endoscopic cadever dissection

8/6/2019 Endoscopic Cadever Dissection

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E r i doscoprc Cacavor I )issuction tor 1each ing Anterior ~1k tJ I I R , , :-= - ,e3Ul ~ , ~ r y

Table of Contents1.02.02.12 . 2 .3 . 03. 13.24.04.14.2

4 . 35 . 0

6.06.16.27.08.08.1ft28.2.18.2.29.09.19.2

IntroductionAnatomic Dissection of the Lacrimal SacEndoscopic Al1rttOrlly ,", ,', ,', .Anatomic Dissection ,",........ . , .Identification of the Sphl:!r1up-


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6 Endascopic Cadaver Dissection for 'TreachingAnte r i o r S!k.ul IBa se Surgery

Fi' ; 0 "IOsb3.o: ' logy a t tn,e tacIal skul l v iewoo 'from,above.A = = r'I asa~process of 'he lfruntaJboneB I = na s a 1 oo eC = oonta~ process e rf the mat


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E n o sc o p jc C 'a d a ve r Dissec'ion 'f or T re s e h ~l1gAIJi l t .e( o r Skull 8 a s Surgery- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ ~ - - - - - - - - ~ = - -

2'E d l -A '-;~. - :-:-.(-;-- ,"._ ," ". -' . _ -.- - - ~" ._I -n os,co ~,IC- [lIal0 _yTh B' I lacM rna sac is located i t n t the la~er-, a j I na s_a l w aJ II ( F i g l ; o 1) ante r ior to the il n-sertton ,of t he ' middle ' turbina l ' e, Theupper ma_ in of '~he sac ex' l endsabove h e ' anachmel i l r t o f the m'iddleturbinate wh , I e the p o ste rro - marg l ln t isr o c -a i 'e d i nf 'e ,no l 1 y (F i: g . 2 ,) . I F rom an en-d o sc o p tc pO ln l ,o f view! th e m a_x~ lIa ryI r i n o ' is a 11muritan! "\opograp hie-a!I l and imank ' ~ , o ridenbflcation o f n e ante-rior margin o w . he lacrimal sac. Thls~in' 'forms a. curvUi~ar prornlnenceth a stretlChes between th s' insertlo 1 1points. o~the m l i d c J : l e turbll'1lat,e and tha

F ig 5 ,CO ron ~da . c r yo -C l sean o f th e na sa l a c n m.. . .a ! duc1 t s y s tem . ots ~ h e p o o r pneuma; tza -_'on of he a gg e r na si c II tha t d o s s netobscure:' e.lacnmal sac mecHa l :f .SL = Iacr lmal sac= agger asiil l = m id dle tu rb InateS _ ~ m ',.Uary s lnus

infQr~or 'iunbinme and COR'BSponds .w ~ h he endonasa proj,ec ion of henasolaerimal due (lfil~ 3). Pneuma-tlzed celi~s0 the ethmo"d may deve l , op 'in me ,l1lte to',;' , of the' ,a :5 Jcendmngibranc h o~1 1 8 ' maxi U ary sin us . I rn '~hese:cases I h - agger nasi cel ls are sff i tuat-ed betw,e n the tacrl ,B I sac and t ela te ra l na sa l w,al l ( Fi g s, ,, 4 , and,'

Due 0anatomic variabi l i ty . ~h ants merm arg in c ,f 1 he uncin8te p r o ce ss showsd'ifferent po ins o f' h l sertion; it art iCIJ-tates wi_h the ffontal procees of th emax inBry sinus or wr l ' l t h '~he l a c ruma~be ne ( F t i 9 S C I , 6, a ne ~ .I,

Fig.,4 ...C oro na l! C 1 s c a n o f th e fa c ja l b one s. INo tethe h , ypo r l ense areas 0' h ,e pn umatizedagger nasi cells that med iaUy obscure ther ig 'h Imcl i i al sa c ancomp iem ' .,ANI = nght agger ni~ SJ = ri g ht laorima~sac:--,' = ,'ddle ulfb[nate:II= f n f eno r turbinate.

l'i-g,6,Ax ia l d acryo-,cr s ca n o f th e na so la cnrna l, u e ,s y s te ~ , e 'c o ntra s a ge n t. i :l G cumu -la r 'a s ~n th e ' 9 , nasa Ia c rlr na l d u c t, 'g lv I rn gU ~ e s 'tr u c tu re a h yp e ns e , a p p ea r, an ce ; th e,an' ienior lI1liaJgi I ' i I of th e u nc jn ate p " o ce sslo r i g ina tes . fro the onal maxi l la ryp ro c e ss , PFO I I = f ro r r ta ~ma l< i I~ fJ r y p ro c e ss :D _ = na s o la c nm 'a l d ue : P I, = uncina. l lep r o c e s s ; 11 ' = m id d ie tu n b in ate

7

-11 . 3bndcseopic vie D' the raft nasal cavity.1(4-mm telescope, 0 , . -S ~ na s a l up tu rn : 1 1_, = m id dl e ill r rb ina te~I , I = a gg , e nas i : IP U := : u nc in ate p ro c e ss ;L--I ~ m a > : illary' l ine

' F i g " " 7A J (ia l d acryo-CT s e e n 0.the t l l i lasolacrfmaJduct ~'tem. Rig: no E li ' the ant ,"'Of marg inof m 1 S U J J cinate preeess tha t Q ' g ina tes ' f r -am~he la . c l i' ilma~ 0 1 1 1 ' .,I L = ~acrima~s e: PU :::::ncrnate prccees'D L =l a c r i l l a J b e e ; IS ' = ma J ilia ry 's inu .s1 M =m id d Ie tu rb in a rte ~ 5 S = s p h eno i ds~nusBE ~ b u I a t l l hmo i daUs


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8 E n doseop le C ad av e r D is s e cUo n fo r "IBa c h ir ig ' Ante rlor Sku n IBa se S urge ry~~--------------------------------------------

IF l ~ 8O~i'leoog y of the fadaJ skullA, = a s a J l boneE I , - f rontm process of '~nemaxillaI e : : colo ,I Plu icine intnldu'Ced fntol' 'elacrimal ducts rom "he lacrimal sac to thel a cnma ' J1 os lu rn o f h e inFerior mea I L J S ~Til= in ', er ic , hll' i rna:~e,;S ;::::mml se p t urn

F;j-~ 11I E Jde rr nl a ll i/ iew ; a fiber-a" lc n g,~tprobe tsinse.ed into the II e f t. i nf , rlor lac I~lmaJductIF O = flt~ ' o p t D G l i gh t probePI = Infe 'or ~acrimal plljIIlctum

I.gl~9ElI "u: loscop ic . v i ew Q" he I I 9 I f t n a s a l 03vtty,(' ..mm telesoo , ~I.S = n a s a l , s e p h , J m,- = m3dd le l I I rb lnate ; 'T 1 1 i nf er io r turbina e- , - I = infe io " me us'

The ~ower portion o lf '~nelatrimal sac,ns r ro w s ta l beeon e ' - th e or ig in of enaso l ac r im '8 ~duct, that passes fum ug h, a r J 055 io u 5 c an ned embedded iln ! he'la cf im E d b ene , 'th e maxl l a ry bone andths n fe r i o r tu rb Ina te (F ig . 8 ).i.Th e na so -lacr imal due passes below and is, ID-ea e o about 10 mm anterior 0 the nat-u ra l max l i I a I r Y o stium . "a va il ing th ro u g han 0$900115. channel I~hout 12 mm in~e:ngthand oontim'1ues below he ~nerior

; .12E ndo s co ic v i raw o f Ule ~eflna sa J ca v i ty ,(4~mm '-tr'rsco' ' 'I cfrectioJl of view 3.~.5, ~ n a sa l s e p tumr.__middle l U J r l : n n a , t eS = i"ranSiliuminatedi sped. prominence 0't he . r a c lnmal sac on' 8 ' l a te ra ] v ,a UCl thB n a s mc a Y i ' y do r s aJ l y t o ' l t J 1 e lmul i l e ry l i n e r a nd la~ernl!-Iy to he' f H a J I porf [on of e .ddl ' rb i,n a t , e , : l.-;-= Imwf l la ! l ) ' I l r n e

tu rbi n te as a membranous duct foranolher 5 mm be'fore it : opens out intothre interlcr mea:tus~' "e once of th educt Uas at: rh e ]unct i ian between th ean te r i o r and 'h e med i ' a1 thi rd o, f ' h enasal mea US" abou' B m m p os te rio r o . fth e head o f the i nf r e rt o r t unb ina e. 'Thisoriiae is o. en COVIe-red by a mucousembl"aJfle~_ the so-called Hasnersva lve 'th a t p re veni s reUux o f n as a J se-cretions (Ftg ,,9 and 10)., ', ' .2.An ato te a I D iis s ec 'i 0nE nd ona sa J a n a to mic ai id ent '. D c a tio n o f 'the la ci im aJ s ac is fac iUta, tedl by intro-duc ing a f f i i iber c pne Iliig h ' p r obe ' Uuoughth e I r o w , e r c an afio ulu s 'fo r b ,a ns m um i n a -tia " 0,' ~ e! a rt- ra l l na s a l - aU lr .h e a re aa f ,th e IIae r ima J l s a c (figs," 11 ra nd 12).,T h e ' a re a o f rna x lm urn [b r 'g h me s s d o esn ot c o rr es p en d I 'wu~h t I' e a nt.erior part oft I e ' I tlc r1 ma l sa c b ut ra th e r . ~It ' Ispes-t e r c rned l a l pomon. whe~e 'he oveny ingcortical bone' is hlnner (lacrimal bo e)~At imes " -j"ie :MC ls no t r l ead i l y vsableb s c s u se 0' I t e inte rposition o 'i the", g-g a r 1 1 ; 3 ; 9 1 ' c eUs .O n rd l~ ss ec tio n rc lre u l a ,=shaped rnu-co sa l f l a ip 'v J 'f,about 1 c m ls r emc l v ' edalon91 f H i ! ' maxiUary line (Fig- ' 1 , 3 ) .


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E ino o50op i c ICadaver Dissection fe n Teaching Ant~1ior Skul l! ! Base Surgery------------~~---======----==----------~======~

F ig . , 13Era - dos c cp i c aspect o f the dissected leftnasa! cavity using a.4, -mm te' l ' ,esca pe~ : : 3 ~ , .'S = nasaJ , septum; Tf -.:;;;midd lE ! t ,W"binat 'eILM = = moii Iary ~ina:Sl = medial bony wallof nil!Sl' iacri mal sacThe ,e ~posed oone' i s, r e s e e te d by L i seo f .;J d la mo n d b urr unt~ th e me d ia ~ wallo f '~ he ia cnm 'a ~ sac :i S re a c h e d (F mg l . . 1 1 4 ) . ,R e se ctio n o fi th e bony waJI m a .y Ii n ..e lud e th e an[erior m a rg in o f '~heunc r -nata pmcess I ,thel' le by 31~owingfor anassessrn ent of the variabh~:th~Qkne s sof' '~,8' Cortical be fl'8' that covers the~acrimal sac in '~ne, an te rn posterior di-

Fi;g~16E r u: 10 50 0p ic a s p e e " l O r ,t~e d ls s e ere d ~e ftn8 l sa l ca , v it y using a ,4,mm-telesoopa,ti 30gThe med laJ wall ot t~II!;dacrima~sac is per-to ra t : ed w nlh a O i l! 11= t ipped p ro be th art is in~ se r te d thrulw IQ~ the lower eanallculus,TMI ~ m id d l i e ' turb inateS_';:;;eft lac rimel sac

Rg~i,Erildoscopic aspect of the d[ssec1ed ~eftn a se l G ~ a .v ityus~ngla , 4-mm telesoope', 30.The medial bony portion o\rer~yingthelacrimB~ sa c is I r emoved ! wuth a d h u n o n dbur r .S ! ! ! ! ! :~aMJ s e p t u m : TM = m~ddl'e'turilj [lIst'eSL = medl al beny wall or u~~a,crimalsacr1ect ion, If the ,~gger nas i 'forms a . d ls-tinct buIgi9 Bnteni[)rfly~ tne s,trUCltllre!ne e d s to ' b 8' resected to 9 a iln a cc e ss ,to t ln l9 l ac r imai sac. 1Me IIac rima l sac is~n.c i sed b y us ~ ng a . ro u nd - ' J p p e d k l1 i fe ,d i i : s , t a J l l y ang~ed at 45 01 I O n ce the g a p isin s p .ec~edI t J n e breach is eni 'aJ rg ,ed withfo rc ep s, d is l'a Hy a ng le d a ,4,s.o~Figs~,5,and ' 1 1 1 ) or b y L J sa of a shave r,

I F I , g " ' 1 1 1 ,IEndo8oop lc asp-ec . t t{40,m m- te~esco ,pe ; 30,o f th e di j ssoot . ,er j left F I asaA cavity. Onoo ~rnova l oW~~em i f. 3d i ir l w , ! :! 1~of th e ~ a .c rim aJsac Is complete! ~1he2j~e ra land d o r sa lwa l l s come in to v ie w ,.'TNt = = . middle turbinate. p ! ! ! ! ! : l am in a pmpyn"aoea,St ~ ~ . a c r t m i I 3 J J s a c

9

c~Jtio".:l !\ib 'o g e nic Ie s io n , of 'the l am: f l " ' l ~papyn lce~ .


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10 Endoscopic Cada v e r Djssection for Teach ing Anterior SlkuU IBas "8Surgery- - - - - - - - - - ~ ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - -

fi ,- ~11OS te o 1o g y o f th e f ac ia l ib o ne s. witlh s a in in go 'f th e , ar te ri a~ . r a nc h e s. RIT ~ nfratempoJraltossa; .. I I = _ 'emaJ maxi l la ry arteryFPiMI ~ pterygomaxillary ssureA S 1 _ - 1 = s h e no p a .1 a ine rtery

Fig~18O s _ o o 1 o g y o f ' t he ' e lm S: 1 1 +endoscopIca s p e c t t ' m m-te le ae op - . ~ -5a )o 'f t l te , leftn le a~~ . ith' I' s p enD alatirJe to r a -men [F~D lfV'JIi- I =m de lle ' rbrnae ; = IS = 'P e o idone "p o O p .: = a rb tta J p r o c e s s o f' e p Bia tine ' b oru~ ;PSO IP ~ , spheno ld J p ro c e ss , o f ;n e p-a la in8 1bene

-51 .2 1 E nc os oo plc a sp ec t of the I ' R na sa lc av i, (, m m= te le sc Dp e~ O C " J I . Mao I C e a -c ia , - s p e c im en o f th e I ! = i t r ; g :om~Jl la tV'ossa.

,-'natomym sphenopalatine, ,ar tery s a, le nnina J

bran ch of the internal maxi Uary artery~I~torigi'nates in he' ptBryQopa~at in le fcs-sa and reaches .'he nasal c av ' -thmug h t he . s p h enopa J a i ine foramen,(F,,~ 1'-I~ located P O S'I J 9 to r to the rearend of ' the nniddlle ' turb lnate. In's lowers e c tio n .e sphernopaJart ine f lo ra m e n isma d - up o f' 1 h e ' verticall process 0 thepa la t ine bone, the' eranijl m e rg i n o fwhich divides in~ lo a rposte-ror~~coateds ho r t sphenoidal 're c e ss a _ d an ante-I r~orJ~ocar t , edwide l o rb , utm p r o c e s s thatuses 'with the max i l i l a r y bone r~-gl~18)1.

