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Ricardo L. Carrau - One of the best experts on this subject based on the ideXlab platform.
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anatomical variants of post ganglionic fibers within the pterygopalatine fossa implications for endonasal skull base surgery
Skull Base Surgery, 2021Co-Authors: Daniel M Prevedello, Nyall R London, Ricardo L. CarrauAbstract:Objectives The Vidian Nerve provides parasympathetic innervation to the nasal cavity and the lacrimal gland. Previous anatomic studies have primarily focused on preservation or severance of the Vidian Nerve proximal to the pterygopalatine ganglion (PPG). This study aimed to assess its neural fibers within the pterygopalatine fossa after synapsing at the PPG, and to explore potential clinical implications for endoscopic endonasal skull base surgery. Methods An endonasal transpterygoid approach was performed on eight cadaveric specimens (16 sides). The PPG and maxillary Nerve within the pterygopalatine fossa were divided. The Vidian Nerve was traced retrograde into the foramen lacerum, and postganglionic fibers distal to the PPG were dissected following the zygomatic Nerve into the orbit. Potential communicating branches between the ophthalmic Nerve (V1) and the PPG were also explored. Results All sides showed a plexus of neural communications between the PPG and the maxillary Nerve. The zygomatic Nerve exits the maxillary Nerve close to the foramen rotundum, piercing the orbitalis muscle to enter the orbit in all sides. The zygomatic Nerve was identified running beneath the inferior rectus muscle toward a lateral direction. In 7/16 sides (43.75%), a connecting branch between V1 and the pterygopalatine ganglion was observed. Conclusion Neural communications between the PPG and the maxillary Nerve were present in all specimens. A neural branch from V1 to the PPG potentially contributes additional postganglionic parasympathetic function to the lacrimal gland.
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Surgical anatomy and nuances of the expanded transpterygoid approach to the pterygopalatine fossa and upper parapharyngeal space: a stepwise cadaveric dissection.
Acta neurochirurgica, 2020Co-Authors: Giuliano Silveira-bertazzo, Ricardo L. Carrau, Rafael Martinez-perez, Daniel M PrevedelloAbstract:Superb knowledge of anatomy and techniques to remove the natural barriers preventing full access to the most lateral aspect of the skull base determines the ease of using the transpterygoid approach (ETPA) as the main gateway for all the coronal planes during endonasal surgeries. Throughout stepwise image-guided cadaveric dissections, we describe the surgical anatomy and nuances of the ETPA to the pterygopalatine fossa (PPF) and upper parapharyngeal space (UPPS). The ETPA represents a lateral extension of the midline corridor and provides a valuable route to access the PPF/UPPS. Major landmarks for this EEA are the infraorbital canal, sphenopalatine foramen, and Vidian Nerve. It comprises the removal of the palatine bone, posterior wall of the maxillary sinus, and PPF transposition to drill the pterygoid process.
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the anterolateral triangle implications for a transnasal prelacrimal approach to the floor of the middle cranial fossa
American Journal of Rhinology & Allergy, 2020Co-Authors: Daniel M Prevedello, Nyall R London, Ricardo L. CarrauAbstract:BACKGROUND The anterolateral triangle enclosed by the foramen rotundum and foramen ovale constitutes part of the floor of the middle cranial fossa (MCF). OBJECTIVE To assess the feasibility of a transnasal prelacrimal approach for accessing the floor of MCF via an anterolateral triangle corridor and to determine the extent of maximal exposure while safeguarding neurovascular structures. METHODS A transnasal prelacrimal approach was performed in 5 cadaveric specimens (10 sides). Following the identification of foramen rotundum and foramen ovale, the bony ridge between 2 was drilled to expose the MCF. The temporal lobe dura was then elevated laterally, and the distances from foramen ovale to the respective borders of the area of the MCF window were measured using a surgical navigation device. RESULTS The MCF was exposed with a 0° scope in all specimens also exposing significant landmarks including the middle meningeal artery, greater superficial petrosal Nerve, superior petrous sinus, and arcuate eminence. Average distances from foramen ovale to the anterior, posterior, and lateral exposed borders were 22.86 ± 1.87 mm, 27.24 ± 0.94 mm, and 24.23 ± 1.61 mm, respectively. The average area of exposed MCF window was 554.12 ± 60.22 mm2. Preservation of Vidian Nerve, greater palatine Nerve, lateral nasal wall, and nasolacrimal duct was possible in all 10 sides. CONCLUSION It is feasible to access the floor of MCF via an endoscopic transnasal prelacrimal approach with seemingly low risk.
