Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Transoral & Transorbital approaches of skull base

3,034 views

Published on

Transoral & Transorbital approaches of skull base

Published in: Education
  • How can I get a flat stomach in 2 days?  https://tinyurl.com/bkfitness4u
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • how to lose weight in a week without exercise ♥♥♥ http://ishbv.com/bkfitness3/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Transoral & Transorbital approaches of skull base

  1. 1. Transoral & Transorbital approaches of skull base 14-8-2016 12.26 pm
  2. 2. Great teachers – All this is their work . I am just the reader of their books . Prof. Paolo castelnuovo Prof. Aldo Stamm Prof. Mario Sanna Prof. Magnan
  3. 3. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.
  4. 4. Infratemporal fossa anatomy
  5. 5. IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial pterygoid muscle , LPM = lateral pterygoid muscle Different layers of muscles & aponeurosis protecting great vessels in infratemporal fossa – Main protectors are medial & lateral pterygoid mucles & temporalis muscle - great vessels are posterior to these 3 muscles – small contribution of protection of great vessels are done by tensor veli palatini & styloid muscles & stylopharyngeal aponeurosis
  6. 6. IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial pterygoid muscle , LPM = lateral pterygoid muscle
  7. 7. TVPM is triangular muscle , LVPM is cylindrical muscle
  8. 8. SPM attached to superior constrictor , SGM attached to tongue , SHM attached to lesser cornu of hyoid bone
  9. 9. After drilling LPP & MPP longissmus capitis & superior constrictor seen .
  10. 10. Trans - Oral approach to Infratemporal fossa
  11. 11. STEP 1 = Incision : anterior to anterior to anterior pillar of tonsil for “Trans - Oral approach to infratemporal fossa”
  12. 12. STEP 2 = Seperation of deep tissue identification of palato pharyngeus and palato glossus and superior consrictor muscles above medially below medial pterygoid and ramus of mandible identification of triangles identification of ascending palatine and ascending pharyngeal ( resident friend) artery
  13. 13. STEP 3 = finally identification of our friends ica and jugular and vagus in the upper triangle formed by s c m stylopharyngeus and stylo glossusmuscles Triangle between SPM & SGM & Superior constrictor Left side
  14. 14. Transoral approach to SUPERO-MEDIAL Parapharyngeal tumors – incision anterior to anterior pillar of tonsil
  15. 15. Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar of tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below diagrams MPM reflected back for understanding purpose
  16. 16. MPM is reflected back – which shows the structures seen in trans-oral approach of ITF – incision anterior to anterior pillar of tonsil
  17. 17. Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar of tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below diagrams MPM reflected back for understanding purpose
  18. 18. 1. Each styloid muscle accompanied by one nerve – SPM by 9th nerve , SGM by lingual nerve , SHM by 12th nerve 2. SPM & SGM protects ICA whereas SHM protects both ECA & ICA – that is the reasonwhy wheen you dissect a plane over posterior belly of diagastric & SHM , you won’t get vital structures 3. ECA & ICA & CCA are like tuning fork – caricature diagram
  19. 19. Each styloid muscle accompanied by one nerve – SPM by 9th nerve , SGM by lingual nerve , SHM by 12th nerve
  20. 20. Note the 9th nerve accompanying Stylopharyngeus
  21. 21. The SPM runs inferiorly on the lateral aspect of the ICAp. The SHM is lateral to the ECA. The SGM passes lateral to the ICAp, medially to the ECA. The stylomandibular ligament is a condensation of the deep layer of the parotid fascia. It connects the styloid process with the angle of the mandible. DMpb posterior belly of the digastric muscle, FA facial artery, ICAp parapharyngeal portion of the internal carotid artery, IJV internal jugular vein, SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, VIIcn facial nerve, Xcn vagus nerve, XIcn accessory nerve, XIIcn hypoglossal nerve, black asterisk glossopharyngeal nerve at the skull base
  22. 22. MPM is reflected back – which shows the structures seen in trans-oral approach of ITF – incision anterior to anterior pillar of tonsil
  23. 23. ApaA ascending palatine artery, BFP buccal fat pad, BM buccinator muscle, ICAp parapharyngeal portion of the internal carotid artery, IJV internal jugular vein, LN lingual nerve, MPM medial pterygoid muscle, PG parotid gland, PP pharyngeal plexus, SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, IXcn glossopharyngeal nerve, Xcn vagus nerve, black asterisk stylomandibular ligament
  24. 24. Transoral endoscopic view of the parapharyngeal region ApaA ascending palatine artery, ICAp parapharyngeal portion of the internal carotid artery, LCapM longus capitis muscle, PP pharyngeal plexus, SCM superior constrictor muscle, SGM styloglossus muscle, SPM stylopharyngeus muscle, white arrows glossopharyngeal nerve The external carotid artery passes deeply to the digastric and stylohyoid muscles, but super fi cially to the stylopharyngeus and styloglossal muscle when running toward the parotid gland (Janfaza et al. 2001 ) . With a transoral window it is possible to control the space between the medial pterygoid muscle laterally and the superior constrictor muscle medially. The stylopharyngeus and styloglossus muscles are critical landmarks, being usually placed anterior to the great vessels (Dallan et al. 2011 ). Note that the presence of kinking or looping of the ICAp could make this statement untrue.
