ENDOSCOPIC SURGICAL ANATOMY

OF THE LAMB’S HEAD

Prof. Ranko MLADINA, M.D.

Professor of Otorhinolaryngology
and Plastic Surgery of the Head and Neck
ENT Department
University Hospital Rebro-KBC Zagreb, Croatia
Head of the Referral Center for Rhinosinusology
and Endoscopic Sinus Surgery
Ministry of Health and Social Care
Republic of Croatia
4 Endoscopic Surgical Anatomy of the Lamb’s Head
Important notice:
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research and clinical experience broaden our
knowledge, changes in treatment and therapy
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or changes in medical knowledge, neither the
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who has been involved in the preparation of this
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herein is in every respect accurate or complete,
and they are not responsible for any errors or
omissions or for the results obtained from use
of such information. The information contained
within this brochure is intended for use by doctors
and other health care professionals. This material
is not intended for use as a basis for treatment
decisions, and is not a substitute for professional
consultation and/or use of peer-reviewed medical
literature.
Endoscopic Surgical Anatomy of the Lamb’s Head
Prof. Ranko Mladina, M.D.
Professor of Otorhinolaryngology and Plastic Surgery of the Head and Neck
ENT Department, University Hospital Rebro-KBC Zagreb, Croatia
Head of the Referral Center for Rhinosinusology and Endoscopic Sinus Surgery
Ministry of Health and Social Care Republic of Croatia
Address for correspondence:
Prof. Dr. Ranko Mladina
Pročelnik Referentnog centra za rinosinusologiju i endoskopsku sinusnu kirurgiju
Ministarstva zdravstva i socijalne skrbi Republike Hrvatske
Redoviti član Hrvatske akademije medicinskih znanosti
E-pošta: prof_mladina@yahoo.com
rmladina@gmail.com
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 Endoscopic Surgical Anatomy of the Lamb’s Head 5

Content
Prof. Radovan Subotić, MD, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7
Preparation of the Lamb’s Head for Dissection . . . . . . . . . . . . . . . . . . . . . . . . .  8
Preparation of the Endoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14
Special Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23
Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24
Ethmoid Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  35
Endonasal Endoscopic CSF Leak Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  40
Endonasal Endoscopic Orbital Decompression (EEOD) . . . . . . . . . . . . . . . . . .  44
Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  48
Endoscopic Endonasal Frontal Sinus Procedures according to Draf . . . . . . .  52
Draf I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Draf II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Draf III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Endonasal Endoscopic Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . .  59
Recommended Endoscopes, Surgical Instruments,
Powered Instrumentation, Navigation Panel Unit and Accessories,
Video Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  62
6 Endoscopic Surgical Anatomy of the Lamb’s Head

As the main author, I have the honour to dedicate this book to my teacher

Prof. Radovan Subotić, MD, PhD

without whose initiative and comprehensive support I would not have started the
development of the endonasal endoscopic sinus surgery in Croatia in the year 1989.

The author and his collaborators are grateful to Drago Prgomet, MD, PhD, Professor of
­ to­rhinolaryngology, Head of ENT Department, University Hospital Rebro, Zagreb, Croatia, for
O
his generous support in every respect throughout the entire editing process.
Particular gratitude goes to the colleagues from the Institute of Anatomy of the Veterinary Faculty
in Zagreb: Professor Hrvoje Gomerčić, Dr. Tomislav Gomerčić, and Dr. Martina Duras Gomerčić.
They did a great job in that project by producing precise anatomical sections of the frozen lamb
heads and taking fascinating images, on which they meticulously labeled all relevant anatomical
structures. This was considerably helpful in the editing of this comprehensive monograph on the
descriptive and surgical anatomy of the lamb’s nose and paranasal sinuses. Based on our current
state of knowledge, we have reason to assume that nothing similar, as far as lambs or sheep are
concerned, has been published so far.
Prof. Dr. Radovan Subotić, MD, PhD.
Our gratitude also goes to the radiological team of the private radiological office “Dijagnostika
2000” in Zagreb for the excellent CT-scans of the lamb’s head prepared for scientific purposes.
All of our dissections were performed in the late afternoons, which required additional efforts from
our nurses and technicians in the operating rooms, headed by Mrs. Katica Gugić, chief-nurse.
We very much appreciated all the support given to us during all working sessions of this project.
All of the excellent and brilliantly clear endoscopic pictures were taken by Dr. Katarina Vuković,
MD using a KARL STORZ AIDA System for this purpose. Macroscopic pictures were taken by the
author, who performed all dissections in joint collaboration with Dr. Vuković.
Finally, as the main author of this monograph, I would like to take the opportunity to extend my
special gratitude to those, who have not been mentioned explicitely herein, for the considerable
support and assistance in the realisation of this important reading.
The personnel of our department and I are very proud to the fact that this monograph has been
published at the dawn of the year 2011, the year in which our department is celebrating its 90th
anniversary!

Ranko Mladina
Zagreb, July 2010.
 Endoscopic Surgical Anatomy of the Lamb’s Head 7

Introduction
Endonasal endoscopic sinus surgery is a very challenging surgical discipline. This is mainly due
to the fact, that it is performed within very narrow spaces, all surrounded by anatomical ­structures
of vital importance, like large vessels (carotid artery, basilar artery) and involves ­structures that,
during surgery, are susceptible to potentially adverse effects of iatrogenic injury, most ­commonly
associated with lesions that do not immediately lead to a fatal end, but still can produce
­awkward consequences, whether during surgery itself, or in the early or late postoperative period
­(ophthalmic artery, sphenopalatine artery, frontopolar artery and ethmoid arteries). Apart from
the presence of vital blood vessels, this region is in close proximity to a number of extremely
important nerve structures, such as the optic nerve canal in the lateral sphenoid sinus wall, the
infraorbital nerve canal in the roof of the maxillary sinus, and the pituitary gland within the sella
turcica, at the sphenoid sinus roof, to mention but a few of the most important ones.
Proper surgical orientation in this area is another key factor in mastering the challenges of this
­relatively demanding type of surgery. Since in most cases endoscopic sinus s­ urgery is performed
using 30° or 45°  telescopes, a high level of proficiency is required in order to appropriately
interpret the endoscopic image of the surgical field. Proper ­anatomical knowledge and good
orientation are prerequisites that must be met before considering to perform a surgical procedure
at all. To plan surgery without having a good orientation about the anatomical landmarks and
their locations in the operating field, can lead the unwary surgeon astray, into the wrong direction,
which is fraught with the risk of iatrogenic injury instead of benefit to the patient.
Moreover, the inherent nature of endonasal endoscopic procedures involves that they are
­performed while watching the operative field on the video screen. This means, that the ­surgeon
should be able to concurrently watch the image on the screen while performing surgical
­maneuvers, with the hands pointing in a completely different direction. At first sight, this type
of eye-hand coordination seems to be relatively easy to do, but it is not at all. The best proof
for this phenomenon comes from beginners in endoscopic surgery: they are usually “lost in
space” – confused, they can not trace the tip of the instrument in the operative field, the picture
is not properly orientated etc. Therefore, the factor of bimanual working on one location while
simultaneously following the process at another site makes this otherwise extremely useful
­
­technique very difficult to learn.
This is why, for instance, the initial orientation of the surgical field is based on appropriate
­theoretical knowledge and tenacious exercising. In terms of theoretical knowledge, the trainee is
required to acquire a high level of proficiency in both descriptive and surgical anatomy, including
its numerous variations. Meticulous exercises of dissection constitute a good basis for d
­ eveloping
and improving surgical skills spontaneously, by time. One should also take into account that
nobody in this world is talented for all jobs, which hence applies to endonasal endoscopic sinus
surgery. This does not involve, that someone who is not that good in endoscopic sinus surgery is
not, at the same time, an excellent otorhinolaryngologist. On the contrary!
But all those, who want to develop their endonasal endoscopic skills should ­continuously strive
to improve the technique. A positive outcome will be achieved rapidly by those who are gifted for
this kind of surgery. In the course of time, the less talented colleagues will become aware of this
point, and will spontaneously accept it as a fact.
However, the question is how to make the distinction between gifted and non-­gifted persons?
The most practical solution is to exercise on an animal model, p ­ articularly because dissections on
human cadavers are becoming increasingly expensive, not to mention ethical issues or ­juridicial
regulations restricting or inhibiting their use in many countries in the world.
Besides, the main objective of dissection training is not to learn how to treat a disease, but to
acquire a satisfactory level of basic surgical skills by hands-on training with suitable surgical
instruments. Our dissection course is aimed at trainees who want to familiarize themselves with
the use of endoscopes (in one hand) and various instruments which are inserted into very narrow
spaces of the nasal cavities and sinuses (in the other hand). This is the point!
Once the trainee has gained adequate skills and experience in dissecting on the model, it will be
much easier to begin surgical procedures on humans, under the supervision of a senior surgeon.
Because of that, we have developed a detailed training program for dissection on a lamb’s head
which has been employed in most of our annual traditional courses, known as CIRAS (Croatian
International Rhinosurgical Advanced School). The participants have been very satisfied all the
time, regardless of whether the course was dedicated to septal surgery and rhinoplasties, or to
endonasal endoscopic sinus surgery.
In conclusion, this booklet is intended to serve as a practical guide to a pleasant, ­comprehensive
and thorough learning experience with training on a lamb specimen. Both descriptive and surgic­al
anatomy are explained in detail, just following the usual course of the dissection training session
on a step-by-step basis.
The booklet has been designed to allow trainees to follow each step of the dissection exercises.
We cordially wish a sharp eye, placid hand and a lot of patience, competencies which all are
indispensable for those who consider to go through this exciting experience.

