Sublabial Transmaxillary Approach Research Articles

Sublabial transmaxillary approach to the inferior aspect of the orbit.

The objective was to demonstrate the surgical steps and outcomes of the sublabial transmaxillary microsurgical approach with endoscopic assistance to treat lesions in the inferior aspect of the orbit, as well as to describe the use of patient-specific 3D models to facilitate surgical preparation and improve experience with the technique. The authors' study evaluated data from patients who underwent an endoscope-assisted sublabial transmaxillary approach for inferior orbital lesions. For 2 patients, 3D models were created for preoperative planning and assessment of the approach. Surgical steps comprised osteotomy to access the maxillary sinus, bony resection of the orbital floor, opening of the periorbital fascia, and dissecting and removing the lesion, followed by closure. The neuroendoscope was used to inspect the surgical cavity between each step. The study included 5 patients with varying visual field defects and proptosis who underwent the sublabial transmaxillary microsurgical approach with endoscopic assistance. Complete resection was achieved in all, and all patients reported improvement in visual field defects and proptosis after the procedure. No complications were observed except for transient unilateral maxillary edema noted around the incision site in 3 patients during the early postoperative period, which resolved within a few days. Histopathological examination confirmed the diagnosis of cavernous malformation in all patients. The sublabial transmaxillary approach is a direct and safe method to resect cavernous malformations at the inferior aspect of the orbit. It reduces the risk of complications associated with lateral, transcranial, and transnasal approaches that may cross critical structures. The microsurgical approach provides the benefit of two-handed dissection for lesions embedded in orbital fat, which can be challenging because of adhesions to surrounding tissues. The use of 3D models can facilitate surgical planning and enhance familiarity with the approach.

Anterior endoscopic sublabial transmaxillary access to middle cranial base lesions.

Anterior endoscopic access to middle cranial base lesions becomes feasible in the presence of infratemporal fossa (ITF) involvement. Various approaches, including endoscopic endonasal, transoral sublabial, and transorbital methods, have been described for accessing the ITF through a transmaxillary corridor. Among these approaches, endonasal access is the most commonly preferred, while the transorbital approach is a novel technique gaining popularity. The transoral sublabial approach is considered suitable for selected lesions. Patients who underwent the anterior endoscopic transoral/sublabial transmaxillary approach to middle cranial base lesions at a single institute from 2016 to 2023 were included in this retrospective study. Malignant lesions were excluded from the study. The sublabial approach was exclusively performed in all cases, with the exception of one patient who required a combined approach. The anterior endoscopic transoral sublabial transmaxillary approach to the infratemporal fossa, upper parapharyngeal space, and middle cranial fossa was performed on 14 patients. The underlying conditions for these patients were as follows: trigeminal schwannomas (n = 8), meningiomas (n = 2), juvenile nasopharyngeal angiofibroma, osteochondroma, arachnoid cyst and encephalocele (n = 1 each). Gross total resection was achieved in 11 cases. The most common complication was numbness in the territory of the maxillary and mandibular nerves (n = 4). Two patients needed endoscopic maxillary antrostomy for persistent suppuration. No wound problems or CSF rhinorrhea occurred. The average follow-up time was 26.6 months. The endoscopic sublabial transmaxillary approach provides direct access to the infratemporal fossa and middle cranial base, enhancing the surgical range of maneuverability while sparing the sinonasal cavity. This procedure is safe, less invasive, and could be used as an efficient corridor for the resection of selected infratemporal fossa lesions with or without extension to the middle cranial base and parapharyngeal space.

Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections.

Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially. To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging. We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc). A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date. JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

Endoscopic Multiport Approach for Exenteration of the Infratemporal Fossa.

