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Anatomic Study and Clinical Significance of Extended Endonasal Anterior Skull Base Surgery

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Anatomic Study and Clinical Significance of Extended Endonasal Anterior Skull Base Surgery [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 Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5 525 [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 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 526 Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5 [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 Wang, et al.: Anatomy of anterior skull base surgery
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