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endoscopic prelacrimal approach to lateral recess of sphenoid sinus feasibility study
International Forum of Allergy & Rhinology, 2020Co-Authors: Daniel M Prevedello, Nyall R London, Lifeng Li, Ricardo L. CarrauAbstract:BACKGROUND: Various pathologies, including cerebrospinal fluid leaks and meningoencephaloceles, may arise in the lateral recess of the sphenoid sinus (LRSS), which may be accessed via an endonasal transpterygoid approach. The objective of this study was to evaluate the feasibility of accessing the LRSS via an endoscopic prelacrimal approach. Furthermore, we hypothesized that this approach may protect the pterygopalatine ganglion and Vidian Nerve. METHODS: Five cadaveric heads (9 sides) with a well-pneumatized LRSS were identified and an endonasal prelacrimal approach was performed. The infraorbital Nerve, at the orbital floor, served as a critical landmark. After identification of the foramen rotundum at the pterygoid base, the vascular compartment of the pterygopalatine fossa and the pterygopalatine ganglion were displaced inferomedially and superomedially, respectively. Drilling of the bone inferomedial to the foramen rotundum allowed entry into the LRSS. RESULTS: The average distances from the prelacrimal window to the pterygoid base and the posterior wall of the LRSS were 6.22 ± 0.39 cm and 7.16 ± 0.50 cm, respectively. The average areas of the bony prelacrimal window and pterygoid base window were 4.33 ± 0.32 cm2 and 0.73 ± 0.10 cm2 , respectively. The LRSS could be accessed using a 0-degree endoscope, and pterygopalatine neurovascular structures, including the pterygopalatine ganglion and Vidian Nerve, could be preserved on all 9 sides. CONCLUSION: Our findings suggest that an endonasal prelacrimal approach provides a reasonable alternative to access the LRSS while preserving the Vidian Nerve and pterygopalatine ganglion.
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Endoscopic prelacrimal approach to lateral recess of sphenoid sinus: feasibility study.
International forum of allergy & rhinology, 2019Co-Authors: Nyall R London, Daniel M Prevedello, Ricardo L. CarrauAbstract:BACKGROUND Various pathologies, including cerebrospinal fluid leaks and meningoencephaloceles, may arise in the lateral recess of the sphenoid sinus (LRSS), which may be accessed via an endonasal transpterygoid approach. The objective of this study was to evaluate the feasibility of accessing the LRSS via an endoscopic prelacrimal approach. Furthermore, we hypothesized that this approach may protect the pterygopalatine ganglion and Vidian Nerve. METHODS Five cadaveric heads (9 sides) with a well-pneumatized LRSS were identified and an endonasal prelacrimal approach was performed. The infraorbital Nerve, at the orbital floor, served as a critical landmark. After identification of the foramen rotundum at the pterygoid base, the vascular compartment of the pterygopalatine fossa and the pterygopalatine ganglion were displaced inferomedially and superomedially, respectively. Drilling of the bone inferomedial to the foramen rotundum allowed entry into the LRSS. RESULTS The average distances from the prelacrimal window to the pterygoid base and the posterior wall of the LRSS were 6.22 ± 0.39 cm and 7.16 ± 0.50 cm, respectively. The average areas of the bony prelacrimal window and pterygoid base window were 4.33 ± 0.32 cm2 and 0.73 ± 0.10 cm2 , respectively. The LRSS could be accessed using a 0-degree endoscope, and pterygopalatine neurovascular structures, including the pterygopalatine ganglion and Vidian Nerve, could be preserved on all 9 sides. CONCLUSION Our findings suggest that an endonasal prelacrimal approach provides a reasonable alternative to access the LRSS while preserving the Vidian Nerve and pterygopalatine ganglion.
Daniel M Prevedello - One of the best experts on this subject based on the ideXlab platform.
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anatomical variants of post ganglionic fibers within the pterygopalatine fossa implications for endonasal skull base surgery
Skull Base Surgery, 2021Co-Authors: Daniel M Prevedello, Nyall R London, Ricardo L. CarrauAbstract:Objectives The Vidian Nerve provides parasympathetic innervation to the nasal cavity and the lacrimal gland. Previous anatomic studies have primarily focused on preservation or severance of the Vidian Nerve proximal to the pterygopalatine ganglion (PPG). This study aimed to assess its neural fibers within the pterygopalatine fossa after synapsing at the PPG, and to explore potential clinical implications for endoscopic endonasal skull base surgery. Methods An endonasal transpterygoid approach was performed on eight cadaveric specimens (16 sides). The PPG and maxillary Nerve within the pterygopalatine fossa were divided. The Vidian Nerve was traced retrograde into the foramen lacerum, and postganglionic fibers distal to the PPG were dissected following the zygomatic Nerve into the orbit. Potential communicating branches between the ophthalmic Nerve (V1) and the PPG were also explored. Results All sides showed a plexus of neural communications between the PPG and the maxillary Nerve. The zygomatic Nerve exits the maxillary Nerve close to the foramen rotundum, piercing the orbitalis muscle to enter the orbit in all sides. The zygomatic Nerve was identified running beneath the inferior rectus muscle toward a lateral direction. In 7/16 sides (43.75%), a connecting branch between V1 and the pterygopalatine ganglion was observed. Conclusion Neural communications between the PPG and the maxillary Nerve were present in all specimens. A neural branch from V1 to the PPG potentially contributes additional postganglionic parasympathetic function to the lacrimal gland.