IF ig .1 ISEndosc:op~c;asp:ct 0 the te n n as al c av ! V(4 , r nm -te le sc op e C PJ .NO N ' the 1 r '( 'u I n d e e lknife ' (ang led ~ use d ' f a ' "h e ' . ucope r i o s tea li n ;c i s10:n"0' e x p o se the. sp 1h s I 1 1 o paJa'tiine8 1 1 e r y .TiMI '= m id d le tu rb inat -e; fir - . in e rro r ' :urolnate~Air = _'0 t .a n e ll e a r e a SI = ill s a sep~um

U S 1 ng knife with an an g lu lated t I ' p . ' . ' t . h , 9muco sa o f th e conch a ll w a J I ~sincisedU_der endoscop,ic vis to n (_-mm tele-scope 0 ) 1 1 about' 11em anter i lor ly to'he raar end of ne mIddle, turbinateI F I lg . . 19 1 )~The " II ~ O l i s elevatedsub:pe~rios ~eallryby use of a C ott lie E t e 'V a , t o r(KARL STORZ 479100) as w , t J r , a s hes p lne .no p ala ijns ' toramen im lm ld ia te~y... Noe 'lh- corn plat .~ y eXpoSed sp en,oidsinu s and ca I ve ; r ~QUJSlinus.Ti' = mtidd~eturbinate' =i J nor urbi-iiia,t t l , ;S = n as a ~ s e ptu m ~ AM~= intennalma x il la J Y a r 1 :GFY . ,5pl:!!!!! s e no pa Ja tinea i 1 e r y (A.. :1 1 = n las .opa ja1~ne a r te ry ;B = posterior nasa1 artery):

The roof 0' the sph nepal aline 'fora-men is made up of the body 10 the51ph naid bone the rests on 1 : 1 1 0 II O Jprocesses o 'the palat ne bone. O nr eac h ing the nasal cav i t y : ~he sp h eno -palatine, , a r te r y s ;p l1 e a d s 'f, or w a rd witn'two branches. The mediall branch is,c aHed the naso lpaJat ine artery'' a ' fa-ceeds as far as ~h8nasal septum closeto, t E ' anterior pa:~at~necanal, The I~a.ter., a J one is ca J1 1d Ih e p om ,e io r 'asal, a r te r y l wtii.ch vascularizes ' the wmi -nates and amas~omoses with th e 8 tl1 -mold a l1er ies (b r ,anclJ i les m the 0ph..tt h a~mic IMary) ..

-Ig~ a l lE nd os co pic v ie w 0 "the 18,ft n:asa : l lcavi ty( , 4 ] , mm- te !escops , o , ~Nom the eMp o s e dspnenopa'l'at ne mtery ( urb ina l lb ra ru:h)1 andthe , sptle~opa]a 'ne neNe..AS P = sphenopal'mj 8' ar te ry (urb ina l ra nc h)NSP:= ~phencpalatine n (Vi (turbinal b r a J 1 c h ~_~.n : r :_ - bony la nd rna r ." = ~rnf lerior ' lu~i na Bdorsal '~O the rsar end of the Im idd Ieturb ina te ..S~ighUyin '~rol1 o, f ' his rora-Ime tnere js a smaU hony s .jne thatserves as,a land mark for the to ramen,itself I ( F i i ' g " :20). Once, the 'erminalbranches 0 Ute sp _Ienopa:a ' ine arterycome lnto Yif~ ' fWI ' t hey ,m-e eX IPosoo UPIto 'he inserUon o'~nl_ reer ends, of theturbina es and as, far as "he upper rimof th e . Ichoana ( I F i g~ :21 ) ._JO I = Infraorbital nerve'; AID ::;i.,oribf~almary. A A S : : l J ,lP P r , ah l6 0 1a t a r t ' e : r y :, .e 'l = intraeavemous 1n 'emal carotida r te r y . IPf,:U'~fio.l!i I4, ; sa , = , spheno id s i nu S :,~.-::::;descendingharyngeal artery.


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Endosoopic Cada v l e r Di'ssadion 'for Tea ch i ng AJ1tenlor SkuUBa o o ' Surgery 11------------------------------------

Pi!)..HM a c r ns eo p te ils>pect of ;j) S ' I C ; ~ II Ipre,paratiQnt n s a g tt ~ a J section.SS : : : : : ! . s ph enced . s i l 1 l Js :T S = S L J pe r io f'tI"uminate: " T M ' ~ imTd,dl~'tu f lO !nete :TI ~ inferior tu rb in a te : . I e = optic ch~asm~all = a ; de r ul t' iy p q p h y s 1 ~ : III := r i l eu rohypo= I p h y s J s ; DS,= d i ra p h~gma wUaie,:IT::::U tlaJ t of US .

Filg., :~3Macroscop.i~a:spect of a ,slkull pmpa r a : l i o f lin sag i t taJ secU,a]n.,,A ~ d Ia ph~agma sellae (0 L J ral m em bra ne I) :B ~ pOrlCiS'tea1 dur,a ( - ( iura l memb r ane M} :I e = p1tuitary c a p s u ~ e (0u ra l membrane 1 1 1 1 ) ;a = ade ru ; ) h y rp gp hYS~5 : ,ni l .= ne ll r o iJ1y ,po=p h Y S ] $ ; on Si S := n;atl lJ F 8 J 1ostlum, sp '~,enCld:sinus~ l i n N I t: : = t r a 1nj cram! i t i l l l nerve:ACpl ~ posterior cembral artery.

ndonasal I D l i : s : s , e c t i i , o n :_,~ppro,a,c lhto fhea nd Parase 1 1 8 - Re ' g t - onS I4 . ' 1 1 An,atlomyThe oval- shaped hypophys isi 0r p[~u-li t8 1 ry 1 91 1 81 '"d. has an average t ransversed ia me ,te r o f abo L it ., 5 m rn a a sagittal!d~a'metero ' r : '1~0m rn, and a vert ica~d~ameter of' abo ut 5 rnrn. ~twei Q 'h sabout C U l l g and ls made up 18S$' I1t . iaJ = ., I . y o lf two lobes covered wit ln ,a rnern-br ,ane n~ra.tedto the dura. mater: ' "he 'adenohypophysis and 't he neuro-hy pophy . s i s : .li t is , a t t a cJhed tDI th e m o o ' i a r n em i neneeof the tub~r C U 1 1 e r e u m o :~ U n , B 'hypotha-lamus throtlgh th8' infundib ui a r sialk,w h ~chis ' ~ f 9 1se rtedl l 0n~ " y lin the neu r l oh r y -pop hysi'5, and Iodged ~n '~ l1e 's e U l a tun:~=ea of' the sphenoid s, inu5", below thedJa,phragm a . se 'naa ~fig~2 2 ] 1 , . 1 11e d ia -I~hragrna s e l ~ae is a qua.drilate r , a JIa m e n a .JSlUh!FN!d a b ov e 'th e se~a tu r c ~=ca of the sptienoid~, which 9',xite n o 5' f r om ' Ins' pesterior mar l g in o~ithe opt icc tu i 'asm to th e up p e r Im a rg in ID~ tM equad r i l a t e r a l ~amel~aClFi'g~23,).

li t 'then proceeds I Ia n each sid~,10 mak8up the u ,p p@ r w a ll of the cavernous S I ~nus o f: th e d u ra ma~er .T ih e d ia p n l r . a . g =rna s eUe .1 ! has a sm a l n centra I hlatus~h'mugh w t 1 i C 1 9 1 ths hlfiund ibu la r staH~t:passes,Th e c a ve rno L IS ,s ~n US us a m.u~ t i ~N3p ta t -ad vsnous channell'ocated lab!r,a' i l ly 0''the sph e n 01d b o dy " im erc .o nnectGd b~,.nea rly curcular=s~apedsinu Ses'i named[nte IC 8J va rnO U 5 s i nuse s , w h ie n a re 5 1 j' u-ated an te rlor a.ndl pcsterier '1 . '0 th epitu ii'tary 9 lam d (a n te r io :r ~ posterior andj 'n fe f 'i l: o f' s ~nus c ircu I ans~ acco,rding toW i ns ~ o w ) (fIg ~2~,),The f oUow ing pass 'through it: the ln-ternal ca~tidl ,art!ery' (leA) winth its in-tr a c a v e r no I L l S e ra n c ne s, th e a b d ue e n snerve I ' C O l D ~ ) and th~fbers of thes ym pa i th et[c ne r ve ~iin g the I l eA(fl ig s . . ,IS a nd 2)1 ,)"

Fti l l~ , 2 4 ,Ma;r . : roscoplc upec t I!l ' f :siltllJ I ,prepar,a.t ' ion msag f ' l ' i t a l section,5S .= s p h e li lc i d smu sSC = c av erno us , s inu s

i i f:i ,i!'IiC:~i~M a c re s co p lc a na to lf f l l l e a I a s p e c t O f a . s ku t~preparation in sagittal section ..Note tila course of the .I'ltemm carotidartery in its in b- ac a ve m o u s p o rtio n.C1 = POSh:llri o r v e rtJ c a i sscJtorn :

Ie!~p !l ls h ~ 1 'i i r e UNO: C 3 = ho r i zon t a j sec -tton; 0 4, :: . al1te~or cu r ve ' ; ' C5, = an t eno f 'v e r n c a l .seGt]o.n~ , SS ; ;; ;; .p h eno i d s i nu s :E I F " = pos~erir e th rn o i d~ 'NO = l op t ic nel f ' lJe

IF i ig~~ - GOs t : e o l o g y C J f n~~s i k . ' 1 Y l 1 1 i t h stai ni'ng o f 'thea r te r ta l b r r anC ' rn es ,.Note! ' i~e internal cilrmidalrte lV and \M Ins ~poIY'90fll.


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1 1 2

The ocu lommiM nB n ve ~IIII le, 'n~)" thetro ch I'e ar ne w e (I V e.n.), l ih e o p h th a l m lc' - \ 1 ) and max i l l a ry branch 2} of' ttte V:.emll'i a l ne rv e'l 1 0 I nl th e other h 8 l 1 ' i d , ~ p a s s"hr ,oug n its la te r,e JI waJ I in a d u ra~ split.Schma t ~ c ~nterpretatJj 0n o:~ tMis f,eg o n

w T I I ~I rw ' lc~\ fe ' d e s c r i ri'hle .stu dy of the'to "og r a p l 1 ' i e r~il~mtjonshps with beriaIve in I ,a rte ry and InaNS' com partments(Fi;g~27).Topog r a p h i c r e ! atio R s l~ ip lS w .ir t~ bonys lruG tum s: m ed n a J ~ Y I wi th th e s pna no j d !bod l y : anter~or~ wi~h ttle le sse r wing:s, o f"the sphenah jl ;, ~n f e ri o rl ry , with the great ierw in g5 o f' th e sphe rtoid; an d pnS't~ri c r ly ,w it h U 'E 3 'apex 1 0 1 ' n e petrolls portion le fI n e te rnp era l b on e ,The seUa occu p ias th e c entra Jl part o ftl h e s ip h e no id body and ~iesbetween t he 't :w o ' [; f1 i :\ f, e m O I L l l5 ,s r n u ses,The carutLd e M in ne ll~ a bony g l r n o , v e ,wh em the ~nnacavemous [CA passes. islocated I later,al! ly to .he' ~i~henoidbooY ' ,and medlal l :y t~ t lhe f O r i ll 1 1 i 'n a ova te andrc tu nd um ~ a nd to t~ e su perior lo rb ! ta l~r8SUM. The , fo ra me n ro hU1 d urn ls lo ca t-ed a t 'th e , jun etian between U i l . S ' g rea t s rwong a nd t h @ s :~ ihenod l body. Th ef ,{ )mm l na o~ale an d sp in 05Um are lo ca t-ed ,along ],e p os te F"lio r margi'n of: theg~ea ' t , e r w in g. Th e fo ram en la c e ru m is~ocated between 'l h B poste r~or wa l l of. u ,e cruO'~id groove, and the pe t r osa :~apex,llh a a nte rio r c l ino i d p ro ce ss ; makes up:h e te rmi r, II ~ntract~nij31 s e c t n C D n o ~ tlh eoptic dhanrtel. The mldid le clinoidp re ce ss is ~ ' ,o c a t e d , la t e r ,a n y '0 tlfl e tuber=cu Iu rn se~~ a e and 1 m00 ia~y 'to the carotidgroOVEt Th e p os te rio r Ic llno id p ro oe ss lslocated 1 m the sup e ro Ia te r,a l m arg ~ n o fth e d o rsu m s e IU a e . ..At limes~ a bony bridge m1 ' 1 / be ob-s e rv e d b em ee n th e e nte rio r and I r D ' i r d d l e(o r p 0 3 h :~ ri C D" 1 e li no id IPre ce ss , trans-" om1~ng l the carot~d g;I l ] :OV9' ln to acaroUd-c l ino id fo ra me n. lin some cases.th e f eu 'a m e n of the s p he no id c a na lic u IUgm a y be obse Ned 'O n the greater w in g o ,f th e s p tu !l no l d Im ,~d i any to ' the f:or~meno v a le . Th is a l lo w s ~assagB' o f a vein5 . y s t ' e . m II n ~ing ' t h e \ 1 ' e n o u s s in L IS with ' t h ep te r ; g c r , d ! venous IP I~exusRe l a tD tu " l i s ' h i ~ sof the venou s plexl~s are .a s ' f e U ows :

IF i~g ,"1 7SChemat i c iIIushaUgn [ O f t h E ! ' cav e rn ous sintJs ~ naxi id section ..C M = = ollt~c chiasm;~I. =: r1eurohv.~p~y.siS: al = , aden :Oh : y pophy s i s ; - C~= I . ra te r~a in ' , . t r ,a_ca~e~no~~caro t id a J i 1 a r y ;S , S i . =. sphenQ l d , smus; II U = 3m cranial naN, !! ' ( ,eu :u tcmcto r } : IV = 4trn cra. l i l I ia~nBrve fooch lemi\1 1 = 'o p h 1; h a 1!lllLC IfilenJe~'V :2 = maxillary neNS; 'V I = IS c ra nia l ne Na (a b d uo e ns ). . ,' b n s ' c a v e rn a L J S 's'lnu 51 in re la t i o n to theIGA~has, ~our venolJ6 spIeS's! rnedial,la ta r al, a n te roinferior and po s t e r e su pe-r lo r ; E ve ry c a v e rn 0 L J s 8 1 1nu S , com m un i~e a t e s a n 1 I D e n c r~ y wi~h th e sphene-parte-'tal s in us" '~ he su pe r io r o p l1 th a j'm ic v lii nan d ' ~he s up e mcia l l Sy lv ia n v el n~ la te r aj I y' w il tth ' th e , s ~ nu s a c c o rn p an !t~ngJle m id =die men'ingeal a tbe ry ' and posterio~~y\v i h th e: b as aJ :6 ~ nu 5 1 , (o n 'th e poSi t r 'e r io ts ur fa ce o f. the do r sum . se l la e ) . . Th e ' l a ne ris th e most im p o rtant c o n nection b e -tw ee n U .e tw o s id es , a nd co m m u nic a oo sw ith 'Ih e uppe r - a nd lo w er petrosal s inus-65",Th e c a v e rnous, s In use s a re irne r con -ne c t a d w u t h ~ h e iI n~ e r ca v er no u s s ln USErStha t c ross ~he1 m e d i an ~ie o f the se l l ia .'T o p og r ap h ie lFe~a. jons h ips o f th e arterialp ie 'XlJS,; ex i ti ng l 'Worn the ,anter ior .0 ra -men laeeru m the leA sni ters the pos-tJ e .m in fe r ic r w a l l of the cavernous s inusa nd e xte rn dSU~lmugh W 1r fo r ' abo ut '18 m m.Th e int ra , cavem 0 us IP O n r o n is dl iv id e oi r lr ~ o l ' fU v t f a ,seg m ants:til p 0 0 6 ' - 'Sl iOF' ' v e n D cal p o s '~ ,e l1 " io ,l1 " curve h o r iz 'o n lb a Ji ll a n t le r io r cUlf\le anterior vel1~cal.