  25. 25. transoral endoscopic views of the tongue base and parapharyngeal regions APA ascending pharyngeal artery, ApaA ascending palatine artery, DM digastric muscle, FA facial artery, HGM hyoglossus muscle, IAN inferior alveolar nerve, ICAp parapharyngeal portion of the internal carotid artery, IJV internal jugular vein, LA lingual artery, LN lingual nerve, M mandible, MPM medial pterygoid muscle, SCM superior constrictor muscle, SGM styloglossus muscle, SPM stylopharyngeus muscle, TB tongue base, XIIcn hypoglossal nerve, black arrows glossopharyngeal nerve
  26. 26. Lateral vision of the upper cervical and lower parapharyngeal regions. The vertical branch of the mandible has been removed DM digastric muscle, ECA external carotid artery, FA facial artery, ICAp parapharyngeal portion of the internal carotid artery, IJV internal jugular vein, LFVT linguofacial venous trunk, LN lingual nerve, MPM medial pterygoid muscle, OA occipital artery, SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SMG submandibular gland, SPM stylopharyngeus muscle, IXcn glossopharyngeal nerve, XIcn accessory nerve, XIIcn hypoglossal nerve, yellow arrow ansa cervicalis profunda
  27. 27. Transoral endoscopic view of the parapharyngeal region APA ascending pharyngeal artery, ApaA ascending palatine artery, ICAp parapharyngeal portion of the internal carotid artery, IJV internal jugular vein, LN lingual nerve, M mandible, SCM superior constrictor muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, TB tongue base, white arrow hypoglossal nerve, black arrows glossopharyngeal nerve, blue arrows lingual nerve
  28. 28. Sree ram murthy sir dissection in Italy Dear surgeons today we did cadavèric dissection to endoscopic transoral approach to parapharyngeal space The indications are 1. removal of small tumours of parapharyngeal space 2. biopsy of growths 3. to enter in to infratemporal space 4. para mandibular approaches to mid cranial fossa The dissection was done by us with dr Dallan Of Pisa medical university of PISA ITALY 1. Incision over soft palate above anterior pillar 2. Seperation of deep tissue identification of palato pharyngeus and palato glossus and superior consrictor muscles above medially below medial pterygoid and ramus of mandible identification of triangles identification of ascending palatine and ascending pharyngeal ( resident friend) artery 3. Finally identification of our friends ica and jugular and vagus in the upper triangle formed by s c m stylopharyngeus and stylo glossusmuscles inferiorly mtm and mandible v3 branches entering infra temporal space are important things. Trans oral endoscopy of pps is gaining popularity now a days a new procedure hence friends just pass deeper to tonsil we see wonders The video is thrilling to see It is a anatomical feast
  29. 29. finally identification of our friends ica and jugular andvagus in the upper triangle formed by s c m stylopharyngeus and stylo glossusmuscles
  30. 30. Dear surgeons it is trans oral endoscopic pic of parapharyngeal space to show ascending pharyngeal artery and other structures of neck 1ascending palatine artery 2 ascending pharyngeal artery 3 ica 4 ij v 5 stylo pharyngeus muscle
  31. 31. ARTERY OF TROUBLE ARTERY OF TROUBLE: The inferior tympanic artery which supplies medial wall of middle ear. Normally it is a small branch of ascending pharyngeal artery a middle terminal twig along with anterior pharyngeal branch and posterior neuro meningeal branch. In 50% cases, it is visible But in glomous tumours the major blood supply to the tumour is from this artery. In glomous tumours it is engorged more than 8 times Inferior tympanic artery enter the floor of middle ear through tympanic canaliculus at crotch along with jocobsons nerve. Finiculus island mark to this artery entry. Surgical implications: • 1) In glomus tympanicus tumours initial coagulation of this vessel at the region of finiculus reduces bleeding • 2) It can have anastomoses with petrous segment of ICA so glomous tumour may be supplied by EAC and ICA
  32. 32. 1 Inferior tympanic artery 2 anterior crus of stapes 3 long process of incus 4 malleus
  33. 33. 1 Inferior tympanic artery 2 anterior crus of stapes 3 long process of incus 4 malleus
  34. 34. Paraphayrngeal JNA removal by Endoscopic trans-oral approach by Dr.Janakiram
  35. 35. Another case of MUCOEPIDERMOID TUMOR – OPERATED TWICE BEFORE.. ENDOSCOPIC TRANSORAL EXCISION by Dr.Janakiram – Click https://www.facebook.com/narayanan.janakiram /media_set?set=a.862837223808213.107374193 9.100002458306921&type=3
  36. 36. Trans-Oral approach to CVJ [ cranio- vertebral junction ]
  37. 37. Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palate was excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally. D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebral body and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica: anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1 nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil, saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.
