Lateral Sinus Wall Research Articles

Efficacy and Predictability of a Synthetic Hydroxyapatite in Lateral Wall Sinus Augmentation

Efficacy and Predictability of a Synthetic Hydroxyapatite in Lateral Wall Sinus Augmentation

Epidural and subdural interdural approach to the lateral wall of the cavernous sinus for preserving the laterocavernous sinus in trigeminal schwannoma.

Evacuation of middle fossa trigeminal schwannomas (TS) warrants a subtemporal interdural approach through the lateral wall of the cavernous sinus (CS). The dura comprises the dura propria, which follows the trigeminal nerve and develops into the epineurium, and periosteal layer. The interdural approach involves peeling off the dura propria and exposing the epineural sheath. The venous route around the CS is often obstructed due to TS progression. The interdural approach based on venous route preservation remains to be discussed. The laterocavernous sinus (LCS) is formed in these layers, draining to either the medial or lateral route. In the lateral route, the LCS drains to the pterygoid plexus via the middle cranial fossa foramen. Exposure of the interdural space disturbs the lateral route's venous flow. We describe an operative strategy for venous route preservation in TS via the LCS lateral route. The venous route can be preserved by peeling off the dura propria from the posterior end of the foramen ovale short of the venous drainage route to the pterygoid plexus epidurally and then cutting from the middle cranial fossa dura posterior to the venous route subdurally to the exposed interdural space. This technique helps in avoiding postoperative venous complications.

The prevalence and location of the posterior superior alveolar artery in the maxillary sinus wall: A preliminary computed-cone beam study

The lateral wall of the maxillary sinus is supplied by the posterior superior alveolar artery (PSAA). It may be affected by trauma, pathology, or surgery performed to access or correct any fracture involving the maxillary sinus. This study analysed the prevalence and distance of the PSAA from the floor of the maxillary sinus in selected Southeast Asian patients. Methods: This is a cross sectional study conducted using cone-beam computed tomographic images of 83 dentate patients with a mean age of 38.3 years. Results: One hundred sixty-six maxillary sinuses of 54 males and 29 females were evaluated, with PSAA observed in 91.6 % of sinuses. Of the PSAA identified (n = 152), 64.5 % were intraosseous (n = 98), 25.7 % were beneath the sinus membrane (n = 39), and the remaining 15 (9.9 %) were on the external cortex of the lateral sinus wall. The mean distance between PSAA and the lowest point of the sinus floor was 11.44 mm (SD, 3.36). Sixty-four maxillary sinus walls (38.6 %) presented with 2 PSAA branches. The inferior and superior branches were located 6.42 mm (SD, 2.68) and 8.48 mm (SD, 3.56) from the floor of the maxillary sinus, respectively. The mean difference between these 2 branches was 2.25 mm (SD, 1.90). Conclusion: This study confirms the different locations of the PSAA in relation to the lateral wall of the maxillary sinus with no gender influence. Branching of PSAA occurs, and should be highlighted to surgeons.

A Frontal Route to Middle and Posterior Cranial Fossa: Quantitative Study for the Lateral Transorbital Endoscopic Approach and Comparison with the Subtemporal Approach

Skull base lesions within the middle cranial fossa (MCF) remain challenging. Recent reports suggest that transorbital endoscopic approaches (TOEAs) might be particularly suitable to access the MCF and expose the lateral wall of the cavernous sinus and the Meckel's cave. The present study was developed to compare the nuances of the subtemporal approach (STA) with those of the lateral TOEA (LTOEA) to the MCF and posterior cranial fossa (PCF) in cadaveric specimens. After orbital craniectomy, interdural opening of the cavernous sinus lateral wall (CSlw), exposure of the Gasserian ganglion, and extradural elevation of the temporal lobe was performed. Next, anterior endoscopic petrosectomy was performed and the PCF was accessed. We quantitatively analyzed and compared the angles of attack and distances between LTOEA and STA to different structures at the CSlw, petrous apex (PA), and PCF. Cadaveric dissection through the LTOEA completely exposed the CSlw and PA. LTOA exhibited larger distances than the STA to all targets. Importantly, these differences were greater at the PA and its surrounding key anatomic landmarks. The horizontal and vertical angles of attack allowed by the LTOA were smaller both for the CSlw and PA. However, these differences were not significant for the vertical angle of attack at the CSlw. LTOEA provides a direct ventral route to the medial aspect of MCF, PA, and PCF. Although TOEAs are versatile approaches, the unfamiliar surgical anatomy and limited instrument maneuverability demand extensive cadaveric dissection before moving to the clinical setting.