Prof. Dr. Ranko Mladina and collaborators

8 Endoscopic Surgical Anatomy of the Lamb’s Head

Preparation of the Lamb’s Head for Dissection

Provided we have ample supplies of lamb heads, we keep them in the freezer and
use them according to our needs. Still, we must take care about the time planned for
dissection since the head should be melted exactly to the level that is most convenient
for surgical training. This means, that the head which has been frozen at an average
temperature of -15  °C to -20  °C takes eight hours to defrost until thawed at an average
room temperature of 22  °C, or some 12 to 16 hours when it is left to melt slowly, for
instance in a standard refrigerator at an average temperature of +5  °C to +6  °C.
Once the melting process is complete, we recommend that the head be washed
and rinsed carefully under hot tap water, first. Then, the head is cleansed by use of
paper towels, and finally placed on a lump of fresh sculptor’s clay (Fig. 1a), or more
­effectively ­(particularly for the needs of neuronavigation), fixed with the aid of a special
head holder (Figs. 1 b, c, d and e).
However, our recommendation is to soak the lamb’s head in water for 24 hours. The
most important thing is to immerse the head in such a way that the parietal part shows
toward the bottom of the receptacle (Fig. 2). Furthermore, we usually add some spirit
vinegar, approximately 3 tablespoons per two liters of water in order to dissolve all
slimy, mucilaginous secretions, which otherwise are found to accumulate in the n ­ asal

1a 1b 1c

The lamb’s head is placed onto a lump of clay.
Now, that it is attached firmly enough,
dissection can start in a relaxed atmosphere.
Lateral view of the lamb’s head fixed into
the head holder. In this case, only the upper
­posterior and both right / left lateral screws
have been used for fixation.
Three-quarter view of the lamb’s head,
which has been firmly secured in the head
holder. U
­ sually, one screw from behind
and one screw on each side of the head are
enough to firmly fix the head in position,
allowing dissection to be performed with
ease and comfort.

1d 1e
Anterior view of the lamb’s head, which has The head holder is a very useful device that
been fixed to the head holder. allows to work with highest accuracy while
employing a neuronavigation system.
 Endoscopic Surgical Anatomy of the Lamb’s Head 9

cavities of the lamb’s head. If left inside, such secretions can substantially impede
­dissection by smudging the lens of the scope each time the surgeon enters the nasal
cavity. After 24 hours, the head can be taken out from the solution, dried and used for
prompt dissection or stored in the freezer.
If dissection is not planned to be initiated in the short term, the head can be dried in
the same way as described above, i.e., the specimens are just rinsed under tap water,
put in a plastic bag, and stored in the freezer. We found the heads prepared in this way
to be more suitable for successful dissection.
At the very beginning of dissection, it is recommended to remove the main part of the
muzzle including the related portion of the nasal septum (Figs. 3a–o), because, from
the author’s point of view, they have no relevance at all for e ­ ndoscopic sinus surgery. 2
­Moreover, con­sidering that the entrance to the lamb’s nasal cavity is relatively ­narrow
(more narrow than in humans) introduction of instruments into the nasal cavity is Two lamb’s heads are soaked in a mixed
solution of water and spirit vinegar for 24 hours.
­practically ­impossible, if the scope has already been inserted.
We cut the muzzle by using a surgical blade No. 10, which we find most ­appropriate
because it is wide, long and sturdy enough to be safely used for this purpose. F
­ ollowing
removal of the muzzle and the anterior part of the nasal septum, the entrance site is
wide enough to allow for a comfortable approach to the nasal cavities and a smooth
proceeding of dissection.

3a 3b 3c

The handle of the surgical knife is used to The incision is made exactly at this point and The scalpel is guided towards the distal end of
palpate the soft tissues surrounding the carried in anterior direction. the nasal bones …
piriform aperture to localize the site of the
first incision.

3d 3e 3f

… and passes just below the tip of the nasal The incision is continued along the contours … and carrried across to the other side.
bones. of the piriform aperture …
10 Endoscopic Surgical Anatomy of the Lamb’s Head

3g 3h
The incision is continued at the opposite side of the piriform aperture … it joins the incision already made on the other side.
until …

3i 3j
A transverse incision is made from above. The nasal septum still obscures vision of the nasal cavities …

3k 3l
…which is why we remove practically most of the anterior part of the The specimen is now ready for endoscopy.
nasal septum.
 Endoscopic Surgical Anatomy of the Lamb’s Head 11

3m 3n
The preparatory measures have considerably improved vision of the show the vomero-nasal canal, whereas point to the
nasal cavities. – plica recta. cavernous plexus.

The plica recta is a very interesting

anatomical structure which is r­ eadily
noticeable once the scope has been
­
inserted into the nasal cavities (Figs.  3 m
and 3 o). Essentially, the plica recta
­re­presents a mucosal fold located in the
anterior-most part of the nasal ­ cavity.
Proceeding dorsally, the plica recta
shows an increasing degree of pneuma-
tization and finally transforms into the
­superior turbinate. The inferior-most part
of this anatomical configuration stays
superior to the ethmoid labyrinth, ends
blindly and stays very close to the frontal
sinus while approaching its most antero-
inferior ­portions. This is clearly demon-
strated on coronal anatomical sections
(Figs. 21 and 25), and on coronal CT 3o
scans (Figs. 20 and 28).
View to the left lateral nasal wall. – plica recta (counterpart of the ethmoid bulla in
As described above, the plica recta, or, humans), – middle turbinate, – ethmoid labyrinth hidden behind a number of smaller
more posteriorly, the superior turbinate, shell-like formations, – inferior turbinate, – vomero-nasal nerve and canal
is nothing else but the counterpart of (the nerve is of a gray color).
the ethmoid bulla in humans. In order to
preserve integrity of the ethmoid bulla during human endonasal endoscopic surgery, it
is of paramount importance that the surgeon always keeps to the safe side while being
fully aware of the risks involved when searching for the nasofrontal recess and the
frontal sinus ostium itself. Accordingly, the same applies to the plica recta and superior
turbinate in the lamb.

Preparation of the Endoscope

Most of the dissections are performed using 30°-telescopes. In rare cases, and just
for the purpose of training we may also use a 0°-scope. The 70°-scope is used for
the most part in advanced levels of dissections, which involves that the trainee has
already reached a certain degree of surgical skills and experience and is able to cope
with intrinsic challenges related to spacial orientation, an issue that has shown to be
difficult even for the experienced senior surgeon.
At the very beginning of dissection, one has to check the scope’s depth of field and
image quality, which practically means that the image, regardless of whether it is 4
observed directly through the eyepiece or via screen, must be crystal clear. This also One design feature of the upward-oriented
includes cleaning of the distal lens by gently sliding it over a special, wet sponge, or an 30° forward­-oblique telescope is that it has
alcohol-soaked gauze pad. The lens should not be cleaned just by rubbing it against a a beveled tip. Hence, for cleaning, the lens
cleaning sponge or wet gauze, but rather by performing semicircular movements with should be gently slid from back to forth over
the scope's tip which is gently slid from back to forth against the gauze or sponge, as the sponge, which on the i­mage looks as if
the scope was moved from left to right.
demonstrated on Fig. 4, with a 30°-scope.
12 Endoscopic Surgical Anatomy of the Lamb’s Head

Generally speaking, the problem with fogging up of the scope’s distal lens occurs
both in real endonasal endoscopic surgery and in all kinds of cadaver dissections.
In ­contrast to the situation in the living patient, where moisture condensation occurs
­owing to difference in temperature between the internal parts of the nose and the
outside air, fogging during cadaver dissection is the consequence of near contact
­between the optic lens and the extremely mucilaginous, greasy mucus found in all
nasal and paranasal cavities of the lamb. It is therefore prudent to have available a
bundle of gauze soaked in physio­logic solution which allows to clean the lens from
time to time before protecting it against fogging up by wiping it against a pad of gauze
soaked in alcohol or moving it over the surface of a special, prefabricated sponge
used for this purpose. Once the lens has been cleaned properly, the focus should be
­assessed first. The test is very simple: just look through the eyepiece of the scope
which is directed toward the light source. The image should be perfectly clear (Fig. 5).
The second test, intended to assess the quality of the screen image, requires that the
scope be first coupled to the video camera (Fig. 6). The highest level of clarity and
sharpness can be achieved by adjusting the rotatable outer ring on the camera head,
which is a constant component in all KARL STORZ cameras that we have been using
for decades (Fig. 7).
Once the required quality of the screen image has been confirmed, the position of the
image usually needs to be adjusted, i.e., the proper position of the screen ­image of the

5 6
A first test is performed to evaluate the image quality of the scope. The eyepiece of the telescope is coupled to the video camera.

