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De Simone M, Zoia C, Choucha A, Kong DS, De Maria L. The Transorbital Approach: A Comprehensive Review of Targets, Surgical Techniques, and Multiportal Variants. J Clin Med 2024; 13:2712. [PMID: 38731240 PMCID: PMC11084817 DOI: 10.3390/jcm13092712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/24/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The transorbital approach (TOA) is gaining popularity in skull base surgery scenarios. This approach represents a valuable surgical corridor to access various compartments and safely address several intracranial pathologies, both intradurally and extradurally, including tumors of the olfactory groove in the anterior cranial fossa (ACF), cavernous sinus in the middle cranial fossa (MCF), and the cerebellopontine angle in the posterior cranial fossa (PCF). The TOA exists in many variants, both from the point of view of invasiveness and from that of the entry point to the orbit, corresponding to the four orbital quadrants: the superior eyelid crease (SLC), the precaruncular (PC), the lateral retrocanthal (LRC), and the preseptal lower eyelid (PS). Moreover, multiportal variants, consisting of the combination of the transorbital approach with others, exist and are relevant to reach peculiar surgical territories. The significance of the TOA in neurosurgery, coupled with the dearth of thorough studies assessing its various applications and adaptations, underscores the necessity for this research. This extensive review delineates the multitude of target lesions reachable through the transorbital route, categorizing them based on surgical complexity. Furthermore, it provides an overview of the different transorbital variations, both standalone and in conjunction with other techniques. By offering a comprehensive understanding, this study aims to enhance awareness and knowledge regarding the current utility of the transorbital approach in neurosurgery. Additionally, it aims to steer future investigations toward deeper exploration, refinement, and exploration of additional perspectives concerning this surgical method.
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Affiliation(s)
- Matteo De Simone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Cesare Zoia
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015 Gravedona, Italy;
| | - Anis Choucha
- Department of Neurosurgery, Aix Marseille University, APHM, UH Timone, 13005 Marseille, France;
- Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, 13005 Marseille, France
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea;
| | - Lucio De Maria
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy;
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
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Plata-Bello J, Mosteiro-Cadaval A, Torné R, Di Somma A, Enseñat J, Prats-Galino A. Optimizing the Endoscopic Transorbital Approach: MacCarty Keyhole for Enhanced Surgical Exposure in the Opticocarotid Region. World Neurosurg 2024; 185:290-296. [PMID: 38453005 DOI: 10.1016/j.wneu.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/01/2024] [Accepted: 03/02/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In recent years, the endoscopic transorbital (TO) approach has gained increasing interest for the treatment of middle cranial fossa lesions. We propose a technical refinement to the conventional superior eyelid TO approach, which improves the surgical exposure and augments the working angles when targeting the opticocarotid region. METHODS Four embalmed adult cadaveric specimens (8 sides) were dissected at the Laboratory of Surgical Neuroanatomy of our institution. A TO approach was performed, with removal of the anterior clinoid process and the lateral orbital rim. Subsequently, the MacCarty keyhole was drilled in the superolateral orbital wall. Given that the lesser sphenoid wing was already drilled in the conventional TO craniectomy, the opening of the keyhole was essentially a lateral extension of the craniectomy. RESULTS The procedure was successfully conducted in all 4 orbits. Clinoidectomy was performed either before or after extending the craniectomy to the MacCarty point. Extending the craniectomy made anterior clinoidectomy easier, by increasing the surgical exposure, and allowing a more lateral entrance for the endoscope. The extension also facilitated frontal lobe retraction, and it facilitated the optic nerve and carotid artery manipulation. Postoperative computed tomography scans showed a minimal 10-mm craniectomy extension, which remained covered by the temporal muscle after reconstruction. CONCLUSIONS The modified endoscopic TO approach with the extension of the craniectomy to MacCarty point improves surgical access and visualization of the opticocarotid region. This facilitates anterior clinoidectomy and optic nerve decompression. Although it implies judicious instrument manipulation and a larger incision size, further studies can define its potential benefits.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Ramón Torné
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Zoli M, Sollini G, Rustici A, Carretta A, Magnani M, Guaraldi F, Asioli S, Faustini-Fustini M, Pasquini E, Mazzatenta D. Combined Endoscopic Transorbital and Transmaxillary-Pterygoid Approach for a Recurrent Spheno-Orbital Meningioma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01078. [PMID: 38442482 DOI: 10.1227/ons.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/08/2024] [Indexed: 03/07/2024] Open
Abstract
Spheno-orbital meningiomas are challenging invasive tumors, involving different cranial regions, requiring multiple surgical approaches and often with an unfavorable biological behavior characterized by multiple recurrences and possible escape from standard treatments.1 We present a case of a 57-year-old woman, already undergone a transcranial approach, an endoscopic transorbital surgery, and a radiosurgical treatment for a spheno-orbital meningioma. She presented a further tumoral recurrence, involving the orbit and the infratemporal and pterygopalatine fossa, and we proposed a combined fully endoscopic multistaged approach. The patient consented to the procedure and to the publication of his/her image. We adopted the endoscopic transorbital and the endoscopic transmaxillary-pterygoid corridors for the different portions of the tumor, followed by radiation therapy with carbon ions, achieving a large tumor resection with no progression at 12-month follow-up and without complications or neurological sequelae. This treatment strategy gave us the possibility to fully manage the tumoral extension with 2 innovative minimally invasive surgical procedures, which resulted well-tolerated and favored the prompt patient recovery and quality-of-life preservation, leaving the meningioma remnant to the external radiation therapy.2-6 Our case emphasizes the possibilities given by the endoscopic approaches to manage at 360° the multiregional extensions of a spheno-orbital meningioma, demonstrating how such direct and extracranial corridors could allow the surgeon to remove these tumors, with no brain retraction or manipulation and limited functional or neurological sequelae.7,8.