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Surgical anatomy and nuances of the expanded transpterygoid approach to the pterygopalatine fossa and upper parapharyngeal space: a stepwise cadaveric dissection.
Acta neurochirurgica, 2020Co-Authors: Giuliano Silveira-bertazzo, Ricardo L. Carrau, Rafael Martinez-perez, Daniel M PrevedelloAbstract:Superb knowledge of anatomy and techniques to remove the natural barriers preventing full access to the most lateral aspect of the skull base determines the ease of using the transpterygoid approach (ETPA) as the main gateway for all the coronal planes during endonasal surgeries. Throughout stepwise image-guided cadaveric dissections, we describe the surgical anatomy and nuances of the ETPA to the pterygopalatine fossa (PPF) and upper parapharyngeal space (UPPS). The ETPA represents a lateral extension of the midline corridor and provides a valuable route to access the PPF/UPPS. Major landmarks for this EEA are the infraorbital canal, sphenopalatine foramen, and Vidian Nerve. It comprises the removal of the palatine bone, posterior wall of the maxillary sinus, and PPF transposition to drill the pterygoid process.
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the anterolateral triangle implications for a transnasal prelacrimal approach to the floor of the middle cranial fossa
American Journal of Rhinology & Allergy, 2020Co-Authors: Daniel M Prevedello, Nyall R London, Ricardo L. CarrauAbstract:BACKGROUND The anterolateral triangle enclosed by the foramen rotundum and foramen ovale constitutes part of the floor of the middle cranial fossa (MCF). OBJECTIVE To assess the feasibility of a transnasal prelacrimal approach for accessing the floor of MCF via an anterolateral triangle corridor and to determine the extent of maximal exposure while safeguarding neurovascular structures. METHODS A transnasal prelacrimal approach was performed in 5 cadaveric specimens (10 sides). Following the identification of foramen rotundum and foramen ovale, the bony ridge between 2 was drilled to expose the MCF. The temporal lobe dura was then elevated laterally, and the distances from foramen ovale to the respective borders of the area of the MCF window were measured using a surgical navigation device. RESULTS The MCF was exposed with a 0° scope in all specimens also exposing significant landmarks including the middle meningeal artery, greater superficial petrosal Nerve, superior petrous sinus, and arcuate eminence. Average distances from foramen ovale to the anterior, posterior, and lateral exposed borders were 22.86 ± 1.87 mm, 27.24 ± 0.94 mm, and 24.23 ± 1.61 mm, respectively. The average area of exposed MCF window was 554.12 ± 60.22 mm2. Preservation of Vidian Nerve, greater palatine Nerve, lateral nasal wall, and nasolacrimal duct was possible in all 10 sides. CONCLUSION It is feasible to access the floor of MCF via an endoscopic transnasal prelacrimal approach with seemingly low risk.
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endoscopic prelacrimal approach to lateral recess of sphenoid sinus feasibility study
International Forum of Allergy & Rhinology, 2020Co-Authors: Daniel M Prevedello, Nyall R London, Lifeng Li, Ricardo L. CarrauAbstract:BACKGROUND: Various pathologies, including cerebrospinal fluid leaks and meningoencephaloceles, may arise in the lateral recess of the sphenoid sinus (LRSS), which may be accessed via an endonasal transpterygoid approach. The objective of this study was to evaluate the feasibility of accessing the LRSS via an endoscopic prelacrimal approach. Furthermore, we hypothesized that this approach may protect the pterygopalatine ganglion and Vidian Nerve. METHODS: Five cadaveric heads (9 sides) with a well-pneumatized LRSS were identified and an endonasal prelacrimal approach was performed. The infraorbital Nerve, at the orbital floor, served as a critical landmark. After identification of the foramen rotundum at the pterygoid base, the vascular compartment of the pterygopalatine fossa and the pterygopalatine ganglion were displaced inferomedially and superomedially, respectively. Drilling of the bone inferomedial to the foramen rotundum allowed entry into the LRSS. RESULTS: The average distances from the prelacrimal window to the pterygoid base and the posterior wall of the LRSS were 6.22 ± 0.39 cm and 7.16 ± 0.50 cm, respectively. The average areas of the bony prelacrimal window and pterygoid base window were 4.33 ± 0.32 cm2 and 0.73 ± 0.10 cm2 , respectively. The LRSS could be accessed using a 0-degree endoscope, and pterygopalatine neurovascular structures, including the pterygopalatine ganglion and Vidian Nerve, could be preserved on all 9 sides. CONCLUSION: Our findings suggest that an endonasal prelacrimal approach provides a reasonable alternative to access the LRSS while preserving the Vidian Nerve and pterygopalatine ganglion.
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Endoscopic prelacrimal approach to lateral recess of sphenoid sinus: feasibility study.