T r U 9 rnain branches O '~ ttle [ntraca,v-ernou s leA are the manin gohypophy-seal a r 1 :e r y' a n d the artery o lf th e ~Dwercavemous s inUrs. The men~nQ C O ~h y p o p h y s e a l artery 0 ri g ina~e5from '~ hs'inferior curve , a n d - tenminar~es, in thmebranches, The inferior hypophyseal,anlary t ha t 't ravle~'s med~ i a J l y tOI th e IPi hJ - 'i t a _ r y ' 9 Ian d I ,9 nd it a e do r s aJl 'm enin g ; e a Jerte ry , f ,ead ing ta l ' the d ura o t the supe. . .rio r c I i v u s. The artery o f tiMe i f n~ l e r~o rIc t8 vem o u s, S n us beg ins, at 1 h e ho r i - zonta~ segrm,ent and li'n most l eases ,passes above tne VI. c.n, (abducens).A J n a ' t o r n , i C B . 1 relation ships wi~h n e r v estructures;' 'I he cell i O ' rn o t o - r - nerve (I~~C . .1 1 1 ~ ) ~the troehl~aJ nerve ~V c"n) l j andthe ~]rst 1 ( V ' 1 } and '~he' .5'800fi:d I' - , 2 : }branch of the ' ~ r ' l i le m i ll1 aj nerve rI' c..n..travel between two dura[ m,emlt) ' r f lU1Q,S(t he ex~e'rnallme'mlbmn e ~s th icker) tha;~'fa nm th e la te r,a J ' w , a J U a ,f ' :he c B v l B w n o u ss l 1 1 U s , T h e I I 1 1 1 .n, , p e n h ) r a 1 1 ~ :S , t h e r o o t o f' Ur ,e s ~1 1us Ia te ra l Ir y to ' the anter l o r c li =no l d p r e c e s s ' - : l1en I sn te rs th e supe r io ro rb l r ~a i 'Ussu m.. Th e IV c . n . e nt:e r s thero o f I O ' F th e s ~'rn'S , posten) Iate r a J Iy t o , theIII C..'L ~ below a nd me d ~alry,~,o-the 'fre ele d g e ' o f the o e rebe i l la r ' ~ 'e 'n tDri[Jm .


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,E ndo s cop lc C a d a ve r D l s s e cnon fo r lT ea ch ~ng Aniano f' Skui I Ba s e Su f i gs ry- - - - - - - - - - - - - - - - - - - - - - - = = = = = = = ~ ~ ~ ~ - -V '1 a nd V 2 ~n~l~r~ e l ow , es t pan 6 ' , . th e!a te ' raJ wa J I I a nd pas s (.1 b li q uely upwa r dto enter tha superior orbita~ 'r1


11/41

14 s l~n [Base ' Surge ry

Fig~32Macroscopic aspect a. f a sk~11pre,parat i jolM1" 1 i.I seeno n "f r an se th m oi d a J a p pr oa c h.Th t ethmoid and spheno d bone po ions.hrghli - ' ed l In r B- d aM -, ' c ted to p o v i d e 'opt imum op8 l rn s .p ac e f or ' t he . t ranse mofda l -'n lnsphen.ot rJaJ a p p r o a c h . Nell'. h e w U~ i~seco -d ~ectiniQua p r o v u :: :l a s mprov vi-,sua l co tro 1o f _ e Ila te r._1w all o f l e sphe ~nord s r l "1US !1r:1d 1 t n partieular~ nf ~he ca,\I Iem~o us s inu s r e g i o . r n . re = ' o el" c p tlc U gh 'pro ;,. _:;;:middle turbina e; S = nasalsee rn:55,= spheno i d sinus:- C~= in e n-6 1 i n t ) f 'aca ' l f f l rnous carotid a r te ry .

I~n .~,rll~il .. .E n . - osceple v laW 0_ . h e ' righ1 nasal c . a v r j-( :m m ='elesco . Q P ) " -8, = n ' s a J j septum; TM1 :: midd ~ turbinate(ant,erior thlrd~sag R" ta ! ): ,'T M3 ;;;;;;m td d I ': IIrbin ate (pQSte~or thirdl!h art to n all; 1 1 := n erior urb ina "e ;PU = uncI nate PJ'OCeGS

IFig~33Mac r 'Oscop tC aspect o f ill skull prepar ,a t io l ' i it coronal SiOOtiorl.Note Iii anatom ie c on=dttion cbs rumingl' he pa h a for df rrec tli n rSJ l I asa l '-rafisSphenoldal a c c e s s . Th e ana -tomic preparation 8xhibl s pronounced hy =pento p~ie deg' n - o e ra t io n lo f 'th a m id d leturbl nate. pa r t i cula f1y in ' he sagu t ta l port on.w ' h ~ u r b il 1 a 1 i .l e = s @ p M J j contac and a r'ght~conv ,ex l y dev i a te d nasal se p u rn forming th esh a p e o ff a lat CUNe. S = na sa l septum:ll- = middle, r b i na , te ; n = - in e r i o r turbi-nate: ,P U - = unem e t t a process,

F iO " 3 5,E nd o so o ,p i c vi~ 0'Hla r~gh1na sa l oav i y1( 4 mm~ lesoope O ~ ~Transethomoidal app roach.'U= I li Ic i ns "e ~p roce -ss .D,E - = . thmoid D~illa'TM2 = m i tjjie tum I a e (mi .d~ehirdl. ' ~ontaJ)'TM'1 = midd Ie urb ina:fa (an eno F 'ttlirds ag tH ai)

[Itr,a naa _Tirran s ~;thmD i . - ali- 'Trans-s p he n o id all ,Ap ~IlfJlJachIf a direct approach to 'he sph en0-eUlmoid recess is not 'feasible 'forana to m i c rea so ns M the t f ,anse tt h mo td ruapproach mlJs~ be chosen 1( -19 . . 32).e "oHowing mU3~be considered: am e d ia J I~tn arged inserU o n o f the mld-

d ie turb i n ate (Fig ..3 3 ) ~ th e presence' 'o fa deV~lated' se ,p lu 0 I a St8p't a ' l : e r e smay impede access to the spheno-ethmoid reoess.As a ,iF:! step In the transethmoidaJI,a'ppmach "he basal lamana of 'he mid-dl e turbinats' is fenest ra ted i . . Uncinec-tom a nc I resec; io n o f the a nte r ia . e n =moio 'bul la are performed in rellalton toh e medial i nser t r .on o lf the middl1e' _urb ina te and the uncinate process, As arp, spoon-shaped Durette is usedfor this step in dissection. The pen,8=trati on site of .he instru ment must besli,ghtly superola 'er~ to 'the conve' ~g S TIc e p o in t' o f tIMe : h re e p o r flc n s o f!'the Im'ddle turb~nate ~ -iig SO l - -.-'6).The basal lamana of 1he middle,u rb ina te ' ~ m1d o la t!Wdrd)is tota Iy re-sected (Rg:s ..,37 an' 38).

FI Ig l , , 36E nd o sc o pIC , v ie w of U le r ig h t nasel cavity(- mm-tsc-opet 0,. T~set maida)approaoh .. ob~the t a _ r g s ' t s e here as po on-Sh 8'p oo ,c ure tte ls us ed 'to fenestrate~ h e b a sa l la m ella b e;-:w e .e Tl he 5 OOI ! i lC a nd'~ rd po l i 11on 0 me ml(:lcUe turbinatal~ a saJes ' e ' fa glaining access ~Q 'he pos ter to rethmoid.P I L I l = u nc in ate p ro e es s : BE = e t l1mo i : d bull~:, . . ; 3 , =midle . rb m ate (posteno ~.o r i zon a : J ) ~ , TL_ 2, = n rudd re urb in e (midd etJiird. ontal~~Tl 1 = middte turbinate(ante no r th ir d . s a g itl aJ l)


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In a s e o o nd step, the friBe __a lQ it n o fthe S IJ perlor tu rb inate is ~den' r i f t ed(Ar CO , 3 9 . ) 1 . The spoon-shaped 'C[ 'JIIre. te is,us d '1 0 carry d i s . :s , E t c t iO I 1 ,along heeran lal ace 1 m th 8' posterior ttll i I'd oftfle Imiddfe turbi a e a d to ,e ,le va t . theinferior marg~n lo f ~hesupeno r turbi-nate, The superior conch a is, gent] y- e . dl [a 1 ii ze d ~ 'I a king !s xtne ms ! c are nc W I'vr:acture 'I he basa~ lam et la, o f 't h eturbinates. Usingl a straIght ~hl'iough~,cuft i ~gIRH INOFORCE 'fo rc e p s - Iii ".~)'t h e f e neS1 ttf 8!tio In Ii s enl tug e o untIl tih eexpose natural o3t~um0 .he ' sphe-noid sinus comes ina v~e,w lF ig"" 4 , 1 1 ) .

Ig\,.39En 00pi c vie _o .f th right naMI eavl( ,mm-m~e s cqpe. o a ) . Transe thmotdaJ8Il_mach. The ~reeedge of e supenotu rb n s 'te is med ia l ized b y U[IS' o f a 'Sh arpsp.oon~sh~pe.deurette to gain access to and\!~!5ualoOI1 ' li ro l o f the S1Jheriooth aid recessA s a ll polypI (P ) can be seen ' h a t 0 _. i-rrates from th : olfactory' cllaft a n . p ro Je ctsinto . e sp e -.a:liilmoid recess,JS = superior ur b jna te ; IR I ,e = ~s~tHi!no~e h jd f, cess: r- : 2 ; ; ; ; m id d te ' ~ u rb 'na elmiddle 'thim~lrontaj); IE' = pcstertor,e thmoid

937'Endoscopic "'[ew IO f th e right nassl c-avhy~ .mm-telescce I Q r e ) . TmnsethmOH1aJ iapproach. Ru .ction of' th e l middle th fr o ol ftne midd r e rbinate' using lIB thmug h~cuttingnasal f o rce ! ) s wittn 45 rl' up1!J .1mad j a w s ,PU = unc ina '~e ,p r locess ; III~thmo'd buffa;_ ~3~ middle f.urb~nte (posterior' third.he 'zon al}; T . 2, ~ middle' uJ 'b i nam I ~m~d d lethird. rontal~l;T 11= midd i 9' i ' JUrb fna teI (a l i l l te r i o thu'dl . sag i t ta J ) .

Ilg..._Endo.5COP~Cv e ,Q 'h e righi, Ilasa),cavityI~ mm- te l e s cc e, I C P ) t . IC is s oc ti o n o f th es up e 'o r L !m b'na t . while p r e s s ing'thebasal lamell I of t u ; , ] na'Sal l u binates to gainaccesa to the sphel l i !o hmoid racass.Ef' = posterior ethmaid', lC' ::; tlasal lamell0'" the nasal urninate ,;ASE ~ sphsne-e ~ l nmo i d r e c& ti ,; S :;;:nasal se -p tum :'IS . ~:sup ..or ' l U I m f nate -

'1 5

RII.asE !n~doscopIe v iew 1 0 ~ e right nassl cavit)l( mm-Ie:lescqpe. O ~ . lirarlissthmoidaJlappreach, SUDto ta1 rssectlcn of th ~ middle'hJrd of he middfe 1urtfn te expos'ng ': epostenior e t l1mord jill postericr IOCEtT [On a ndtliIe superior' u~binatJ8~irS = superio 'turbinate: Epi = postsrier eth..mo id ~ T _ ._2 ~ mid 1 tu Iflla e (middfe - ird.f rGnt:al).

Fig.,; 1Endosco~ic view of .,h e rig n :nasal cavity{ 4 . mm- e le so o; If!. 0,. F ijns l a s peet o f th'tra ns . th mo ld al p ha se to g aJ n . c ce ss to 'I espns rbo i d c a J U ' n t y w i h l e~ p o s L Jr eo f' h e n a tu ra lJ h . . . . . ;Ii"sp . e . n( l!I ~ smus e snum ,~E = ethmaid buna : '2 = m f ddh ;~ urb inmemiddle Ljrd. oon~ : - ~~ ]:;Mu1dle turoinal ( pos !e r io r thh'd1 hor izor rmJ' I ; R~~E = sp i t no -

t' ! rn o -d re c es s; 'O SS = o s ium ,o f', esp e _ old s d nus


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Endoscopic Cadaver D i's se ctio l1 'fo r T ea ch in gl A nte rio F s ~un Base Surge r y--------------------------------~----

"h l" , 2:E rid os co p ic v ie w o f tile righl nasal OO\1 i ty (4r n r n - t e l e seepe . [f). INoi le ' ,t l l~ ,sphenoids c i -n u s o s IL Im enlmg;ed by u s e o f a c r r o U ila l f -CUiH~"gpu neh - -I i. . C : :: :;basa l l rams ' I. e o f th e t ! J l rb ina t e s ;OSSI =:ostium of the sphencjd! sinus;E P ,= p o ste rio r e h m oid ; ,S ;::; ;;a s a l septum'.

Tr,anssphEHfI oidal ,Appro8lCh TO I The, S e i l l a r Reg(on (Standard ,"pprn,ach~O n ce th e natural osn I! Jm 0,1 'Ule sphe-noid s~nus comes into v'iew~the 08-'Uu m l ~s e 'n~ '81~ged In i t t l ali ly using a c lr cu -I t a r o o ; c u ~ " t i n g SlAM MB E JR GE IR IPuneh(F~I.'42) and subseq lu ent'ly with 8,McKE lNlY b one punch , (KAR L STOF l Z) ~I 'f "tlh e d i r ec t pa f J hway to ' ;~he sp ,heno~ ' d'S inus o s ti urm is , ,obstrud~d by ana tom 1stru ctures I access to Has ' na,tural os-tium e an b e g a ine d by l IsinQI a d iamond=

F h J . , 45En~oSieopio Vt lew 0, 1 tha 'sphenoid sinus.Giese-up '~lew o'f 'ltie posterior- wall !O,f ' thesphenoid 5~rnJcsand opt i : coc .a ro ' l id recess .N 0 1 ~ cpti~neNe;RJ IOC = i L ' l lp t jcocaroUdr ec e s's ; A C tl = i ' rlt:em a l caro,t~dar te ry .

F ig " 4 3,End o s c o p i c : \ fi e 'l l of 'tne l e f t na sa l ca v [ l y t{ 4 . mm~uel~copei Cc~.~F l t r anasa~ transsphe-l I ' 1 I o i d l a J a p p r o a c h , Once the sphenoid s i n u s.ostium is '~fllar.ged us~nga d Iamond-tipPf!db u rr th e ~r r i te rsphe i l1c id s e p t urn is , r emo v e d ., S ; ; = nasa~septum:588 ~.right s p h e n o i d rnemi=sinys,Issl(, = l e A : s p h e n o id h e r nl -s ln us,tjpped burr' fa r' resect ~Qnof '~he spi'le-l 1 o ~ d ro strum . Illn tJ hi's waY I ' the , e n t i i ' l " eenteric waJI ,of me sph ana~dsinus lsre m oved to 'iJ i 1sua lil@ the antenDr rnsr -gin of' 't he i nte r s p h e n o l d ' s e IP~urn,The interspheno ld septum is takend own b y use lof an intranas 8 , 1 1 dr i~ I w l f ~11a d lamo nd-l l i ,(J pad b urr (Figl~43}. IA~mova l of the septum ls comple~ed u S/ -'~ nQ 'U l f,o ug h -c uH :i r ig ~n s tr um 'e n rn . s u chas 'GROINWALD 'f or o'e p s (P ig " ,44}r

~" ,A,~lI!m,'~EndosOO \pk ; i nte rs ;p i l e .nn tt l \ l ' i e l l N (4 mm-te~e-~ojle, (]'~ Sadd l B - ' s t i i aped sphenmd i sim u s . ,l e x~ e n s iv e 1 y p n e u r n aU~e d witn clNrly v i stble,anatomIc- IMe rn Irks.SI S = i n temp 'heno icJ1 'SBph i lm ; AC - = , in te rna l~r i t r acavemcn. ! lS caro tud a r te r y ' (pOr t i (D1 l C1 .v e r ti c a l. ~ o s ' ~ , e ri o r) .;PI :; se l l a r 'rloor:R :I :O C ; ; ; opt icoCWI01id 1 J ' l 9Ces5 .