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Affiliation(s)
- Matteo Zoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Giacomo Sollini
- ENT Unit, Azienda USL di Bologna, Bellaria Hospital, Bologna, Italy
| | - Arianna Rustici
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, Bologna, Italy
| | - Alessandro Carretta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Marcello Magnani
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Federica Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marco Faustini-Fustini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
| | - Ernesto Pasquini
- ENT Unit, Azienda USL di Bologna, Bellaria Hospital, Bologna, Italy
| | - Diego Mazzatenta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
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Ortega-Ruiz OR, Olivas JAL, Sangrador-Deitos MV, Magaña RM, Gurria JAR, Amador JLG. Combined endoscopic transorbital and transnasal approach for the management of a solitary plasmacytoma of the sphenoid bone: A case report and literature review. Surg Neurol Int 2024; 15:45. [PMID: 38468666 PMCID: PMC10927175 DOI: 10.25259/sni_915_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/14/2024] [Indexed: 03/13/2024] Open
Abstract
Background Parasellar plasmacytomas are rare neurosurgical entities. Intrinsic characteristics of these tumors, such as adjacent bone erosion and symptoms resulting from invasion and mass effect, may lead to the possibility of a solitary extramedullary plasmacytoma (SEP) as a differential diagnosis. Case Description We present the case of a 39-year-old male with a 1-month history of bilateral decreased visual acuity, retroocular pulsating pain, and chromatic vision loss. A computed tomography scan of the head revealed a parasellar lesion causing chiasmatic compression, as well as clival, orbital, sphenoidal, and ethmoidal invasion. A combined transorbital and endonasal endoscopic approach was found suitable, and gross total resection was achieved. Histological analysis of the lesion established the diagnosis of a SEP. After radiotherapy, a new magnetic resonance imaging was performed, revealing a recurrence of the lesion with a high grade of invasion. The patient was treated with palliative radiotherapy, as surgical resection did not seem feasible. Conclusion Surgical resection and radiotherapy may achieve remission of these lesions; however, recurrence rates remain high despite any treatment modality. Patients with this condition must be followed up with a multidisciplinary team due to the high risk of multiple myeloma progression.
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Affiliation(s)
- Omar R. Ortega-Ruiz
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | | | | | - Ricardo Marian Magaña
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Juan Luis Gomez Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Stefko ST, Terrarosa AK. Ophthalmology and oculoplastics for the rhinologist. Curr Opin Otolaryngol Head Neck Surg 2024; 32:1-4. [PMID: 38116989 DOI: 10.1097/moo.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW As the management of ophthalmic and sinus disease advances, it is important to stay abreast of all current management options. This involves knowledge of adjacent anatomy and disease processes, and collaboration between multiple specialties. The authors provide a review of relevant ophthalmic and oculoplastic topics for the rhinologist. RECENT FINDINGS The scope and surgical skills of oculoplastic and rhinologist specialists have grown in conjunction with medical and technological advancements. Familiarity with the presentations of sinus disease in the orbit can decrease the time to disease recognition, and improve morbidity and mortality. Collaborative approaches provide improved access to areas of interest throughout the orbit and sinuses. Multiportal, transorbital, and endoscopic techniques can improve patient morbidity and mortality compared to conventional open approaches. Familiarity with all medical and surgical treatment options can help tailor treatments to patients' needs. SUMMARY Multidisciplinary approaches to sinus and orbit disease and the incorporation of new surgical technologies can improve patient options and outcomes.
