Smita Upadhyay

Effect of Incremental Endoscopic Maxillectomy on Surgical Exposure of the Pterygopalatine and Infratemporal Fossae

Objective Access to the pterygopalatine and infratemporal fossae presents a significant surgical challenge, owing to their deep-seated location and complex neurovascular anatomy. This study elucidates the benefits of incremental medial maxillectomies to access this region. We compared access to the medial aspect of the infratemporal fossa provided by medial maxillectomy, anteriorly extended medial maxillectomy, endoscopic Denker approach (i.e., Sturmann-Canfield approach), contralateral transseptal approach, and the sublabial anterior maxillotomy (SAM). Methods We studied 10 cadaveric specimens (20 sides) dissecting the pterygopalatine and infratemporal fossae bilaterally. Radius of access was calculated using a navigation probe aligned with the endoscopic line of sight. Area of exposure was calculated as the area removed from the posterior wall of maxillary sinus. Surgical freedom was calculated by computing the working area at the proximal end of the instrument with the distal end fixed at a target. Results The endoscopic Denker approach offered a superior area of exposure (8.46 ± 1.56 cm(2)) and superior surgical freedom. Degree of lateral access with the SAM approach was similar to that of the Denker. Conclusion Our study suggests that an anterior extension of the medial maxillectomy or a cross-court approach increases both the area of exposure and surgical freedom. Further increases can be seen upon progression to a Denker approach.

Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships.

The quadrangular space permits an anterior entry into Meckels cave while obviating the need for cerebral or cranial nerve retraction. This avenue is intimately associated with the cavernous sinus; thus, from this ventral perspective, it is feasible to visualize the anteromedial, anterolateral, and Parkinson triangles.

Possible esthesioneuroblastoma metastasis to paranasal sinuses: Clinical report and literature review

Local recurrence, and regional and distant metastases, respectively, develop in 30% and 15% of patients with esthesioneuroblastoma (ENB).

Periodic olfactory assessment in patients undergoing skull base surgery with preservation of the olfactory strip

Others have reported olfactory disturbances following endoscopic approaches to the skull base. However, there is a lack of consensus on the extent and duration of dysfunction. This study aimed to compare our results with previously published work and to validate the olfactory strip–sparing approach.

Endoscopic endonasal anterior maxillotomy

INTRODUCTION The last few decades have witnessed radical changes in the management of pathologic processes of the sinonasal cavity. Endoscopy precipitated a paradigm shift in the diagnostic and surgical approach to lesions in the paranasal sinuses and skull base. A better understanding of the surgical anatomy, aided by the superior visualization of the endoscope catapulted the design and adoption of minimally invasive techniques. This is exemplified by the transition from medial maxillectomy via transfacial incisions (i.e., lateral rhinotomy) to a completely endoscopic approach. Another notable example is that of the Caldwell-Luc procedure, which was widely performed in the last century, yet has fallen out of favor owing to its relatively high incidence of complications and the successful treatment of sinonasal diseases, either by current medical management or by safer and less invasive endoscopic sinus surgery. However, access to the anterior half of the maxillary sinus is challenging, even with the use of a 45 and 70 rod-lens endoscope and angled instruments. The anterior half of the maxillary sinus has been traditionally accessed sublabially by way of a canine fossa puncture or an anterior maxillotomy. There is abundant literature discussing the advantages, disadvantages, and potential complications associated with these procedures, and therefore the need for various technical modifications. This study describes an alternative technique for performing an endonasal anterior maxillotomy, thus obviating the need for a separate sublabial incision. Endoscopic endonasal anterior maxillotomy is a versatile technique, and the size and site of the maxillotomy can be modified according to the course of the anterosuperior alveolar nerve to minimize the possibility of damage.

Anatomical nuances of the internal carotid artery in relation to the quadrangular space

OBJECTIVE The aim of this study was to evaluate the anatomical variations of the internal carotid artery (ICA) in relation to the quadrangular space (QS) and to propose a classification system based on the results. METHODS A total of 44 human cadaveric specimens were dissected endonasally under direct endoscopic visualization. During the dissection, the anatomical variations of the ICA and their relationship with the QS were noted. RESULTS The space between the paraclival ICAs (i.e., intercarotid space) can be classified as 1 of 3 different shapes (i.e., trapezoid, square, or hourglass) based on the trajectory of the ICAs. The ICA trajectories also directly influence the volumetric area of the QS. Based on its geometry, the QS was classified as one of the following: 1) Type A has the smallest QS area and is associated with a trapezoid intercarotid space, 2) Type B corresponds to the expected QS area (not minimized or enlarged) and is associated with a square intercarotid space, and 3) Type C has the largest QS area and is associated with an hourglass intercarotid space. CONCLUSIONS The different trajectories of the ICAs can modify the area of the QS and may be an essential parameter to consider for preoperative planning and defining the most appropriate corridor to reach Meckels cave. In addition, ICA trajectories should be considered prior to surgery to avoid injuring the vessels.

First olfactory fiber as an anatomical landmark for frontal sinus surgery

Access to the frontal sinuses is technically challenging owing to their anterosuperior location, diverse anatomy, close proximity to critical structures and the need to work in a relatively narrow space with angled‐lens endoscopes and instruments. This study attempts to study the relationship of the first olfactory fiber with the frontal sinus posterior wall, assessing its fidelity as a surgical landmark during frontal sinus surgery.

Newly Diagnosed Sellar Tumors in Patients with Cancer: A Diagnostic Challenge and Management Dilemma

BACKGROUND The use of combined positron emission tomography/computed tomography for staging in patients with cancer and the widespread use of magnetic resonance imaging has led to increased detection of incidental sellar masses. The imaging findings can be suggestive of a benign pituitary tumor, but metastasis can never be completely ruled out with noninvasive work-up. Appropriate diagnosis of sellar masses is critical, as the treatment paradigm might change in the presence of a pituitary metastasis. Definitive tissue diagnosis might prevent unnecessary radiotherapy to the skull base or the need for systemic treatment when benign pituitary disease is confirmed. METHODS A retrospective chart review from 2010 to 2015 of all patients with recently diagnosed cancer and undergoing surgery for sellar region masses was performed. RESULTS There were 9 patients (3 female and 6 male) identified. Lung cancer was the primary condition in 4 patients; the remaining 5 patients had breast cancer, follicular thyroid cancer, cutaneous melanoma, colorectal carcinoma, and renal cell carcinoma. On final pathology, the sellar mass was a benign pituitary adenoma in 5 patients, metastatic cancer in 3 patients, and a granular cell tumor in 1 patient. CONCLUSIONS Surgical resection of a sellar mass in patients with known cancer helps in the definitive diagnosis, relieves compressive symptoms, and avoids unnecessary empiric radiotherapy in cases of confirmed benign pituitary disease.