  38. 38. Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palate was excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally. D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebral body and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica: anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1 nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil, saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.
  39. 39. TRANSORBITAL ENDOSCOPIC APPROACHES TO THE ANTERIOR CRANIAL FOSSA
  40. 40. Updated soon Read Chapter 15 TRANSORBITAL ENDOSCOPIC APPROACHES TO THE ANTERIOR CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul +gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y
  41. 41. Sree ram murthy sir dissection in italy Dear surgeons to day we dissected Transorbital approach to infratemporal fossa on cadaver under guidence of pro Sellari franchisco of PISA italy He is expert for this approaches So far he has done 1980 cases through approach The main indications are 1 orbital decompression 2 clenoid meningiomas and other tumours of anterior cranial fossa 3cavernous sinus pathologies 4 meckles cave tumours 5 infratemporal fossa pathologies 6 this one approach is for all pathologies of anterior middle cranial and infra temporal fossa superior lid incision sub periosteal elivation of globe identification of sof and meningo orbital artery drillng of greater wing of sphenoid for mid fossa alittle inferior for itf frotal bone for acf and incision of dura finally visualisation of structures are steps these are some pics
  42. 42. Dr. Sree ram murthy & Pro Sellari franchisco of PISA italy
  43. 43. TRANSORBITAL ENDOSCOPIC APPROACHES TO THE MIDDLE CRANIAL FOSSA
  44. 44. Orbital apex
  45. 45. ORBIT • 1. Two Ice cream cones in orbit -mnemonic - SOF & IOF - superior orbital fissure & inferior orbital fissure. • 2. Bone between OC ( optic canal ) & SOF is optic strut ( OS) • 3. Bone between SOF & V2 ( foramen rotundum ) is MS ( maxillary strut ) - front door of cavernous sinus • 4. So SOF is presents between two struts - OS & MS • 5. Bone above SOF is LWS ( leader wing of sphenoid ) • 6. Bone between SOF & IOF is GWS ( greater wing of sphenoid ) • 7. Four semilunar lines 1, 2, 3, 4 are - orbital surface of frontal bone , orbital surface of zygomatic none , orbital surface of maxillary none , laminae papyracea resp. • 8. Medial wall of SOF is nothing but nasal surface of SOF which is just anterior to cavernous sinus
  46. 46. ORBITAL APEX [ SOF = ALSC + Orbital apex] Extraconal & intraconal compartmements
  47. 47. A - trajectory leads to middle cranial fossa B - trajectory leads to infra-temporal fossa
  48. 48. GWS=Greater wing of sphenoid LWS = Lesser wing of sphenoid
  49. 49. Updated soon Read Chapter 34 TRANSORBITAL ENDOSCOPIC APPROACHES TO THE MIDDLE CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul +gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y
  50. 50. Six handed technique ?? Read Chapter 34 TRANSORBITAL ENDOSCOPIC APPROACHES TO THE MIDDLE CRANIAL FOSSA in Dr. Paul Gardner book – click - https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq= paul+gardner+skull+base+surgery&hl=en&sa=X&redir_esc= y
  51. 51. TRANS ORBITAL APPROACH cadaveric approach to middle cranial fossa In future it will be good easy approach for ent surgeons It is devised by pro castelneuvo with my friends Dallan and Battaglea There are 3 approaches to ent surgeons for cavernous sinus 1 trans sellar approach 2 transpterygoid approach 3 trans orbital approach - this approach is easy . The trans orbital approach steps are 1 upper lid incision 2 subperiosteal dissection of globe and identification superior orbital fissure and meningo orbital artery 3 identification of c s 4 seperation of two walls of c s 4 identification of structures 5 incision of mid cranial fossa dura 6 meckles cave visualisation along with other structures - small incision , no injury to eye , entrance of cv in between two layers , no much bleeding , no csf leaks are advantages .
  52. 52. TRANSORBITAL ENDOSCOPIC APPROACHES TO THE MIDDLE CRANIAL FOSSA – cadaver study
  53. 53. meningo orbital artery
  54. 54. endoscopic endonasal cadaveric ORBITAL TRANSPOSITION
  55. 55. Murali Chand Nallamothu: What are indications of orbital transposition. Sree Ram Murthy Dr Vizak ENT: Now a days it is important part the indications 1. removal of infections lateral to mid pupillary level 2. lateral osteomas of frontal sinuses 3. trans orbital approaches to middle cranial tumours 4. exposure of cavernous sinus trans orbitally I think 1 & 2 indications can be done by external approaches by brow or bicoronal incisions
  56. 56. Sree Ram Murthy Dr : Dear surgeons it is a endoscopic endonasal cadaveric ORBITAL TRANSPOSITION technique The steps follows 1 complete exposure of anterior skull base 2 identification of septal branch of a e a and 1st olfactory fibre 3 removal of lamina papyracea 4 identification of aea and pea 5 cutting of both arteries and release the globe 6 gentle lateralization globe along with periorbita up to mid pupillary point 7 complete exposure of medial orbital roof and further according to pathology
  57. 57. 1 septal branch of a e a
  58. 58. 2 orbital roof 4 posterior ethmoidal groove
  59. 59. 3 first olfactory fibre
  60. 60. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.

×