Clinicopathological Study of Sinonasal Malignancy-Experience in a Tertiary Level Hospital in Bangladesh

Objectives: To assess the clinical presentation and histopathological types and extensions of the disease at the time of presentation.
 Methods: Cross sectional observational study of 40 patients with sinonasal malignancy from the department of otolaryngology and Head neck surgery, Sylhet MAG Osmani Medical College Hospital, Sylhet Bangladesh, period from May 2019 to April 2020. The patients were examined after admission into hospital pre-operatively and in the postoperative period. The surgical specimens were sent for Histopathology.
 Results: Majority patients were at 4th to 6th decade where male outnumbered the female with male female ratio was 3.4:1. Out of 40 patients, the majority of patients complaints of nasal obstruction followed by nasal discharge, facial pain, facial swelling and headache. About the site of the lesion maximum patients having the lesion in Maxillary sinus (60%) followed by nasal cavity (15%) multiple sinuses (12.5%) involvement in Ethmoidal sinus (10%) lateral wall of nose (2.5%)
 Conclusion: Sinonasal Malignancy is usually a disease of middle age and elderly people. Most of the patients (in this study 65% patients come at T3 & T4 stage) presented late with multiple symptoms.
 Bangladesh J Otorhinolaryngol 2022; 28(1): 37-42

Incidence of Sinus Membrane Perforation Using Two Types of Implant Drills: An Ex Vivo Animal Study.

This ex vivo study evaluates the incidence of sinus membrane perforation during implant site osteotomy with two different types of drills and drilling techniques. Fifty goat heads with 50 sinus pairs (100 sinus sides) were assigned to two groups (osseodensification bur [OB] group and inverse conical shape bur [ICSB] group) to simulate transcrestal sinus elevation (50 sinus sides per group). An osteotomy was performed to pass through the lateral sinus wall no more than 3 mm. The integrity of the sinus membranes was examined and confirmed under a microscope. Of the 50 sinuses per group, the OB group presented with 14 (28%) perforated sinuses, while the ICSB group presented with 2 (4%) perforated sinuses. Of the 14 perforations from the OB group, 6 (42.9%) showed a pinpoint perforation pattern, 4 (28.5%) of which were not visible until direct air pressure was applied. Overall, the ICSB drill group demonstrated a lower sinus perforation rate than the OB group.

Radiographic assessment of maxillary sinus lateral wall and anatomy of posterior superior alveolar artery: A Cone-Beam Computed Tomographic

hickness of maxillary sinus (MS) lateral wall and to assess the prevalence, distance from maxillary sinus floor, diameter and course of posterior superior alveolar artery (PSAA) based on age, gender and dental status using conebeam computed tomography (CBCT) that might be relevant to accomplish complication free surgeries in posterior maxilla. CBCT images of maxillary sinus (right and left) were obtained for 40 patients, which included 20 males and 20 females. Maxillary sinus lateral wall and PSAA parameters were measured and evaluated. The data obtained were then subjected to descriptive statistical analysis; independent t-test and oneway Anova test were performed and compared based on age, gender and dental status. The results showed that the average thickness of the lateral wall of the maxillary sinus was determined to be approximately around 2.50 mm. PSAA was observed in 25% of subjects with a maximum distance of 8.83 mm from the maxillary sinus floor and a minimum distance of 6.90 mm. PSAA had a diameter of 1-2 mm with the intraosseous course in most individuals. Comparison between CBCT images of the selected individuals among age groups, gender and dental status were not statistically significant on measuring the above mentioned parameters. This study concluded that CBCT provides valuable diagnostic information pertaining to sinus and related landmarks that assist during surgical procedures.

