Transoral & Transorbital approaches of skull base

1. Transoral & Transorbital
approaches of skull base
14-8-2016
12.26 pm

2. Great teachers – All this is their work .
I am just the reader of their books .
Prof. Paolo castelnuovo
Prof. Aldo Stamm Prof. Mario Sanna
Prof. Magnan

3. For Other powerpoint presentatioins
of
“ Skull base 360° ”
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getting more & more information
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5. Infratemporal fossa anatomy

6. IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial
pterygoid muscle , LPM = lateral pterygoid muscle
Different layers of
muscles & aponeurosis
protecting great vessels
in infratemporal fossa –
Main protectors are
medial & lateral
pterygoid mucles &
temporalis muscle -
great vessels are
posterior to these 3
muscles –
small contribution of
protection of great
vessels are done by
tensor veli palatini &
styloid muscles &
stylopharyngeal
aponeurosis

7. IAN = inferior alveolar nerve , LN = lingual nerve , MPM = medial
pterygoid muscle , LPM = lateral pterygoid muscle

9. TVPM is triangular muscle , LVPM is
cylindrical muscle

11. SPM attached
to superior
constrictor ,
SGM attached
to tongue ,
SHM attached
to lesser cornu
of hyoid bone

13. After drilling LPP & MPP longissmus capitis & superior
constrictor seen .

14. Trans - Oral approach to
Infratemporal fossa

15. STEP 1 = Incision : anterior to anterior
to anterior pillar of tonsil for “Trans -
Oral approach to infratemporal fossa”

16. STEP 2 = Seperation of deep tissue identification of palato pharyngeus
and palato glossus and superior consrictor muscles above medially below medial
pterygoid and ramus of mandible identification of triangles identification of
ascending palatine and ascending pharyngeal ( resident friend) artery

17. STEP 3 = finally identification of our friends ica and jugular
and vagus in the upper triangle formed by s c m stylopharyngeus
and stylo glossusmuscles
Triangle between SPM & SGM &
Superior constrictor Left side

18. Transoral approach to SUPERO-MEDIAL Parapharyngeal
tumors – incision anterior to anterior pillar of tonsil

19. Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal
carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli
palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar
of tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below
diagrams MPM reflected back for understanding purpose

20. MPM is reflected back – which shows the structures seen in trans-oral
approach of ITF – incision anterior to anterior pillar of tonsil

21. Two planes posterior to MPM which have greater surgical importance ...... …..1. Nasopharyngeal
carcinoma/JNA excision - plane between medial pterygoid muscle ( MPM ) & ET tube/TVPM ( tensor veli
palatini muscle)........ 2 . Trans-oral exposure of Infratemporal fossa (ITF) - incision anterior to anterior pillar of
tonsil - leads to - plane between MPM & superior constrictor / styloid muscles............In the below diagrams
MPM reflected back for understanding purpose

22. 1. Each styloid muscle accompanied by one nerve – SPM by 9th nerve , SGM by lingual nerve , SHM by 12th
nerve
2. SPM & SGM protects ICA whereas SHM protects both ECA & ICA – that is the reasonwhy wheen you
dissect a plane over posterior belly of diagastric & SHM , you won’t get vital structures
3. ECA & ICA & CCA are like tuning fork – caricature diagram

23. Each styloid muscle accompanied by one nerve – SPM by 9th
nerve , SGM by lingual nerve , SHM by 12th nerve

24. Note the 9th nerve accompanying Stylopharyngeus

25. The SPM runs inferiorly on the lateral
aspect of the ICAp. The SHM is lateral
to the ECA. The SGM passes lateral to
the ICAp, medially to the ECA. The
stylomandibular ligament is a
condensation of the deep layer of the
parotid fascia. It connects the styloid
process with the angle of the
mandible.
DMpb posterior belly of the digastric
muscle, FA facial artery, ICAp
parapharyngeal portion of
the internal carotid artery, IJV internal
jugular vein, SCM superior constrictor
muscle, SGM styloglossus muscle, SHM
stylohyoid muscle, SPM stylopharyngeus
muscle, VIIcn facial nerve, Xcn vagus nerve,
XIcn accessory nerve, XIIcn hypoglossal
nerve, black asterisk glossopharyngeal
nerve at the skull base