International forum of allergy & rhinology, 2019Co-Authors: Nyall R London, Daniel M Prevedello, Ricardo L. CarrauAbstract:BACKGROUND Various pathologies, including cerebrospinal fluid leaks and meningoencephaloceles, may arise in the lateral recess of the sphenoid sinus (LRSS), which may be accessed via an endonasal transpterygoid approach. The objective of this study was to evaluate the feasibility of accessing the LRSS via an endoscopic prelacrimal approach. Furthermore, we hypothesized that this approach may protect the pterygopalatine ganglion and Vidian Nerve. METHODS Five cadaveric heads (9 sides) with a well-pneumatized LRSS were identified and an endonasal prelacrimal approach was performed. The infraorbital Nerve, at the orbital floor, served as a critical landmark. After identification of the foramen rotundum at the pterygoid base, the vascular compartment of the pterygopalatine fossa and the pterygopalatine ganglion were displaced inferomedially and superomedially, respectively. Drilling of the bone inferomedial to the foramen rotundum allowed entry into the LRSS. RESULTS The average distances from the prelacrimal window to the pterygoid base and the posterior wall of the LRSS were 6.22 ± 0.39 cm and 7.16 ± 0.50 cm, respectively. The average areas of the bony prelacrimal window and pterygoid base window were 4.33 ± 0.32 cm2 and 0.73 ± 0.10 cm2 , respectively. The LRSS could be accessed using a 0-degree endoscope, and pterygopalatine neurovascular structures, including the pterygopalatine ganglion and Vidian Nerve, could be preserved on all 9 sides. CONCLUSION Our findings suggest that an endonasal prelacrimal approach provides a reasonable alternative to access the LRSS while preserving the Vidian Nerve and pterygopalatine ganglion.
Carl H Snyderman - One of the best experts on this subject based on the ideXlab platform.
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reduced tearing with stable quality of life after Vidian neurectomy a prospective controlled trial
Laryngoscope, 2021Co-Authors: Eric W Wang, Paul A Gardner, Shannon Fraser, Tonya S Stefko, Juan C Fernandezmiranda, Carl H SnydermanAbstract:OBJECTIVES/HYPOTHESIS Although Vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality-of-life is not well-defined. Endoscopic endonasal transpterygoid approaches (EETA) may require Vidian Nerve sacrifice. STUDY DESIGN A prospective cohort trial. METHODS A prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five-item Dry Eye Questionnaire (DEQ-5) was performed. Preservation of the contralateral Vidian Nerve allowed comparison between the eye subjected to VN and the control eye postoperatively. RESULTS Twenty-one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre- and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ-5 score for dry eye severity between the pre- and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ-5 scores when compared to patients with normal tearing (P < .0056). CONCLUSIONS VN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk. LEVEL OF EVIDENCE 2 Laryngoscope, 131:1487-1491, 2021.
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lateral transorbital versus endonasal transpterygoid approach to the lateral recess of the sphenoid sinus a comparative anatomic study
Operative Neurosurgery, 2019Co-Authors: Joao T Alvesbelo, Eric W Wang, Paul A Gardner, Tonya S Stefko, Juan C Fernandezmiranda, Carl H Snyderman, Joao Mangussigomes, Huy Q Truong, Salomon CohenAbstract:BACKGROUND The treatment of cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus (LRSS) faces difficulties due to the deep location of the osseous defect. When treated with craniotomies, brain retraction is a concern. The endoscopic endonasal transpterygoid approach (EETA) is a direct and less invasive procedure; however, it may require transection of the Vidian Nerve (VN). OBJECTIVE To investigate the feasibility of a lateral transorbital approach (LTOA) as an alternative pathway to the LRSS that avoids VN sacrifice. METHODS Six embalmed heads with well-pneumatized LRSS were preselected by inspecting their computed tomography scans. One LTOA and one EETA were performed on 1 side of each specimen. The approaches were compared regarding working distance and neurovascular structures being sacrificed. The working area of the LTOA was also measured. RESULTS The average working distances were 59.9 (±2.94) mm for the LTOA and 76.4 (±3.99) mm for the EETA (P < .001). The LTOA generated a working area with a diameter of 9 to 14 mm. The EETA demanded the sacrifice of VN and the sphenopalatine artery in all specimens to expose the LRSS. No neurovascular structures were found in the trajectory of the LTOA. CONCLUSION The LTOA to the LRSS is feasible, with minimal risk of injuring neurovascular structures. It offers a shorter pathway when compared to the EETA. Although the LTOA provides no options for vascularized flap reconstruction, it allows immediate access to muscle grafts. The LTOA may serve as an alternative to treating cerebrospinal fluid leaks of the LRSS.