To demonstrate anatomic relationships pertinent to the endoscopic multiport approach to the infratemporal fossa (ITF). Discuss advantages and limitations of each individual approach. Cadaveric study. Endoscopic and endoscopic-assisted endonasal transpterygoid, sublabial transmaxillary, endoscopic transorbital, and endoscopic transoral approaches to accessing the ITF were completed in five silicone-injected fresh cadaveric specimens (10 sides) with the assistance of 0, 30, and 450 rods-lens endoscopes. Image guidance was used to confirm and document the anatomical relationships encountered in each approach. The endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure to median structures. Endoscopic-assisted sublabial transmaxillary approach enhances the field of exposure, angle of attack, and ease of instrumentation to the lateral part of the ITF. Endoscopic-assisted transorbital approach via the inferior orbital fissure provided cephalic and anterior access. Endoscopic-assisted transoral approach complements the access to lesions extending inferior to the hard palate or far lateral to the mandibular condyle. A combination of minimal access infratemporal approaches can provide adequate exposure of the entire ITF while avoiding some of the morbidity associated with open approaches. NA Laryngoscope, 133:1367-1374, 2023.

Combined endoscopic endonasal transpterygoid and sublabial transmaxillary approaches for a large infratemporal fossa trigeminal schwannoma.

Trigeminal schwannomas (TSs) with solitary extracranial location are rare, and surgical excision is challenging. In recent years, the endoscopic endonasal transmaxillary transpterygoid approach (EETPA) has been advocated as an effective strategy for TSs in the infratemporal fossa (ITF). We describe the steps of the EETPA combined with the sublabial transmaxillary approach for the surgical excision of a giant mandibular schwannoma of the ITF. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. A combined EETPA and sublabial transmaxillary approach represents a safe and effective option for the surgical excision of extracranial TSs.

Endoscopic sublabial transmaxillary approach to the inferior orbit: pearls and pitfalls-A comparative anatomical study.

Although orbital surgery has always represented a challenge for neurosurgeons, keyhole and endoscopic techniques are gradually surging in popularity maximizing functional and esthetic outcomes. This quantitative anatomical study first compared the surgical operability achieved through three endoscopic approaches within the inferior orbit: the endoscopic sublabial transmaxillary (ESTMax), the endoscopic endonasal transethmoidal (EETEth), and the endoscope-assisted lateral orbitotomy (ELO). Each of these approaches was performed bilaterally on five specimens. We described the ESTMax step-by-step, underlining its advantages and pitfalls in comparison with EETEth and ELO. Then, we assessed surgical measurements and operability in ESTMax, EETEth, and ELO. The ESTMax provided the most favorable operative window (278.9 ± 43.8 mm2; EETEth: 240.8 ± 21.5 mm2, p < 0.001; ELO: 263.1 ± 19.8 mm2, p = 0.006), the broadest surgical field area (415.9 ± 26.4 mm2; EETEth: 386.7 ± 30.1 mm2, p = 0.041; ELO: 305.2 ± 26.3 mm2, p < 0.001), surgical field depths significantly shorter than EETEth (p < 0.001) but similar to ELO, the widest surgical angles of attack (45°-65°; EETEth: 20°-30°, p < 0.001; ELO: 25°-50°, p < 0.001), and the greatest surgical mobility areas (EETEth: p < 0.001; ELO: p < 0.001). Furthermore, the ESTMax allowed multi-angled exposure and handy maneuverability around all the inferior intraorbital targets. Small anterior antrostomy, blunt intraorbital dissections, direct targets' approach, orbital floor reconstruction, and maxillary bone flap replacement may limit the ESTMax morbidity rates. The ESTMax is a minimally invasive "head-on" orbital approach that exploits endoscopic surgery advantages avoiding the cranio-orbital and trans-nasal approach limitations and possible complications. It represents a promising alternative to EETEth and ELO because of its optimal operability for resecting lesions extending into the entire inferior orbit.