26. MPM is reflected back – which shows the structures seen in trans-oral
approach of ITF – incision anterior to anterior pillar of tonsil

27. ApaA ascending palatine artery, BFP buccal fat pad, BM buccinator muscle, ICAp parapharyngeal
portion of the internal carotid artery, IJV internal jugular vein, LN lingual nerve, MPM
medial pterygoid muscle, PG parotid gland, PP pharyngeal plexus, SCM superior constrictor
muscle, SGM styloglossus muscle, SHM stylohyoid muscle, SPM stylopharyngeus muscle, IXcn
glossopharyngeal nerve, Xcn vagus nerve, black asterisk stylomandibular ligament

28. Transoral endoscopic view of the parapharyngeal region
ApaA ascending palatine artery, ICAp parapharyngeal portion of the internal carotid artery, LCapM longus capitis
muscle, PP pharyngeal plexus, SCM superior constrictor muscle, SGM styloglossus muscle, SPM stylopharyngeus
muscle, white arrows glossopharyngeal nerve
The external carotid artery passes deeply to the digastric and stylohyoid muscles, but super fi cially to
the stylopharyngeus and styloglossal muscle when running toward the parotid gland (Janfaza et al.
2001 ) . With a transoral window it is possible to control the space between the medial pterygoid
muscle laterally and the superior constrictor muscle medially. The stylopharyngeus and styloglossus
muscles are critical landmarks, being usually placed anterior to the great vessels (Dallan et al. 2011 ).
Note that the presence of kinking or looping of the ICAp could make this statement untrue.

29. transoral endoscopic views of the tongue base and
parapharyngeal regions
APA ascending pharyngeal artery, ApaA ascending palatine artery, DM digastric muscle, FA
facial artery, HGM hyoglossus muscle, IAN inferior alveolar nerve, ICAp parapharyngeal portion
of the internal carotid artery, IJV internal jugular vein, LA lingual artery, LN lingual nerve,
M mandible, MPM medial pterygoid muscle, SCM superior constrictor muscle, SGM styloglossus
muscle, SPM stylopharyngeus muscle, TB tongue base, XIIcn hypoglossal nerve, black arrows
glossopharyngeal nerve

30. Lateral vision of the upper
cervical and lower
parapharyngeal regions. The
vertical branch
of the mandible has been
removed
DM digastric muscle, ECA external
carotid artery, FA facial artery, ICAp
parapharyngeal portion
of the internal carotid artery, IJV
internal jugular vein, LFVT linguofacial
venous trunk,
LN lingual nerve, MPM medial
pterygoid muscle, OA occipital artery,
SCM superior constrictor
muscle, SGM styloglossus muscle,
SHM stylohyoid muscle, SMG
submandibular gland, SPM
stylopharyngeus muscle, IXcn
glossopharyngeal nerve, XIcn
accessory nerve, XIIcn hypoglossal
nerve, yellow arrow ansa cervicalis
profunda

31. Transoral endoscopic view
of the parapharyngeal
region
APA ascending pharyngeal
artery, ApaA ascending
palatine artery, ICAp
parapharyngeal portion
of the internal carotid artery,
IJV internal jugular vein, LN
lingual nerve, M mandible,
SCM superior constrictor
muscle, SGM styloglossus
muscle, SHM stylohyoid
muscle, SPM stylopharyngeus
muscle, TB tongue base,
white arrow hypoglossal
nerve, black arrows
glossopharyngeal
nerve, blue arrows lingual
nerve

32. Sree ram murthy sir dissection in Italy
Dear surgeons today we did cadavèric dissection to endoscopic transoral approach to
parapharyngeal space The indications are
1. removal of small tumours of parapharyngeal space
2. biopsy of growths
3. to enter in to infratemporal space
4. para mandibular approaches to mid cranial fossa
The dissection was done by us with dr Dallan Of Pisa medical university of PISA ITALY
1. Incision over soft palate above anterior pillar
2. Seperation of deep tissue identification of palato pharyngeus and palato glossus and
superior consrictor muscles above medially below medial pterygoid and ramus of
mandible identification of triangles identification of ascending palatine and ascending
pharyngeal ( resident friend) artery
3. Finally identification of our friends ica and jugular and vagus in the upper triangle
formed by s c m stylopharyngeus and stylo glossusmuscles inferiorly mtm and
mandible v3 branches entering infra temporal space are important things.
Trans oral endoscopy of pps is gaining popularity now a days a new procedure hence friends
just pass deeper to tonsil we see wonders The video is thrilling to see It is a anatomical feast