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eustachian tube and internal carotid artery in skull base surgery an anatomical study
Laryngoscope, 2014Co-Authors: Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos D Pinheironeto, Jianfeng Liu, Barry E Hirsch, Eric W WangAbstract:Objectives/Hypothesis The eustachian tube (ET) is an important landmark in skull base surgery, which has a close relationship with the petrous segment of the internal carotid artery (ICA). The goal of the current study was to establish the detailed anatomic relationship of the ET and petrous segment of the ICA. Study Design Anatomical study. Methods Six silicon-injected adult cadaveric heads (12 sides) were dissected using a lateral infratemporal fossa approach (type C) and endoscopic endonasal approach. The ET and ICA were exposed; their detailed relationships were demonstrated. High-quality pictures were obtained. Results In the anterior genu/foramen lacerum segment of the ICA, the Vidian Nerve was an important landmark. The cartilaginous ET was divided into four segments, from anterior to posterior: nasopharyngeal, pterygoid, lacerum, and petrosal segment. The anterior and inferior wall of the carotid canal was consistently between the horizontal ICA and petrous segment of the cartilaginous ET. In the posterior genu of the ICA, the bony part of the ET, and the tendon of the tensor tympani muscle were paramount landmarks. The posterior genu of the ICA was imbedded in the carotid canal. The landmarks of the junction of the cartilaginous ET and bony ET were the sphenoid spine and foramen spinosum. Conclusions The anatomical segmentation of the ET provides the basis for safe and effective transection of the ET in skull base surgery. An understanding of the complex relationships of the ET and petrous segment of the ICA is paramount for surgically dealing with disease located within the region of the ET and petrous segment of the ICA. Level of Evidence NA Laryngoscope, 124:2655–2664, 2014
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transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches
Skull Base Surgery, 2013Co-Authors: Carlos D Pinheironeto, Ricardo L. Carrau, Daniel M Prevedello, Paul A Gardner, Juan C Fernandezmiranda, Carl H SnydermanAbstract:Introduction Complete or partial removal of the pterygoid process provides lateral extension of the endonasal corridor necessary to approach the Meckel cave, infrapetrous skull base, and medial infratemporal fossa. This paper provides the anatomical foundations for the endoscopic endonasal transpterygoid approach with preservation of all neurovascular structures inside the pterygopalatine fossa. Methods Eight endoscopic transpterygoid approaches were performed in fresh cadaveric specimens. In all dissections the Vidian Nerve and the periosteal sac enclosing the pterygopalatine fossa were preserved. Results We reliably transposed the pterygopalatine fossa to approach the Meckel cave, infrapetrous skull base, and medial infratemporal region, preserving the neurovascular structures inside the pterygopalatine fossa in all specimens. Conclusions The transposition of the pterygopalatine fossa neurovascular structures for endoscopic endonasal approaches to the skull base is an alternative technique that is both feasible and desirable. The transposition requires no additional technical skills but requires comprehensive knowledge of its anatomy. The anatomical preservation of the neurovascular structures is potentially beneficial to the quality of life of patients. Clinical studies are necessary to prove the real benefits of this technique.
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endoscopic anatomy of the palatovaginal canal palatosphenoidal canal a landmark for dissection of the Vidian Nerve during endonasal transpterygoid approaches
Laryngoscope, 2012Co-Authors: Carlos D Pinheironeto, Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos M Riveraserrano, Alessandro Paluzzi, Luiz Ubirajara SennesAbstract:Objectives/Hypothesis: Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the Vidian Nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the Vidian Nerve. Show that the traditionally known PV canal is a misnomer and should be renamed. Study Design: Experimental study: anatomical and radiological. Methods: Dissection of eight cadaveric heads was performed to demonstrate the endoscopic anatomy of the PV canal. Computed tomography scan analysis of 20 patients was used to evaluate the length of the PV canal, the angle formed between this canal and the Vidian Nerve, and the distance between the Vidian canal and the PV canal. Study of 10 dry skull bases was performed to verify the structures involved in the formation of the PV canal. Results: Anatomic steps and foundations for dissection of the Vidian Nerve using the PV canal as a landmark were described. The mean length of the PV canal was 7.15 mm. The mean proximal distance between the Vidian and the PV canal was 1.95 mm, and the mean distal distance was 4.14 mm. The mean angle between those canals was 48 degrees. The osteology study showed the vaginal process of the sphenoid bone did not contribute to the formation of the PV canal. Conclusions: Our anatomic investigations, radiologic studies, and surgical experience demonstrate the important anatomic relationship of the PV canal with the Vidian canal and the relevance of the PV canal as a surgical landmark in endoscopic endonasal transpterygoid approaches. Anatomically, PV canal is a misnomer and should be replaced with palatosphenoidal canal.
Juan C Fernandezmiranda - One of the best experts on this subject based on the ideXlab platform.
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reduced tearing with stable quality of life after Vidian neurectomy a prospective controlled trial
Laryngoscope, 2021Co-Authors: Eric W Wang, Paul A Gardner, Shannon Fraser, Tonya S Stefko, Juan C Fernandezmiranda, Carl H SnydermanAbstract:OBJECTIVES/HYPOTHESIS Although Vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality-of-life is not well-defined. Endoscopic endonasal transpterygoid approaches (EETA) may require Vidian Nerve sacrifice. STUDY DESIGN A prospective cohort trial. METHODS A prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five-item Dry Eye Questionnaire (DEQ-5) was performed. Preservation of the contralateral Vidian Nerve allowed comparison between the eye subjected to VN and the control eye postoperatively. RESULTS Twenty-one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre- and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ-5 score for dry eye severity between the pre- and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ-5 scores when compared to patients with normal tearing (P < .0056). CONCLUSIONS VN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk. LEVEL OF EVIDENCE 2 Laryngoscope, 131:1487-1491, 2021.
