Faculty Bibliography

BACKGROUND:The lateral craniopharyngeal or Sternberg's canal (SC) originates from superior orbital fissure (SOF) and traverses the sphenoid body into the nasopharynx. A remnant of the canal, Sternberg's defect (SD), has been debated as a source of cerebrospinal fluid (CSF) leak. The canal was described in 1888, and there is limited accurate visual illustration in the literature. OBJECTIVE:To provide a detailed anatomic and radiological illustration of the canal in pediatric and adult population including the mechanism undermining the incidence of the canal, and the possibility of the canal as a source of CSF leak. METHODS:A total of 195 high-resolution computed tomographies (CT) of patients (50 3-yr-old, 20 5-yr-old, and 125 adults) and 43 dry adult skulls (86 sides) were analyzed for a canal matching the description of the SC. RESULTS:A SC was identified in 86% of the 3-yr-old and 40% of 5-yr-old patients. The diameter and length were 2.12 mm and 12 mm, respectively. The incidence of the canal decreased with age as sinus pneumatization extended into the sphenoid sinus. Only 0.8% of the adult skull on CT had the canal. The canal was not present on the dry adult skulls examination, but SD was found in 4.65%. CONCLUSION:SC exists with high incidence in the pediatric group. Sinus pneumatization obliterates the canal in the adult population, leaving a defect in 4.65% of cases, which given the location and related anatomic structures, is unlikely to be a source of CSF leak.

BACKGROUND:The pedicled nasoseptal flap (NSF) is the mainstay for endoscopic skull base reconstruction. We present a novel technique using a semirigid chondromucosal NSF that improves the reinforcement and protection of intracranial structures. METHODS:Composite NSFs were performed to repair intraoperative high-flow cerebrospinal fluid leaks in 2 patients who had undergone endoscopic endonasal resection of a suprasellar mass. The surgical technique and postoperative outcomes are described. RESULTS:The flaps were sufficient for defect coverage, and the patients did not experience any cerebrospinal fluid leak in the immediate and delayed postoperative periods. No complications related to the composite flap had developed. CONCLUSIONS:The composite chondromucosal NSF is a reliable reconstruction option for select ventral cranial base reconstruction cases with the potential to improve the protection of intracranial structures. Additional surgical cases and longer follow-up are required for a better assessment of long-term outcomes.

OBJECTIVES/HYPOTHESIS:Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications. STUDY DESIGN:Anatomical study and retrospective clinical cohort study. METHODS:Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies. RESULTS:The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 ± 0.40 cm/9.3 ± 0.39 cm following standard harvest, 2.52 ± 0.61 cm/9.75±1.06 cm following SPA foramen release, 4.93 ± 0.89 cm/12.16 ± 0.54 cm following full IMAX dissection, and 6.18 ± 0.68 cm/13.41 ± 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients. CONCLUSIONS:Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting. LEVEL OF EVIDENCE:4 Laryngoscope, 130:18-24, 2020.

Advances in skull base and orbital surgery have led to an increased need to understand the anatomy of the orbit and surrounding structures to safely perform surgeries in this area. The purpose of this article is to review the surrounding anatomy of the orbit from a practical and operative point of view. We describe the orbit from an inferomedial endoscopic endonasal perspective (focusing on its inferior relationship with the maxillary sinus and related structures and its medial relationship with the ethmoid bone), from a posterior and superolateral intracranial perspective (describing the anatomy of the superior orbital fissure, optic canal, inferior orbital fissure, cavernous sinus, orbitofrontal cortex, and surrounding dura) and from an anterior perspective (focusing on the muscles, connective tissue, lateral and medial canthus, and relevant neurovascular anatomy). A deep knowledge of the critical neurovascular and osseous structures surrounding the orbit is necessary for adequately choosing and performing the most favorable orbital approach in every case.

A 49-year-old otherwise healthy male presented with an odontogenic abscess and mild left facial swelling. CT imaging revealed gaseous hypodensities within the inferior orbital fissure and pterygopalatine fossa in addition to infection of the left masseter and temporalis muscle. Despite dental drainage, this rapidly progressed to orbital cellulitis with temporalis muscles abscess leading to compartment syndrome and globe tenting. He had an excellent outcome after canthotomy and cantholysis, urgent endoscopic and transconjunctival orbital decompression, temporalis muscle abscess drainage, and intravenous antibiotics. This case describes the use of bony orbital decompression for orbital compartment syndrome and globe tenting from odontogenic orbital cellulitis. In addition, this case radiographically demonstrates a transinferior orbital fissure passageway of an odontogenic abscess in the orbit.