7 8
shows the outer ring of the endo-camera which can be turned The surgeon is seated next to the table, but viewing the image on the
to right or left to control sharpness and clarity of the screen image. screen creates the impression as if positioned in front of the columella.
 Endoscopic Surgical Anatomy of the Lamb’s Head 13

operating field. An adequately positioned screen image of the operating field enables
the surgeon to remain comfortably seated and relaxed while watching the screen and
getting an impression of “sitting on the patient’s thorax”, in the midline, introducing
the scope exactly in the medio-sagittal plane (Figs. 8 and 9). If the surgeon’s preferred
(dominant) hand is the right, he or she usually assumes a sitting or standing position
at the right side of the patient, and vice versa. Anyhow, while sitting or standing next
to the operating table and viewing straight ahead, the surgeon will see the wall or the
door or some other part of the operating room, not the patient’s nose. Accordingly,
there is a very simple solution for this situation: the screen should be placed almost
opposite to the surgeon so that it can be observed very easily.
While defining the position of the image on the video screen, the scope stays 7–8
centi­meters away from the object. The body of the endo-camera is gently rotated to
the left or right using the right hand, while the left hand assists in holding the scope in
the same position, which means that the longitudinal axis of the scope is aligned
­symmetrically towards the columella (Figs. 10 and 11). In this way, it is possible to
obtain an overall view ranging from 0° to 360° (Fig. 12).
Once we have managed to position the screen image of the surgical field, it is time to
introduce the scope in the nose. Prior to doing so, we usually rinse both nasal cavities
using several 20 mL-syringes of alcohol or 2% hydrogen peroxide solution. At the end,
we just irrigate both cavities with saline solution and aspirate all liquids from the nose
with a suction cannula.

9 10
The surgeon looks straight ahead without using the screen, and Orientation of the surgical field. The left hand holds the scope in a fixed
therefore looks at the wall or some other part of the operating room, position, while the right hand rotates the camera around its longitudinal
not at the patient’s nose itself. axis.

11
Proper visualization of the surgical field. The distal lens of the
30°-scope points forward-oblique toward the remnants of the nasal
septum.
12
Inappropriate alignment of the screen image showing the surgical field
(large image on the right). The lens of the scope points to the right, but
both scope and camera should be appropriate, so that the ­images of
the surgical field have the same orientation (small insert image, bottom
left on the screen).
 14 Endoscopic Surgical Anatomy of the Lamb’s Head

Endoscopy
Endoscopy is initiated by carefully advancing the scope along the floor of the nasal
cavity.
The first distinctive feature that arises when entering the nose of the lamb, is the
­similarity with the human nasal cavity: nasal septum, then a structure that resembles
very much the inferior turbinate in humans, and another one amazingly resembling the
human middle turbinate (Fig. 13).
This could be most confusing because the structure – resembling very much the
middle ­turbinate in man – in veterinary medical terminology is named concha ventralis,
­meaning inferior turbinate. On coronal anatomical section, it looks like a 4-month
old embryo, with its back directed towards the nasal septum (Fig. 14). According to
the veterinary anatomical nomen­clature, the term “middle turbinate” (concha nasalis
media) in the lamb is used to denominate a structure that is located much deeper in
the lamb’s nose, and can be clearly seen only if almost all of the inferior turbinate has
been r­emoved. The lamb’s inferior turbinate has two main portions: the superior pars
dorsalis and the inferior pars ­ventralis.
The nasal septum is straight as in all other quadrupeds. There is only one structure
which very rarely can be found in humans: the vomero-nasal prominence at the most
anterior and basal parts of the septum, formed by vomero-nasal cartilage ( on
Fig. 3 n and  on Fig. 13). This cartilage covers the vomero-nasal canal bilaterally.

1 os nasale 16 ductus vomeronasalis 32 labium inferius

2 cartilago nasi lateralis
dorsalis
3 meatus nasi dorsalis
4 cartilago septi nasi
5 incisura nasoincisiva
6 meatus nasi medius
7 plica recta
8 pars dorsalis conchae
nasalis ventralis
9 processus nasalis
ossis incisivi
10 meatus nasi
­communis
11 concha nasalis
ventralis
12 pars ventralis conchae
nasalis ventralis
13 meatus nasi ventralis
14 vomer
15 cartilago
vomeronasalis
17 plexus cavernosi 33 m. orbicularis oris
nasales 34 m. hyoglossus
18 n. infraorbitalis 35 a. sublingualis
19 corpus maxillae 36 gl. sublingualis
20 maxilla – processus poly­stomatica
palatinus 37 m. mylohyoideus
21 plexus venosus palati 38 m. depressor labii
duri inferioris
22 a. palatina major 39 a., v. et n. alveolaris
23 gll. buccales dorsales inferior
40 canalis mandibulae
24 palatum durum
41 m. genioglossus
25 lingua – tunica
mucosa 42 gl. sublingualis
­mono­stomatica
26 papillae labiales
27 corpus linguae 43 corpus mandibulae –
substantia compacta
28 cavum oris proprium 44 m. geniohyoideus
29 septum linguae
30 cavum oris proprium –
tunica mucosa
31 n. hypoglossus

13 14
Endoscopic appearance of the lamb’s left nasal cavity. Coronal anatomical section through the anterior aspect of the lamb’s
indicates the vomero-nasal prominence formed by vomero-­ head.
nasal cartilage.    indicates a structure resembling the human
middle turbinate, which in veterinary medicine is called concha ventralis
(inferior turbinate). The structure indicated by the is not the
inferior turbinate, but actually refers to the cavernous nasal plexus. Its
dilated vessels are clearly demonstrated. The shows the meatus
nasi ventralis (inferior nasal meatus) and the indicates the meatus
nasi communis (common nasal meatus).
 Endoscopic Surgical Anatomy of the Lamb’s Head 15

There are at least two good reasons that can explain why such structure is only
­exceptionally seen in man. The first reason is the fact that rhinologists generally do
not think about the existence of a vomeronasal (Jacobson’s) organ hence they do not
look for it while inspecting the nose. The second reason is simple ignorance: very few
rhinologists have an idea how the rudimentary vomero-nasal Jacobson’s organ in man
looks like. Therefore, they can not trace it, even in its presence because they can not
identify it properly. Furthermore, during endoscopy of this part of the nasal cavity, we
can clearly see a structure resembling very much the inferior turbinate in humans. But
in the lamb, this “inferior turbinate” still does not exactly look like the human inferior
turbinate. This is because in reality it does not refer to any kind of turbinate, but to the
cavernous plexus located within the nasal mucosa, exactly in the region where one
would expect to see the inferior turbinate in humans. The name of this anatomical
­detail is plexus cavernosus nasalis ( on Fig. 3 n, Fig. 14 No. 17,  on Figs. 15
and 16.
The space between the vomeronasal prominence and the cavernous plexus has been
named meatus nasi ventralis, while the space between the nasal septum and inferior
turbinate (concha ventralis) has been named meatus nasi communis (common nasal
meatus). All these details are clearly demonstrated on coronal CT scans of the lamb’s
head on Fig. 17.

15 16
Cadaver specimen of the lamb’s head. The pointers indicate the S – septum, – plexus cavernosus nasalis.
cavernous plexus bilaterally, which can be found at the same site as
the inferior turbinate in humans.

17
Coronal CT-scan of the lamb’s head demonstrating the same sectional
plane as in Figs. 15 and 16. The cavernous plexus is not visible. It is
only detectable as a grayish boundary above the bony floor of the nasal
cavity ( ).
16 Endoscopic Surgical Anatomy of the Lamb’s Head

18a
Endoscopic view of the left nasal cavity. At first sight, there seems to
be some sort of septal defect. Actually, an integral part of the normal
anatomy of the lamb’s nasal septum is shown, called meatus naso-
pharyngicus. The indicates the vertical crest of the palatal bone
which forms the inferior margin of this “defect”. The indicates
the superior part and margin, while the represents a collection of the
mucus. In the deepest aspects of the nasal cavity, a whitish tissue can
be seen (   ) that stems from adenoids.
The next amazing anatomical detail that comes into view when
the scope is advanced more deeply into the nose for just ­another
centimeter, is the absence of almost half of the nasal s­ eptum. At
very first sight, it resembles a defect of the nasal septum in man
(otherwise wrongly named as septal perforation). However, this
is not a defect of the nasal septum, this is a typic­al s­ tructure
in the lamb’s nose called meatus naso-pharyngicus. The
superior margin of this “defect” is formed by so-called septum
pharyngis, consisting of septal cartilage and vomer. The inferior
margin is constituted by the lamina horizontalis ossis palatini
(a horizontal plate of the palatine bone). These two parts are
in close proximity and merge anteriorly, exactly at the opening
of the vomeronasal canal, which is the site where Jacobson’s
nerve arises and terminates with a small branch, the so-called
­terminal nerve (nervus terminalis). Pronounced manifestations
of adenoid vegetations are usually found in the choanal region
(Figs. 18 a–g, and Figs. 22, 23 and 23 b).