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lateral transorbital versus endonasal transpterygoid approach to the lateral recess of the sphenoid sinus a comparative anatomic study
Operative Neurosurgery, 2019Co-Authors: Joao T Alvesbelo, Eric W Wang, Paul A Gardner, Tonya S Stefko, Juan C Fernandezmiranda, Carl H Snyderman, Joao Mangussigomes, Huy Q Truong, Salomon CohenAbstract:BACKGROUND The treatment of cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus (LRSS) faces difficulties due to the deep location of the osseous defect. When treated with craniotomies, brain retraction is a concern. The endoscopic endonasal transpterygoid approach (EETA) is a direct and less invasive procedure; however, it may require transection of the Vidian Nerve (VN). OBJECTIVE To investigate the feasibility of a lateral transorbital approach (LTOA) as an alternative pathway to the LRSS that avoids VN sacrifice. METHODS Six embalmed heads with well-pneumatized LRSS were preselected by inspecting their computed tomography scans. One LTOA and one EETA were performed on 1 side of each specimen. The approaches were compared regarding working distance and neurovascular structures being sacrificed. The working area of the LTOA was also measured. RESULTS The average working distances were 59.9 (±2.94) mm for the LTOA and 76.4 (±3.99) mm for the EETA (P < .001). The LTOA generated a working area with a diameter of 9 to 14 mm. The EETA demanded the sacrifice of VN and the sphenopalatine artery in all specimens to expose the LRSS. No neurovascular structures were found in the trajectory of the LTOA. CONCLUSION The LTOA to the LRSS is feasible, with minimal risk of injuring neurovascular structures. It offers a shorter pathway when compared to the EETA. Although the LTOA provides no options for vascularized flap reconstruction, it allows immediate access to muscle grafts. The LTOA may serve as an alternative to treating cerebrospinal fluid leaks of the LRSS.
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eustachian tube and internal carotid artery in skull base surgery an anatomical study
Laryngoscope, 2014Co-Authors: Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos D Pinheironeto, Jianfeng Liu, Barry E Hirsch, Eric W WangAbstract:Objectives/Hypothesis The eustachian tube (ET) is an important landmark in skull base surgery, which has a close relationship with the petrous segment of the internal carotid artery (ICA). The goal of the current study was to establish the detailed anatomic relationship of the ET and petrous segment of the ICA. Study Design Anatomical study. Methods Six silicon-injected adult cadaveric heads (12 sides) were dissected using a lateral infratemporal fossa approach (type C) and endoscopic endonasal approach. The ET and ICA were exposed; their detailed relationships were demonstrated. High-quality pictures were obtained. Results In the anterior genu/foramen lacerum segment of the ICA, the Vidian Nerve was an important landmark. The cartilaginous ET was divided into four segments, from anterior to posterior: nasopharyngeal, pterygoid, lacerum, and petrosal segment. The anterior and inferior wall of the carotid canal was consistently between the horizontal ICA and petrous segment of the cartilaginous ET. In the posterior genu of the ICA, the bony part of the ET, and the tendon of the tensor tympani muscle were paramount landmarks. The posterior genu of the ICA was imbedded in the carotid canal. The landmarks of the junction of the cartilaginous ET and bony ET were the sphenoid spine and foramen spinosum. Conclusions The anatomical segmentation of the ET provides the basis for safe and effective transection of the ET in skull base surgery. An understanding of the complex relationships of the ET and petrous segment of the ICA is paramount for surgically dealing with disease located within the region of the ET and petrous segment of the ICA. Level of Evidence NA Laryngoscope, 124:2655–2664, 2014
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transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches
Skull Base Surgery, 2013Co-Authors: Carlos D Pinheironeto, Ricardo L. Carrau, Daniel M Prevedello, Paul A Gardner, Juan C Fernandezmiranda, Carl H SnydermanAbstract:Introduction Complete or partial removal of the pterygoid process provides lateral extension of the endonasal corridor necessary to approach the Meckel cave, infrapetrous skull base, and medial infratemporal fossa. This paper provides the anatomical foundations for the endoscopic endonasal transpterygoid approach with preservation of all neurovascular structures inside the pterygopalatine fossa. Methods Eight endoscopic transpterygoid approaches were performed in fresh cadaveric specimens. In all dissections the Vidian Nerve and the periosteal sac enclosing the pterygopalatine fossa were preserved. Results We reliably transposed the pterygopalatine fossa to approach the Meckel cave, infrapetrous skull base, and medial infratemporal region, preserving the neurovascular structures inside the pterygopalatine fossa in all specimens. Conclusions The transposition of the pterygopalatine fossa neurovascular structures for endoscopic endonasal approaches to the skull base is an alternative technique that is both feasible and desirable. The transposition requires no additional technical skills but requires comprehensive knowledge of its anatomy. The anatomical preservation of the neurovascular structures is potentially beneficial to the quality of life of patients. Clinical studies are necessary to prove the real benefits of this technique.