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Affiliation(s)
- S Tonya Stefko
- Departments of Ophthalmology, Otolaryngology, and Neurological Surgery
| | - Anna K Terrarosa
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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De Rosa A, Mosteiro A, Guizzardi G, Roldán P, Torales J, Matas Fassi J, Cavallo LM, Solari D, Prats-Galino A, Di Somma A, Enseñat J. Endoscopic transorbital resection of the temporal lobe: anatomic qualitative and quantitative study. Front Neuroanat 2023; 17:1282226. [PMID: 37818154 PMCID: PMC10560990 DOI: 10.3389/fnana.2023.1282226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 10/12/2023] Open
Abstract
Objective Starting from an anatomic study describing the possibility of reaching the temporal region through an endoscopic transorbital approach, many clinical reports have now demonstrated the applicability of this strategy when dealing with intra-axial lesions. The study aimed to provide both a qualitative anatomic description of the temporal region, as seen through a transorbital perspective, and a quantitative analysis of the amount of temporal lobe resection achievable via this route. Material and methods A total of four cadaveric heads (eight sides) were dissected at the Laboratory of Surgical Neuroanatomy (LSNA) of the University of Barcelona, Spain. A stepwise description of the resection of the temporal lobe through a transorbital perspective is provided. Qualitative anatomical descriptions and quantitative analysis of the amount of the resection were evaluated by means of pre- and post-dissection CT and MRI scans, and three-dimensional reconstructions were made by means of BrainLab®Software. Results The transorbital route gives easy access to the temporal region, without the need for extensive bone removal. The resection of the temporal lobe proceeded in a subpial fashion, mimicking what happens in a surgical scenario. According to our quantitative analysis, the mean volume removed was 51.26%, with the most superior and lateral portion of the temporal lobe being the most difficult to reach. Conclusion This anatomic study provides qualitative and quantitative details about the resection of the temporal lobe via an endoscopic transorbital approach. Our results showed that the resection of more than half of the temporal lobe is possible through this surgical corridor. While the anterior, inferior, and mesial portions of the temporal lobe were easily accessible, the most superior and lateral segment was more difficult to reach and resect. Our study serves as an integration to the current anatomic knowledge and clinical practice knowledge highlighting and also as a starting point for further anatomic studies addressing more selected segments of the temporal lobe, i.e., the mesial temporal region.
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Affiliation(s)
- Andrea De Rosa
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | | | | | - Pedro Roldán
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jorge Torales
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jessica Matas Fassi
- Department of Ophthalmology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
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Serioli S, Nizzola M, Plou P, De Bonis A, Meyer J, Leonel LCPC, Tooley AA, Wagner LH, Bradley EA, Van Gompel JJ, Benini ME, Dallan I, Peris-Celda M. Surgical Anatomy of the Microscopic and Endoscopic Transorbital Approach to the Middle Fossa and Cavernous Sinus: Anatomo-Radiological Study with Clinical Applications. Cancers (Basel) 2023; 15:4435. [PMID: 37760405 PMCID: PMC10527149 DOI: 10.3390/cancers15184435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The transorbital approaches (TOAs) have acquired growing notoriety, thanks to their ability to offer alternative corridors to the skull base. However, the limited access and the unfamiliarity with this surgical perspective make recognition of key landmarks difficult, especially for less experienced surgeons. The study wants to offer a detailed description of the anatomy to comprehend the potential and limitations of TOAs. METHODS Measurements of the orbit region and the surrounding areas were performed on two hundred high-resolution CT scans and thirty-nine dry skulls. Five specimens were dissected to illustrate the TOA, and one was used to perform the extradural clinoidectomy. Three clinical cases highlighted the surgical applications. RESULTS A step-by-step description of the key steps of the TOA was proposed and a comparison with the transcranial anterior clinoidectomy was discussed. The mean work distance was 6.1 ± 0.4 cm, and the lateral working angle increased 20 ± 5.4° after removing the lateral orbital rim. CONCLUSIONS TOAs are indicated in selected cases when tumor involves the lateral portion of the cavernous sinus or the middle skull base, obtaining a direct decompression of the optic nerve and avoiding excessive manipulation of the neurovascular structures. Comprehension of surgical anatomy of the orbit and its surrounding structures is essential to safely perform these approaches.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Mariagrazia Nizzola
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Alessandro De Bonis
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Jenna Meyer
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Andrea A. Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Lilly H. Wagner
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Elizabeth A. Bradley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Jamie J. Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Maria Elena Benini
- Department of Neurosurgery—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Iacopo Dallan
- Department of Otolaryngology—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
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