18b 18c
The meatus nasopharyngicus represents the fusion of the right and left Adenoids mask the Eustachian tube orifice.
­nasal cavities. Adenoids ( ) obscuring the Eustachian tube
opening, are located more laterally. The indicates the pituitary
gland. There is no sella turcica as in humans. There is no sphenoid sinus
either since there is no angulation of the skull base. The skull base is
straight in quadrupeds. The indicates the optic nerve chiasm.

18d 18e
The adenoids have been moved superiorly, so the tonsilla tubaria has Once, the tonsilla tubaria has been elevated as well, the entrance to
been nicely presented ( ). The indicates neurohypophysis, the Eustachian tube becomes clearly visible. Just anteriorly to it lies a
while the shows the adenohypophysis. The points to the mucosal fold: torus tubarius ( ).
intercavernous sinus.
 Endoscopic Surgical Anatomy of the Lamb’s Head 17

18f 18g
The anatomical forceps has been inserted into the Eustachian tube The forceps has been inserted into the Eustachian tube.
without any problem. The tip of the instrument has emerged at the
anticipated level of the middle ear (see Fig. 25, No. 66).

1 os frontale 14 cartilago septi nasi 28 adenohypophysis 41 impressio medullaris 52 processus palatinus 65 radix linguae
2 septum sinuum 15 jugum sphenoidale 29 arbor vitae 42 septum pharyngis ossis incisivi 66 frenulum linguae
frontalium 16 hippocampus 30 neurohypophysis 43 n. vomeronasalis et 53 tunica mucosa linguae 67 dens incisivus
3 os nasale (cornu Ammonis) 31 os basisphenoidale n. terminalis et papillae linguales ­mandibularis I
4 os parietale 17 sinus rectus 32 dorsum sellae turcicae 44 Organum 54 cavum oris proprium 68 corpus mandibulae –
5 dura mater encephali 18 tentorium cerebelli 33 fossa hypophysialis ­vomeronasale 55 papilla incisiva pars incisiva
6 hemispherium cerebri membranaceum 34 pons 45 vomer 56 pulvinus dentalis 69 m. genioglossus
7 corpus calosum 19 thalamus 35 impressio pontina 46 meatus 57 torus linguae 70 m. thyroaritenoideus
8 nucleus caudatus 20 chiasma opticum 36 pars lateralis ossis ­naso­pharyngeus 58 fossa linguae
21 sulcus chiasmatis 59 pharynx – paries 71 processus lingualis
9 crista galli occipitalis 47 maxilla – processus basihyoidei
10 septum nasi – 22 squama occipitalis 37 medulla oblongata palatinus lateralis
tunica mucosa 23 lamina quadrigemina 48 tunica mucosa nasi 60 palatum molle et 72 cartilago ­thyroidea –
38 synchondrosis corpus
11 cavum 24 os presphenoidale ­spheno­ocipitalis 49 os palatinum – tonsila palatina
­subarach­noidale 25 synchondrosis 39 pyramis medullae lamina horizontal 61 corpus linguae 73 basihyoideum
12 lamina perpendicularis ­inter­sphenoidalis oblongatae 50 plexus venosus palati 62 m. lingualis proprius 74 m. hyoglossus
ossis ethmoidals 26 vermis cerebelli 40 pars basilaris ossis duri (artefakt) 63 apex linguae 75 m. sternohyoideus
13 ventriculus lateralis 27 diaphragma sellae occipitalis 51 rugae palatinae 64 epiglottis 76 m. geniohyoideus
19
Medio-saggital anatomic section through the lamb’s head. The tip of the Pay attention to the black line demonstrating the straight course of the
points to the meatus nasopharyngicus, the bottom of which is lamb’s skull base, i.e., there is no angulation (Huxley’s angle) between the
occupied by the palatine tonsil. The indicates the vomero-nasal anterior and posterior skull base. There is no sphenoid sinus in lambs and
organ (canal). other quadrupeds, most probably for the same reason.
18 Endoscopic Surgical Anatomy of the Lamb’s Head

The “septal defect” can be clearly seen also on coronal anatomical sections and
­coro­nal CT-scans (Figs. 20 and 21). Advancing deeper into the nose, the next
­anatomical detail that presents itself, is the choanal region. Unlike the one found
in man, this region is not oval-shaped, dark and spacious, and there is not a clear
junction of pathways leading to the nasopharynx. Approaching the lateral wall of the
­nasopharynx, the torus tubarius comes into view (Fig. 18 e and Figs. 22 and 23).
Occasionally, the Eustachian tube orifice can also be visualized (Figs. 18 e-g). The
curved ­suction ­cannula, – frequently used in human medicine during endoscopic
surgery of the maxillary sinus, – has been inserted transorally, and appears in the
nasopharynx (Figs. 22 and 23). Performing the same maneuver in the lamb always
takes some effort because its soft palate is very long. If carried out bilaterally, one
might be led to believe that the lamb has two separate nasopharyngeal cavities. Even
more, this false hypo­thesis is confirmed by findings demonstrated on coronal and
sagittal anatomic sections (Figs. 24 and 25). The coronal CT scans support this idea
as well (Fig. 26). Still, in case we remove the posterior septal portion, we shall find the
unique nasopharyngeal cavity, adenoids at the typical place and the torus tubarius,
that serves as a landmark indicating the area of the Eustachian tube orifice (Fig. 23 d
20 and e).
Coronal CT-scan at the level of the meatus
naso-pharyingicus. The partial absence of
the septum is obvious. The indicates
a pneumatized superior turbinate and should
not be mixed up with the frontal sinus, which
will be dissected later on.

1 os nasale 12 concha nasalis media 21 dens molaris III 30 cavum oris proprium 38 n. buccalis 49 m. ceratohyoideus
2 os nasale – 13 corpus maxillae maxillae 31 maxilla – processus 39 v. buccalis 50 m. hyoepigloticus
crista ethmoidalis 14 sulcus vomeris 22 pulpa dentis palatinus 40 papillae buccales
3 meatus nasi dorsalis 23 meatus naso­ 51 corpus mandibulae –
15 maxilla – facies nasalis 32 a. palatina major 41 corpus linguae substantia spongiosa
4 os frontale pharyngeus 42 n. lingualis
16 sinus maxillaris 24 m. masseter 33 corona dentis – 52 n. hypoglossus
5 concha nasalis dorsalis ­enamelum 43 dens molaris III
6 meatus ethmoidales 17 canalis infraorbitalis et 25 infundibulum dentis ­mandibulae 53 basihyoideum
7 sinus frontalis n. infraorbitalis 26 maxilla – processus 34 palatum durum – 44 m. hyoglossus
tunica mucosa 54 a., v. et n. alveolaris
8 meatus nasi communis 18 vomer alveolaris 45 epihyoideum inferior
9 canalis lacrimalis et 19 plexus cavernosi 27 corona dentis – 35 torus linguae 46 m. styloglossus 55 m. digastricus
ductus nasolacrimalis nasales ­denti­num 36 m. buccinator – 47 corpus mandibulae –
10 os lacrimale 20 concha nasalis 28 gll. buccales dorsales pars molaris substantia compacta 56 canalis mandibulae
11 cartilago septi nasi ventralis 29 m. pterygoideus medialis 37 cavum oris 48 m. mylohyoideus 57 m. geniohyoideus
21
The meatus nasopharyngicus (   ) is clearly presented. The septal (­ ­ ) are related to an area that can be easily misinterpreted as frontal
cartilage (No.  11) forming the superior border, and, as in humans, snugly sinus during endoscopic surgery. A finding, that may be adduced in favor
fits into the vomerine groove (No.  14) . The mucosa covering the vomer of this assumption, is the fact that light emanating from the scope shines
is richly vascularized thus forming another cavernous plexus aside the through the bony skeleton of the lamb’s forehead. However, in reality, the
one already found anteriorly (Figs. 15 and 16). The superior turbinates frontal sinus is located in superodorsal direction from this point.
 Endoscopic Surgical Anatomy of the Lamb’s Head 19

22 23
The suction tip is in the left choana. The suction tip is in the right choana.
The septum pharyngis is indicated by
on both Figs. 22 and 23. The refers
to the body of the levator veli palatini muscle.
The indicates the mucosal fold
anteriorly to the Eustachian tube orifice, i.e.
the torus tubarius itself, whereas the
refers to adenoids.