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endoscopic anatomy of the palatovaginal canal palatosphenoidal canal a landmark for dissection of the Vidian Nerve during endonasal transpterygoid approaches
Laryngoscope, 2012Co-Authors: Carlos D Pinheironeto, Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos M Riveraserrano, Alessandro Paluzzi, Luiz Ubirajara SennesAbstract:Objectives/Hypothesis: Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the Vidian Nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the Vidian Nerve. Show that the traditionally known PV canal is a misnomer and should be renamed. Study Design: Experimental study: anatomical and radiological. Methods: Dissection of eight cadaveric heads was performed to demonstrate the endoscopic anatomy of the PV canal. Computed tomography scan analysis of 20 patients was used to evaluate the length of the PV canal, the angle formed between this canal and the Vidian Nerve, and the distance between the Vidian canal and the PV canal. Study of 10 dry skull bases was performed to verify the structures involved in the formation of the PV canal. Results: Anatomic steps and foundations for dissection of the Vidian Nerve using the PV canal as a landmark were described. The mean length of the PV canal was 7.15 mm. The mean proximal distance between the Vidian and the PV canal was 1.95 mm, and the mean distal distance was 4.14 mm. The mean angle between those canals was 48 degrees. The osteology study showed the vaginal process of the sphenoid bone did not contribute to the formation of the PV canal. Conclusions: Our anatomic investigations, radiologic studies, and surgical experience demonstrate the important anatomic relationship of the PV canal with the Vidian canal and the relevance of the PV canal as a surgical landmark in endoscopic endonasal transpterygoid approaches. Anatomically, PV canal is a misnomer and should be replaced with palatosphenoidal canal.
Paul A Gardner - One of the best experts on this subject based on the ideXlab platform.
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reduced tearing with stable quality of life after Vidian neurectomy a prospective controlled trial
Laryngoscope, 2021Co-Authors: Eric W Wang, Paul A Gardner, Shannon Fraser, Tonya S Stefko, Juan C Fernandezmiranda, Carl H SnydermanAbstract:OBJECTIVES/HYPOTHESIS Although Vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality-of-life is not well-defined. Endoscopic endonasal transpterygoid approaches (EETA) may require Vidian Nerve sacrifice. STUDY DESIGN A prospective cohort trial. METHODS A prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five-item Dry Eye Questionnaire (DEQ-5) was performed. Preservation of the contralateral Vidian Nerve allowed comparison between the eye subjected to VN and the control eye postoperatively. RESULTS Twenty-one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre- and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ-5 score for dry eye severity between the pre- and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ-5 scores when compared to patients with normal tearing (P < .0056). CONCLUSIONS VN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk. LEVEL OF EVIDENCE 2 Laryngoscope, 131:1487-1491, 2021.
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lateral transorbital versus endonasal transpterygoid approach to the lateral recess of the sphenoid sinus a comparative anatomic study
Operative Neurosurgery, 2019Co-Authors: Joao T Alvesbelo, Eric W Wang, Paul A Gardner, Tonya S Stefko, Juan C Fernandezmiranda, Carl H Snyderman, Joao Mangussigomes, Huy Q Truong, Salomon CohenAbstract:BACKGROUND The treatment of cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus (LRSS) faces difficulties due to the deep location of the osseous defect. When treated with craniotomies, brain retraction is a concern. The endoscopic endonasal transpterygoid approach (EETA) is a direct and less invasive procedure; however, it may require transection of the Vidian Nerve (VN). OBJECTIVE To investigate the feasibility of a lateral transorbital approach (LTOA) as an alternative pathway to the LRSS that avoids VN sacrifice. METHODS Six embalmed heads with well-pneumatized LRSS were preselected by inspecting their computed tomography scans. One LTOA and one EETA were performed on 1 side of each specimen. The approaches were compared regarding working distance and neurovascular structures being sacrificed. The working area of the LTOA was also measured. RESULTS The average working distances were 59.9 (±2.94) mm for the LTOA and 76.4 (±3.99) mm for the EETA (P < .001). The LTOA generated a working area with a diameter of 9 to 14 mm. The EETA demanded the sacrifice of VN and the sphenopalatine artery in all specimens to expose the LRSS. No neurovascular structures were found in the trajectory of the LTOA. CONCLUSION The LTOA to the LRSS is feasible, with minimal risk of injuring neurovascular structures. It offers a shorter pathway when compared to the EETA. Although the LTOA provides no options for vascularized flap reconstruction, it allows immediate access to muscle grafts. The LTOA may serve as an alternative to treating cerebrospinal fluid leaks of the LRSS.
