Endoscopic Transmaxillary Approach Research Articles

Combined Endoscopic Transmaxillary Approach for Resection of an Extracranial V3 Schwannoma: 2-Dimensional Operative Video.

Tumours of the pterygopalatine (PPF) and infratemporal fossa (ITF) are rare tumours and are difficult to access. The lateral cervical approach is hampered by the mandibular angle and the vascular nervous elements.1 The classic endonasal endoscopic medial maxillectomy approach has been developed over the past 2 decades but does not allow good control of the most lateral and inferior part of the ITF.2 The surgical video presents a 68-year-old woman with trigeminal neuralgia. The radiologic workup showed a trigeminal V3 schwannoma (TS) into the PPF and ITF. This tumor grew during the follow-up despite fractionated radiosurgery. A 2-dimensional intraoperative video illustrates the gross total removal of the TS through a combined endoscopic endonasal and transgingival transmaxillary approach. The combination of these 2 approaches allows on the one hand, a better view of the lateral and inferior part of the maxillary sinus and ITF and on the other hand, a gain of handling in the operating field and security for our surgical procedure.3 The mini-Caldwell-Luc approach gives good aesthetic results without stomatological complication. Neuralgia disappeared after the surgery, and a gross total resection was achieved, and no recurrence was observed during the follow-up. This combined approach is a good alternative of medial extended maxillectomy, which presents a risk for the lacrimal duct risk and postoperative aesthetic deformity because of the removal of the medial and anterior wall of the maxillary sinus. The patient consented to the procedure and publication of her image.

Endoscopic transmaxillary approach to the inferior rectus muscle in correcting traumatic diplopia

Abstract: Traumatic diplopia can be caused by an entrapped, ruptured, or lost extraocular muscle, which is clinically challenging. Numerous surgical approaches can be tailored, depending on which muscle is involved. We present a patient suffering from inferior rectus muscle disruption treated with endoscopic transmaxillary approach and muscle plication procedure. This surgical technique is a novel and effective surgical technique in managing traumatic diplopia.

Endoscopic Transmaxillary Approach for Sclerotherapy of an Infratemporal Fossa Venous Malformation

Disfiguring or symptomatic venous and lymphatic malformations are often treated with sclerotherapy. A 10-year-old girl with a history of epilepsy and migraines presented with progressive facial pain along the mandibular division of the trigeminal nerve. Magnetic resonance imaging identified a lobulated, enhancing lesion within the lateral pterygoid muscle, consistent with a venous malformation. It could not be safely approached transcutaneously; therefore, an endoscopic transmaxillary approach was offered. The lesion was localized with neuronavigation, and digital subtraction venography was employed to confirm entry into the lesion. Primary drainage via the pterygoid plexus toward the left retromandibular vein without any connections to the cavernous sinus or left orbit was identified. At this point, foam sclerosant was injected. Postoperatively, the facial pain resolved, and magnetic resonance imaging demonstrated an excellent response to the sclerotherapy. To our knowledge, this is the first report of an endoscopic transmaxillary approach for sclerotherapy of an infratemporal fossa venous malformation.

Оценка локального мукоцилиарного клиренса среднего носового хода при различных хирургических вмешательствах у больных с инородными телами верхнечелюстных пазух

Examination of mucociliary clearance (MCC), evaluation of options for operative access to the maxillary sinus, from the position of MCC, regarding foreign bodies, are of increasing interest in otorhinolaryngology due to the ever-increasing incidence of this pathology, its artificial (secondary) nature—that is, arising against the background of known absence of any initial pathological changes. Objective. To study the local function of the MCC of the middle nasal passage in the postoperative period in patients with foreign bodies of the maxillary sinuses with various methods of surgical intervention on the maxillary sinus. Methods. The study involved 60 patients with foreign bodies of the maxillary sinuses and a comparison group of 60 healthy individuals. The patients were divided into 2 groups of 30 people according to the type of surgical access—trocar endoscopic maxillary sinusotomy, endonasal endoscopic antrostomy. The subjects underwent computed tomography (CT). For examination of local MCC, modern methods of mathematical analysis of data from high-speed video filming of a ciliary epithelium preparation were used. A questionnaire was used to subjectively assess nasal symptoms. The examinations were conducted in the early (1–14 days), late (1–6 months) postoperative period. Results. It was revealed that the normative local value of the MCC of the middle meatus in healthy individuals is 11,76 ± 3,01 Hz. In patients with foreign bodies of the maxillary sinus, the greatest influence on the initial local MCC, its violation in the postoperative period is exerted by changes in the middle meatus, cells of the ethmoid labyrinth, and mycetoma. The values of the local MCC of the middle meatus depend on the access to the maxillary sinus. Conclusion. Using methods for assessing local MCC, it is necessary to optimize access to the maxillary sinus with a wider use of techniques that do not affect the key area of the osteomeatal complex (transmaxillary endoscopic approach, access through the lower meatus).