I F il . . ,4 -4Elf i ldQ:sco1Pf.cv i ew ( 4 , 1 m rn - te tsseope, Q '~IR emOl / a l o f the intersphenc!d o o p t l / . J ! f J l byuse O 'f a ~rough...cuUI f t iQ nasal ~'O{~eps~S,u~!= i n r te rspneFt io id s~ptum.Ssd l = ' r ig h t ' s p h e n o i d hemi -s i l i lusSS~J: :;: l ef t s p 'h e n o i d h e r nl -s ln us '

Duni 1 19 thls maneuver~,i t is im porta rrt'tilat ,a My to rsle n or ~everage on U n . es a p 1 um l b e a ,v riud ed to prevent f ract=u r es , a t 'the ju n etlon b e twOO f l th e ' inter-, sp h e n o ~d sep tum and the p o s te r .i o rspnen o~d wal ~ IIbecause at 't i rnes, t h . e,s ep 1um l a rig ina~e5R 10m 'I' he be ne per-'t]on that. overt ies t he internal caso t idartery O J " th e ' I O p t J i c nerve~ Having ere-a l t too l a s~ngle sphenoid Icavity l a , 45D,-eleseep e ~5 Us ed l 'to iemi fY ttle Iand~,marks on the laJ~eralwal ~6..The uppe l f~a : fl dm .a r k i s, ' rhe o,J):l j ' ,c nerve, th e lower(1ne ish e' lJn~,e1'naicarotid arte ry.'T h es e ,tw o p re m ine l1ces a re separai~edby a 19ruove~, ", e r: y Ipmnotlnoed at'' t ~ me s, n a m ad ' the 0p tu eoe s r on d recess(F~glii..)~The mani f 'eS '~at i .on of hisgroove depends on 'the deg ree ofIp ne u m atiza tio n of th e anterior 01 inoi~dprocess and the sp h e n o ~d sinus; Rse'~f f .'T h e I b'O l 'il fYselar ncar . 'jn m B d ia n p os l-t iom. may b e very th in and, owing '~Othe ~ru~erlyi'ngsellar contents I{Fig~,6}~,may take on a b luT:sh t T . n t


14/41

l E n d o s c o p ~cCad aver Dissectio n 'w o rle a ch ing A nte rio r Skull IBa s e Su rge ry ' =----------------------------------

A(l1.41Eindl lSCOP[(: v i a w ~ 4 m rn- e 1e sc o,P 8. Q 'l).AiCI I = p ro rn in en oo o t ' the r i gh t I i ' 1 ~eMaJ a:vem-e us c a ro tid i l r 1 1 e r y ~ P,S = se l l a r f ro -o r

After repesltlo t : 1 ~n 9 1 t~~ Co 'telescope~th s a nte r io r 'w a ll 'o f th e seU a I~ S a p -p ro a ch e d e : tacUy en 'U n e 'med J an Uneus l ing a n in tJ rMa s a ~ d r ii l ~with d r amo nd-U p pe d b ur r ~ lF iig~ 4 :7 ). The D,PS ni ~ n9 ere-ated is.w~d~noo ina c1reu I8J f : a sh ron, I 'is r -e c o m m end e d ,h a t the f e n o o t r a t l i onbe ~argeenough 'b J e:dend f r oml onecavemou s s inus to ~he orth~r and I in avertica ~direction ~frorn U n e f il oar '~Dthec iir c uia r '" s in us . 'T h e l open ing o f the se~I~e r lo o r ~S 'I' h e n w ii den ed as ' fa r- a s ' themad ~ aIm 'a rg ~ n o t ~ Il e ca v e rno us s i nUs(F i:g~ 4B!) r .,The, prw ~tary 9 Iand fs cover-e d a t th h s le v el by tw o duraJ l a y e r . s : ttH~peri o ste a.l. d u ra exh~f1naJl~y~a nd 'th econ n B C t j v e tl i s su e I c a p s uh3 lo f ~ t u = = 'J : f i~u=i tary g . 1 1 a n d . il1i~l~~n aJly eFig" 41 ) .A s io ~ J e;~ ,h a p ed k Jn'r r~ es u se d ' 1 : 0 makea c ro s s -sh a p e d ineislon G n tlhe pe-riostea~d L a ra to ' expose the sel tar eon-tents (F~g~10). 'lhe inels ~ O I r .1is l e n l af~l'edl a te ra .U"I w ;~ h a m lero-d lssector; dls tat -Iy angled at 450~ and I if necessary ' !w t th a n gu l, a, to o miem- . ' ( o r c eps .O no e 'th e' J - s h ap e d d L ir a l in e [s ian ( 1 1o n -z c r r ! a l ] a n d verU~al ~ n C i I S i o n . s ~ 1 is c am =p l r e 1 : e , ~ the ~nuitary pate l 1 c h yma is 8'X-p o se d . R in g-s h BiP e d' , ( ; .u re f tes wit~ an-gu~ated d i s ta l ends e r f v a r io u s s izQ S ~ rbasket=shaped suction C U i r e t t b e s , mayt a e ! used to' evaeu ate the intraseU f i rcontents ..

Fiigl.,48EooOSGop i i:: Vt iew (, 4 m m- b ~ ~ es - co p e . O p ) . Afterremo\ i ' ru O 'f ' ~ he : s eUa r l f la G ~ th ~ fim t d um l mem-b ra na (p er io ot!e um ) o 'r -th e s e lia r cav i t y Is e x-posed,D'PS, = dura o f th e se l ia r f l oo rA C ~ =p rom ine ne e o f th e 'j n t e m a J J c a I ' ! J \ e m o u scarotid aMe r yR UJ C ; ;; ;o " ,Uooca r o t id I!eC'$.SIn rasellar endo scopic navi 9ation isthe el l [ !c t ive te e hnlque fn,r com pl et~ngev , acua t i on I O ~ 'sellar contents, Th i s i'n-vof l VBB uslng an il r rig a tio fl i p u mp towhich a sped'any ds's,igned i lmgat i :on8he~.th ~s 'conn e c t e o for in r ! t : r a - . o I PB : I r , a =t jv , ~ ' r i n s f 1 n g l o r f th e ' d i s t a ~ teleseep e lens(IKAlRl. STO'Rl C I l EARV IS iONTlJ Sy51'"!e m ). Clea ns'i;n 1 and e V a c L U a tio n o f d&-bris is performed under constant im-merSI I 'o l1 l l eJ i l ab~ ing detJefim~nat~ono f ' '~ h ev , a r i ous i n i l t t r a s s ' l i , a r components. Th eint : raseUar manawa r may be per-formed us i 1 1 g l a u1f1ree- ' l1anc teeh-n~q LJe~11 C [ U ' i Ie a . s u e t l i on , tube ' [s intro-duc a d th r o u 9 h 'th e 'w e e nQs1r~~con =t r m a te m J to the o n B 'J ~ flo ug h w h ic h thef i rs t sU l1 Je on O PBT .3 te S.. fina~y . '~hesuction '~ube is .advanced '~hough '~hesp h en oid s ~ I ' i I J Us ostium.in se~a r S IJ rg ;e : ry i 'th is m aneu ve r 'Is per-'fo,med almost ]n contaot with the,parenchyma under CQ nstant. imm,B ' , r ' -s~on in anopera.tJ n9 cav ~ t y 1 ' if 1 1 1 , 0 0 1 ~ t htra nspa ren~ fi u ld~wh lc h 'fa c ~1 1 at)e s d e -tectiQn af anry debri.s trapped in h id=den spaces.The connnuous flow 01 ' tbe I f l r r iga t ionI lq u id c au s es turn o r a J f ragm,e,nts to b E l i 'e~e - an s ed Q f o l o od aod, as a resu It ofout f low p re ,g Sld R d ' b u g I d i ng u p ~n s ld eth 9' s e I l lar c av~ ' t - y lto be , e v a c uaJted.

.7 '

Rgl,,",1E nd os ;o op lc v ie w (. mrn- te lesccpe , Op ) .&tel"i-~si \ i 'ee ) l ; p o s : u r e ' o f the' s e i ~ W ' c av ity a nd re m ov alI C ; ' ~ :he per ioste ru d u ra l. N o l~ 'th e 'p i t 1 l l i t a r y 9 I 'and\~itlil i ts c a p s u le .AlGII. ; ; ; if'!terna~ i r r l ' t r a C " a v e r n o t i l s caro t id ana r yFlI IOC , = . op tk :oca roUd ~esslP O .: :;;pitUItary g~Eil l i ld

F'II~,m~nITaSphef lo id : endostnp[~ ~~ose=upview(4 mm-te~eSCopB1 0 0 ) 1 . ' lFon(Jw~r : lg r r e m o v m 1 0' the oon y ' w a 1 1 ' o f 1 1 1 8 s e 1 J a r f JO{ J fi a s h c k l e =shaped mire ~ used to incise the periost-eallmembrane and the C'-apsule of tie p i 1 . l ! . I - 'i t a r y dura. , A i e m = interrnal,~verfi!o us cmotidaMeryOI IPO = ttSSlile O O I p s U h~ 'eve r l y ing l th r i l l , p i t U l -Hery gland

This techn~que mes~s the' req lJ i re-m e ru t e ; O 'f m in i lmLa~ly inv,asiv lB SIJrgeryB in d p r o vl des Is rg ono m lc w o rk ing l 00 n-d~1: jons ' , evenl in eritrcail s i. fu siUons whenl c omp l i' c a ~ i on s r e l a t, e d to I~mitedspacefe n" h a nd ling 'tJ h e instruments, arise'f rom tu moral b le e d iin~ ~ size o r c ons ls -ten ( ; 1 J of , the ' t L J n 1 0 r :


15/41

18 E nd o s co p ic C ad a v e r ID~ssectionf o rTeach~"g Antenor Skull Ba se Surg ery

F:igl., . i 1 1~rIi 'tm;senar 8ndoscop ' j e vie w , ,4,mm- te l e~scope. o~~ Note the pit uitary Ig ,~and in ' thece~ter. Cen t~aJ l y . t : M ~ dlaph 'a g m a s e lla e ~DS).cranially. '~heoptic chtasma (C, " and ' th e ' i n-unD ibu ~a r s t a lk (pm).latI .JIl~ly; t e lowerhypophyseal artllry (AII~Ia r ld l ' th e ' in~emaJ~n tf ac a vemO IlJ !i , c ru 'Q fti d m rte rt { ' C I) .

IFI9~ , 5 4 1 8 1 U : iO Q Q p ic d J iS s e c t i' O I 1 1 i o f the cavernous s i-nils (4 -mrn te 1e .s co pe , D ~, R em oval ci 't 13 1~tt,erior and i a r t e m l J wa i lS ! o f t he , sphenoidsmus Me] the, per ios tea~ dI iJm MsuU ls inme{f r , o l la :1 :e raJexpooUI1t ! ' of ' the p i tuitary g l a J ! ' i l d(IIPO, I tJ lr ie infer i jor hY ipophsea l artsry (AJIIl !~ h e Interrt laJ c am 't id a rts r : t in t h I E l ' en 1[1 '8C2'=v aMOUS s e c tio l ll a n d , ~ s r t e r r a n y 'to ' this f thec a vem o ~ s S iin ll ls ,IIII = 'hlrd ICf,aniaJ,neNe (oculomotor):I IV ' = ~'ourlhe raniai neNe (tract! Iear ) ;V II = 's ~ :d h c r, a ni aJ n e rv e (8 D d uc -e rts ):c2 = p oS le rio r C Q.IIv e , ~ntsrn 51Jntlrac~\f ' -le r r !lO t , l s I caro t l ld arts ry~c3 = 'h o r i zo n ta l s 'e c t io n :e4 = anterior CUNe.;e. 5 = vefticm ,anter ior section.

Fi~g"52Intrasp ~'uJfllo~dndoscopic close-up view.Note ~l'lee? t ten s i 'l le t ~ r eeee t ee s -e l la r i \ 1 oo rand the O OrlY w aJ I overlyf n e g ' ' t h e ' c aV , emoU r ss 1n u s . .Th e intemal int raca\ l ' 'mous c . a ro i [dartery , a r u ] putu i~ :a ryg la f id B 1 i e de'at i ly e J i C - 'PQSi d . P a rti al r em o ;v a J of the' p i E ! l ri e ' t a l dura.demons mtin g l th e' laiternll'tDpcgrap~ tc rela-tionoShlips lo f th~ int~m'alcav e rn ous ,carot~dand the p~uitary 9 land~I IPO = pituitary glaJld: ~-_CII= l i r :derna1 lntrs-c a v e r n O 1 l J 5 , c a ro tid a rr te ry ~ea - = horizontalsection 0 ' 1 ' t he ' i n tra t: ;avern O i J J S , I tO I~0.4 = M -t e r ic r curve' o f li e i If 'ItraciBlvernous ACI~10$ = vertical anterior section Df tie 1 ntre-cavern OUSt AC ~: :C -1 1 = !Cl ivusDuring dissect'i'on~ it is Ipreferab~e '~ Ole a .ve th e pitu ~~a,ry~ land 'j 1 1 situ in orderto stu dy 'Ihe topograph ic m1at ~onsh~'ps,to ne . i ' g h b o r i f ig stru ch.Jfes (Flis- , 5 1 1 ) _Lateral'ly! the cavernous sinus, and its,IC O ntents ~Imedi~l l y ' Bnd below,. the infErr io r h yp o ph y se a l a r t, e ri ,e s ; p o s [ e r io r ly , ~'th e c 'l liv u ~; and 5upen lor l y~ the lnfun-dl ibu~ar stalk ,and lts vascu~rization(superi or hypo physea< l arteni & 5 : ) 1 an d'I 'he d : l a ph r agma 8 1 9 1 1 1 3 1 9 .Ciufon~Iatrogenic lesion of the op'~~cnaNte.les lo n ,cd 'the, ~n ' e rn all carotid artery Id U J ral ~esian , and lesion of th e VI. c.n,

: 3 D- t ' " 0' " ' f - Th' ' "' , I: 'Iell!"e:- ' C ~ ~ ' l - I ' D - : - ; n : - I '~ 'e' ,II " !i3i ii II , " ,' , c ' _ 'PafiliS'. ISllr'egiionlI F oUow ing '~enestrat~n o f th e ' s e l 'Ia r f l loor;d ~sseet , f 0n of '~he ,po :s~emla t .e r ,aJ bonyw ,a l~o th e sp he n 0~ d s'inus, is c onn nue d is tta rl i n9 f rom i 'tne ' bon y pmmirl en ee 01'the ~l1ternal ca !w 'tid anery (IIC :,AJ in its T n -' r aca .ve rn 0us ,seg m e nt, upw ,a rd 'to ~ h eopt i c naN'SI which tr a v e ll s ' i 'n its chamel . ~ d ' , j ' ~ e2)~'~n a I~ranlaur,~ eenon . ~ig~~,-. F\ coess ,

F~91"53E i n do s c opu : : : 'J ie w o 'f IF l ~m.sphe l iQid d i s8ect i :an(4 rnm - t e l e s c ope , [J~. Fa l r~in Q oomp~etE ! ! ' rs-mov a J o f 't im e pb l ' s te r io r wtil~c 'f th e s p h 9n o ida ir ur s, th e r nl 'h e rc a v er no lJ s Slfl '1l'US'9S a nd ! 'h eca , v e rn0 us s lnus e nc fo si ng th 9 cav j ty a f " O ! J . I ! n dth e se lla a re e x p o s e d arid ma r k e d by t i l1t fa~'IiMal staining" .A t ' I i i e top I note the l op t i cn erv e an d ttl Ie optic cn i as rn a , beJow. th e AC ia nd 'Hle e r a l1 i a l ' d un i : llm la- ie !.I N I ! O = opt~cne rve~: S C ~ cav e rn ous s~nus:S~C: i~av,erfilcus Sl'iI1IJ:S; eM !!!::. cpt~cc J a i a S l m a ; A le I I ; ; Intema~n twaca vemouscarotid Mery.to the ' c ave rnous s'tnus l s , a cc ampU sh e dby Ir e mova J J ,~f Ule bony w,a l l o f '[heoptiocca!Kltid re cess , w 'ith a d liamQ nd-o b i p p e d b urr and SI J bseq:uent d is se c tl o no f 'th e p e r io steal d iu ra ,If the dura. mEr~e r~emal'nsintact and en-I, y 'lile' bony oomponent is removed, thevenous , ple'xus t tA r oug h w hich th e ' twocave rnous s i l 1 l ( J s e s Icomrnunicme b e -com e s ' tmnslucenrt : and m 1 a y b e v i sua l~' [zed a i H e r ~Ilec t ll [ )n o :~ CI[ ] ,~on~d s ub -stances in~'D ti h e respect i r V i e venous00m p ar lm e nt ( F Ig .. SS) . O n ce th e p .e r l-os tea l d uraJ ~a.yeris r , emov 1ed ' i 'the itenn-al c a . r o , t J j d artery may be visuaj iz IBdth r rougho Ul t its in tr a c a ~ 'e r ng 1 J J S COLJ me .TMle' bon e und,er1y ing ~hepltu ia ry glandi 's th e up pe r ponion o f th e clivus. la~er=aUy '1 0 ' the ve rtjCa l l 3 1 1 39 m ent o f n , e iflrh~r=na1 c a ro tti d ar!t:ery , '~he!abou cen s r1eNSca n ro a ~dernUIF,ied ,art u ~ s ;nser t ion tn 0 ' thecave rnous sinus'; Im'ed ia U y to ' t n ~ s , . ttlesympa theUc p ts xus . 'D f t lh~ ICA , c ome sinto , v li:e w . T he m e nr ng o hY lP op ih ys e ala r te r y ' or igu 'nates moo i ; d l y 'f ro m 'th e im r.a -ca ve rnous, s eg me rn:t: 0 : ,ttl s I C A 'tlha rs rn -i f ies tO I f,o ,rm th e lo we hypophyseal ar .". , fF" I I ! : : " " 1 \tenes ~_Ig ,. :~f.