Endoscopic Endonasal Approach to a Giant Dentigerous Cyst

Dentigerous cysts constitute 20% of all odontogenic cysts and are often located in the mandible and maxilla. They are often seen at young ages and in men. Patients are usually asymptomatic, and the diagnosis is established by dental radiographs in routine scans. Surgery is recommended for dentigerous cysts because ameloblastoma, intraosseous mucoepidermoid carcinoma, or intraosseous squamous cell carcinoma may develop from them. Generally the transoral route is preferred over the endoscopic route for dentigerous cysts located in the maxilla. In addition to the question of the transnasal versus oral approach to dentigerous cysts, another controversy is the removal or marsupialization of the entire cyst. In our 10-year-old male patient, a cyst that completely filled the right maxillary sinus and eroded the lateral and anterior wall of the maxillary sinus was treated with transnasal endoscopic surgery. The cyst wall and 3 permanent teeth were removed endoscopically. No post-operative complications were observed. The patient’s age and the location and size of the cyst play an important role in the choice of treatment. Furthermore, the most accurate way to choose the appropriate treatment is to make the treatment decision with a multidisciplinary approach.

Dolenc's Approach:Anterior Clinoidectomy and Extradural Approach to Cavernous Sinus

The combined epidural and subdural approach pioneered by Dolenc allows opening of the lateral wall of the cavernous sinus(CS)to treat various pathologies such as tumors and aneurysms in the cavernous, para-cavernous, and central skull base regions. The Dolenc's approach is occasionally performed with the orbitozygomatic approach(OZA), which enables us to look up highly located lesions. We prefer the two-piece method when performing OZA: it involves removing the orbitozygomatic bar separately after frontotemporal craniotomy. Dolenc's approach requires dividing the meningo-orbital band and opening the superior orbital fissure to expose the junction between the dura propria of the temporal lobe and inner membrane of the CS, which separates the neurovascular structures and the venous plexus inside. Peeling of the dura propria from the inner membrane is continued until the anterior clinoid process is exposed epidurally. Extradural clinoidectomy and optic canal opening are then performed. After the epidural procedures, intradural procedures are also performed. The falciform ligament and the distal dural ring are incised to mobilize the optic nerve and the internal carotid artery. The tentorium is incised along the anterior petroclinoid ligament. Dolenc's approach allows extradural retraction of the temporal lobe, which provides a surgical corridor to the retro-carotid space and the inter-peduncular cistern through the opened anterior part of the CS.

Surgical Anatomy of the Cavernous Sinus, Parasellar Region, and Orbit

The cavernous sinus, para-sellar region, and orbit have intricately intertwined cranial nerves, blood vessels, and dura mater. In surgery, anatomical understanding is very important. Recognizing the location(depth)of the cranial nerves running on the lateral and upper wall of the cavernous sinus is vital and is directly linked to postoperative complications. In addition, understanding the dural ring in the clinoid segment of the internal carotid artery is important. The periosteum on the upper surface of the anterior clinoid is the distal dural ring of the internal carotid artery, and the periosteum on the lower surface is the proximal dural ring. The orbit is filled with adipose tissue and is completely different from other intracranial parts. However, understanding the anatomy from the orbital apex to the superior orbital fissure is important in the pterional approach.

Evaluation of alveolar antral anastomosis in south Indian population using cone beam computed tomography: a prospective study.

The posterior superior alveolar artery (PSAA) and the infraorbital artery (IOA), both of which are ultimate branches of the maxillary artery, are connected by a horizontal anastomosis. PSAA anastomoses intraosseously and extraosseously with IOA. Profuse bleeding from the lateral wall while performing the direct sinus augmentation is a significant intraoperative complication.Thus the present study focused to assess the location of an alveolar antral anastomosis (AAA) in relation to the crest of the alveolar bone using cone beam computed tomography (CBCT). A total of 200 CBCT scans of patients who were indicated for implant surgery were chosen and assessed. Group 1 includes 100 dentate patients and Group 2 includes 100 partially edentulous patients. The location of anastomosis along the lateral wall of the maxillary sinus was evaluated in association with alveolar bone height with respect to three posterior maxillary teeth: first premolar, second premolar, and first molar. The mean distance for P1, P2, and M1 was 21.94 ± 1.02mm, 19.41 ± 0.40mm, and 17.36 ± 0.51mm, respectively, in the dentate group, whereas in the edentulous group, it was 20.07 ± 0.46mm, 18.95 ± 0.32mm, and 16.08 ± 0.16mm. In 80% of participants, the distance of an AAA from the alveolar crest was between 16 and 23mm, whereas in 12% of the participants the distance of an AAA from the alveolar crest was less than 16mm. The present study concludes that the first premolar region is safe for preparing the lateral window but for the second premolar and first molar additional care should be taken prior to surgery.

Prevalence of the Alveolar Antral Artery and Its Accessory Arteries in Cone-Beam Computed Tomography Scans.