Endoscopic Anatomy of the Zygomatic Nerve: Implications for the Endoscopic Transmaxillary Approach.

Introduction Understanding the anatomic features of the zygomatic nerve is critical for performing the endoscopic transmaxillary approach properly. Injury to the zygomatic nerve can result in facial numbness and corneal problems. Objective To evaluate the surgical anatomy of the zygomatic nerve and its segments from an endoscopic endonasal perspective for clinical implications of performing the endoscopic transmaxillary approach. Methods The origin, course, length, and segments of the zygomatic nerve were studied in four specimens from an endonasal perspective. Results The zygomatic nerve arises 4.1 ± 1.7 mm from the foramen rotundum of the maxillary nerve in the superolateral pterygopalatine fossa (PPF). According to its anatomic region in endonasal endoscopic surgery, we divided the zygomatic nerve into two segments: the PPF segment, from origin to the point of entry under Muller's muscle, which runs superolaterally to the inferior orbital fissure (IOF) (length, 4.6 ± 1.3 mm), and the IOF segment, starting at the entry point in Muller's muscle and terminating at the exit point in the IOF, which travels between Muller's muscle and the great wing of the sphenoid bone (length, 19.6 ± 3.6 mm). In the transmaxillary approach, the zygomatic nerve is a critical landmark in the superolateral PPF. Conclusion The zygomatic nerve travels in the PPF and the IOF; better visualization and preservation of this nerve during endonasal endoscopic surgery are crucial for successful outcomes.

Repair of the orbital floor fractures: The endoscopic trans-maxillary approach as minimally invasive approach: A case-report.

IntroductionThe endoscopy in orbital surgery provides, similar to other surgical fields, the option of combining an extended view of the surgical field with minimally invasive approaches; also allows an excellent functional and esthetic results. Trans-maxillary endoscopy of the orbital floor offers excellent visualization of the posterior bony shelf and confirms that the implant rests securely in place.Presentation of caseThe authors report a ten years-old male child, reported to the oral and maxillofacial surgery department, Ibn Rochd university hospital, Casablanca, Morocco. The child was diagnosed for left orbital floor fracture, complaining of orbital trauma due to road accident. The injury occurred at the left orbit level. There was no general story of any disease.DiscussionIn more than 40% of all the facial fractures parts of the orbital rim or/and the internal orbit are injured with a variety of fracture patterns. Accurate assessment is required in order to correct any bone defects or displacements. The surgical approaches have become more reduced offering better control of orbital pathological processes. Orbital lesions are precisely localized through imaging. Also, the approach decision depends on location, size and vascularization. No consensus exists regarding the timing of the repair, the repair technique and the optimal implant. In this case presentation, the defect on the orbital floor was extended by mobilization of the fragments. A combination of incisions was necessary due to the change in the dimensions of the defects intraoperatively and entrapment of orbital tissue by the placement of an implant.ConclusionThe endoscopic approaches provide excellent visualization and safe from eyelid complications with no visible scar when secondary open fracture reduction is avoided. Also; the rate of postoperative complications are reduced: optic nerve injury, orbital apex injury.

Minimally invasive transmaxillary endoscopic retrieval of a displaced third maxillary molar into the infratemporal fossa

The aim of this paper was to report a case of displaced impacted maxillary third molar into the infratemporal fossa during extraction, which was referred to the Otorhinolaryngology Department, Tanta University Hospital, Egypt. Retrieval of such displaced tooth was done through transmaxillary endoscopic approach, with no reported complication within 3 years of follow-up.

Successful endoscopic endonasal surgery for very huge trigeminal schwannomas in nasopharynx

We present a 60-year-old female diagnosed with a giant trigeminal tumor (5.2*6.4*8.2 cm) situated in the middle cranial fossa and nasopharyngeal area. The patient was operated on by endoscopic endonasal transmaxillary, transpterygoid and infratemporal approaches. Postoperatively she was stable, with no neurologic complication and no cerebrospinal fluid leakage. We review the literature on extremely large trigeminal schwannomas.

