The work horse of skull base surgery: orbitozygomatic approach. Technique, modifications, and applications

Object The aim of this study was to describe the microsurgical anatomy of the orbitozygomatic craniotomy and its modifications, and detail the stepwise dissection of the temporalis fascia and muscle and explain the craniotomy techniques involved in these approaches. Methods Nine cadaveric embalmed heads injected with colored silicone were used to demonstrate a stepwise dissection of the 3 variations of orbitozygomatic craniotomy. The craniotomies and dissections were performed with standard surgical instruments, and the microsurgical anatomy was studied under microscopic magnification and illumination. Results The authors performed 2-piece, 1-piece, and supraorbital orbitozygomatic craniotomies in 3 cadaveric heads each. Stepwise dissection of the temporalis fascia and muscle, and osteotomy cuts were shown and the relevant microsurgical anatomy of the anterior and middle fossae was demonstrated in cadaveric heads. Surgical case examples were also presented to demonstrate the application of and indications for the orbitozygomatic approach. Conclusions The orbitozygomatic approach provides access to the anterior and middle cranial fossae as well as the deep sellar and basilar apex regions. Increased bone removal from the skull base obviates the need for vigorous brain retraction and offers an improved multiangled trajectory and shallower operative field. Modifications to the orbitozygomatic approach provide alternatives that can be tailored to particular lesions, enabling the surgeon to use the best technique in each individual case rather than a “one size fits all” approach.

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Modifications to the orbitozygomatic approach

Journal of Neurosurgery ◽

10.3171/jns.2003.99.5.0924 ◽

2003 ◽

Vol 99 (5) ◽

pp. 924-930 ◽

Cited By ~ 62

Author(s):

G. Michael Lemole ◽

Jeffrey S. Henn ◽

Joseph M. Zabramski ◽

Robert F. Spetzler

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Complete Removal ◽

Surgical Indications ◽

Content Type ◽

Orbitozygomatic Approach ◽

Technical Details ◽

Surgical Field ◽

Brain Retraction ◽

Fine Print

✓ The orbitozygomatic craniotomy is one of the workhorse approaches of skull base surgery, providing wide, multidirectional access to the anterior and middle cranial fossae as well as the basilar apex. Complete removal of the orbitozygomatic bar increases the angles of exposure, decreases the working depth of the surgical field, and minimizes brain retraction. In many cases, however, only a portion of the exposure provided by the full orbitozygomatic approach is needed. Tailoring the extent of the bone resection to the specific lesion being treated can help lower approach-related morbidity while maintaining its advantages. The authors describe the technical details of the supraorbital and subtemporal modified orbitozygomatic approaches and discuss the surgical indications for their use. Modifications to the orbitozygomatic approach are an example of the ongoing adaptation of skull base procedures to general neurosurgical practice.

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Endoscopic and Microsurgical Anatomy of the Opticocarotid Recess of the Sphenoid Sinus Applied to Endoscopic Transnasal Skull Base Surgery

Skull Base ◽

10.1055/s-2007-984130 ◽

2007 ◽

Vol 17 (S 1) ◽

Author(s):

J. Kunicki ◽

T. Skadorwa ◽

P. Poppe ◽

W. Bonicki

Keyword(s):

Skull Base ◽

Sphenoid Sinus ◽

Skull Base Surgery ◽

Microsurgical Anatomy

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Expanded endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma

Neurosurgical FOCUS ◽

10.3171/2012.v3.focus11300 ◽

2012 ◽

Vol 32 (Suppl1) ◽

pp. E3 ◽

Cited By ~ 6

Author(s):

James K. Liu ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Tumor Resection ◽

Cranial Base ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Anterior Cranial Base ◽

Ventral Skull Base ◽

Brain Retraction

Anterior skull base (ASB) schwannomas are extremely rare and can often mimic other pathologies involving the ASB such as olfactory groove meningiomas, hemangiopericytomas, esthesioneuroblastomas, and other malignant ASB tumors. The mainstay of treatment for these lesions is gross-total resection. Traditionally, resection for tumors in this location is performed through a bifrontal transbasal approach that can involve some degree of brain retraction or manipulation for tumor exposure. With the recent advances in endoscopic skull base surgery, various ASB tumors can be resected successfully using an expanded endoscopic endonasal transcribriform approach through a “keyhole craniectomy” in the ventral skull base. This approach represents the most direct route to the anterior cranial base without any brain retraction. Tumor involving the paranasal sinuses, medial orbits, and cribriform plate can be readily resected. In this video atlas report, the authors demonstrate their step-by-step techniques for resection of an ASB olfactory schwannoma using a purely endoscopic endonasal transcribriform approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/NLtOGfKWC6U.

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Aerosolization in Endoscopic Sinus Surgery and Risk Mitigation in the COVID-19 Era: A Scoping Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1718768 ◽

2020 ◽

Author(s):

Catherine F. Roy ◽

Emily Kay-Rivest ◽

Lily H.P. Nguyen ◽

Denis Sirhan ◽

Marc A. Tewfik

Keyword(s):

Health Care ◽

Skull Base ◽

Scoping Review ◽

Skull Base Surgery ◽

Care Delivery ◽

Surgical Instruments ◽

Sinus Surgery ◽

Pubmed Database ◽

Scoping Reviews ◽

Expert Recommendations

Abstract Background The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic. Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews. Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders. Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.

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