Alveolar antral artery (AAA) damage can cause perioperative hemorrhage during osteotomy. The aim of this study was to assess the prevalence of AAA presence and evaluate its characteristics using cone-beam computerized tomography (CBCT). One hundred maxillary sinuses were evaluated from 70 CBCT scans. The anteroposterior dimension of each sinus was divided into four equal quarters, and the main artery presence was noted for each section. Arterial diameter as well as distance to sinus floor and to alveolar ridge were measured, and the position of the main artery according to its location relative to the lateral sinus wall was determined. In cases where additional arteries were detected, their diameter and position were also determined. Artery prevalence was 87.0%. In 42% and 8% of the cases respectively, a second and third artery were visualized. No significant association was found between the prevalence of the arteries and age of participants. However, the prevalence of a secondary artery among men (56.4%) was significantly higher than in women (32.8%) (P = .02). Moreover, the main artery diameter was significantly different between sections (P = .014), as was its position. AAA was radiographically detectable in the majority of studied sinuses. In 2 cases, 3 arteries were visible. Arteries with a diameter ≥ 2 mm were not frequent. However, arteries exceeding this diameter must be factored in when choosing surgical techniques. The findings of this study suggest there might be accessory arteries associated with AAA. Therefore, preoperative radiological CBCT examination is necessary prior to any sinus floor elevation surgery.

CLINICAL APPLICATIONS OF SAFESCRAPER® IN MAXILLARY SINUS FLOOR ELEVATION AND RIDGE AUGMENTATION

Introduction. Although there is a wide variety of bone grafting materials for the augmentation of the deficient alveolar ridge, autogenous bone is still considered to be the gold standard. There are various methods for harvesting autologous bone grafts. Among these, Safescraper® is conveniently used as a harvesting device of autogenous cortical bone in oral Implantology and reconstructive surgery, ensuring high volumes of grafting material with a minimally invasive and predictable procedure. Purpose. The purpose of this presentation is to showcase the clinical applications of Safescraper® in various augmentation procedures and to review the existing literature for the evidence supporting its application in clinical practice. Materials and Methods. In the presented cases, Safescraper® provided surface-derived autogenous bone graft deriving from the maxillary tuberosity, the zygomatic buttress, the lateral sinus wall, the pyriform aperture of the nose, the external oblique ridge and the mandibular symphysis. The collected autogenous bone has been mixed either with xenograft, or autologous venous blood, or platelet-rich fibrin and used in procedures such as: Maxillary sinus floor elevation, Reconstruction of periimplant defects, Reconstruction of alveolar ridge defects with onlay autogenous blocks, or bone rings, Ridge augmentations using resorbable collagen membranes, titanium-reinforced non-resorbable membranes or titanium meshes, Ridge augmentations using the Khoury technique. Results. Satisfactory amounts of autogenous bone have been harvested in all cases. The bone harvesting procedure was swift, reliable and devoid of any complications. Conclusion. Safescraper® is an extremely useful, cost-effective and minimally invasive device for collecting bone to adequately cover the needs in autogenous grafts everyday clinical practice.

Orbital and Maxillary Sinus Wall Fractures as a Late Complication of Endosteal Implants

A 63-year-old woman applied to us with a complaint of ecchymosis on the left half of her face and left subconjunctival hemorrhage after talking on her cell phone. There was no history of trauma or known medical diseases, but the patient had multiple endosteal implants, nine of them from 12 years ago, and a recent one on her left maxilla from last year. After detailed anamnesis, it is learned that the patient was not using any bisphosphonate treatment, but she was on Vitamin D treatment due to Vitamin D deficiency and using mirtazapine and alprazolam for anxiety. However, her T-score calculated for osteoporosis was above −2.5. All of the maxillofacial examinations were normal except for suspicious step deformity in the palpation of the left infraorbital rim. However, on the computed tomography imaging, it showed that there were fractures on the left lateral and infraorbital wall and left inferior maxillary sinus wall. MRI imaging ruled out any possible fracture caused by an aneurysmal bone cyst. With all these findings and careful examinations, the cause of these fractures was considered a late complication of her dental implants.