16/41

E f1 do sto p~ c C ad av e r' D i sse -e l i o n ' for ' ' ~ B a c h r m 9 A nte rio r Sku I~ Ba se Surg ery--~----------------------------~-------

I F ig . , 5 'SEf i ldo5C'Qpi C c lose -up v i ew ( 4 . mm- te i e scose ,Op )a f lj e r d ~ s s e c L io i il 0' the , r : l i vL iS"AlB - = bas i l a Ja r t J ' r y : I I I I = ' I t . h ~ r d cr.an~aJflSNe (ocu~omotDt~;ACI - = i f l : terJi la~ carottd ar tery . posterior venn- 'c a l s e c ti on (C1): Aep .= posterior C E ! ! e t m a Bar te ry : ,AeOp = p o s te r to r c ommun j, ca ti I 'IIgartery: '.C E S , : : ; ;: super io r oe r ebe l l a r artery;P I = p U i u i ta lY i n f ll .U n d i l :u l r u m .

O n DCn ti nu ing l d issect io n , ' th e ' c o u rs e O 1 ft he I~~ an d I IV OCU~omo to r n SN5S co n-' ta in&d in' he dura~ a u pi t ca t ion o 'f thela te ra J w a ~I o f th e 'CriJVlar~o UISs i flUS and -l ess , r e a d i Iyi th e n e rv e b ra n c h e s 1 :h a tt 'I -nal~ym ake ' up th e II a nd !~~division of'the V I c r a n~m nerve-can be' 'ObSBnfed .O nc ~ sb ra s iall o f the c I l ival bone' a ndth e iQrmf i'c e0" th e crania l d u ra . m a te r lslo[)'mp~~e.th e bas~Ien ' arts r y l the peste-n o r ee r e b r a l m e n e s a nd th e super io . rc ere b e Ua r a r t e r y can b 8 . ' s e e n . Lab9ral l l 'yto 'Ule p i . t l i ' . a r y 9 ! a n d and mad iaUy tothe ~CA j the ' posterior comm U J f ] i c B . t r n gar te f ' l i e s c a n be v is ua~ized (Plgl" 5i).~whih9 do rsaUy ~D t1MeC , se c tio n o f ths'int r ,ac:ave:rncLJs UJA '~ ,e du r a ~ ringf( jtm ed b y Dorello~schanne ' l and ~hein -s e rijo n o f t h e V ~ ,c ra n ia l ne rv Q in~ Q ~ he 'c a v e r r o us 5 'i ntis c oms into v iew+Upon re m o va l o f ' t he bony w,a~ '1 b e =tw~en ti1 e ~o op,~,~ne r v e s an d these l l a r conb~nts,.the d L ira o f' th e p la n LImE'ln~ e n ' ! I ' " i t ' I . . . . I I ~ ~a ' I 'S '~_i'Ii W ' . . . ' 1 .. .. 1 1 .. . c . . . . . . , , ' ti..,!3...gr-~k. Vl.U~~~ ." ~~~I~!I Ill \. iil l. " .U~n I !. ~ ~tO I f o rm the ro o f 0 ' '~heS 9 1 1 1a . ReS lBcUo l lo f th e ~aH,e r s tru ctu re e xp o se s '~he i i 'n-' f u nd i b I L J la J ' s ta J k and tho' supe r i o r h y -pe ph y se a l BJ r te r i e s ~ ,~ h e op f l c chlasrnaand the orjg~n o f tt l e ' 0phtha'~m~ a r t a~from th e int,enna l l,c8 !Q, tid ar l!ery, 'til e an-te r io r cereb ra ' l a rnery a n d I th e an~eliorc omr nu n r e atin g artery (FiIS~51 ,a n d , 51 ). .

Figl.,,5GEh d o o o o p i c dlssec1 ' i a n ~ 4 rn m -'teleooo,p!! i J ! = ! ) .CH ~ o ~ tl c e n is s r n a : P II= p; lu~ j~ry stalk:A.CO P ~ ~oshuiorcomrnu nicat ing artery;A .CA ; ;; ::an te r io r e ommun ic a ti ng mery;A:1 = (!Interlor cerebrSJI a l1 e ry (fir st . s e C ' t l antAS:::;;:'antetior c e ' r , e i : m a l wi. 'ery ~s econd . se~ tl ic n) .

'1 9

Fry. 51Eru : h : ~s oop i cdkSSeoi io f1J {4 m m~tel lescop-e! i .t o , . IDe'taj I o ,f tn e p a . r e ! S e U a r region,HIO = !Op~'[C'nerve; AC I = op~t~~lmlrcartery;'1 '0 ;; pibl l l ta: ry g la n d; A C E ;; ;; ;;n1em i!1~ I Intra-cavern ODj:5; . c a r o ti d : a r te r y . a.rl l ' tenor curve (Ir:;~)and Bflh;!rh:n vertk:al section {oo) ; II~:= th rre tGrani:;;!] nerve {oc!JJ lo mo to r); 1 1\1= :ourLh CmTI~[al ne rv e (tr oc h le a r); 'V I = :sbrth cranial nenl ,e(~bdueer.lS)

E th m o id disseaio n by us a of tna c en - tl l" ip~ ta l11 !BchniQlJ 'e a lms a d e n -b l oc k re -S6'C:'Uon of 'mU'co5w an d bony contents(en~m a id c ell 'S i, an d b o n y tu r b ]n at .es) .e lev,at i l lon IO~ a . m uo o= pe no ,s ,b 9a l fla pd es e r i o i ng a S E 'm i, e ~ r c J eth e . t c o v e r s th ela te ra I na s a ll w a l ~ (f ro m th e m 'w


17/41

20 Endoscop IC Cadaver Oissec . io n 'f or Teach in; An e rr or Sktu~1Ba se .s u rgery------------------~~~----

R,_ 51E nc Jo sc op ' c vi rw 0 ' "the l r i ght ' nasal cavity( m rn-telescope, 0), A rou nldat_tpped kn' eis us ed '1 0 c .a rry th e m uo op G'r iQ ste aJ in 1lc is io ndown' r e i b ginning at ,he l e ve l of HiBlm,umary l in ~S :: na sa l s ep t!J Jm ~ _, = = midd[, ~!Jrbinate:;I U M I . : m : 8 J X ~ ~ ~ a r y l 1 l 1 l 9 ~

F 1 9 1. 6 11 1Endnsoopf G view Df tlte right na s a l cavi( rnm-telascc pe ' Of)I. 'The mucc p e ' .ostealap lse aval te .d rom 'the Ismln papymcea.[liP ; l:a m tna p ap aY f; C a; - , P = mueo-- r D os te aJ a p.

fig" 5gE dosoopic view ol f th , right nasal caV il " l { o i Imm" ' - e te soope . O , ~The lneisien is G 3 I T t 1 e d' f l l J r tne r a n d e1evati o fl l 0'[ the ' r nu c a p e r ! os teaJf l _ begins.P = uncinal process: ' T _ ' ; ; ; ; ; ;middleru rb l f la te~ , I,E = e th m o id bulla; 5, := nasa l, s ep t um.

T- .~lol~ j' g a '. p t ies ' lt~ the'advance"Dissect~on commences under endo-s cop i c '[sic u s ~n, 'tin e s ka ig h l, =f OMa rdte ~e sc op e ' (~ m m d ia me ,: s r 0' ~ . he mu-coperioste~1 inc i s i o f 1 1 is 'm'sde ,a~ the.maxillary I level wdh the mund-'ip,pedkn ' e =igs.. ,58 , a nd ,59)~ : A n e le v a to r isused 'for the mucope r i o s t e a l f l a . p . and' the une lna :9' Dfl~SS i s med ii a'! i z ed after

F 1 i .82E ind os eo p ic v ie w o 'f th e le ft nasal cav f t y( ,mm~te~est:optil}. iNo '~e,the [prominenceof tha POgt@rlO'f nasal artery, a br -net! 0 thespha nopaJa ina ru1 I - :S ) a nd '_h epromi-nenc e , ,0 : e s ph ena pm a ine ne rv e (NSP );t n e a rr ow T l i ' ! l dt 'Ca tes to the b o n y c res t ,

Fig 11 0[E n osco " tc vie , of th righ nasal cav( , r nr n- te i e se e B. O,~ The' rrnJeoperiosteaJ'f la p r ~ s , levated ~rum' he l a t. e r a l r n i8 ISaJw.ali .L- = 2ixUlary I ,n-e : ,LMP :::mucope r i o s te a lnap'; P 'U = uncinate proc,ess~ a ,E = etnmo -de u H a: ' r - . : 1 1= s . 'w pe .i n 'D o f 1 ln e m lddletur i b l n ab e ; -f--3 '= ho r t zon al por t ion of thif ! 'nil i dd le tUlioin a te ; S = nas , I s e p tL i r n

d is s ec ting itts ,a nte rio r aJ ' ig l i rn C i , g l ~ O O ) .Th te ch niq ue proceeds by iden Iifyingthe S L U bpenos lea~~aye r ' at in e I I L e v e l of ' ~hela 1e ra l w a U o f he ,e thmo. id inrundfbul'um(lam in a p a p yr ac -e a ) II . 'g . ,6 - 1 - ) and e leva : -ing " h e f ia p a nte rlo po ote no rly im h e sub -periosteal p]ane as ' far as '~he apex ' of1 h e , ami (fig., 62)1 .,DUrl ing th i s maneuve rrem,Qve the bony ethmo d septa tha'o rfg rna te fro m 'th e la mlna p ap yra ce a un-o skieletoniza to n is co plete.

[Hg. e aEndoscopic view of ttlie I n sal cawty(4 , mm-tell~cope. O ~ ,, ' ,S ' -RS = s p h enopma r t i i e . a rte ry s ep ta lbranch, uopa] t 1 '1 l': T_' = : : . nmijddlet i . . I I r b i n i l ie : A F i D = d e s c en d fJ ]Q p h a ry n g ea Ja n e ry: A S iP - F l iT ' = sphencpaJat i ru ; !1 a t t r l ; 9 . 1 Y ~tu rb lr lla l b r a nc h (pes' 'or nasal ) ;NIIO :: infi'aorbi' ,aj ne e


18/41

IE nd os co p ic C 'a da ve r D i's s.e ctio n '~ o r Te ac hing Anterior ,S "ull Base S L U r g : B r y- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

lmIME nd ao o op ic e l 'o 5'e ~u p vl8W olu~,~,: i ' 9 h t r tI a Si ll,cav i ty (4 mm- te l e scope i C~ _Note,th~thfOugh-cuttin 9 1 in1 s1n Jmen~ used to removea Ila m ina p a py ra oe a 'fragme fit I P 'C ~ pet ior :=b its : I llP ' : ;; l a m l n a p :a p ~ ra c ~ ,a ; A iE A , _ ' ante r i -.ore'~moid 1 ar te ry

V e m r , E J j u y to the' rear of tihe m~ d Ieturi l i lnl~:tt,e~'ttiB sphB r ' t o p a J a t y ne ' f ; o rwnen~s iden tu r l ed by ' the a , r t ISry of the s ame ,1 r1 ame ttN~Jt ramifies i n i t l C ] 'Mo main~ b r a n o n e 5 ' n : ' f g . . 63), The a r 1 e r y ls d u s =sected with s~aight 'oreeps and 5UD=p e rio s t e a l e h ;T .= v a ti 'o nproceeds as ' f , a r as.th e uppe r ma rg in o ,f ' th e e h o an a . ,A . d i s =sec ion mod ~ f i c a1 jj' o n may be "h e re-mev ,a l o f 'th e la rnl rn a p ap 'y ra ce a'f c ere -f i J J U y p re s e rv in g, th e , p~ l'ir Q rb it that de~er-m o n e s ' t t u ~ i e v, s~ o f J e f ,e v a t i - o n (Fig~64)~na no tlh e r mod umcat~onl ' d issecno n mayeoctend r e i ' t~e o l fa c t .o r y cleft. ;~ o 'thiS m e -d!sn 'septal portion and to the root 0"' t r i e I1lt!sopharynnt T he BiB ' a n,a J~ Dm k:st ruch . l r tes 8 . J ' 1 6 a l lw ,a ,ys d i ssec ted subpe=ri Mi'U T!L-.. .~ . ~ - ho r se shos. Q ~ t ; .e a , y ., II~,~epmlllmifilaty ~'la1SBS" oe-s h a p e d i ru:1:Son I w h ; i ( ) h o om rnencesa n t t J r I O l f 1 IY i is . , c a r r i e d toward t h e o t J n e r'in c:is to n o f the maxiHa ry UD 1 e ~ ' t he rebypass ing d o r saUy' to , th e u pper rtasa~, sp~ne 'an d reaching th e' oorrespond j i l l 9 's e p ta l ,p o rtio n ~F:gs..65 ,and 66).Cmnlany~ tn B flap is elevat~edin an an-teroposterior dimcUof1~ g'raduruly' , e ( ) ( ' ~ ,p o s ir n ,g 'U N e 'o t f :actory ' f i Iaments , Ib y dis~section. I~nthe ' course of this 'step, ' the 'b ( 9 j s a J I l a m 8 1 1 1 . a , 'O f 'UU9 bUribinates ( P ig ~ 6 7 )ts inc Ised as far as,'~heupper I F i m O'f ' t he 'n ar ur a l s iP h eno id sinus ostiJum.Tha rnu-c op en'c s~ 'e aJ fla p ts ' then e 'levated

Fin l. &5En - d o s co p i c vi ew o f' th e ' r igh t . n a sa l ca v i ~(4 mm- ' t e l e~cope~ C r O ] . U p pers~artin~point, cd the hor:se~ce-sha,p!9d f nclsion 'f or e le -vafi O~ o'~- h e w i I . I I cope r t i o sbaa l ' f l a p . ,II..M :=maxi jl la r y tu ne~: ! r - s , = s l Jpe r t o r n~ J'~pin o ; S' ~ n a sa J : s e p tu m : tMI = micld IeIL l rbi f l1 late.