Efficacy of the Endoscopic Triportal Transmaxillary Approach for Treating Lateral Middle Skull Base Tumors: A Technical Note and Retrospective Case Series

The endoscopic approach, chiefly via the maxillary sinus, has growing applications for the lateral skull base, and can be classified into the use of "endonasal" or "sublabial" entry. Although the endonasal transmaxillary approach has been well accepted, it has a limitation with respect to the lateral exposure. A possible solution is the use of the sublabial transmaxillary approach via the canine fossa, which assures lateral accessibility. In clinical practice, we have taken advantage of the concomitant use of the endonasal and sublabial transmaxillary approach for selected patients harboring lateral skull base lesions. In addition to binostril pathways, canine fossa trephination was constructed to facilitate this combined approach, termed the endoscopic triportal transmaxillary approach (ETTA). The efficacy of the ETTA was evaluated within a case series. A single-institution retrospective analysis was performed in patients with lateral middle skull base tumors treated via ETTA. In clinical practice, 4 patients were eligible for the study, including 1 receiving a combined endoscopic and transcranial approach. No major complications occurred in patients included in this series. The ETTA facilitated the dynamic manipulation of instruments, which led to rapid hemostasis and the satisfactory surgical resection of tumors. Furthermore, it reduced intraoperative postural stress experienced by the surgeons who performed the procedures. The concomitant use of the trans-canine fossa approach effectively ameliorated significant technical challenges that tend to occur when using a purely endonasal approach. The ETTA can be an attractive option for treating lateral and middle skull base lesions.

Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances.

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.The video can be found here: https://youtu.be/gy-pkjLdDgE.

Primary Lymphoma of the Skull Base in the Chinese: Clinical, Radiological, Pathological, and Therapeutic Experience in a Series of 8 Patients

Primary lymphoma of the skull base (PLSB) is an extremely rare neoplasm and not much is known regarding the clinical features of, treatment strategies for, and prognoses of these lesions. We investigated the manifestations and clinical outcomes of Chinese patients with PLSB. We retrospectively reviewed the data from 8 consecutive patients with PLSB who had been treated at our center from October 2008 to December 2016 and analyzed their clinical features, treatment strategies, and prognoses. Of the 8 patients, 3 were men and 5 were women, with a male/female ratio of 0.6. The median age was 53.5 years. In most instances, the onset was characterized by headache, followed by dysfunction of the cranial nerves. The most frequently affected region was the cavernous sinus. On magnetic resonance imaging, the main characteristic was that the internal carotid artery was encased by the tumor without an obvious tendency to be deformed, dislocated, or narrowed. All patients underwent surgical biopsy via a transsphenoidal or sublabial-transmaxillary approach. The pathological diagnosis was non-Hodgkin lymphoma for all 8 patients, with diffuse large B-cell lymphoma in 7 patients. The patients underwent chemotherapy and involved-field radiotherapy. The median overall survival was 52 months, and the 1-year progression-free survival rate was 87.5%. PLSB is a rare disease and a diagnostic challenge, with most cases in the Chinese due to diffuse large B-cell lymphoma. We found that the incidence peaked in middle and old age, and the cavernous sinus was usually affected. Multidisciplinary treatment involving surgical biopsy, chemotherapy, and radiotherapy was an effective therapeutic strategy.

The surgical management of nasal skull base schwannoma under endonasal endoscope: a retrospective review of 52 cases

Objective: To discuss the surgical technique and outcome of nasal skull base schwannoma treated under endonasal endoscope. Methods: Fifty-two patients with nasal skull base nonvestibular schwannoma were treated under endonasal endoscope from May 2006 to June 2017 in Shanghai E&ENT Hospital. Of the patients, there were 21 men and 31 women. The age of the patients ranged from 33 to 71 years.Schwannoma mainly came from trigeminal nerve.Clinical symptoms included facial numbness, facial pain, nasal obstruction, headache, hypopsia, diplopia and tinnitus. Surgical approaches included pure endonasal endoscope approach (18 cases) and endoscopic endonasal resection asissted with sublabial transmaxillary approach (34 cases). Results: Total tumor resection was achieved in 42 patients(80.8%), subtotal resection in 8 patients, and partial resection in 2 patients. The relief rate of facial numbness, facial pain, nasal obstruction, headache, hypopsia, diplopia and tinnitus were 68.8%, 45.5%, 100.0%, 90.0%, 60.0%, 40.0% and 100.0%, respectively. During surgery, cerebrospinal fluid leakage was observed in 5 cases. All cases were successfully repaired with a nasoseptal flap or autologous fascia lata and fat obtained from thigh. Four cases with recurrence were observed in the follow-up period (6-134 months). Conclusion: Endonasal endoscopic approach is a safe and feasible procedure for schwannoma in nasal cavity, paranasal sinus, orbital apex, pterygopalatine fossa, infratomporal fossa, cavernous sinus and Meckel cave.