23a 23b 23c

Removal of the posterior portion of the nasal The adenoids can be seen after the removal. The adenoids have been removed as well.
septum. The pointers refer to the torus tubarius,
see Figs. 18 c–g.

23d 23e
The inferior aspect of the lamb's head. The occiput is located on The inferior aspect of the lamb’s head. Now, the occiput is superior,
the left, and the muzzle, on the right. The refers to adenoids, and the muzzle, inferior. The refers to the adenoids, to the
the points to the nasopharynx, the indicates the very soft palate (uvula, in fact), while the indicates to the oropharynx.
elongated soft palate that extends most deeply into the oropharynx,
the shows the oropharynx itself, the indicates the section
plane through the lingual muscle, and the refer to the section
plane through both greater cornua of the hyoid bones.
 20 Endoscopic Surgical Anatomy of the Lamb’s Head

1 sinus frontalis sinister 11 m. retractor bulbi 20 n. maxillaris 28 meatus naso­ 38 m. tensor veli palatini 48 pars nasalis pharyngis
2 septum sinuum 12 gl. lacrimalis 21 a. maxillaris pharyngeus 39 m. masseter 49 n. glossopharyngeus
frontalium 13 labyrinthus ethmoidalis 22 vomer 29 n. buccalis 40 foramen mandibulae 50 m. hyopharyngeus
3 os frontale 14 corpus adiposum 23 periorbita 30 septum pharyngis 41 n. alveolaris inferior 51 a. lingualis
4 meatus ethmoidales intraperiorbitale 24 m. obliquus bulbi 31 os sphenoidale – pro­ 42 v. alveolaris inferior 52 corpus mandibulae
5 bulbus olfactorius 15 camera vitrea bulbi, ventralis cessus pterygoideus 43 m. pterygoideus
32 os pterygoideum 53 n. hypoglossus
6 cornea retina 25 corpus adiposum medialis
7 m. rectus bulbi 16 lens extraperiorbitale 33 m. temporalis 44 a. alveolaris inferior 54 arcus palatinus
medialis 17 m. rectus bulbi 26 m. pterygoideus 34 ramus mandibulae 45 ramus buccalis 55 gl. mandibulars
8 septum nasi osseus ventralis lateralis 35 v. buccalis ­ventralis ni. facialis 56 m. digastricus
9 sclera 18 sinus maxillaris 27 os zygomaticum – 36 m. levator veli palatini 46 mm. palati 57 m. omohyoideus
10 iris 19 bulla lacrimalis ­processus temporalis 37 n. lingualis 47 stylohyoideum 58 In. mandibularis
24
Coronal anatomic section through the related region. It seems to be quite obvious that the septum pharyngis (No.  30) divides the nasopharynx
into halves. It closely communicates with the body of levator veli palatini muscle (No.  36).
 Endoscopic Surgical Anatomy of the Lamb’s Head 21

1 os frontale – 16 os ethmoidale – 27 maxilla – 39 corpus mandibulae – 54 hippocampus (cornu 67 synchondrosis

lamina externa lamina cribrosa processus palatinus pars incisiva Ammonis) ­sphenoocipitalis
2 sinus frontalis 17 hemispherium cerebri 28 cavum oris proprium 40 radix linguae 55 thalamus 68 pons
3 os nasale 18 corpus striatum – 29 plexus venosus palati 41 palatum molle et 56 synchondrosis 69 arbor vitae
4 meatus nasi dorsalis Capsula interna duri (artefactum) tonsilla palatina ­inter­sphenoidalis 70 squama occipitalis
5 sinus conchae dorsalis 19 cavum 30 os palatinum – 42 m. genioglossus 57 diaphragma sellae 71 ventriculus quartus
6 n. ethmoidalis ­subarachnoidale lamina horizontalis 43 m. styloglossus 58 sinus cavernosus et 72 pars lateralis ossis
20 conchae ethmoidales 31 meatus 44 epiglottis rete mirabile epidurale occipitalis
7 os frontale – rostrale
lamina interna et meatus ethmoidales ­naso­pharyngeus 45 m. geniohyoideus 73 medulla oblongata
21 septum nasi – tunica 32 apex linguae 46 m. hyoglossus 59 lamina quadrigemina 74 pars basilaris ossis
8 dura mater encephali mucosa, meatus nasi 60 colliculus rostralis
47 m. hyoepiglotticus occipitalis
9 concha nasalis dorsalis communis 33 fossa linguae 61 tentorium cerebelli
48 basihyoideum 75 cisterna
10 concha nasalis media 22 cartilago nasi lateralis 34 torus linguae 49 cartilago thyroidea – membranaceum ­cerebello­medullaris
11 meatus nasi medius ventralis 35 tunica mucosa linguae corpus 62 sinus transversus 76 In. retropharyngeus
12 sinus conchae mediae 23 septum pharyngis et papillae linguales 50 os presphenoidale 63 colliculus caudalis medialis
13 bulbus olfactorius 24 corpus ossis incisivi 36 dens incisivus 51 ventriculus lateralis 64 os basisphenoidale 77 mm. constrictores
14 os parietale 25 pulvinus dentalis ­mandibularis II 52 jugum sphenoidale 65 hemispherium cerebelli pharyngis
15 concha nasalis 26 tunica mucosa oris – 37 m. lingualis proprius 53 sulcus chiasmatis et 66 tuba auditiva (tuba 78 m. longus capitis
ventralis – pars dorsalis rugae palatinae 38 corpus linguae chiasma opticum Eustachii) 79 foramen magnum
25
Parasagittal anatomic section through the lamb’s head. marks the lateral part of the oro-pharyngeal space. The shows the frontal
sinus, whereas the points to the pneumatized posterior part of the plica recta, which has already transformed into the superior turbinate
that approaches the frontal sinus from below.
22 Endoscopic Surgical Anatomy of the Lamb’s Head

Conversely, coronal CT scans of deeper located planes confirm unobstructed patency

of the c
­ ommunication between the hypothetic right and left halves of the nasopharynx.­
Moreover, it can be assumed that the nasopharynx in lambs is quite spacious and
voluminous (Figs. 27–30).

26
It seems as if the septum pharyngis extends
posterosuperiorly as far as the praesphenoid
and basisphenoid bones, in this way dividing
the nasopharynx into halves.
27
Coronal CT scan taken at the level of the
structures presented in Figs. 22–24. In deeper
aspects, there is still a wide communication
between both sides. It seems to be closed
in virtual sense only because of the mass of
the levator veli palatini muscle ( ). This
muscle has been changed post mortem,
i.e. it is relaxed and flaccid leading to the
­impression of a closed space.

28 29 30

Left image: coronal CT scan; middle and right
images: axial CT scans. All of them clearly
show that the nasopharynx, oropharynx
and hypopharynx form one and the same
cavity. The on Fig. 28 refers to the
concha nasalis superior as continuation of the
plica recta. It literally fuses with the ethmoid
labyrinth and approaches the frontal sinus
from below.
Endoscopic Surgical Anatomy of the Lamb’s Head 23

Special Section

Maxillary Sinus

Ethmoid Sinus

CSF Leak Repair

Orbital Decompression

Frontal Sinus

Frontal Sinus Operations

according to Draf

Dacryocystorhinostomy (DCR)
24 Endoscopic Surgical Anatomy of the Lamb’s Head

Maxillary Sinus
The maxillary sinus in lambs is not a cavity that represents an integral entity, as in
humans. The point here is that even three sinuses can be found at the same place:
maxillary sinus proper, lacrimal sinus and palatinal sinus (Figs. 52, 54 and 56). The
position of these sinuses at coronal anatomic sections and CT scans, reminds one of
an elevated ground floor of a house. The attic of this house accomodates the lacrimal
sinus, whereas in the ground floor there are two rooms, incompletely divided by a
high partition (maxillary sinus proper, located laterally, and palatinal sinus, located
medially. Amazingly, it seems as if the main entrance to this “house”, instead of ­being
located on the ground floor, as front doors usually are, is found on the roof, i.e., the
only, n­ atural entrance to these three ­sinuses passes through the “skylight”, the natural
ostium of the lacrimal sinus. The other two sinuses, that can be found below the first
one, ventilate and drain themselves through this orifice, because all of these three
­sinuses are mutually connected in the anterior part of the complex. If a few drops
of dye are administered into the maxillary sinus from outside through the artificial
­opening in this region, the dye will immediately appear in the second out of five niches

31 32
Right recessus ostiarum. The niche designated as (1) ends blindly, Close-up view of the recessus ostiarum. blind niche (1), the posterior
the second one (2) conceals the entrance to the lacrimal sinus, part; lacrimal sinus niche (2), niches of frontal sinus drainage (3 and 4)
(3) represents the outlet towards the frontal sinus. The indicates (see Fig. 34); most posterior niche (E), probably fusing with the ethmoid
another niche, apparently ending blindly, but it is also possible that sinuses, only visible after advancing the scope until it is very close to
there is a connection to the ethmoid sinuses. This is quite obvious the recess.
on Fig. 32. The indicates the level at which the degree of
pneumatization of the middle turbinate noticeably increases. This
is exactly the point that corresponds to the basal lamella in human
anatomy. Traversing this point and proceeding superiorly at an angle
of approximately 45°, one can directly reach the ethmoid labyrinth.