,Fi !J~1 6 7En -do s c c ph c c ;la se -iJ Jp v Je w o f t h ' i t ! r t g~ t 1 l 1 ; e I ! s : ~ dca,\i' ity I r 4 , mm - te le s c o p e , O ~ sh oW1ng Uleupper port-on 0Ithe e i evE l ~ t ed l rn uoope rinst-e al W ia pwlth th e e thmo id r o o '~ a J l iI d lthe ' Qi jac -tiClty cfeft Usjng ~t.escissors '1 0 disS8Ct theb a sa Jl ~ a me Ua o f U18 ' 1 ;u ' rn i n a ;le i S ~n a . ven-~rodor~aId i faction (to).LP ' := : ~aminapap,y rac f ! 'a ; AlEA = anteriore ,th m o ld , ar te ry : Fa = a lla m,o r! c le ft ~'-101 = o~factory ' f i l ament5; ,S ~ n .asa l septum

downward 'from the' eJ l hmoid roofO = i : g . l 68 i) , Erndoscop l c dissec~io~(4 'mm~'tele5oope.4~'io~''~he mucosaof 't h 9' etnmoid roof' is . oomp~e'tedwit h a4S~upturned Slrumpe~~Vossf o rceps ; ora 300 upbJnned l B~,akoor ,ey ' -W e H f o r ceps "

21

Fig. HiEndo l o op i c V lf ew o f 'th e r i g : h t l fl 3 :saJ c i3 \1 i i fy1 , , 4 mm='~e le . sco~e . O ) l J ~ . Comp le l t an o'~ Ih en o rse-sh o ; e - 'S i llC L P O O I n C is io n ' for e 'Jev ,a tiO 'n o fth e mu c o p er io s te a l ' ifl l, :p. 1 1 o 'd od


19/41

22 Endosco pic C ' daver D,b~section for leach ing Anterior Skull Bas-a Su rgery- - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - -

Fig. 69,E rndoscQ p ic v iew o f ths right I l I " I i a s a l cav.t ty{ 4 . r rTn. ,~te les 'Ccpe '~O~. Note the to g i ,udinalmucoperiosteal inc~sion in he nasal sept=urn ex ending Haf as the choana ~~rn,S ~ nass~s_:tum; _ 'P = mucope(os_eaJ~: CO =choana ,

Fim72O s , e o ~ o g ~ 0, ' 1 18 ' fet : iBI bones, f l f l d osCDPCview ( mm- lescape. 0). later,aJ v; " '0''!h e le ft p te ry gc pa la ti n e fnssa ~'FClPP).FSP ~ SJph ' nopalatine foramenI F I O I I , = in "e o rr orblta'l l ' Il s s u r e'1M a ;::::maxillary prom i f'l9fl08'PP I : :: ,p~et}fgo.idprocess

F ti ; ~ '7 0lr2nd o sc op i'c v le w o f the"ght n as a l c a vity(4 mm- t e~&s : c . ope " C p ] " T ne sa me mue o p e n i . .o ot, a H~ nc i ion 8' he _eveJo f e la teraJn a s al 'w a l ll r un s 'tl r'om n n e p o s t:e rto r fo nta n ~ella area to the nasopharyrtx1 herebyIpassing over the' ubal prom In_noo ~n= torus 'tubarius: ' 1 M . : . : : dorsa] end ofhe Imc d d~eturb nate; Til = i nf e ri o r tu r il ir "I 1 l ! a t e ; ~lSE = sphel1oathmoid recess;S = nasal septumAt the. septum l e v .e ~ , !a l o ng l tud~l1a'~n-cision ~s carried as 'ar as '~hedorsalrim of the vorns r (FMg. l l9)w Cant inueth e '~ ncis ~on f in th e nasa phaJryn 9 ;ooJImof as 'far as the pasb;~~tio~a l of thenasopharyn)!: where it jo lins a : s . , im l i :~aTICQntrolats'r,aJi l lncision. This i inCirrsion s'x...tsnds he mucope t l o s t ea l l s l ' 8VS ' i o i l '01[ h 8' f'ontan e~learea and i keep ing to hasupratu b i nal l e V t 9 II~ reaches 'I h e ,postenor wans lo f '_he nasopharynx(f'ig'~70lh AU ',~sues dissected in [this,w a y are sh~fted en-block iowar, theoantralll port to olf the 119581 cav i tycenripetam technique) and then,passing Ibeyon 'the choana d I r e c 1ed ito w a rd s . h e na so lPh amynx "lr ,om 'h e re'ttu:~y am e _',racted transerally ~nthis' way '~ i h , Q , sno re contems of the ulPpertwo 'thi~s 0:' the nasal ca .vny that are.Irm~ connected to the r o o f r O v ' _ I " ' e n '-soph arynx are r emov l e d transo' l a J l l y ' inth e s u b p er iD s l, ea J p ' lane ' whi t .e l p~e se r v ~ling t l1e mucosa of the inf,erio r s.eptum,the nasa~ floor, the in f,er ior t, rbinsf'eand '~hB' ustachlan tube (F~~g~' ).

I ~e.~1EndC500(J1C v i ew Df ' h ta ' "g h ' na sa l cavt ty(4m m -t;e 1e sc o - t 0"" F i Ina ) a spe c t of themucope r ro s t , e a J ~~ap 'r e - tock l r i amova lof ' he c o m @ ; rU s of 'h , .hrneld G e l t Nate Ihew he prooedure h s ,arrived at i n 8post-eri o r wal o r the na :sopha r ; ynx" p r .e se r v ingtne' ,ubal p rom Ine nce ' '. the inferiorurblnste __1 ) and the l o w e r ~al'farhenis i s e p lUm (5),

1 6 i D I IEndo ln,8Sail iD i , s s ~ - c tO l j 'D n l1 ~ , l f t h , e; " l e e g l o ~ a l a t j i n l e I'~ s s a6.,1 AnatoT t H 3 . pterygop ' 1 2 1 _ .ne 'fossa is , a py a-Im"d-shaped cavity wi th a supericrf 1I :0 01 . '0 e n I te.rail ly to w a r-d I'h e ' ln-fr,atemporfd ',ossa. wh ich co mm uo i ~ea 'es wi~nthe nasal cavity throu g h ',.hespnenopa 21'tii lns'oramen and ~ 1 ' l h 'I heorbi: ''hrougn the. inferior 0 rb Hw l ~IS=sure~In lits fow'erour-' _~_'81the an lie "-o 'wall is made up by 'he maxillaryp rom inence a_ d "n '[h e s u p e r m o r . fi i ftih by'the o~bitaJ process of' 'the pa~atinebo .e- 'The uppe _ w an corresponcswi th the' crania] plane of the I Q , r e a f i lt e, , i n g IO~the l s p h en . o i snd the a n- ie n o rsphe.noid s~nus wal tThe l m ed lal waUl o f UnB'p t le rygopahMi l1ebssa ( F i I S l . . 12) comlprises 'the vertica~la m e ~a o f' th e paler! n, ' , 011 ,8 i ar t icu la ' =ed ' ~ o l '\Na .r d w i th ' t lhe ,max i Ilary b o n eand backwards, w:th tie pterygcirdp l ' \ocess. ,A t ':h e . 1oP " t hB la me lla 'th atseparates, the p, t ,erygo. alatin ' 1'05S8,fro'm the' co r re sp ond ing nasaJ ca,vitydiv~d8S,~ntD two l ameUa precesseswittl an i te r lo r (o r orb i taO a nd I Po s 'te rio r(0 . sphen oid) locat ions.


20/41

Endoscopic Ca d a v e r I [) jssectDOIiI tor Tea c : h ~ng ' A n ,e r ic r Skul~B~selSurgery--~------------======~==---=~~--

I F i l l. , rsOs~eorogyoi l the f a c i a l bOJ'U3S. IInrtrarn9sa_1Bndos.cc p ic v f~ w 0;' the ~ eft nasa I ca'!Ji~y~4mm-teleseo pe. 45'. C!ose-up view cdth.e , s p h S nCJ)a fat in 9 'fo ra m e n. 'O S = O ss , phe i 'l !J l da l e '; [ pGOP = , o rb i ; ' a l i process ~[palatine bon e: p S l l C H F ! I =s pheno i : d process",~~a,t.ine bene: p'IO = ~D f : ! r optic lig r n t ,be I I ' "p:r6'tllJdin!J ' f rom 'the ,anb!rlo! laDE!ra tedfQrameJ :1 .T he f lrs t proeass i o the m e st vo l u r nln-o us a nd ~il ' a ; pneuma:tized~ i t : f u se swith the m8!X~I l lary bone to form the su-p e ro rne d ~ a l aspect o f 'u~e ma xi I II2I'fy'Mtru ml and ls a~so ,~o~ed to th e eth-moid and 'ttlle sphenold s,~nlJ~es;the~ e co f1 d l p ro ce ss is ,smailler a nd thi rular:,a n d 'fo rm s 'th e p te ry go pa l8 !~ :i ne c ana lt o g e t he r ' wHh the p t e r ygo id cana l , lh e's p h e no p iJ la t1 n e a rte ry ' a nd th 8 ' I P o s te r i =or nasal nerves; .rave I '1 1 rough thespnenopa la r t t i ne ' f c n , a r r n l e ' r l in tile cortes-P C )~d~g Iis a l cav ~ ty ( F l i g:s~ 13 ,andT _ } .Th e m a x i'na ry a r ljs ry , w h ic h t i r ,ave~si J lJong t ff1e a J f : l t sw ie r m arg in o f 'th e iateralpte ryQo ' jd muscle in '~ne in f ' ra tempara l(o ss a, (F ig l. . 7 58 ) re ac h es the p t e r y -gopa~ ] t t i ne ' fOiSS2J thm ~Q ~ the pterygo-m wdHa ry ,1 SSUR~t Thls anery f oUo ,ws a ,~ l s t ed an d 'v a ria b ~ e pa t n but h i , a J -w a y , s , in tlh e i B n ' t t e ' r i o r p a s i'~ io n tO I t J t . l efiSr\f'BS ins id e 'th e ' f l ossa . Th e, m axm a ; r yerte ry in~ba ,ny fa l i I o r w . s a v e r tu c a l c o u rs e ,i h en turn s m e dh~I ly N o r Q ! 5 ' s ir m g the ' f o ssa ,he d.wntal l iy . and 'f a nT IS , Uile, ma jo r tsr-minaJ branch ()f ~he sp hen o p ,2 1 la ,t J n e 'ar te ry (F ig " 7 ,5 !b ) a nd tJ ~e d es c@ n dingpa ' ia r ~ i ne a r te r ie s ~Figl~' 6 ) , .

FJ'DI .,74E~-dcscop[c dissec'rian O i' the ~eftInasalcav l i ' ly ( 4 , mm-'Ietescopei C O . ) . N10te tne'5p henopaJat Ir;;9' ' f o ramer l l " M ' l i H h ,~~s,rom i~ne f lees - ,of ' t lhe sp~ ~flopar,~tine .,~ry (AS')and 'the pos tQn i o r nasal n e- rv e (N' NP ).I e ~ choana; liM = middle turbi !'iFa~9:8 1 M '= max~ ~a ry 's r,i~S,

F ' " g . , 16,Endos-cnpic aspect of the r r g h t nasal cavm.,{4- mm '~elescope; a~), 'T h e im a g e : s l i O w sthe course ,o f ~!he in t iemal m8 ! l i i : l ~ L a ry a r te r y(A . II)wj'lh its term ~nW branche-soICD = chean a; ,AS p i = spn eno paJ 'a t ineartefjf; AJP[) ' = desGend if'I 9 paleJt]ne artery:INPI0 = d 6soell ding lP~aUne InSNB.

~ig ,. 15a,and b1 5& IIE nd os co p. ic a s ~t o f ' I i i a l e: ft n a sa lca\ l ' i~ 'Y (4 f i f ' lm-te tesoope '~ ( ] F ) demO l 1 l - 'stmtin; 'theOOU'r 'Se o f me intemalmaJI: iHary a'fitety in ' the ~n1 ra tempo raJ,a nd s p hem lo p ala tio e c ;a vi1 y a r f t e r re -moval o f '~lhe, pos t e nor maxillaJl ,strliUSwa . 1 ' ! ;and sVr i lOua t i on 1 0 ' 1 th e ir!itracavl~ta ry fatAM~ ': iiiitannalmaxiUary ar te ry . hon-:zon-ta~section , abQ,ve tt l i9 pterygoidmuse Ie ( M I P ' ) ; ' ,MPS = = . superior -pos~e;-nor aJvoo~ar , a r 1e r y~ : _J tO .= i f ' ! I Taom i l a lneIVa; G ,5P ... s ph el'1 op aja tine na rv eDenter: ,APD' = ' d e s c e m d f l 1 i i Q pm a 11 eaitery: ,ASP ;;;:sphem"J~la1jns artery;Ail0 ~,lnfraorb r t B i l Bn)ery

1:50 EndoscoFlic a5~~ of: '~hele ' r I-asaicavl ty ( 4 mm - fe l e sc o p - ej 0, demon-S'tfa t~ng tJhe c ou r s e ' ~ J f I h e sp i1erao-p a la ina a rte ry in the p t e .r :y g omo i l la r y' f ! ! S S I ! . U ' i ea f t e r r em o v a l o f th e ' p o s t e r io rwa]1 o '~ ttne maxi i r :a ry sinus a l i i C ' e~cua:-UOI l1 I J f fatty content.C : eh Dana ; 5, :::;:nasal ~ep'tum:filS = seph ; l l tn~aFle h (nasopa la r t in e liartery) o f !th e s : phe fu :~p . a ' a~une a r it en) ';R 1 ' = ~urrbl:n~Jb r sneh (posterior 1i I~~a rte ry -) o f th e s p he no p a1 a rtin e artery;ASP ' . :: .. .p l l e n o p a la t in !8 art,sty;A I__I- = iliftema~I m a x m a r y artery:, A P I D I : ;: :'d e se en ding p a a ,t jn e ' a r ts :r y ;N 1 :0 1 :: "rdmu]:uJtaI news:TM ;i;ii' m i d d 'e tu rb f na l te


21/41

Endoseopl c Cadaver' Di , ssec t i on for Te a c h i ' n lQ I Antle no r Sku ~ tlB as ,e s . 1 J r ge r y- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ - - ~ - - - - - - - - ~ - - - - ~ - - - - - - -

Fl ,g . . '1 JEn d o s o o p le a s p e c t o f t J l i e , ri;h 1 n as m cavity'( , 4 , mm ..' te lsscope I0 ' .N 0:-:',f l F ' r n ; ..J....II; j' ~ -A,.ilil 'n*e ~_ = = = In.I, gC~Ur'",al n~ntl'; HlYI_ = , I '~ Ii"nB~maxillary artery~AIIO = inhorbla1 ,~H1e~:~-- " '.APDI := d e sc -e nd ing p~Jat~1 1 1 : 9 ' artery:AAPS, = pos t e ' JOs U I p e r h lr a l\ ll ,e o ia f arte ry.