35. finally identification of our friends ica and jugular andvagus in
the upper triangle formed by s c m stylopharyngeus and stylo
glossusmuscles

38. Dear surgeons it is
trans oral endoscopic
pic of parapharyngeal
space to show
ascending pharyngeal
artery and other
structures of neck
1ascending palatine artery
2 ascending pharyngeal
artery
3 ica
4 ij v
5 stylo pharyngeus muscle

39. ARTERY OF TROUBLE
ARTERY OF TROUBLE:
The inferior tympanic artery which supplies medial wall of
middle ear. Normally it is a small branch of ascending pharyngeal
artery a middle terminal twig along with anterior pharyngeal
branch and posterior neuro meningeal branch. In 50% cases, it is
visible But in glomous tumours the major blood supply to the
tumour is from this artery. In glomous tumours it is engorged
more than 8 times Inferior tympanic artery enter the floor of
middle ear through tympanic canaliculus at crotch along with
jocobsons nerve. Finiculus island mark to this artery entry.
Surgical implications:
• 1) In glomus tympanicus tumours initial coagulation of this
vessel at the region of finiculus reduces bleeding
• 2) It can have anastomoses with petrous segment of ICA so
glomous tumour may be supplied by EAC and ICA

40. 1 Inferior tympanic artery 2 anterior crus of stapes 3 long
process of incus 4 malleus

41. 1 Inferior tympanic artery 2 anterior crus of stapes 3 long
process of incus 4 malleus

42. Paraphayrngeal JNA removal by
Endoscopic trans-oral approach by
Dr.Janakiram

45. Another case of MUCOEPIDERMOID
TUMOR – OPERATED TWICE
BEFORE.. ENDOSCOPIC TRANSORAL
EXCISION by Dr.Janakiram – Click
https://www.facebook.com/narayanan.janakiram
/media_set?set=a.862837223808213.107374193
9.100002458306921&type=3

46. Trans-Oral approach to CVJ [ cranio-
vertebral junction ]

47. Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palate
was excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally.
D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebral
body and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica:
anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1
nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis
muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil,
saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.

48. Transoral exposure of the craniocervical junction region. A. Mandibular bone and the tongue were excised. B. The soft palate
was excised and pharyngeal mucosa was retracted bilaterally and clivus was exposed. C. The clivus, atlas, and axis were exposed transorally.
D. Inferior third of the clivus, anterior arch of atlas, and the anterior part of the axis were excised down to level of the C3 vertebral
body and the dura was also excised correspondingly to demonstrate craniocervical junction region. aaa: anterior arch of atlas, aica:
anterior inferior cerebellar artery, asa: anterior spinal artery, at: atlas, ata: anterior tubercle of atlas, ax: axis, ba: basilar artery, C1: C-1
nerve root, C2: C-2 nerve root, cl: clivus, d: dens, du:dura, hp: hard palate, iaf-at: inferior articular facet of atlas, lcap: longus capitis
muscle, ma: mandible, mo: medulla oblangata, mu: pharyngeal mucosa, pns: posterior nasal spine of palatine bone, pt: palatine tonsil,
saf-ax: superior articular facet of axis, sc: spinal cord, sp: soft palate, u: uvula, V4: intradural segment of vertebral artery, vo: vomer.

49. TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE ANTERIOR
CRANIAL FOSSA

50. Updated soon
Read Chapter 15 TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE ANTERIOR
CRANIAL FOSSA in Dr. Paul Gardner book – click -
https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul
+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y

51. Sree ram murthy sir dissection in italy
Dear surgeons to day we dissected Transorbital approach to
infratemporal fossa on cadaver under guidence of pro Sellari
franchisco of PISA italy He is expert for this approaches So far he has
done 1980 cases through approach The main indications are
1 orbital decompression
2 clenoid meningiomas and other tumours of anterior cranial fossa
3cavernous sinus pathologies
4 meckles cave tumours
5 infratemporal fossa pathologies
6 this one approach is for all pathologies of anterior middle cranial and
infra temporal fossa
superior lid incision sub periosteal elivation of globe identification of
sof and meningo orbital artery drillng of greater wing of sphenoid for
mid fossa alittle inferior for itf frotal bone for acf and incision of dura
finally visualisation of structures are steps these are some pics