33
Right recessus ostiarum. The dye, administered into the maxillary sinus
from outside, emanates from the lacrimal sinus, and thus confirms
that the three sinuses are mutually connected and maintain drainage
through the same opening.
34
The scope has been inserted into the left frontal sinus to get an
impression about the bone thickness. An opening is made at a site
where bone thickness is expected to be minimal, which is determined
by transillumination from the other side. Following administration of just
a few drops of dye through the opening, the dye is supposed to appear
somewhere in the recessus ostiarum region.
– lacrimal sinus.
 Endoscopic Surgical Anatomy of the Lamb’s Head 25

in the area of the recessus ostiarum (recess of the sinus openings). This can be seen
on Figs. 31–35.
The lacrimal sinus is partly separated from the palatinal and maxillary sinus by an
almost horizontal bony plate that never extends as far as the anterior wall of these
sinuses, thus providing a passageway in between them (Figs. 42–46, 76 and 98).
Removal of the inferior turbinate is essential for proper identification of the ­maxillary
sinus because the inferior turbinate obscures vision of the middle turbinate, an
­indispensable landmark for localizing the natural ostium of the maxillary sinus, be it
in man or lamb. The lamb’s inferior turbinate, as anatomical structure per se, is not
that interesting to the endoscopic surgeon. This step of dissection is a good exercise
for beginners regarding bimanual maneuvering and is useful in developing the right
feel for the force required during its removal. In this way, trainees are offered the
­opportunity to build their skills in cutting, punching and crunching without putting at
risk the integrity of critical anatomical and surgical landmarks.
The inferior turbinate should be transected with scissors along its insertion to the
lateral nasal wall (Figs. 37–40 ).

35
The dye appears in the niches 3 and 4 simultaneously, immediately
after administration from outside, through the artificially created
opening in the frontal bone.
36
Coronal CT scan of a plane immediately behind the level of the basal
lamella. The refers to the left tuberculum Mladinae, which is
orientated ­laterally and anteriorly, in this way coming into close proximity
to the natural ostium of the lacrimal sinus. This detail can not be seen on
the right side, most probably because of the oblique projection during CT
imaging. The lower portion of the ethmoid labyrinth, therefore, lies at the
same level as the roof of the maxillary sinus (   ). The
indicates the superior turbinate (well-pneumatized!). In deeper regions,
pneumatization of the superior turbinate gradually decreases, and finally
ends blindly anteroinferior to the frontal sinus (see Fig. 68).

37 The inferior turbinate is transected along

its lateral insertion.
37 38 38 The cut is carried deeper ( ).

39 The blade of the scissors partly masks

the head of the middle turbinate ( ),
The refers to the posterior part of
the plica recta.
40 Right inferior turbinate (resembling an
embryo). The left inferior turbinate has
been already removed, therefore the
complete plica recta is visible ( ).
The pointers indicate two out of
three tubercula of the head of the middle
39 40 turbinate.
26 Endoscopic Surgical Anatomy of the Lamb’s Head

It is advisable to remove most part of the plica recta because in this way an
­unobstructed view of the head of the middle turbinate is provided. At first sight, the
middle turbinate seems to have a bifid appearance, so the medial prominence is called
tuberculum septalis ­conchae nasalis mediae Proversae, whereas the lateral one is
named tuberculum conchae ­nasalis mediae Petradae (Figs. 41–43).

41
Bifid head of the right middle turbinate. refers to the prominence,
called tuberculum Petradae, obstructing the view of the recessus
ostiarum (see Fig. 33). Opposite to it, more medially, there is another
prominence, close to the nasal septum, called tuberculum Proversae (P).
42
The outer bony wall of the maxilla has been partly removed, so the natural
ostium of the lacrimal (and both palatinal and maxillary) sinuses can be
clearly identified. The third prominence of the head of the middle turbinate,
tuberculum Mladinae, has almost penetrated this opening ­(­ ). The
indicates the infraorbital nerve. The shows part of the almost
horizontal bony plate which divides the lacri­mal sinus above from the
maxillary and palatinal sinuses below it. Noticeably, these two sinuses
have a good communication between them, and owing to the absence of
the horizontal partition in most anterior aspects, they also communicate
with the lacrimal sinus, located just above them.

43
The main part of the outer bony wall of the right maxilla has been removed,
revealing the course of the infraorbital nerve ( ), the middle turbinate
with the tuberculum Mladinae ( ), and most part of the lateral
surface of the inferior turbinate ( ). The indicates the lateral
prominence of the head of the middle turbinate (tuberculum Petradae),
which obscures vision of the sinus ostia. The refers to the lacrimal
sinus, a cavity located above the maxillary and palatinal sinuses. The
indicates the remnant of the bony partition which divides the
lacrimal sinus from the other two cavities located inferiorly.
44
The main part of the outer bony wall of the right maxilla has been
removed. indicate the remnants of the horizontal bony partition,
the indicates the natural ostium, whereas the refers to
the joint space of those three sinuses located directly superior to the
area traversed by the infraorbital nerve and infraorbital rim. Neither of
the two structures mentioned above can be visualized yet, because the
lower portion of the outer wall of the maxillary sinus, so far, has not been
removed.
 Endoscopic Surgical Anatomy of the Lamb’s Head 27

45 46
The diaphanoscopic effect of the 30° telescope light. The tip of the shows the tip of the curette which has been inserted through the
telescope has been inserted in the region of the recessus ostiarum, natural ostium of the lacrimal sinus. The shows the infraorbital
or more precisely, in front of the niche No. 2 (see Figs. 31 and 32). nerve, and the refers to the palatinal sinus, whereas the
Based on this diaphanoscopic finding, it seems that we are dealing points to the maxillary sinus proper.
with specific types of fontanelles at the medial wall of the palatinal and
lacrimal sinuses. The main difference between fontanelles in the lamb
and those in humans is the fact that human fontanelles are formed
by two layers of mucosa with no additional bony support. Yet, this
finding suggests that the bone at this site is very thin and can be easily
perforated by curved instruments, as is the case in endonasal surgery.

At the level of the head of the middle turbinate, the plica recta passing above,
a ­considerable degree of pneumatization is demonstrated (Figs. 47 and 48).

47 48
shows the pneumatized part of the right plica recta; in fact, this Close up view of the head of the middle turbinate. – tuberculum
part of the plica recta is already the superior turbinate (concha dorsalis). Proversae, – tuberculum Petradae, – tuberculum Mladinae.
– tuberculum Petradae, – tuber­culum Proversae.
28 Endoscopic Surgical Anatomy of the Lamb’s Head

In the next step, the middle turbinate is medialized using a blunt instrument (elevator,
for instance). In this way, the recessus ostiarum comes into view (Figs. 49 and 50).
To clearly demonstrate that the cavity to which the white pointer indicates in Fig. 49,
is actually the lacrimal sinus ostium, it is enough to administer a few drops of dye
into the maxillary sinus from outside. Just a couple of seconds thereafter, the dye
becomes visible in the niche (Fig. 50). It is strongly advised, that the area be inspected
­endoscopically prior to applying the dye, in order to be prepared as to see where
exactly it will flow out. A close-up view of this area allows the tuber­culum Mladinae
to be nicely demonstrated (Fig. 51), which otherwise, in most cases, may be missed.
Once we have placed the scope at the proper place, the diaphano­scop­ic effect ­becomes
noticeable when the light emitted from the tip of the endoscope is directed toward
the bony outer wall of the maxillary sinus (Fig. 52). Next, a back-biting forceps can
be used to remove adjacent tissue and to begin creating a large middle antrostomy
window (Fig. 53).

49 50
The complete head of the middle turbinate and particularly the In order to demonstrate that the cavity to which the refers in Fig. 49
tuberculum Mladinae ( ) have been medialized. The points is actually the lacrimal sinus ostium, a few drops of dye may be applied to
to the ostium of the lacrimal sinus. – tuberculum Petradae. the maxillary sinus from outside. Just a few seconds later, the dye can be
clearly visualized in the niche. – tuberculum Mladinae.
– tuberculum Petradae.