Endoscopic endonasal approach for trigeminal schwannomas: our experience of 39 patients in 10years.

The anatomical locations involved in trigeminal schwannomas (TSs) are quite complex. The endoscopic endonasal approach provides a minimal damage access corridor to both anterior and middle skull base for surgery. Given the nerve function recovery and postoperative neurological deterioration varied in different reports, the author demonstrates his surgery tips and the functional outcomes under endoscopic surgery in one single institution. A retrospective review of patients with TSs was undertaken to assess the outcome of endoscopic surgery from 2006 to 2016. Clinical features, imaging findings, preoperative/postoperative neurological deficits, surgical approaches and followed up data were collected. Thirty-nine patients with TSs were included in this study. Surgical approaches include endoscopic medial maxillectomy approach (n = 8), endoscopic endonasal-assisted sublabial transmaxillary approach (n = 27) and endoscopic endonasal-assisted sublabial transmaxillary combined with septectomy (n = 4). Gross total resection and sub-total resection were achieved in 27 and 10 patients, respectively. The most common chief complaint was facial numbness, accounting for 41%, with a resolved rate of 62.5% after treatment. Fifteen patients developed new neurologic symptoms, including facial numbness/pain (n = 9 and 2, respectively), dry eye (n = 3) and mastication weakness (n = 1). Eight of these patients had partial improvement except for patients with dry eye. Endoscopic endonasal approach represents a safe and effective surgical procedure for TSs in pterygopalatine fossa, infratemporal fossa and even Meckel cave. Tumor resection can be achieved by endoscope with few neurologic deficits and complications.

Quantitative Comparison of Three Endoscopic Approaches to the Parasellar Region: Laboratory Investigation.

Endoscopic endonasal transsphenoidal and contralateral sublabial transmaxillary approaches are used for approaching parasellar lesions. The aim of this anatomical study was to compare endoscopic endonasal uninostril and binostril (contralateral) and contralateral sublabial transmaxillary approaches via a quantitative analysis of exposure limits and instrument working avenues. Six formalin-fixed silicone-injected adult cadaveric heads (12 sides) were studied. The surgical working area, depth of the surgical corridor, angle of attack, and surgical freedom were measured and compared for the 3 approaches. The endoscopic binostril endonasal approach to the parasellar area provided greater surgical freedom in the opticocarotid recess (OCR) and superior orbital fissure (SOF) compared with that of the uninostril endonasal approach (OCR, P < 0.01; SOF, P= 0.01) and the contralateral sublabial transmaxillary approach (OCR, P= 0.01; SOF, P= 0.03). The horizontal and vertical angles of attack with the binostril endonasal approach also were greater than those of the uninostril approach (OCR, P ≤ 0.05; SOF, P≤ 0.01) and the contralateral transmaxillary approach (OCR, P ≤ 0.01; SOF, P ≤ 0.01). However, the contralateral sublabial transmaxillary approach provided more lateral exposure than the uninostril or binostril endonasal approach to the parasellar area, and it enabled a shorter surgical trajectory to the contralateral parasellar area (P < 0.01). An anatomical comparison of the 3 endoscopic approaches to the parasellar area showed that the binostril approach provides greater exposure and freedom for instrument manipulation. The contralateral transmaxillary route provided a more lateral view, increasing exposure on average by 48%, with shorter surgical depth; however, surgical freedom was inferior to that of the binostril approach.

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.

