Endoscopic Endonasal Approach to the Infraorbital Nerve with Nasolacrimal Duct Preservation

Abstract

Objectives Infraorbital nerve (ION) decompression, excision to remove intrinsic tumors, and resection with oncological margins in malignancies with perineural invasion or dissemination are usually accomplished with an open approach. The objective is to describe the surgical anatomy, technique, and indications of the endonasal endoscopic approach (EEA) to the ION with nasolacrimal duct preservation. Design Eleven sides of formalin-fixed specimens were dissected. An anterior maxillary antrostomy was performed. The length of the ION prominence within the sinus and anatomic features of the covering bone were studied. A 45-degree endoscope visualized the infraorbital prominence endonasally. An angled dissector and dural blade allowed for dissection and resection of the ION ipsilaterally and contralaterally. Results The bone features of the ION prominence allowed for ipsilateral dissection in 10 out of 11 sides. In one case with the ION surrounded by thick cortical bone, the dissection could only be started by drilling contralaterally. The 45-degree endoscope visualized 92.2% and 100% of the length of the nerve using the ipsilateral and contralateral nostrils, respectively. Ipsilaterally, 83% of its length was resected, and 96.3% was resected contralaterally. Conclusion The ION can be approached using an ipsilateral EEA with nasolacrimal duct preservation in most cases. The contralateral approach provides a wider angle to access the ION. This technique is primarily indicated in cases where the EEA can be used for tumor resection and oncological margins within the ION.

Transorbital Endoscopic Approach to the Foramen Rotundum for Infraorbital Nerve Stripping

“…Therefore, we recommend using the ball probe to free the ION and its intraosseous fascial attachments to the canal as it heads toward the infraorbital foramen. 29 In radiological studies, the infraorbital foramen is situated 8.95–11.87 mm inferior to the orbital rim. 25 During the excision of the ION, it must also be stripped from its branching nerves, which include the ganglionic, zygomatic branches, and posterior alveolar branches while it is still the maxillary nerve within the PPF, then the middle and anterior superior alveolar nerves within the orbital floor.…”

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit

“…5 ). 23 Lesions located anterior to the posterior plane of the globe, as well as those that involve the skin or require orbit exenteration, should be approached by an anterior route or a combined strategy. 24…”

“…5). 23 Lesions located anterior to the posterior plane of the globe, as well as those that involve the skin or require orbit exenteration, should be approached by an anterior route or a combined strategy. 24 With respect to endoscopic optimization, a 0-degree scope provides an excellent view of the medial orbit from the optic canal to the anterior medial wall.…”

“…Special care must be taken during the uncinectomy and maxillary antrostomy to avoid injury to the nasolacrimal duct by extending the resection anteriorly to the lacrimal bone. 23,32 Diplopia can be prevented by preserving an anterior bony strut between the medial and inferior orbital wall with a posterior length that extends approximately to the level of the natural ostium of the maxillary sinus which will prevent the eye globe from rotating medially, and by respect-ing the muscles during the dissection to preserve their function. 33 Lastly, it is important to remember during ethmoidectomy that the anterior ethmoidal artery exits the orbit along the cranial base from posterior to anterior toward the cribriform plate, and it can be totally covered by bone or freely suspended in the ethmoidal labyrinth, placing it at risk of inadvertent injury.…”

Commentary: Combined Orbitozygomatic Pretemporal Transcavernous and Endonasal Transmaxillary Approach for Resection of a Giant Trigeminal Schwannoma: 2-Dimensional Operative Video

“…[2][3][4] It has been modified in recent years, however, to serve as an additional endoscopic corridor to augment a variety of endonasal approaches. 5,6 In this case, the approach provided the surgeons with direct access to the portion of the large mass filling the maxillary sinus, which was used in tandem with the familiar endoscopic endonasal approach, allowing for further resection of the sinonasal, infratemporal, and pterygopalatine portions of the mass. Using both endoscopic vantage points in conjunction with the orbitozygomatic craniotomy allowed for a successful oncological outcome.…”