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Endoscopic endonasal approach to the ethmoidal planum: anatomic study

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Abstract

The endoscopic endonasal technique is currently used by otolaryngologists for the management of different extradural lesions located below the ethmoidal planum. The cooperation between ENTs and neurosurgeons has recently pushed the use of such approach also in the removal of some intradural lesions, which has promoted the interest for an anatomic study to identify the anatomical landmarks and the dangerous points during the endoscopic approach to this area. In six fresh cadaver heads, unilateral and bilateral measurements between the main landmarks of the approach were performed by means of an endoscopic endonasal approach. A wide exposure of the midline anterior skull base was realized. The maximum of lateral extension was obtained between the two medial orbital walls, at the middle of the cribriform plate (mean distance 25,33 mm), while the mean distance between the anterior and posterior ethmoidal arteries at the level of the lamina papyracea was 16 mm. The endoscopic endonasal route can be considered a minimally invasive technique to approach the ethmoidal planum. It requires adequate anatomical knowledge and endoscopic skill for its realization. Due to the wide window realizable through this corridor, it could be considered in selected cases for the removal of intradural lesions such as meningiomas or estesioneuroblastomas.

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Acknowledgements

This study was supported by Grant I/05/A/PL-154419-SU of the Leonardo da Vinci European Community Vocational Training Action Programme.

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Authors and Affiliations

  1. Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Via Sergio Pansini, 5, 80131, Naples, Italy

    Matteo de Notaris, Isabella Esposito, Luigi Maria Cavallo, Felice Esposito & Paolo Cappabianca

  2. Department of Neurosurgery, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    José M. Poblete & Enrique Ferrer

  3. Department of Human Anatomy and Embryology, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Anna Carrera Burgaya & Alberto Prats Galino

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  1. Matteo de Notaris
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  2. Isabella Esposito
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Correspondence to Paolo Cappabianca.

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Comments

Henry Schröder, Greifswald, Germany

De Notaris et al. present an interesting anatomical endonasal dissection study. They performed an endoscopic endonasal approach to the ethmoidal planum in six cadaver heads. The main anatomical landmarks were described, and measurements of the most important distances were performed. The authors considered the extended endonasal approach to the anterior skullbase to be a minimally invasive alternative to the transcranial approaches.

This is a well-written paper. Although numerous publications on the surgical anatomy of the endoscopic endonasal approaches to the skullbase have already been published in the last years, this article is interesting to skullbase surgeons. It describes clearly the steps of the approach and provides useful information. There is no question that the endoscope is an invaluable tool in pituitary and other skullbase surgery. However, I really question the statement that the described extended endonasal approach with destruction of most of the normal anatomy of the inner nose is really minimally invasive. Moreover, the problem of CSF leaks is still obvious in these approaches. The avoidance of a visible skin incision is only of minor importance. I think that a small supraorbital craniotomy via an eyebrow incision is less invasive than the approach described in this paper. The cosmetic results are excellent too. The main advantage of the endonasal approach, in my opinion, is the avoidance of any brain retraction.

I am sure that the use of endoscopes in skullbase surgery will become more and more common in the near future. With further improvement in video camera resolution, as recently having been achieved with the High Definition (HD) imaging, endoscopes will displace the microscope in more fields of neurosurgery.

Comments

Daniel Kelly, Santa Monica, USA

In this well-illustrated cadaveric study of the endonasal approach to the ethmoidal planum, Dr. Cappabianca et al. have demonstrated the feasibility of this approach, its anatomical limits and potential pitfalls. As they note, this approach is potentially advantageous for a number of anterior skull-based lesions by obviating the need for direct brain retraction and facial or scalp incisions. The potential down-sides of this approach include three major issues that over time will need to be further clarified: (1) the extent of access for lesions that extend laterally beyond the midline, (2) the ability to consistently achieve an effective skull base repair and avoid a postoperative CSF leak, and (3) the long-term sino-nasal consequences of extensive bony and soft tissue removal including bilateral middle turbinate resections, superior nasal–septal resection, and ethmoidectomies. It is through detailed anatomical dissections like these and their applied experience that such approaches will become more widely used in the clinical arena. Already over the last few years, the postoperative CSF leak rate for these approaches appears to be declining significantly at specialized endonasal surgery centers around the world. However, as the authors note, these endoscopic skull-based techniques are technically demanding and require an experienced surgical team such as the one in Naples to maximize their safety and efficacy.

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de Notaris, M., Esposito, I., Cavallo, L.M. et al. Endoscopic endonasal approach to the ethmoidal planum: anatomic study. Neurosurg Rev 31, 309–317 (2008). https://doi.org/10.1007/s10143-008-0130-z

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  • DOI: https://doi.org/10.1007/s10143-008-0130-z

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