ENDOSCOPIC SUBLABIAL TRANSMAXILLARY APPROACH TO THE ROSTRAL MIDDLE FOSSA

The rostral middle fossa faces the temporal pole and is the endocranial anterosuperior aspect of the greater wing of the sphenoid. Standard approaches to this region, such as the subtemporal, pterional, or orbitozygomatic approaches, require significant brain retraction or manipulation of the temporalis muscle. We report an endoscopic sublabial transmaxillary approach to this cranial base region that avoids the aforementioned pitfalls. Ten adult cadaveric half heads were used to develop the endoscopic approach and to identify the salient surgical landmarks. The approach was divided into three stages: entry into the maxillary sinus, entry into the infratemporal fossa, and entry into the middle fossa. A craniotomy of greater than 20 mm in diameter can be safely created in the rostral middle fossa. When coupled with image guidance, the approach provides the flexibility to tailor the size and location of the middle fossa craniotomy. Although endonasal endoscopic approaches are increasing in popularity, the middle fossa has not been adequately accessed with these techniques. The endoscopic sublabial transmaxillary approach provides safe and direct access to the rostral middle fossa, eliminating the need for brain retraction, temporalis muscle manipulation, or an external incision. The approach also permits early devascularization of cranial- or dural-based lesions.

Sublabial Transmaxillary Approach to the Rostral Middle Fossa

Introduction: The rostral middle fossa faces the temporal pole and is the endocranial anterosuperior aspect of the greater wing of the sphenoid. Standard approaches to this region such as the subtemporal, pterional, or orbitozygomatic require significant brain retraction or manipulation of the temporalis muscle. We report an endoscopic sublabial transmaxillary approach to this skull base region that avoids the aforementioned pitfalls.

Combined Endoscopic Transmaxillary-Transnasal Approach to the Pterygoid Region, Lateral Sphenoid Sinus, and Retrobulbar Orbit

The sublabial transmaxillary approach to the pterygoid region was a popular one during the Caldwell-Luc, pre-endoscopic era. It was the procedure of choice for management of lesions of the pterygopalatine space, for internal maxillary artery ligation, and for vidian neurectomy. With the introduction of endoscopic instrumentation and techniques, the Caldwell-Luc procedure is rarely performed today. Also, because vidian neurectomy is performed less frequently, and because internal maxillary artery ligation for severe epistaxis has been replaced with transnasal endoscopic sphenopalatine artery ligation, the sublabial transmaxillary route is rarely used. We have found that combining the use of endoscopes via the sublabial approach and the transnasal endoscopic approach is very helpful for management of extreme lateral lesions of the sphenoid sinus, as well as the pterygoid region and the posterior orbit. The records of patients who underwent a combined endoscopic transmaxillary-transnasal approach between 1994 and 2002 were reviewed. Indications for the procedure included extreme lateral sphenoid and pterygoid encephalocele (3 patients), pterygoid mucocele (2 patients), orbital apex lesion (2 patients), and pterygopalatine tumor (2 patients). Nine patients underwent the above-mentioned procedure. Wide and comfortable exposure of the involved region was achieved in all cases. Compared with the transnasal approach, the working distance, working comfort, and maneuverability of instruments were significantly enhanced. There were no major complications related to the approach. Because the maxillary wall opening is very small, infraorbital hypoesthesia is very limited and of short duration. Combining the transmaxillary and transnasal approaches for endoscopic management of pterygoid, lateral sphenoid, and retrobulbar orbit lesions provides excellent exposure and avoids the limited working angle and surgical struggle that may be associated with the use of the transnasal approach alone.

Treatment of a sphenoid sinus mucocele using an endoscope combined with a navigating system: a case report

A sphenoid sinus mucocele extending into the middle cranial fossa and the pterygomaxillary fissure was decompressed using an endoscope in combination with a navigation system. A 59-year-old woman was admitted with a 3 month history of retro-ocular pain and right sided exophthalmos. To evaluate the cystic lesion, a fibreoptic endoscope was inserted into the cyst through an erosive defect in the temporal bone. The histopathological appearance of cyst wall tissue confirmed the diagnosis of mucocele. After 4 months, the mucocele had refilled and the exophthalmos had recurred. At reoperation, the cyst was fenestrated using a rigid endoscope combined with a navigation system inserted via a sublabial transmaxillary approach. The proper site of cyst fenestration was precisely determined using the navigation system, permitting complete evacuation of this large lesion with minimal invasiveness.