Robotic-assisted transmaxillary approach for removal of juvenile nasopharyngeal angiofibroma of the pterygopalatine and infratemporal fossa.

Endoscopic transmaxillary approaches to remove juvenile nasopharyngeal angiofibromas (JNAs) have been described previously and are used for tumors that extend laterally in the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). There is no previous description of robotic-assisted JNA removal in the literature. The video will demonstrate the success of this technique. Robotic transmaxillary approaches to the lateral PPF and ITF are easily achieved through an extended Caldwell-Luc antrostomy. Total operative time was 519 minutes. Total robotic operative time was 283 minutes. The endoscopic approach provided no assistance in tumor dissection or removal. Robotic-assisted transmaxillary JNA removal allows the operating surgeon to control the endoscope and to operate free of collisions from the robotic console while having an active assistant surgeon at the patient bedside. A video demonstrating the technique is found on Head & Neck's web site.

Endoscopically assisted computer-guided repair of internal orbital floor fractures: an updated protocol for minimally invasive management

BackgroundPerforming accurate anatomical reconstruction is a challenging task in the treatment of internal orbital floor fractures. Compared with traditional transcutaneous incisions, endoscopic transmaxillary approaches have the advantage of avoiding complications related to external scars, and provide direct access to the orbital floor. Autogenous bone provides the ideal material for defect reconstruction, but determination of the correct size and shape of the graft is crucial for a stable support. This study introduces a new protocol for the treatment of internal orbital floor fractures that combines endoscopy, virtual reality, and 3D printing. The authors also investigated the impact of computer-aided surgery (CAS) on the overall accuracy of reconstruction in aiming to achieve the triple objective of restoring anatomy, volume, and function. Materials and methodsFourteen patients with orbital floor fractures were recruited for this study. High-resolution CT scans provided appropriate imaging for detailed orbital floor defect visualization. A virtual reconstruction of the orbital floor defect was developed and a 3D printed template was fabricated to provide intraoperative guidance in the graft harvesting phase, according to the orbital defect. Virtual analyses were conducted to evaluate the accuracy of reconstruction both in terms of graft size and graft orientation. ResultsPostoperative CT scans showed that in all cases orbital floor reconstruction was successfully performed, resulting in restoration of the correct globe position. No intraoperative complications occurred. Correspondence of graft size was evaluated using color-coded maps and RMSE, while comparison of angular measurements allowed the authors to relate simulated and actual reconstruction. ConclusionsOrbital floor reconstruction performed via transmaxillary endoscopy is a safe technique, which allows for detailed visualization of the fracture rim, avoids external scars, and permits an easier reduction of the prolapsed orbital content into the overlying orbital cavity. Virtual planning plays an important role in defining the appropriate geometry of the bone graft and establishing the optimal reconstruction strategy. Our preliminary results indicate that virtual planning and 3D printing should become part of an integrated protocol for the endoscopic treatment of orbital floor fractures.

Commentary: Toward Supratotal Resection of Clival Chordoma: Combined Endoscopic Endonasal and Contralateral Transmaxillary Approaches.

Commentary: Toward Supratotal Resection of Clival Chordoma: Combined Endoscopic Endonasal and Contralateral Transmaxillary Approaches.

Endoscope-assisted contralateral transmaxillary approach to the clivus and the hypoglossal canal: technical case report.

Clival lesions are still considered surgically complex due to their anatomical location. Critical structures, such as the internal carotid arteries (ICAs), cavernous sinuses, cranial nerves, and brainstem, may be encased within the lesion. Although advances in endoscopic endonasal approaches have provided new routes to these lesions, exposure and resection of clival tumors through the endonasal route remain a technical challenge. Here, the authors report a left-sided endoscopic transmaxillary approach to access the right aspect of the clivus and the hypoglossal canal.A 35-year-old woman presented with progressive right 6th cranial nerve palsy. MRI revealed a contrast-enhancing right petroclival chondrosarcoma that involved Meckel's cave and extended into the right hypoglossal canal. An endoscopic-contralateral-transmaxillary approach through a left sublabial incision was used to access the right petroclival region and right hypoglossal canal. A left maxillary osteoplastic flap was elevated to expose the left maxillary sinus. This was followed by a left medial maxillectomy, gaining access to the left posterior nasal cavity. The posterior third of the left inferior turbinate and nasal septum were removed to access the right side of the petroclival region. Near-total resection was achieved without any vascular or neurological complications. A thin shell of residual tumor was left behind due to involvement of vital structures, such as the ICA, and further treated with proton-beam radiotherapy.The endoscopic-contralateral-transmaxillary approach provides a direct surgical corridor and good lateral visualization of the skull base vasculature. This approach allows wide maneuverability around the ICA and hypoglossal canal, which, in this case, allowed maximal tumor resection with full preservation of neurological function.