Successful Management of Neonatal Orbital Cellulitis: A Rare Case Report

Objective: To report a rare case of neonatal orbital cellulitis along with the successful management. Introduction: Orbital cellulitis is a sight- and life-threatening infection of the post-septal tissues of the orbit, and is a considerably rare finding in neonates. Prompt diagnosis and treatment is essential, as 11-26% of cases of orbital cellulitis result in death and visual loss. Case Presentation: A one-month-old neonate presented with rapidly progressive swelling and redness of the right eyelid along with persistent subfebrile fever seven days before admission to the hospital. Blinking reaction to light stimulation was good on the left eye. Ocular motility was difficult to be evaluated. Conjunctival appearance on the right eye showed severe chemosis, while the other parts of both eyes were within normal limit. Orbital Computed Tomography (CT) scan revealed diffuse soft-tissue swelling at the superior and inferior palpebra of the right eye and partial erosion of the lateral wall of the right ethmoidal sinus, suggesting sino-orbital inflammation. Diagnosis of orbital cellulitis was confirmed on the right eye in this patient. Incision and drainage surgery of the right eyelids were done immediately as improvement was only seen on the upper eyelid after empirical intravenous (IV) antibiotic administration. Strain of Methicillin-Resistant Staphylococcus Aureus (MRSA) was found from the discharge’s culture. At one month follow up, the swelling of the right eyelid had markedly decreased with no signs of inflammation. Conclusion: This case highlights and showed a rare case and successful management of neonatal orbital cellulitis. Early diagnosis and prompt treatment of neonatal orbital cellulitis may benefit patient and prevent sight- and life-threatening condition.

Defining the limits and indications of the Draf III endoscopic approach to the lateral frontal sinus and maximizing visualization and maneuverability: a cadaveric and radiological study

PurposeThe DRAF III procedure has been used for access to the lateralmost part of the frontal sinus. We sought to identify anatomical and radiological measurements as well as modifications that predict the lateral limits of visualization and surgical access after this procedure.MethodsSeven cadaver heads were imaged with computed tomography scan. The distance from midline to the medial orbital wall (MOWD), midline to the lateral end of the frontal sinus (MLD), the sum of MLDs (SMLD), interorbital distance (IOD) and the shortest anteroposterior distance of the frontal recess (APD) were utilized. The ratios MLD/MOWD, and SMLD/IOD were calculated. The same distances were measured on 41 CT scans. Orbital transposition (OT) and partial resection of the piriform aperture (PAR) were performed; the visualization and reach were assessed. The angle of insertion was measured before and after the modifications.ResultsOnly the ratio MLD/MOWD was consistently predictive of access to the lateral, superior and posterior wall of the frontal sinus. Following the modifications, a visualization of 100% laterally was achieved with the 30- and 45 degree endoscopes and every lateral recess could be reached with the 70 degree suction. A mean increase of the angle of insertion of 25.3 and 59.6% was recorded after OT and PAR, respectively.ConclusionsIOD rather than APD defines the limits of the Draf III approach to the lateral frontal sinus and MLD/MOWD ratio can serve as a useful preoperative tool. Along to the already described OT, PAR increases visualization and reach of the lateral frontal sinus.

"Sagittal Crest": Definition, Stepwise Dissection, and Clinical Implications From a Transorbital Perspective.

The recent development of the superior eyelid endoscopic transorbital approach (SETOA) offered a new route for the management of cavernous sinus and middle cranial fossa tumors. As a result, a constant anatomic landmark of the surgical pathway after drilling the medial edge of the greater sphenoid wing (GSW) is represented by a triangular-shaped bone ridge appearing as a "crest." To perform an anatomic study to define this surgical landmark, named the "sagittal crest" (SC) as seen from the transorbital endoscopic view. Four adult cadaveric specimens (8 sides) were dissected performing an endoscopic transorbital approach to the middle fossa and the SC was removed to perform interdural opening of the cavernous sinus. Computed tomography scans were made before and after removal of the SC to perform quantitative analysis and building a 3-dimensional model of the bone resection of the GSW via the SETOA. The SC is a bone ridge triangle shaping dorsally the superior orbital fissure resulting as the residual fragment after drilling the lateral aspect of the greater sphenoid wing. Predissection and postdissection computed tomography scans allowed to objectively assess SC features and dimensions (mean 1.08 ± 0.2 cm). The SC is a constant anatomic landmark constituted of the residual medial portion of the GSW. Complete resection of this key landmark provides adequate working space and appears to be mandatory during SETOA to guide the subsequent interdural dissection of the lateral wall of cavernous sinus.