'Fig., ' 7 , B ,I En d o so o p i c , aspec t o f th e n g t 1 ~ na sa l CC l I J i l i i t y( ,4 rum-telescope, D~.I N I I C I = = lnfr.acrb:a~'lr1Ief\ ! 'e: A A P , S , = paste ro -superior alveolar artery : A I O I = r r1 ' r~ac rb ';a~'C!L -

Ttie maxil~afjf nervel ~he,second rammca ' t ion IO'~~he'~nigemin-a l neW J8 ,1 r e a c h as the pterygo pala~ine fossm thm ug h th e ~o r a -men ro tu nd u m a nd eme rg e s th rn ug h 'th e ~ r feM to f o r bi ita J '~ is=sure, Running 1 0 1 1 am -S-shl lped course , ~treaches the i n r f r a =o r b u ~m channel. Reaching the Ipt 'srr)"Qjopal,aine 'tossa it g iv les'off four col lateral branch a s: th e midd Ie men] . , gea~",th e post-e rio r a lv eo la r; 'th e :zigomat'ic a nd '~hesphenopalattine ne rve s ,The ' rl e ~ a , o f t~hepte ryg ;o i d canal ( , O : f V i di liifl ne.'Ne) is,made 'Upof p reg l ang l i o n i c p.arasvmpathetic fib e rs t ha~ , o r ig f l1 a t \8 ' ' f ' ro . r in lth e s u p er le r s a l ~ v a tory nu c ~ e u 1 (o f : eN V IO ~ deocrib~dbyV ag lta, Itoc~t",;~d t h e p a n s V 9 ro '~ ii o ,f the b ra in ste m ~ T he s e'f i b e rn re a ch '~ he I Q enijculslte g a n g il ro n ~hrnug h t h e ' ~,ac iaJneNeand joj n th e 9 r i l~ate;r 'supe r l i c ia l pe~rosaJ nerve, Th is nerve in~'c lue a s po s t-g a ng ! io ni c o r 1 lh o o 'Y 1mp3 . ~ h 9t~ cf b ars a rls ]119 wo rn ''the uPI~er c . e r v u ' e a l glang' l l ion and a somatit:, sens i~ iv le ' bund~eo f' ne rv~$ o rig n a t i n g , ' f ru r fl th e Ig s nh :u l a te g am 9 11o n.At '~ 11' anter ior f o r amen i ' l i J o e r u m i befbre enterrh191 the p te ry - ,g o ld can aI 'I th e g r e a t' e r s u p e r fi c' ia J petros1~n~ r v ; joins 'tth9deep l P e ; L r o s , a 1 1 n e J ' J .G ' to f o rm '~h!' V i d ian nerve, < F i g l ~ '1 '9 1 ) ~

On e n_ er in g 'th e p t e r y gom i a xma r y fis-sure, f~~' sP henopalatlne arte ry 9~vesoff: M,o co~ater,als i t n e po shB !r osup eM i o ra]veo'~ar branch I ~ F 1 i ' g l ; ; '11) that hass rn a JI d ~mens&0f15~ a,nd ttl8 ,i nfr,aorbi , ta lbra~netl, w hich tra ve lis with ' t h e , Ii n' frao r",bwma lne rve in 'f h e fo ram en o 'fr '~h . es amename ( F l h I J I ; ; 1 , 1 ) .Because the sphenopalatine ,anef)f isloca'~ed !superr ior and 'men ia l tOI the' f ossa O 'f ' ~ he same nam~' i~ may bem as ke d ,a t tim es b ,y th e o rb ita l apo =p l 1 y s is of '~h,epa lmH ne, On reach~ng thenasa~ cav i t y posterlo rly to. ttle re ar erndof I h 9' m~ e l l l e tumin ate, the sphen 0-'palatinm anery gives off two, branches';one mo o i aI cal ~ed the ,n ,asapala,t rne, f!u1ery travels to ' the septum j and theo\her' laler;al, named \he posteriornasa;~a r te ry ' , reaches the dorsaJ end o l f ;tlne tu I '1Dinates. The Ial,e raj waJ~is made 'up o rf th,e pite ryg,omax~llary ~iS'5Ue thatconnects the ' ~ n f r a ' - b3 'mpo ra l and ',hepte :rygop,a~at in e fo s s ae .

IFi ig~11S ch ema itl c: d e pl eti on 01 th e ne rv e c , f ' tl l tnepterygOid c-anaJ I (or Vid ia . ! i lI l i I e'NiiEi', .R ' e d :: c . n 1 1 1 r ii !r js , ~m pa ,t ha ti c n 1 L tClei an d 'f ! bers; I b~ue : pa.rasym~p a H 'n e 1 10 f ib e ! rS ; N I F ' P ' = d ~p pe t r osa l in eNS; N GiPS = 'greater SUm~e 'Icial pet fo .Sla l l r .h~rve , ; INV = V i di an n er ve /; asp =:sphe nDpa~atinBgangl ionl : NY :;::Vag i ta gangl io :n; ,eSG = eervlcal s ' lJ l pe r ic r gang l i o lf il


22/41

E n do s co p 'c C 'a d av e r D]ssection 'k lr T e .a c h n g Anterior S.kull l Ba s e SUrg lSry

Rg.IIIIE nd o sc o pic a s pe c t (if the r ig h t n as a Dcavl-ty f - m m -tle1escope r O ~ .IN1 0 1 = [ m h o c : rb i ta~ n , B I I ' V e : AflD = descend-i 9 a r y n ge a l a rte ry : ' SP I = s,phenopala-',-11 a r t e r y : AV '= a r te ' ry Df the nerve of t he 'p - go i d ca rLa l I : AMI. := intern I max i l a J r Yl11'el); GSP = sphene p Jati e ' g ang l on;- ,N PA = nase paJs t i ne lirtery~

The' sph e n o p a J - t ~neor , eckel 's gan-g 'l ion 'Fig~,BO } is a d istri b ut len cents'for o r th O / iP a r8 s y;m pathetIc bundrs,sar r iv in 91 t heou g h ~ he V lId i an ne r ve a n dh ro g h se ns l i'8 s om a le 'f ib e rs , or ig in -at in.1 at 'he maxil~ary n e rv e , O v e r ly in gthe opening 0 the pterygoidcanel, i i l ttakes all an Ob l on . g lor lent icul a rs f h ape , grey-~' dish co l o r and isabou ,2 mm in diameter .. It receives,, 0 a ersn branches, the Vidianrll!Ne and ~hesp h , no p a l B I tu n e nerve,and g l f r v e s rise ' tO I five efferent branchesrespecbvely: o r b l r m a l . , posterior stJp'8riorn a se l. n a so p a ta tln s p e ry g o ,a la tln ea nd d e so e ndin9 p a la 'j ne nerves,~ 2 - ' A ' ~ D ' I I -Ai,:'UI~ r '.naoml '," ; . , , ~sse~U lonAcce s s to U1B' p , te rygopa la ' i f lLB fossa isaccomplished by complete r e s e c .r onof ttls' fOnl~a!1e l le .a~ Dissec t i on b,ogl ins

o va h partie uncinsctom y to exposethe nmural os 'i um o f" ', ' e maxi I l larys inus . Th e o s:U Ulm [8 ttlen , en la rg 00dorsa Iy , p r o ceed i ng with removal ofthe ..ontaneHe area. This event lJaJ lyprovides, temple e lexposure' ot thepos t e r l o r wall of th e ma x I l lary s i n u s ,~ich ~sth e ' ~ i lr s' anatomic Ia n mark .D,issecUng ' tne periosteum 0 the

25

IFig.81E nd o sc -o p ic a s ec t o f th e r ig ht na sa l , caV i ty(4 mm-teleseope, l oe ) demDns~lng .;h eus e o f' a blunt h oc 0 to re mo ve ~he,pOS{rsriorwa II of t' e maxi ' I I 'ary :s~ns .p . P,! M = - p os te rlo r wai l i . max iUary ' s inus ;A P [D = descend l ng ,p ela : ina artery;AS-' ~ sphenopala'~ne mery;AlFD' = descend ing Ipha J rYng ,ea Ja r t e ry ;ANP ' = posterio r nasal artery.

l~ e 'S id u a lf ,o n ta n e lle a r e a ~n J e f c r ly ,8 - dV9 ntral ~ y to h 8' I'>e~rof th e m id d Ietu rbinate 'B 1 1 1 a b l , s s ~dent i f i , ca tuon o f "h es e co nd la nd m ar , j '~ w h lle h s the turb.inaJbranch of the s p h en o p a l,a t~ n e,a r te ry . ~n~he next stag e, tlhe pes enor walll ofthe max'Uary sinus l i r s re m o iV e d w ith asharp spoon ~shaped c urette or aCdell' [punch rst 0 - -ittl straigh,., andthen wirth angl d jaws.The' bony re s ec tio n m a r . g ' f n , s a r e :rne d ia l ~y , the pe 'endicul~ar piate ' 0:-~ h e p a la ittjn e b o n e a n d ~ Ia t 1 e r , a U y , theang l l'8' betw,oon the' posterior and j ra~ ,e r -a l i i w 'a fls o f th e mm


23/41

Endo s c o p~ , c Cadaver I lD i s s e c t~ on f o r -Te a ch i ng l A nte r io r S ku ll Ba$9 Su~ery- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

'E"' ,o;ij i,rlg"wl'Endo s c C b p f c aspect of ' the rig h t, nasm cavi f'ty (4 ,mm-teleseope, O!! i ) . I incis ion o f' f he .n 1 1 d e l te th i rd o ff tne ~l i f : tl r lo r , t ~mbinale ' con -tinuing ttl l E I ' 1 ncision of ~ 9 maxi nary Ii i I 1 ! i 1 'wh ile r ,a la rm in g in tegr i ty ' o 't t lW t e head o f theinfe ric r ' ~L IDib ina '@.'JI :;;::n~er TDrtu r b i na r~e :S = iiiasa l sept l lJml .

F J i g . . , E U i ,E 'nooocop l c , aspect o f Utle rn ,Q~'l na s a l C3'iJ ity(4 mm-telescope, D~).A c la m o nd = 'U pp o ob I . J I f i ' i J ' " is IL lsed , to re m o ve tih e lbony noor O ' f '' ~ lhe'med ia l wa l l 0" ' ~~e m ax i l l an j Sin u s ,, '.,= nasalJ~oor: 'J = inferic r tu r~it~at,e':p "S M =m ed ia l w a Jl o r th e' m 8 X l l ma r y s inus .

F i i g~ 84 ,E ln -d l oscop l c : 8SJpOCt l o ' f [b e right f]a sa l c a "~ t y '(04mm-te lescope . O~}.Th e , lnelsion ls m ad edomally 'to ' U h e lhead of' the i n f e t r : U o r' ~ ! I J rb i r r lateT - : ;; ;; :n'fe~or tL J r b i n a ',~ ;o S = nasal sepnnn :' l :J I .= h e a d o f in ' 'e r io f ' hjrbl'nate~

PMSM

I~~ . ItIIil:'IFI~I., ~EndooGop i c : aspect o f the' r i gh~ nasal ,cavl rty(4 mm-'~;eOOCUpei I O I J ) . . A le ng th y mucosali'ncisk)n is ma d F a I~I~neloor of the i i l Ifefl iorm e s h w l s : tih e ' muccperfosteal 'fllijp . s ' e J e ' l l a t =ed a t: the ie . v e l of 'lhe,m uj~ Im r y s l nUlS.,MI ,= ~ I f i i f , e r i i , a rmeatus; T~ ~ ~n, fe r ' i c rtu! r Ib inate; f i lM S_~:= m edia~ Imun Uary s inus'Wan: IP N = na s a l ~ oc r

17 : ' O " ' ~ ' - nd ' - J - o ' : : : ' l n~~e : - [ 'D l l l I s - e e = , c ~ - - I! ! ! "O " : - - I!!II. !!IIIl," __ _ _ I I ~I __ ,"' ~I - ~ .. -j ,", [.1[ - _ l l e d , ' - _ _ J ', axlllecto yThis s t a g e of d i s ' S } B c 1 J ~ o n first invo~vestde:ntif i 'c,atiol l c ,f 'th e ~al ra J na sa l w'a~I I "l h en l' '~ 1 1 I 'a lte r' s tru ctu re o r, b e tte r ; 'jh eImedi iarn wan ' of ttle max i l I , a r y sinus ls re -sected by en b~oc-techf1iqlJe~'0 com-p~,e'~e'em ava~ o ,f the late:ra~ nas a J w , a J ~ ~ ,ttle ! prneed IJre ma,y b el corn o i n 00 w~tlhJU9 os n tr i pe ' ta l tech n iquo. There ar~etil re e rno du f ica ! t ons of U, e proced u re,each p r 'O v ~ d i n Q I a , b e t te r con' ro l o f t t U 3 'd lSS! l!CI ] o n I I ei lt h e r v ~a the Ia te ra l w a ~ I o lfthe ma x i II ~a ry s [n us , ( ty p e I II I} lo r ~u s a n te =IiDr wall (ty p .e ~~n . ,Typ'. IIIdissectiion lnvolves removal ofth e rne d im ~walll of 'th e max n lary s~nus,wtI n ,e pfeservi'ng 'th e 1nteg i r i ty o f thea n il er i o r ' t l h ir d of th e interlo r tu r lb inateand '~he nasa lacrtim3 1 duct Th is , typ e 'of d isssct'ion Iprov ides goodl conr t ro l o lft h ,s ' p o s t e rt o r and UP ip er w a lls , ~ 1c om -p iate' in the anterior port iO I 1 ) o f tt l e 'ma J ~ d lla r y a l i n u s , .Ai nlUCOSa ll in c is ion ' is mad e und e r e n-dosecplc ~i~si.Dn(4 mm=t,e! e sco ; pe l ~ O~)u ~ dn gl a round knuf'e with a ,4 .5c angh id'J p at the 1 1 0 or 1 0 , 'tilne nf'erio r meatus.Th~ exact s~:~ef' 'the inctslon corre-s p en d s with "~hepmb l J d i nQ I pos'teni ow

m a rg [n o f ' th 1 3 ' IHasns r v a lv e ~ lo e a tedabout: " ..3 em l dorna] Iy ' to t he h~ad ofthe turbinat.e',. The, mucosal incisIon isca r r i ed ' tO I th e Ia t,e ra l 'w a! I i posteriorly'to ,t h,~ Ha sn e r v a lV ie a n d t h E ! enoo-mea ta l 'fa ce c ,f th e i rM f , e r io r ~unb~l1atle.At,the I,o-wet marg in o,f the inferlort urbinate, ttle knrrle is rev,ersed andmoved upward aleng its mlsd ia i Iin a toreach (Crilrl ia~y ) 'the anter io r m'atg l i n of'the unci na te ' precess o r, mo rs ante ri_,o r i Y I ' the pretrus to n of tt l e nsso lacri m a ]dud (max i'l~a.ryI f ne ) (f~gl~83 1 ). A, SIJ b p e n =oste,a~ 'f t ap ~5c ~eBlt ;ed above t he' I~nf 'eri_.o r tu r bi na t e a nd a n u nclnectomy ~8pe , r f o rm e d , th us , e na bl ing t in e n aJ tl l~ a ~1m Q x '! ! la ry s ~nusl ostiu m land th8' eth-mo id l in fu nd i b u Ium to be iden~~fied.Th 8' un- f e ri o r tu rbJn ete is dissected a~,the slte e,f the previous ~ymade lrtei-ston us ing l tuwbinate, mrlceps with CCI1=v ex, 'b lladee CUNed into ' the nasa l ca:vi-' tv (F iQI~84 )" A t 'the ~I,oorow ~ h e i r r f ; lsr iormeatus, ~Pl i 'Q, . ,S 5 } i 't~emucosa I it) c is~oni Ic


24/41

IRQ.lelI En do s co p J c a s p en : t, o f 'th e ngh~.nasai cav i ty(4 ,mm-tel~cope'l ( l [ ] ) . T he in -tr an as a l d ri~ 1 Isa p prle d to the media~wa J l of the maxi~l~rysinus,P SMI=:m a d a m waH~m~ i~ la ry sinus';P i N l = nasa l noo~ SM :::i: marx iUsry sinus