Transmaxillary Endoscopic Approach to the Lateral Recess of the Sphenoid Sinus: An Anatomical Study

Transmaxillary Endoscopic Approach to the Lateral Recess of the Sphenoid Sinus: An Anatomical Study

Surgical Anatomy of the Orbit in Human Cadavers-An Endoscopic Pictorial Documentation.

Background The aim of our study was a pictorial documentation of the anatomical structures of the orbit. Methods We performed a transmaxillary endoscopic approach in nine formalin-fixed human heads. We identified and documented the anatomy of the inferior part of the orbit. Results The first intraorbital anatomical landmark was the inferior rectus muscle, from which important structures medially and laterally could be identified. Anatomical structures and their relation to each other were documented and presented as illustrative figures. Conclusion Knowledge of the topographic anatomy of the inferior part of the orbit could be sufficiently imparted by our illustrations. The presented transmaxillary approach allowed a wide overview of the anatomical structures located in the inferior part of the orbit. Our pictorial documentation may provide neurosurgeons more safety and the opportunity to become familiar with the endoscopic anatomy.

Endoscopic transmaxillary approach in resection of lateral skull base tumor

The resection of lateral skull base tumour has always been a crucial and difficult aspect of skull base surgery. Its operation development has experienced several evolutionary phases, including unaided eye-surgery which could result in huge trauma, microsurgery and completely endoscopic surgery. At present, the endoscopic technique known for its panoramic visibility, minimal invasion and extensive scope of operation, has opened up a brand new perspective for the lateral skull base tumour surgery. Currently, the approach of lateral skull base tumour endoscopic surgery can be generalized as endoscopic transmaxillary approach (ETA). And based on different pathways and methods to expose the maxillary sinus, ETAs can be divided into three, endonasal transmaxillary approach(ENTA), endoscopic sublabial transmaxillary approach (ESTA) and combined approach, while ENTA includes ipsilateral endonasal transmaxillary approach (IENTA), prelacrimal recess approach (PRA), contralateral endonasal transseptal approach (CENTA) and transnasal Denker approach. In this paper, on the basis of the summarization of ETAs related historical evolution, anatomical studys and clinical researches, the merit and demerit of all sorts of ETAs are compared and analyzed. We hope this review could act as a reference for selecting the personalized endoscopic surgery approach of lateral skull base tumour. Key words: Skull base neoplasms; Maxillary sinus; Endoscopy

Erratum to: Combined endonasal and sublabial endoscopic transmaxillary approach to the pterygopalatine fossa and orbital apex.

Background The pterygopalatine fossa (PPF) and inferomedial orbital apex are difficult regions for open neurosurgical access. The traditional extensive anterior approach (transfacial or transmandibular) and lateral/posterolateral (transcranial) approach were used to access the PPF. The combined endonasal and sublabial transmaxillary approach is a less invasive access route for these lesions. In this study, we present the technical and clinical details of our experience with the combined endoscopic endonasal and transmaxillary approach.

Infraorbital nerve: a surgically relevant landmark for the pterygopalatine fossa, cavernous sinus, and anterolateral skull base in endoscopic transmaxillary approaches.