52. Dr. Sree ram murthy & Pro Sellari
franchisco of PISA italy

60. TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE MIDDLE
CRANIAL FOSSA

61. Orbital apex

63. ORBIT
• 1. Two Ice cream cones in orbit -mnemonic - SOF
& IOF - superior orbital fissure & inferior orbital
fissure.
• 2. Bone between OC ( optic canal ) & SOF is optic
strut ( OS)
• 3. Bone between SOF & V2 ( foramen rotundum )
is MS ( maxillary strut ) - front door of cavernous
sinus
• 4. So SOF is presents between two struts - OS &
MS
• 5. Bone above SOF is LWS ( leader wing of
sphenoid )
• 6. Bone between SOF & IOF is GWS ( greater
wing of sphenoid )
• 7. Four semilunar lines 1, 2, 3, 4 are - orbital
surface of frontal bone , orbital surface of
zygomatic none , orbital surface of maxillary
none , laminae papyracea resp.
• 8. Medial wall of SOF is nothing but nasal surface
of SOF which is just anterior to cavernous sinus

64. ORBITAL APEX [ SOF = ALSC
+ Orbital apex]
Extraconal & intraconal
compartmements

67. A - trajectory leads to middle cranial fossa
B - trajectory leads to infra-temporal fossa

68. GWS=Greater wing of sphenoid
LWS = Lesser wing of sphenoid

69. Updated soon
Read Chapter 34 TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE MIDDLE
CRANIAL FOSSA in Dr. Paul Gardner book – click -
https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=paul
+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=y

71. Six handed technique ??
Read Chapter 34 TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE MIDDLE
CRANIAL FOSSA in Dr. Paul Gardner book – click -
https://books.google.co.in/books?id=ZzSmBAAAQBAJ&dq=
paul+gardner+skull+base+surgery&hl=en&sa=X&redir_esc=
y

72. TRANS ORBITAL APPROACH cadaveric approach to middle cranial fossa In future it will be good
easy approach for ent surgeons It is devised by pro castelneuvo with my friends Dallan and
Battaglea
There are 3 approaches to ent surgeons for cavernous sinus
1 trans sellar approach
2 transpterygoid approach
3 trans orbital approach - this approach is easy .
The trans orbital approach steps are
1 upper lid incision
2 subperiosteal dissection of globe and identification superior orbital fissure and meningo
orbital artery
3 identification of c s
4 seperation of two walls of c s
4 identification of structures
5 incision of mid cranial fossa dura
6 meckles cave visualisation along with other structures - small incision , no injury to eye ,
entrance of cv in between two layers , no much bleeding , no csf leaks are advantages .

73. TRANSORBITAL ENDOSCOPIC
APPROACHES TO THE MIDDLE
CRANIAL FOSSA – cadaver study

76. meningo orbital artery

80. endoscopic endonasal cadaveric
ORBITAL TRANSPOSITION

81. Murali Chand Nallamothu: What are
indications of orbital transposition.
Sree Ram Murthy Dr Vizak ENT: Now a days it is important
part the indications
1. removal of infections lateral to mid pupillary level
2. lateral osteomas of frontal sinuses
3. trans orbital approaches to middle cranial tumours
4. exposure of cavernous sinus trans orbitally
I think 1 & 2 indications can be done by external
approaches by brow or bicoronal incisions

82. Sree Ram Murthy Dr : Dear surgeons it is a endoscopic endonasal
cadaveric ORBITAL TRANSPOSITION technique
The steps follows
1 complete exposure of anterior skull base
2 identification of septal branch of a e a and 1st olfactory fibre
3 removal of lamina papyracea
4 identification of aea and pea
5 cutting of both arteries and release the globe
6 gentle lateralization globe along with periorbita up to mid
pupillary point
7 complete exposure of medial orbital roof and further
according to pathology

83. 1 septal branch of a e a

84. 2 orbital roof
4 posterior ethmoidal groove

85. 3 first olfactory fibre

87. For Other powerpoint presentatioins
of
“ Skull base 360° ”
I will update continuosly with date tag at the end as I am
getting more & more information
click
www.skullbase360.in
- you have to login to slideshare.net with Facebook
account for downloading.