,and 81), 'VentraJ l ly to '~ he perpendi C L a 1m 'p l a1 :e~o f til81 pa la ti 'n . e be n ei ,he de-s c end ln g pa ~a:~ie branch o f the !s p h e no pa la ti n e a rte rY ' c a n b e i denf i i -' f i i e d 8J n d d issect,ed.A'fter this manewer! the ImedtaJ wall ()ifthe maJdl l lary s~nus is m l e d i i , i a U Z l o o( F i 5 I1 ~ )~ incl L l d ~ 1 1g the' fonta nelle area,fo l lo lwedl by dissectlon of' t~mu cope-rio ste u rn o f '~ he Imax j~amy . 's in u s , O orn-monIy~ elevation o 'f ihe rnucope-riOS,bN~!1 f l ap ls inlt ia ted at tn 8' ~a i t e r a ~ 1w an; th e ro o,f' a lnd l 'R oa r of: the, ma)(~llarys~nu!l j "D~ s se c t ~ on lo f ' the pcsterlor p o r-tion o f Ulte ! Immdl~ary s'~nU5,norma~lydoes , r io t po se aniY problems (Figs ..891a n a 9()1 ' h ow e v e r ! 1 " [8 ne tt ' fe a s ib ~ ' e "01extend ane~lorly into '_tie cavity it5'e~'.O nc e th is :stsp of diis!j8CticuTI ls corn-p~ ,e t ~ ' , ~he max i'Ua r y n lu o o p e ri o s te a lf lap is me d ia J~z 'oo r I F f g .. I S ) , 1 , ) in 'th at ~tistranS'~erredinto the nasal cavity to=ge tne r w tr th 'th e p re v iQ lJ s ~ y medi i ,a l i ,mdmedial vIal IIo lf th e max~ Ilary cavity~

figl~BeI E n dO~Hc : o p ic a sp e c t O w the rig ht naS'alfca~i-'t y (4 . rnrn-telescc PS'l' aO)~NO~lEI'the stirglcaJins:trument used '~Ome d iaU ze th e p re v ir ou srI ' l l dissect,ed pmiolf'l of the maxillary sinusw . a l IL .PM:! : ~ m ed ia J w all o f tlll1ema)tjnary sinus8 _ _ = maxillary sinusTI = infarfor turbinate

IPi'g.9Ill EndoseODJc a sp ec t lo f 'the ~g'ht nassl ca:vt~(4 mm-telesce pe, 45G} mILMp iS -- ~ m tJ COpfjriostea~'flap! maxmarysinus'; p p rS _ :_ - : : : :posterior Wal l . mu:i' liary -$1ri ! U r 5 ' : , PLS.: . = l iB i~efaJwa~I~maxillary sinus;P SS,M I ;;:: ; up e no r w a JI, m axJ I~a r y's~'1 us:N~o i n ' f ' raorb i 1 a J neNe '

" ~ I ~9En dos1 : o p i c ,Upec t IO f . i t ihe 'nght' nasa l cavity(,4-mm telesco pe, [ 1 1 . Elevation 'Q f 8 mUCQ-periosteai Hap l ' p ro ved to be ~he'i d e . m a ,p -p re a ch f.a r th e p es ~ en lor w aJ I r howe\l'er~ ttl isoptionl is,~mi'led ' 1.0 1 the p o st,e rio f U urd of' th~s I L : ! p er le r wal ~Cln~y ja n d may also be!Bp~:died1 0 Ute la / taraJ wall.PPS . = posten , ! ) r w,aU; max i l l a ry s~rII UlSPSSM '= superior' waJ~.maud 11ar:vs inus 'pLSMI ~ j a te ra .~ I f i J aU l1 m a J ( , i U a r y s i ~ !U 5 1

PSSM

Fi,g~91Enckui i i co ,p i c aspect of th,9 righ t' na sa ! c av i-'t v ( 4 - 1 m m '~elesDope~O~).'Bevatton of ttl8'mucoperiosteal i lap of' : h e ma ; l( il la r y sinusIUf1d m lHi ia l i !z i, ti o n of the med~a~m~~ Isrysinus wan , tl og e ' th e r wrr~h the inferiorturbinate',P l l b . S M = Ia 'te nd w all ~ Imax i IJa ry s i nI usPSGNI = su.pe r i o r W, !3 ] ljmaJ ( lj l! a ry s t nu sIWMPSM =:mueo per~~steaJflap. maxi I~e l l . r ysinus; PIM S .' :=.SU I~ e r lO f wall~maxi l la rys~nus~ T i l l = in -e . r ior turb l lf ll ah, ,! '


25/41

28 E nd o s co pic C ad av e r Disssctien for'leachingl Anterior SJkuH B,ase S U f 1 g l e r y '- - - - - - - - ~ ~ - - - - - - - - -

'fi!l~e i'E ruJo&cop i c a s p e c t o f ~hef i gh1 nasal cavi ' ty( ' , m m -te le sc e p e ~ O IJ ).R'S ,~splrtenoethmo~d lrecess~'tT = orustubfJrius; '11= In' '1 9 lor turb'jnate; S = I F T J a s a l ls8 ,p rum l : _' = muca' i i r i io5 ' e -a l "nc is i o

iig~15Er idoscop i , c aspec~' of j e righ' l ~ lasaJca,~itV( ' , r nm - te l e s e c p e , 1 0 0 ) . I ID l& : s e c.o n o f th eh sad of the in' ,.or ' 'U rb in cte.S ::;;:nasal septum; ~ = In fe r ' 0' t rbi nate r' ::::::iddte urb:nate;" II~ ~~'rerlDr meatus.

F i g . ' 3 1IEndascop ic aspect of: the ri .Ih ' nam C vi-ty ( rnm-tetescope, 0)+tTl - head 0', ~nfer'iQ"turb nate~P~..SM ~ Imedic IIwa~l~ma:xi~lmy SinUS:S = nasa l septum; Tl = in ' ,er i iar unbinate

IE h -:v a 'io n o f the mucope r t o s eal dis~s ec tro n is c om p le te d ( F O g l . '9,2) , r n d dis-sec t i on i s , e x :Ie nd e d a s fa r a s th e ' bonydorsal margl in o lf ' Ihe Imax: i l i lectom'y in-c l u d ing th e anterl o r [p ort jon 01 _he p e r-p e nd ,ic u' a r plat ,e ' o f _ h e , lP a J a Un e b e ne ,Once these steps ate a c com ,p l i s h r e dthe dlissec' 'ed tissue il s ramo ,e d viath e ' n as a l or' ra ns ora l p a th w ay flgl .. 93 ,and 94). At the end of his s , , ' e p l ! thelateral nasal wall is Icompletely ex-p o s e d w ~thth e faU o w ing l stru c tu r esspa~: anterior hir rd D' the' inertorturbinate I nasolaerfmal duct. ethrn oidb t iU a and m id die tu rb in a ,h , ~ '. T h e e n tir emaxma r y s nu s 'C 3 ,v 'ilty "8 Edso r e a d ~ ~ y' . o b iVIS' a,1 Y P e ~ll,dissec -)1"1~nvo ves removal ofhe rfH~dlia~walll 0' the , 'axmary sTnus m' l a ss ; of th e ~nterilar turbinate and d "s -~ fig~' 9 6 ,E nd oscop ic a sp ct o f ' t tl ,e ' ngh na .saJ cavity,(4mm "te~escQpel0'. IDlssechon and ex-pnsure lof the na.~olacnma] ductDNl l = nasolaonima duct ;PO = rpe rbo rb it;, s r , =maxiUa't)' s~nus;< S ~ = m e d ia J walt m a : < m ry SilFl L IS .Fig , . 91 ' J i I ; 'lEn osoopic aspec of th e r igh t naSoaJcav ity(4 m m -te le sc e p e, D Q).D "L = naso lac r tmaJ ductSl,= I l ac -r ima~ 5 C:S 1 ' ~ ~ m'axi~a ry sinus:PO = ce -o~b,:~

FiQ~ 9 IEn~oscop -e aspect Q f ' he l i igtht nasal ca\tity'(' m tn-te le sc c p e, 00 ')demons~m1i i ' iIg '~hecad'a,vrlC t~ssuedissec;ted Ue ~ block".l! ,:,S- - mlllcoparios'mll nap. max1 u~s jnus~ P ,:,SM, ~ u ppe r waJ l . ma_x i l l a ry sin-us: TI = Inferior t u mb in a 'e.section o f the n a s c i a c rir na l duct be-low 'the lacrimal s se , as w ,e~1 asen bloc'=femoval of the, tueo-p er io s te a l 'la p c o .v e 'r i n 9 h 8' Ia te raJ i s u =parlor and most lo f ' h e ~ n f,e .. rjo rmra_xl l l~Ia ry s j I1US w aJ I.This technique provides , g o o d V 1 i s u a Jcontrol 'o f ' t h e IPDste r ilo r 1 ) superior anda ts ra l w ,s Us . and parts o f 'th e' inferiormax i l ~ 1 ry s i n L JI s wa l l .In add;t~on tO I ty 'e ~Iithe type II tech-ruque also i lnc ludes completB', issec-tlon o lf he inferior turbinate and re-m e va o m ~ ts , head C P i lg ~ 95)~eXlpos u lmof th e nasa lacrimal dud a Jong i , e na -s om axm ary line ( F 1 i g ~ . = ~by u se ' of d l a -mond tipped bun: I ~ssec io n lin 'B ria ro '~he ~ac f i ,maJ l l sac ( F ~ g~ !I", arid re-mOr~ al of the anteri or portton of the


26/41

Endoscopic CadaV,BJ i Dissection o r Teaching Anterior Skui I Base Surgery- - - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - ~ ~ ~ = - - -

Fiig~98En seoptc a&~ect a i e r ig h t liiI as a i ca!V'I'( 4 m - eleocape O[l_ j c i io n is c am ed 1'\0 gh, 'ucouand cu ls,

',I = , nasa j V,.libu lo rn a I1 d \i!lbrlssae:IP ILAP'= la te ra l w a ll. p ir if,o rm apertureImedial '.all o f ~he'maxi lary oSn us r n-_mantertor t o ' n8' ou e o f 'the nase-c r imat duct

IJp. e ~II d issectiion i lnvo, lv ies remove Io f ,'h e medial w an o f the maxmary s r-nus , loss 0 th e in e r ic r '~urb n ate . , ilnc i.on c'f he nasolacn mal duct rem O V i 6 do "h e ' ~ a ~ e ra j portio clf 'I ' e p[riarma .u re an d le n bloc; r-reseetlon 0 amucope r i o s teeJ f1 Ila p of the maxtllarys ln us cavity~ The ' ~ I e c ,~ique p I ' \ c v l t d esgoo. v ,~ sua l contro l QI' 81 1 maXJi l ia ryells, In addition to typB' II it IncllJdesIe a'lo of the cutts and muco sa 0'

I - " C l a _ e al m arg in ,o f he piriform a p e ~I J , ( . I ~ ii lSI} and farnoval o f its Iateralbony portion by use of a dl arnone-i pped b u r r t i~g";- ~h In t h i s w a y , d 1 is -sec t i on liS c a rr ie d fu r ine r in he antero-f a ) , i l1 1 c t io n~ . . hi,ch provides much,e " vlsu a J co" tro II of he antenomaxillary s inus w a ll l ( ig~,-0( ), so h i atsub e l r ~ D s t e a J J exposure and e n b~ock-re se ctio n a f th e entire m!ax i II Ia r y ' s lnu Se ev ~ty c an b e' extended , 1-i!lS~1 101 a n d1 m 2 ) .

rillg- '~II I, . ;: ,.~E'ndosoopc asp et o~Uuuight na s I C!ViIty{4'~mme~e:s.cop 45). Remo v a l l OTthe la"-e ra l ' algin of t, e P Jr tf om l apertun~JIU s ing .1 .dia.mond-,tip~eddrill~. 'IP ','p = lateral alll~piri orm aperture

F I " g l o ; 1 D 1 IEndosoop c asper , O l ' f the righ" nasal cavity(4~m'[ntalescope, ~;,0) .IPASM = anterlo aJl.maxmary sinusIPLSI " ~ Ia , e r a I al i t rn axi~' a n) " s in U 5PP,SM = posterior walll~maxillary s inusP ,SS [' ":"':superior wall. maxillary s inusDN'L= nasolacrrmal dueILp l = amine p .. pyraceaPV O ;P ~ velool p~ate pa la t ine 'Done '

-llig, ,01'=.flldnsoopic aspect of th e righ1. rn -s -I o a v i ' ,( mm=telesoo - .1 0 .,5 : I =max iU 1 1 1 ' s in s ; S = na sa J sa p o m''CI ~ in ' e na] cs ro ,I d artery;,S! = S i 1 p h e nDid s~n s ; R : = naoo l lh ruynx

29

l i l g .Ell!dosoD [0 a~peet ofh righ nasal l c a V i '(4 mm- ehlmcope~45C).P : , - ' S - ; ; " nterior waJll~maxUl8ry s inus

1 ' ,Nl l


27/41

Endtosco IP~c , Cadaver ID iss J8ctron fo r ~eBching Anter i lo ,r ,Skul~Base Surgery= = ~ - - - - ~ - - ~ ~ - - ~ -0

These hnm t lsehniq e s and the cen-tripe'ta~ tee hn [que req u ire ttle use ofe j l e soopes with a 4.5d~rmc~iono f v ie w

in C ( 'u 1 J IU n c . t m o n l th s o p hi sth :: :a .t)Q di T n _strume ntati on" !n fact" the use o fcurved shei!~h-mnstrum,enlts of onl lyon e ' a n Qu l, atJ ro n 1 (4 511 lo r 90~) canna ,p rov i de a c c s s s to t h e la te ra ~ ,m a rg in sof he Imaxil~ary sinus becaus -e the'CUnJ ,e . d1 sec in is, i ! OO I short. Instru-,ants ,itn an elongated curved sec-ion are dii cuI' or even lrnpossible toins8 rt in 1 he 11a5 a~ 1ca y i l ly 101 Dve r com,e. ass - e lhnca~ challenges" 'nstru-me, s eaJ .n i ng l doub'e Icu' rvQJtures h ea th s h a.v o b ee n develo.J)ed. Doub Jecurvature ensures e a s ' r , e r insertion l into lth8' nasl~c av ity a nd , under endescop-Ie control, provldas access to a~~max-i I Ia ry ,sinus' a l SI inc~uding he anteriorall..

The use' 10 oouble curvature-insfru-ms n 6, in CO j IJn c t ~ cn w~lthteJescopeso f more th a n D@direction o f v e :w al ,lows the 'i lP o~ the instru rnsnt to bekelP' centered In '~hefield 0 view (F ig l .103 ) .I must be' emphask~ed 'that the dis ...sectlon s eps m,enboned , ab o ,v lQ ma ,yo nl be oonduc t l ed leftf!C ivally w tthtelesco pes w a n more 'han a.O~d~rec..tien of IV is,w if ' daub~e eL In la tum- lnst ru-me s are ,S ed to ensure tha~ both-e argel site 8 _ n d distaland 0' ,he in=smument can be kep~ in the t l eTe-s en p e 's field o f v ii s lon.ICa ti~n: I ,a t rogen ic I a s ion of tileSphSE10pa abne ar te r y deso=ndingp 1 a tine " ery p 0 ' ,ati:on o f tiehard pa1 l a te and ,eS1'On a f th e na so -lacr ima l duct.

8.0 E J ld lo ln ~ '_ I I IDll lsse. ' ion: _'eco npresslonof he Or. i . and lie Op_icI ,: : 1 . ' 1 ,'InatolmyThe lateral wall of the' e hmoJd sinus 'i sf o r m e by the lamiMla papyraoea.w ih ~ch is extrern ely th in at its pos e f i n o : rthird so ' h ',t. a; fmes" I ~ is posslible tOISeQ' t lhe pe '"0 bnt ' t t l l r 'Ougn it. The peste-rler ethmoid artery or~ginartes 'from theoph

endoscopic cadever dissection

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