OBJECTIVE Endoscopic transmaxillary approaches (ETMAs) address pathology of the anterolateral skull base, including the cavernous sinus, pterygopalatine fossa, and infratemporal fossa. This anatomically complex region contains branches of the trigeminal nerve and external carotid artery and is in proximity to the internal carotid artery. The authors postulated, on the basis of intraoperative observations, that the infraorbital nerve (ION) is a useful surgical landmark for navigating this region; therefore, they studied the anatomy of the ION and its relationships to critical neurovascular structures and the maxillary nerve (V2) encountered in ETMAs. METHODS Endoscopic anatomical dissections were performed bilaterally in 5 silicone-injected, formalin-fixed cadaveric heads (10 sides). Endonasal transmaxillary and direct transmaxillary (Caldwell-Luc) approaches were performed, and anatomical correlations were analyzed and documented. Stereotactic imaging of each specimen was performed to correlate landmarks and enable precise measurement of each segment. RESULTS The ION was readily identified in the roof of the maxillary sinus at the beginning of the surgical procedure in all specimens. Anatomical dissections of the ION and the maxillary branch of the trigeminal nerve (V2) to the cavernous sinus suggested that the ION/V2 complex has 4 distinct segments that may have implications in endoscopic approaches: 1) Segment I, the cutaneous segment of the ION and its terminal branches (5-11 branches) to the face, distal to the infraorbital foramen; 2) Segment II, the orbitomaxillary segment of the ION within the infraorbital canal from the infraorbital foramen along the infraorbital groove (length 12 ± 3.2 mm); 3) Segment III, the pterygopalatine segment within the pterygopalatine fossa, which starts at the infraorbital groove to the foramen rotundum (13 ± 2.5 mm); and 4) Segment IV, the cavernous segment from the foramen rotundum to the trigeminal ganglion (15 ± 4.1 mm), which passes in the lateral wall of the cavernous sinus. The relationship of the ION/V2 complex to the contents of the cavernous sinus, carotid artery, and pterygopalatine fossa is described in the text. CONCLUSIONS The ION/V2 complex is an easily identifiable and potentially useful surgical landmark to the foramen rotundum, cavernous sinus, carotid artery, pterygopalatine fossa, and anterolateral skull base during ETMAs.

Infraorbital Nerve: A Road Map to the Pterygopalatine Fossa, Cavernous Sinus, and Skull Base in Endoscopic Transmaxillary Approaches

Introduction: Endoscopic transmaxillary approaches are becoming more commonly performed for pathology of the anterolateral skull base, including the cavernous sinus, pterygopalatine fossa, and infratemporal fossa. This is an anatomically complex region which contains branches of the trigeminal nerve, external carotid artery, and is in close proximity to the internal carotid artery. Intraoperatively, we have found the infraorbital nerve (ION) located within the roof maxillary sinus to be an easily identifiable landmark that leads to the skull base. In this study, we sought to study the anatomy of the ION and describe its relationship to other neurovascular structures encountered in endoscopic transmaxillary approaches.

The transmaxillary endoscopic approach to the inferior part of the orbit: how I do it.

Transmaxillary endoscopic approach to the inferior part of the orbit was demonstrated on cadaveric preparations; however, its clinical application has not been reported. We describe a clinically useful technique of the transmaxillary approach to the lower orbit. A four-hand technique is essential for extensive preparation within the orbit; therefore, the tools have to be introduced into the maxillary sinus through two ports: either through the canine fossa and antrostomy or through antrostomy using the bi-nostril transseptal approach. Intraorbital pathologies located in the inferior retrobulbar space can be successfully operated on using the transmaxillary endoscopic approach.

The Loop‐Type Maxillary Artery and Its Relationship with the Lateral Pterygoid Muscle

Objectives: Determine the relationship between a loop-type configuration of the third portion of maxillary artery and its position according to the inferior belly of the lateral pterygoid muscle. Methods: A descriptive transversal study in preserved cadaver head specimens, conducted between August and December of 2013, on a total of 23 hemi-heads of Latin American origin, in which the second and third portions of the maxillary artery were dissected through an endoscopic transmaxillary approach to the pterygopalatine and infratemporal fossa. Results: A total of 23 maxillary arteries were dissected, of which 7 (30.4%) were found to be superficial to the inferior belly of the lateral pterygoid muscle (LPMib) and 16 (69.6%) were found to lie deep. A total of 16 arteries (69.5%) were found on a loop-type configuration, and 7 (30.5%) were found on an ascending configuration. The loop type was found deep to the LPMib in 13 (81.3%) of the cases and superficial in 3 (18.8%) of them. The results were analyzed with Fisher’s exact test with a P value of .091. Conclusions: This study shows a tendency in the Latin American population to have maxillary arteries deep to the LPMib in loop configuration, which emphasizes the need to stay close to the pterigomaxillary fissure during surgical dissection when aiming to find the main trunk of this vessel in its transition point between its second and third portions. Although the results are promising, the results need to be confirmed in a larger sample.