51 52
tuberculum Mladinae. 1 – blind niche, 2 – entrance to the joint The light emitted from the tip of the scope is shining through the maxillary
cavity of the lacrimal, maxillary and palatinal sinus. Also take a look at bone and confirms that we have arrived at the proper site. The illuminated
Fig. 59. area clearly contrasts with the darker part (lacrimal sinus) and presents as
an almost straight line, owing to the fact that the the tip of the telescope
is directed to the inferior fontanelles (see Fig. 45).
 Endoscopic Surgical Anatomy of the Lamb’s Head 29

While performing the middle antrostomy, one should be fully aware that the maxillary
and palatinal sinuses in their posterior aspects are “covered” by an almost horizontal
bony plate, the floor of the lacrimal sinus (Figs. 42–46, 64, 65, 67 and 76).
For this reason, it is strongly recommended that the middle antrostomy window be
created starting from a site located in the posterior-most part to make sure that the
lacrimal sinus is entered first. Once this has been accomplished, the antrostomy
should be enlarged anteriorly first, using back-biting forceps. The horizontal bony
plate, representing the floor of the lacrimal sinus, must be presented clearly. Removal
of this plate opens up the view of the rim of the infraorbital nerve canal and its course.
The procedure requires that the main part of the medial plate of the palatine sinus be
removed. We commonly use the antrum punch for this maneuver (Fig. 55), which in
most of the cases is required to clearly identify the white, distinct linear shape of the
infra­orbital nerve traversing the superior edge of the infraorbital rim (Figs. 20, 42, 43,
46, 54, 56–58 and 63). Total exposure of the floor of the palatinal sinus requires that
its medial wall be ­removed completely (Fig. 56).

53 54
Middle antrostomy involves that an opening be created first in the bone indicates the superior boundary of the infraorbital rim. The punch
of the superior, larger fontanelle (see Fig. 45). is just removing the posterior parts of the middle antrostomy, including
the most anterior cells of the ethmoid labyrinth. – orbital wall.

55 56
The antrum punch is used to remove the inferior part of the antrostomy. The infraorbital rim has been clearly exposed ( ). The floor of the
palatine sinus is visible ( ). – orbital wall.
30 Endoscopic Surgical Anatomy of the Lamb’s Head

Once the infraorbital rim has been fully exposed, and the course of the nerve becomes
visible, an opening can be made in the nerve canal, allowing the nerve to be ­extracted
(Figs. 57 and 58). The next step is performed from the outside and involves e ­ xposure
of the exit point of the infra­orbital nerve arising on the the a
­ nterior surface of the
­maxillary bone (Fig. 59).

57 demonstrates that the infraorbital nerve has been partly

removed from its canal. – maxillary sinus; – palatinal
sinus. refers to the orbital wall. shows the lower portion
of the most anterior ethmoid cells. Notice, that the orbital wall is
located in dorsal aspects of them. 57

58 59
The infraorbital nerve is extracted and incised at the point where it shows the typical exit point of the infraorbital nerve on the maxilla.
enters the infraorbital canal of the maxilla. This is why it just hangs in the It can be identified even through the periosteum. The curette points to
palatine sinus. – a part of the orbital wall. the course of the main nerve trunk.

60 61
Nicely exposed bifurcation of the infraorbital nerve. View of the lumen of the infraorbital canal following nerve extraction.
 Endoscopic Surgical Anatomy of the Lamb’s Head 31

Consistent with human anatomy, the infra­orbital nerve, after arising from the canal,
gives off smaller branches thus forming a network resembling very much the pes
anserinus of the orbital nerve in man (Fig. 60). The nerve than can be transected and
removed from the bony canal, so as to accomodate the 2.7-mm scope (0° direction
of view) which is inserted to gain access to the internal space of the maxillary, lacrimal
and palatinal sinuses (Figs. 61–63).
In conclusion, it can be said that the maxillary sinus in lamb definitely exists. It is just
a part of the specific “sinus complex” which contains three sinuses: lacrimal, palatinal
and maxillary sinus proper. The lacrimal sinus is situated above the other two cavities,
partly separated from them by an almost horizontal bony plate which is absent in the
most anterior aspect of the complex (Fig. 64). The maxillary and palatine sinuses are
divided by the rim of the infraorbital nerve canal (Figs. 56, 57). The former is located in
the lateral compartment, while the latter belongs to the medial parts. Apart from that,
we know exactly where the natural ostium of the lacrimal sinus is. Maxillary and ­palatine
sinuses have their drainage through a common ostium. Finally, we know very well
how to approach this sinus complex and how to perform a middle antrostomy. Once
the middle antrostomy has been completed in compliance with the relevant ­surgical
principles, we are ready to proceed with the next step of dissection: ­exploration of the
ethmoid labyrinth and endonasal endoscopic orbital decompression.

62 63
Endoscopic image, taken from outside, showing the most anterior part The scope has been passed through the canal and its tip is now in the
of the infraorbital canal. The indicates the remaining piece of the lacrimal-palatinal-maxillary sinus complex. The refers to the right
infraorbital nerve at the roof of the canal. maxillary sinus, whereas the shows the emptied posterior part
of the infraorbital nerve canal. The jaws of the Blakesley’s forceps are in
contact with the remaining portion of the nerve canal.

64 Sagittal CT-scan of the maxillary, palatine and lacrimal sinuses

complex. The indicates the horizontal bony plate that
separates the lacrimal sinus from the palatine and maxillary cavities,
but in their posterior parts, only. In most anterior aspects, the three
sinuses can freely communicate. The green oval shows the orbital
region. Above the orbit, a few ethmoid cells are visible too. The
shows the upper edge of the rim of the infraorbital nerve
64 canal.
32
1 os nasale
2 meatus nasi dorsalis
3 os nasale – crista
ethmoidalis
4 concha nasalis dorsalis
5 concha nasalis media
6 meatus nasi medius
7 pars dorsalis conchae
nasalis ventralis
8 cartilago septi nasi
9 apertura naso­maxillaris
10 meatus nasi communis
11 canalis lacrimalis et
ductus nasolacrimalis
12 os lacrimale
65
The anatomical relationship between the lacrimal (13), maxillary (22) and palatinal (29) sinuses is nicely visible. They gradually merge into each
other, forming a joint cavity in the most anterior parts of the complex (Fig. 66).
13 sinus lacrimalis
14 vomer
15 crista conchalis
16 sulcus vomeris
17 corpus maxillae
18 a. infraorbitalis
19 apertura
­maxillo­palatina
20 plexus cavernosi
nasales
21 canalis infraorbitalis et
n. infraorbitalis
22 sinus maxillaris
23 pars ventralis conchae
nasalis ventralis
24 m. masseter
Endoscopic Surgical Anatomy of the Lamb’s Head
25 meatus naso­ 35 corona dentis – 45 papillae buccales 57 gl. sublingualis
pharyngeus ­enamelum 46 m. hyoglossus ­poly­stomatica
26 a. palatina major 36 infundibulum dentis 47 dens molaris I 58 m. styloglossus
27 maxilla – processus 37 dens molaris I maxillae ­mandibulae 59 n. lingualis
palatinus 38 corona dentis – 48 v. labialis inferior 60 n. hypoglossus
28 plexus venosus palati ­denti­num 49 gll. buccales ventrales
duri 39 vestibulum oris 50 septum linguae 61 m. digastricus
29 sinus palatinus 40 m. buccinator – 51 corpus mandibulae – 62 canalis mandibulae
30 pulpa dentis pars buccalis substantia spongiosa 63 m. geniohyoideus
52 corpus mandibulae –
31 m. masseter – pars 41 corpus linguae 64 a., v. et n. alveolaris
superficialis – tendo 42 bucca substantia compacta inferior
32 maxilla – processus 43 cavum oris proprium 53 a. profunda linguae 65 v. sublingualis
alveolaris 44 m. lingualis proprius 54 m. genioglossus
33 palatum durum – (fibrae transversae, 55 m. depressor labii
tunica mucosa perpendiculares et inferioris
34 torus linguae longitudinales) 56 m. mylohyoideus
 Endoscopic Surgical Anatomy of the Lamb’s Head 33