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eustachian tube and internal carotid artery in skull base surgery an anatomical study
Laryngoscope, 2014Co-Authors: Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos D Pinheironeto, Jianfeng Liu, Barry E Hirsch, Eric W WangAbstract:Objectives/Hypothesis The eustachian tube (ET) is an important landmark in skull base surgery, which has a close relationship with the petrous segment of the internal carotid artery (ICA). The goal of the current study was to establish the detailed anatomic relationship of the ET and petrous segment of the ICA. Study Design Anatomical study. Methods Six silicon-injected adult cadaveric heads (12 sides) were dissected using a lateral infratemporal fossa approach (type C) and endoscopic endonasal approach. The ET and ICA were exposed; their detailed relationships were demonstrated. High-quality pictures were obtained. Results In the anterior genu/foramen lacerum segment of the ICA, the Vidian Nerve was an important landmark. The cartilaginous ET was divided into four segments, from anterior to posterior: nasopharyngeal, pterygoid, lacerum, and petrosal segment. The anterior and inferior wall of the carotid canal was consistently between the horizontal ICA and petrous segment of the cartilaginous ET. In the posterior genu of the ICA, the bony part of the ET, and the tendon of the tensor tympani muscle were paramount landmarks. The posterior genu of the ICA was imbedded in the carotid canal. The landmarks of the junction of the cartilaginous ET and bony ET were the sphenoid spine and foramen spinosum. Conclusions The anatomical segmentation of the ET provides the basis for safe and effective transection of the ET in skull base surgery. An understanding of the complex relationships of the ET and petrous segment of the ICA is paramount for surgically dealing with disease located within the region of the ET and petrous segment of the ICA. Level of Evidence NA Laryngoscope, 124:2655–2664, 2014
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transposition of the pterygopalatine fossa during endoscopic endonasal transpterygoid approaches
Skull Base Surgery, 2013Co-Authors: Carlos D Pinheironeto, Ricardo L. Carrau, Daniel M Prevedello, Paul A Gardner, Juan C Fernandezmiranda, Carl H SnydermanAbstract:Introduction Complete or partial removal of the pterygoid process provides lateral extension of the endonasal corridor necessary to approach the Meckel cave, infrapetrous skull base, and medial infratemporal fossa. This paper provides the anatomical foundations for the endoscopic endonasal transpterygoid approach with preservation of all neurovascular structures inside the pterygopalatine fossa. Methods Eight endoscopic transpterygoid approaches were performed in fresh cadaveric specimens. In all dissections the Vidian Nerve and the periosteal sac enclosing the pterygopalatine fossa were preserved. Results We reliably transposed the pterygopalatine fossa to approach the Meckel cave, infrapetrous skull base, and medial infratemporal region, preserving the neurovascular structures inside the pterygopalatine fossa in all specimens. Conclusions The transposition of the pterygopalatine fossa neurovascular structures for endoscopic endonasal approaches to the skull base is an alternative technique that is both feasible and desirable. The transposition requires no additional technical skills but requires comprehensive knowledge of its anatomy. The anatomical preservation of the neurovascular structures is potentially beneficial to the quality of life of patients. Clinical studies are necessary to prove the real benefits of this technique.
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endoscopic anatomy of the palatovaginal canal palatosphenoidal canal a landmark for dissection of the Vidian Nerve during endonasal transpterygoid approaches
Laryngoscope, 2012Co-Authors: Carlos D Pinheironeto, Paul A Gardner, Juan C Fernandezmiranda, Carl H Snyderman, Carlos M Riveraserrano, Alessandro Paluzzi, Luiz Ubirajara SennesAbstract:Objectives/Hypothesis: Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the Vidian Nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the Vidian Nerve. Show that the traditionally known PV canal is a misnomer and should be renamed. Study Design: Experimental study: anatomical and radiological. Methods: Dissection of eight cadaveric heads was performed to demonstrate the endoscopic anatomy of the PV canal. Computed tomography scan analysis of 20 patients was used to evaluate the length of the PV canal, the angle formed between this canal and the Vidian Nerve, and the distance between the Vidian canal and the PV canal. Study of 10 dry skull bases was performed to verify the structures involved in the formation of the PV canal. Results: Anatomic steps and foundations for dissection of the Vidian Nerve using the PV canal as a landmark were described. The mean length of the PV canal was 7.15 mm. The mean proximal distance between the Vidian and the PV canal was 1.95 mm, and the mean distal distance was 4.14 mm. The mean angle between those canals was 48 degrees. The osteology study showed the vaginal process of the sphenoid bone did not contribute to the formation of the PV canal. Conclusions: Our anatomic investigations, radiologic studies, and surgical experience demonstrate the important anatomic relationship of the PV canal with the Vidian canal and the relevance of the PV canal as a surgical landmark in endoscopic endonasal transpterygoid approaches. Anatomically, PV canal is a misnomer and should be replaced with palatosphenoidal canal.