal artery was divided into base surgery nasal septal branch, lateral nasal branches and lamina After the nasal cavity was opened, the structure of cribrosa branch [Figure 3]. middle turbinate, uncinate process and sphenoethmoidal recess was identified under microscope and sphenoidal The operating view field of skull base surgery ostium was found. Anterior ethmoid sinus was exposed The medial walls of both orbits were the lateral by resection of middle turbinate, uncinate process and boundaries of endonasal transsphenoidal and anterior wall of ethmoid bulla. After the anterior ethmoid transethmoidal skull base surgery. If this boundary was sinus was cleaned, anterior ethmoidal artery could be exceeded, the lamina papyracea would be damaged, found by examining from the front to posterior‑superior the fat in the orbits would spill over, and the optic part . After the basal lamellae of the middle turbinate nerve would be injured. The distance between medial were removed and the posterior ethmoid sinus was orbital walls on both sides was different as a result of opened backward along the ethmoid roof, the posterior the diverse measuring locations adopted. The distances ethmoidal artery was found. The prominence of optic canal and prominence of internal carotid artery were measured in the middle of crista galli, anterior, and found when searching backward [Figure 6]. posterior ethmoid canal were (22.31 ± 3.08) mm (range 18.7-27.4 mm), (23 ± 2.93) mm (range 19.7-28.1 mm), and (26.25 ± 2.88) mm (range 21.9-31.4 mm). The Discussion distance between medial margins of the cranial openings of the bilateral optic canals was (14.67 ± 3.82) The midline expanded endonasal approach to the mm (range 9.8-2.1 mm). These four groups of distances cranial base can be broadly divided into four approaches gradually broadened from the crista galli to posterior along rostrocaudal axis: Transcribriform approach, ethmoid canal and then narrowed after the posterior transrubercular/transplanum approach, transsellar ethmoid canal. The data indicates that the operating
Figure 4: Anatomical structures of the midline anterior skull base (Superior view). The roof of the frontal sinus, the ethmoid sinus and the sphenoid Figure 3: The cranial openings of the ethmoidal canal. The brown line in sinus was mostly removed. This figure showed the infundibulum of the lateral margin of the olfactory fossa represents the dura mater branch of frontal sinus, the ethmoidal cells and the roof mucosa of the sphenoidal the anterior ethmoidal artery. The orange line indicates the dura mater sinus. The four horizontal arrows represent the maximum opening window branch of the middle ethmoidal artery. The blue line represents the dura width of the anterior skull base at the level of the central crista galli, the mater branch of the posterior ethmoidal artery. The cranial opening of anterior ethmoidal canal, the posterior ethmoidal canal and the optic canal the optic canal was located at the medial side of the anterior clinoid cranial opening, respectively. Note that the right prominence of the optic process. The red line represents the ophthalmic artery. Crista galli (CG), canal bulges into the Onodi cell. Frontal sinus (FS), anterior ethmoid ophthalmic artery (OA), anterior clinoid process (ACP) sinus (AE), posterior ethmoid sinus (PE)
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Wang, et al.: Anatomy of anterior skull base surgery
approach for resection of anterior skull base tumor under the microscope is suitable for small range lesions in the midline anterior skull base. We suggest that the lesion diameter should be no more than 2.5 cm.
According to de Divitiis et al.,[16] in the treatment of tuberculum sellae meningiomas, the anterior boundary of craniotomy window was between planum sphenoidale and posterior ethmoidal artery, posterior boundary was the upper part of anterior sellar wall, and, the lateral boundary was the opticocarotid recess. While dealing with olfactory groove meningiomas, the anterior boundary was the back wall of frontal sinus, the posterior boundary was posterior ethmoidal artery, and the lateral boundary was the medial orbit walls on both Figure 5: The opticocarotid recess and its adjacent structures. The sides. It was of great importance to identify and protect ethmoid sinus in this specimen developed well. The back wall was reared and the posterior ethmoid sinus formed suprasphenoid cells. The the boundary structures. In addition, the width in one opticocarotid recess was located in the Onodi cell. Posterior ethmoid case of anterior basicranial meningioma was 3.8 cm, sinus (PE), optic nerve protuberance (ONP), tuberculum sellae recess and in another case it was 6 cm.