Topographic assessment of the vascular anastomosis in the maxillary sinus wall using cone-beam computed tomography

The aim of the study was to establish the prevalence, diameter and topography of the intraosseous vascular canal of the maxillary sinus lateral wall. The data of cone-beam computed tomography of 150 dental patients (294 maxillary sinuses) were analyzed. Intraosseus anastomosis of the branches of the posterior superior alveolar artery and infraorbital artery was detected in 87.8% of cases (258 of 294 sinuses). Anastomosis was found inside the wall of the sinus in every tooth location in 9.5% of sinuses; in other cases, the anastomosis was partially or fully embedded in the thickness of the lateral wall of the maxillary sinus in different tooth site. The mean diameter of the vascular anastomosis was 0.95±0.3 mm (range 0.3-2.18 mm). The average distance from the anastomosis to the sinus floor was 8.91±3.39 mm (range 1.68-21.83mm). In most cases, at locations of molars and premolars, the distance from the vascular anastomosis to the alveolar crest was greater than 15 mm (from 75.5% at the location of the first molar to 99.2% at the location of the first premolar). Detection of the topography of the vascular anastomosis by using cone-beam computed tomography is essential when planning the position of the antrostomy for the lateral sinus lift procedure in order to minimize iatrogenic complications.

On the cutting edge: anterior transpetrosal approach – the middle fossa approach. Clinical application, surgical anatomy, and results

Nowadays, the middle cranial fossa approach (MFA) is one of the most useful operative procedures in skull base surgery. When performed properly, it provides a relevant adjunct to treating complex skull base lesions. MFA allows one to resect the anterior petrous bone (anterior petrosectomy), open the internal auditory canal (IAC), and access the lateral wall of the cavernous sinus and the infratemporal fossa. Knowledge of the anatomical structures of the middle cranial fossa and cavernous sinus is mandatory to perform this approach. We report in detail the standard extradural subtemporal route for the anterior petrosectomy and MFA. The main indications for this approach are intradural lesions localized medially to the trigeminal nerve, subtemporal interdural and extradural tumours and neoplasms involving the IAC (including IAC pathology). Moreover, we describe the extended middle fossa approach, consisting in the anterior extension of MFA, indicated for intradural tumours of the superior cerebello-pontine angle and of prepontine clivus (retroclival lesions, ventral brainstem tumours, and cavernomas), for infratemporal fossa lesions, and cavernous sinus pathologies. Even if the anatomical landmarks of the middle cranial fossa and lateral skull base are well known, training with cadaver dissection is necessary for any skull-base surgeon to perform an optimum MFA. The cadaver-lab dissections simplify the learning of anatomical structures, and prepare the surgeon properly for this technically challenging approach.

Microsurgical Resection of Hybrid Nerve Sheath Tumor Involving the Orbit and Lateral Wall of the Cavernous Sinus: 2-Dimensional Operative Video.

Surgical removal of the tumor involving both the orbital and cavernous sinus remains challenging. Hybrid nerve sheath tumors (HNSTs) are defined as benign peripheral nerve sheath tumors with combined features of more than one type of benign peripheral nerve sheath tumors, including schwannoma, neurofibroma, and perineurinoma.1 They rarely arise from the orbit.1-3 This video shows the microsurgical resection of HNST involving both the orbit and lateral wall of the cavernous sinus. A 43-yr-old woman presented with 1-yr history of a slowly growing painless mass in her left medial eyelid. Neuroimaging examinations demonstrated a multilobulated and well-demarcated mass with a heterogeneous enhancement located in the extraconal region, just above the levator muscle, and extending from the eyelid to the middle fossa through the superior orbital fissure. Based on the neuroimaging features, we diagnosed it as trigeminal schwannoma involving the orbit and lateral wall of the cavernous sinus preoperatively. We performed left frontotemporal craniotomy with superolateral orbitotomy to gain access to the tumor. The tumor was grayish yellow and relatively firm. No intact nerve fibers of the frontal and ophthalmic nerves could be identified, making the diagnosis of the tumor originating from both nerves. Finally, we completely resected the tumor, which was confirmed by postoperative magnetic resonance images. Her postoperative course was uneventful, except for transient diplopia and expected left forehead hypesthesia. The pathology returned to HNST containing schwannoma and neurofibroma with no malignancy. The patient consented to the procedure prior to the surgery. And, the patient consented to the publication of their image.