[16] We suppose that it is (TSR), sphenoid sinus (SS), clivus recess (CR), sellar floor (SF), carotid protuberance (CAP), opticocarotid recess (OCR) extremely difficult to resect the lesion that is close to the lateral boundary in these two cases through endonasal approach, and transclival approach,[8] among which, the anterior skull base surgery. And, the operation risk in first two are related to anterior skull base operations. these two cases is relatively high. Additionally, it is Jho and Ha[12] examined the exposure range of three difficult to protect important structures when performing endonasal anterior skull base surgery approaches on endonasal anterior skull base surgery in these two cases. six cadaveric heads. They found that the exposure range Thus, cases like these two should better be excluded from of the anterior skull base in the middle turbinectomy this endonasal approach. approach was the largest, followed by paraseptal approach. Middle meatal approach only exposed Ohnishi et al.,[17] studied endonasal microsurgery of the 2/3 the width of olfactory groove. Thus, the middle ethmoid sinus in 190 cases and suggested that handling meatal approach was suitable for the treatment of of anterior and posterior ethmoidal artery and the cerebrospinal fluid leakage in the olfactory groove. protection of lamina papyracea and optic canal were very In this study, we also analyzed the surgical approach important. Furthermore, optic nerve damage occurred made by middle turbinectomy and found that resection frequently in endonasal ethmoid sinus surgery.[2] of middle turbinate achieved good exposure view to Therefore, identification and protection of optic canal is anterior skull base. Our results suggest that the middle very important during endonasal approaches. There are turbinate is not only an important anatomic landmark, about 13 kinds of variations in the adjacent relationships but also a structure that has to be removed while among the optic canal medial wall, ethmoid sinus and extending the surgical approach. The distances between sphenoid sinus, with most of them showing in the form the medial orbital wall on both sides at crista galli of optic canal prominence. And, the more pneumatized level and at planum sphenoidale were 24 mm (range the posterior ethmoid sinus is, the more obvious the 22-29 mm) and 27 mm (range 24-30 mm) as reported by optic canal prominence is.[13] Our study found that, Jho and Ha.[12] The distance between the optic nerves the course of the prominence of optic canal and the was 18 mm (range 15-22 mm). Our data showed that prominence of internal carotid artery was crossed. The distances between medial orbital wall on both sides at prominence of optic canal went from the back toward the crista galli level and at the planum sphenoidale were the anterior‑lateral, while the prominence of internal relatively shorter than those reported by Jho and Ha.[12] carotid artery went from the posterosuperior toward This difference might be caused by racial difference. lateral‑inferior direction. These two prominences could Jho and Ha reported that, by this middle turbinectomy exist simultaneously or individually. Prominence of approach, lesions (that were 2 cm in width) in the optic canal and prominence of internal carotid artery midline anterior skull base could be resected. Cook et could be used as a group of anatomic landmarks and as al.[15] adopted paraseptal approach and they suggested cross references during surgery. They could be identified that this approach could handle anterior skull base comprehensively by their morphologies and adjacent meningiomas with a diameter no more than 3 cm. The anatomical landmarks. Our results were consistent with anatomical results in this study suggest that, endonasal the anatomic study by Selcuk et al.,[14] suggesting that
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Wang, et al.: Anatomy of anterior skull base surgery
a b c
d e f
g h i Figure 6: Simulation of expanded endonasal approach for anterior skull base surgery. (a) The middle turbinate inside the left nasal cavity revealed under microscope. The lateral was the middle nasal meatus. The medial was the common nasal meatus and nasal septum. (b) Sagittal plane displayed the maximum extent of resection of the middle turbinate (shown in dotted line). (c) Exposure of the anterior ethmoid sinus and anterior ethmoidal artery. (d) Morphological characteristics of the anterior ethmoidal artery in the ethmoid roof examined after removing the anterior ethmoid sinus mucosa. (e) Morphological characteristics of the posterior ethmoidal artery in the ethmoid roof examined after removing the posterior ethmoid sinus mucosa. (f) The region around the midline anterior skull base exposed after the lamina cribiosa and the anterior basicranial bone was opened upward. (g) The dura mater was removed after the removal of the anterior skull base. (h) The exposed olfactory nerve and pia mater. (i) The olfactory nerve and frontal bottom that exposed after anterior basicranial craniotomy. Brain tissue (BT), dura mater (DM), internal carotid artery (ICA), inferior turbinate (IT), middle turbinate (MT), nasal septum (NS), optic chiasma (OC), olfactory nerve (OFN), olfactory nerve (ON), posterior ethmoid sinus (PE), posterior ethmoidal artery (PEA), pia mater (PM), sphenoid sinus (SS), superior turbinate (ST)
protection of the prominence of optic canal, prominence segment of the ethmoid artery and the lamina cribrosa of internal carotid artery and tuberculum sellae are of branch of the anterior ethmoidal artery. Moreover, we great significance. found that the main trunks of anterior and posterior ethmoidal arteries went along or nearby the bony plate The anatomic structure of ethmoid sinus is complicated of ethmoid roof laterally. After opening the ethmoidal and the corridor of endonasal approach for anterior bulla and when cleaning the upward mucous membrane, skull base operation is rather narrow. So only a little careful attention should be paid. Once the anterior and intraoperative bleeding can lead to poor visibility, posterior ethmoidal arteries were indentified, the skull especially when the operation is combined with base was reached. As the distance between posterior endoscope. Anterior and posterior ethmoidal arteries ethmoidal foramen and optic canal orbital opening was are the main arteries of this area. With some variations 5.1 mm (2.0-8.4 mm),[13] so the posterior ethmoidal artery in their positions, identifying them during surgery and anterior optic nerve canal were mural references. is of certain difficulty. Ohnishi et al.,[17] reported that, Both anterior and posterior ethmoidal artery can be identification of anterior ethmoidal artery in the anterior used as constant marks for endonasal anterior skull ethmoid sinus was very important for the prevention base surgery. of complications. Our study found that, while treating the anterior skull base lesions in the anterior ethmoid In this paper, dissection was performed with combined sinus, hemorrhage was mainly related to the intrasinus microscopic and endoscopic techniques. Anatomical
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Wang, et al.: Anatomy of anterior skull base surgery
structure of the skull base was observed and measured Santoreneos S, et al. Endoscopic endonasal resection of anterior skull in the intracranial aspect and the intranasal aspect, base meningiomas. Otolaryngol Head Neck Surg 2012;147:575‑82. 7. Kassam A, Snyderman CH, Mintz A, Gardener P, Carrau RL. Expanded respectively. We found that, during endonasal anterior endonasal approach: The rostrocaudal axis. Part I. Crista galli to the skull base surgery, the structures of the nasal cavity, sella turcica. Neurosurg Focus 2005;19:E3. sphenoid sinus, ethmoid sinus and skull base were 8. Kassam A, Thomas AJ, Snyderman C, Carrau R, Gardner P, Mintz A, identified. And, the surgical corridor made by the middle et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 2007;106:75‑86. turbinate resection should be taken. It was important 9. Patel AA, Friedel ME, Liu JK, Eloy JA. Endoscopic endonasal resection to identify anterior and posterior ethmoidal arteries of extensive anterior skull base sinonasal osteoblastoma. Otolaryngol and then control the bleeding as quickly as possible. a Head Neck Surg 2012;147:594‑6. Anterior and posterior ethmoidal artery could be used 10. Lee JY, Ramakrishnan VR, Chiu AG, Palmer J, Gausas RE. Endoscopic endonasal surgical resection of tumors of the medial orbital apex and as good land marks for identification of the ethmoid wall. Clin Neurol Neurosurg 2012;114:93‑8. sinus roof and the medial wall of orbit and also as 11. Faggin R, Pentimalli L, Grazzini M, Saetti R, Drigo P, D’Avella D. constant marks for endonasal anterior skull base surgery. Combined endoscopic‑microsurgical approach for transsphenoidal Prominence of the optic canal and the prominence of (sphenopalatine) encephalocele with an intralesional pituitary gland. J Neurosurg Pediatr 2009;4:262‑5. the internal carotid artery could be used as a group of 12. Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 1‑The anatomic landmarks and they were mutual references midline anterior fossa skull base. Minim Invasive Neurosurg in operation. To ensure surgical safety, the optic canal 2004;47:1‑8. and the medial wall of orbit should be not exceeded 13. Liao JC, Li J, Lu SC, Xiao BJ, Wang HQ. Applied anatomy of optic canal decompression via external ethmoidal and sphenoidal sinus while performing extended endonasal anterior skull approach. Chin J Clin Otorhinolaryngo 1994;8:221‑2. base surgery. Our study provides experimental data 14. Yilmazlar S, Saraydaroglu O, Korfali E. Anatomical aspects in the for conducting extended endonasal anterior skull base transsphenoidal‑transethmoidal approach to the optic canal: An surgery in the future. anatomice‑cadaveric study. J Craniomaxillofac Surg 2012;40:198‑205. 15. Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: Technical note. Neurosurgery References 2004;55:239‑44. 16. de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O, 1. Griffith HB, Veerapen R. A direct transnasal approach to sphenoid Espostto I. Endoscopic transnasal resection of anterior cranial fossa sinus. J Neurosurg 1987;66:140‑2. meningiomas. Neurosurg Focus 2008;25:E8. 2. Lawson W. The intranasal ethmoidectomy: Evolution and an assessment 17. Ohnishi T, Tachibana T, Kaneko Y, Esaki S. High‑risk areas in of the procedure. Larynqoscope 1994;104:1‑49. endoscopic sinus surgery and prevention of complications. Larynqoscope 3. Casiano RR, Numa WA, Falquez AM. Endoscopic resection of 1993;103:1181‑5. esthesioneuroblastoma. Am J Rhinol 2001;15:271‑9. 4. Fernandez‑Miranda JC, Gardner PA, Prevedello DM, Kassam AB. How to cite this article: Wang S, Lv J, Xue L, Xi Z, Zheng H, Wang R. Expanded endonasal approach for olfactory groove meningioma. Acta Anatomic study and clinical significance of extended endonasal Neurochiir (Wien) 2009;151:287‑8. anterior skull base surgery. Neurol India 2014;62:525-31. 5. Liu JK, Christiano LD, Patel SK, Tubbs RS, Eloy JA. Surgical nuances for removal of olfactory groove meningiomas using the endoscopic Source of Support: This work was supported by Key Project of endonasal transcribriform approach. Neurosurg Focus 2011;30:E3. Medical Research of Nanjing Military Region, China (NO. 06Z50), 6. Padhye V, Naidoo Y, Alexander H, Floreani S, Robinson S, Conflict of Interest: None declared.
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