1 os nasale 12 concha nasalis media 21 dens molaris III 29 m. pterygoideus 37 cavum oris 48 m. mylohyoideus
2 os nasale – crista 13 corpus maxillae maxillae medialis 38 n. buccalis 49 m. ceratohyoideus
ethmoidalis 14 sulcus vomeris 22 pulpa dentis 30 cavum oris proprium 39 v. buccalis 50 m. hyoepigloticus
3 meatus nasi dorsalis 15 maxilla – facies nasalis 23 meatus 31 maxilla – processus 40 papillae buccales 51 corpus mandibulae –
4 os frontale ­naso­pharyngeus palatinus 41 corpus linguae substantia spongiosa
5 concha nasalis dorsalis 16 sinus maxillaris 32 a. palatina major 52 n. hypoglossus
24 m. masseter 42 n. lingualis
6 meatus ethmoidals 17 canalis infraorbitalis et 33 corona dentis – 43 dens molaris III 53 basihyoideum
7 sinus frontalis n. infraorbitalis 25 infundibulum dentis ­enamelum ­mandibulae 54 a., v. et n. alveolaris
8 meatus nasi communis 18 vomer 26 maxilla – processus 34 palatum durum – 44 m. hyoglossus inferior
9 canalis lacrimalis et 19 plexus cavernosi alveolaris tunica mucosa 45 epihyoideum 55 m. digastricus
ductus nasolacrimalis nasales 27 corona dentis – 35 torus linguae 46 m. styloglossus 56 canalis mandibulae
10 os lacrimale 20 concha nasalis dentinum 36 m. buccinator – ­ 47 corpus mandibulae – 57 m. geniohyoideus
11 cartilago septi nasi ventralis 28 gll. buccales dorsales pars molaris substantia compacta
66
Maxillary and palatinal sinuses form a joint cavity in the most anterior parts of the complex.
34 Endoscopic Surgical Anatomy of the Lamb’s Head

1 os nasale 14 crista conchalis 24 meatus 34 corona dentis – 44 papillae buccales 56 gl. sublingualis
2 meatus nasi dorsalis 15 sulcus vomeris ­naso­pharyngeus ­enamelum 45 m. hyoglossus ­poly­stomatica
3 os nasale – crista 25 a. palatina major 35 infundibulum dentis 46 dens molaris I 57 m. styloglossus
16 corpus maxillae
ethmoidalis 26 maxilla – processus 36 dens molaris I maxillae ­mandibulae 58 n. lingualis
4 concha nasalis dorsalis 17 a. infraorbitalis palatinus 37 corona dentis – 47 v. labialis inferior 59 n. hypoglossus
5 concha nasalis media 18 apertura 27 plexus venosus palati dentinum 48 gll. buccales ventrales
6 meatus nasi medius ­maxillo­palatina duri 38 vestibulum oris 49 septum linguae 60 m. digastricus
7 pars dorsalis conchae 19 plexus cavernosi 28 sinus palatinus 39 m. buccinator – 50 corpus mandibulae – 61 canalis mandibulae
nasalis ventralis nasales 29 pulpa dentis pars buccalis substantia spongiosa 62 m. geniohyoideus
8 cartilago septi nasi 20 canalis infraorbitalis et 30 m. masseter – pars 40 corpus linguae 51 corpus mandibulae – 63 a., v. et n. alveolaris
9 meatus nasi communis n. infraorbitalis superficialis – tendo 41 bucca substantia compacta inferior
10 canalis lacrimalis et 31 maxilla – processus 42 cavum oris proprium 52 a. profunda linguae 64 v. sublingualis
ductus nasolacrimalis 21 sinus maxillaris alveolaris 53 m. genioglossus
43 m. lingualis proprius
11 os lacrimale 22 pars ventralis conchae 32 palatum durum – (fibrae transversae, 54 m. depressor labii
12 sinus lacrimalis nasalis ventralis tunica mucosa perpendiculares et inferioris
13 vomer 23 m. masseter 33 torus linguae longitudinales 55 m. mylohyoideus
67
Coronal anatomic section through the middle of the maxillary sinus.
 Endoscopic Surgical Anatomy of the Lamb’s Head 35

Ethmoid Sinus
The ethmoid sinus in the lamb has a labyrinth-like appearance. It literally consists of an
immense amount of small air cells that make up this unique and highly complex entity
located just beneath the superior turbinate (Figs. 28, 47, 68 and 69), which obviously
ends blindly just anterior to the skull base. In this way, the posterior end of the superior
turbinate approaches the frontal sinus from below and from anterior.
Still, it seems that this well-pneumatized entity could be considered the counterpart of
the ethmoid bulla in humans. Namely, it suffices to imagine that the region ­covered by
the green oval in Fig. 68, after rotation to the left for 90°, m ­ imics the natural p
­ osition
of the human ethmoid sinuses. In this new, most anterior
position, the lamb’s superior turbinate in terms of anatomical
arrangement and external appearance distinctly resembles
­
an ethmoid bulla in humans. Finally, the position of the lamb’s
frontal sinus, when translated onto the ­human cranium, results
in some sort of h ­ ypothetic “parietal ­sinus” which, as everybody
knows, does not exist in man at all. Therefore, the human
anatomist is still faced with a great ­dilemma: is the pneumatized
superior turbinate in lambs actually a counterpart of the human
ethmoid bulla or not? (Fig. 69). It is well known that the anterior
wall of the human ethmoid bulla leads directly to the narrowest
parts of the naso-frontal recess. Even in Fig.  69, the recess
­between the superior turbinate and the posterior part (only on
this image, otherwise, the inferior part) of the lamb’s frontal s­ inus
makes the surgeon believe that, most probably, the ostium of
the frontal sinus itself could be localized unequivocally, which
proves to be a misconception.
This is due to the fact that the frontal sinus in lamb is divided in 68
8–10 compartments, so the core issue here is where and how Sagittal CT scan of the lamb’s head. Pay attention to the area covered
they (if at all) communicate with each other, and where do they by the green oval. The refers to the frontal sinus, the
drain into? Do they drain through one and the same ostium on shows a well-pneumatized superior turbinate, which obviously ends
each side, or through several of them? These questions will be blindly, just anterior to the skull base. In this way, the posterior end of
deferred to a subsequent chapter addressing the frontal sinus. the superior turbinate approaches the frontal sinus from below and
from anterior. – ethmoid labyrinth.

69 70 71

Axial CT scan of the lamb’s ethmoid labyrinth Axial CT scan of the lamb’s head. The The CT scan was taken at a lower level. The
after 90° rotation to the left, so as to imic indicates the lateral prominence of the indicates the lacrimal sinus. The
human anatomy. The shows the ethmoid labyrinth which forms the crest Zite refers to the joint space interconnecting the
frontal sinus, the refers to the superior (crista ethmoidalis sinus maxillaris Zite). The maxillary and palatinal sinuses. indicates
­turbinate, while the indicates the floor indicates the very profound recess the plica recta. The ethmoid sinus stays at
of the fronto-ethmoid recess. of the maxillary sinus, which is called orbital ­varying distance from the orbital wall. It is
recess Tido (recessus orbitalis sinus maxillaris therefore prudent to bear this in mind when
Tido). The shows the crista galli. training endoscopic orbital decompression in
the lamb. The – crista galli.
36 Endoscopic Surgical Anatomy of the Lamb’s Head

Anyhow, the superior turbinate posteriorly approximates the cribriform plate, a thin
piece of bone, behind which the olfactory bulb is found bilaterally (Fig. 25, No.  13,
Fig. 80, No. 5 and Fig. 84). Medially, the superior turbinate stays in contact with the
nasal septum, and in lateral direction closely approaches the orbital wall posteriorly. In
anterior ­aspects, it touches the inner surface of the middle turbinate (Figs. 28, 74, 85,
86 and 99).
The largest area of contact between the ethmoid labyrinth and the orbit is found near
the exit point of the infraorbital nerve on the orbit itself, i.e., at the very beginning of
the course of this nerve, above the infraorbital rim. This suggests that one should
keep medially when attempting to train orbital decompression in the lamb, because in
this way, removal of a large portion of the orbital wall is both feasible and safe (Figs.
70–71). Nevertheless, the surgeon must be well aware of the fact that in this specific
area a bony prominence can be found, namely the crista ethmoidalis sinus ­maxillaris
Zite (Fig. 70). Removal of that crest is usually associated with strong, hard and forcible
manipulations, which is incompatible with the minimally invasive technique and can
rapidly cause an iatrogenic skull base trauma.
Fig. 74 nicely shows the relationship between the posterior ethmoid wall and the skull
base, i.e. cribriform plate. The exact site where bone thickness is minimal can be
­visually detected by transillumination of the endocope’s light. It is extremely i­mportant
here to localize the point of insertion of the middle turbinate, which remarkably
­resembles the basal lamella in human medicine, i.e. the boundary between the anterior
and posterior ethmoid labyrinth in humans, whereas in the lamb, it just defines the
demarcation line between the nasal cavity and the ethmoid labyrinth as a whole.
Figs. 74 and 75 clearly show the relationship between the posterior ethmoid and the
endocranium. Figs. 70–73 and 76 nicely demonstrate the relationship between the
ethmoid labyrinth and maxillary sinus, on one side, and the orbit, on the other.

72 Axial CT scan of a lower plane as compar­ed

to Fig. 71. The infraorbital rim is clearly
­visible in the right lacrimal-palatinal-
maxillary complex. This structure divides
the maxillary sinus (laterally) from the
palatinal sinus (medially). There is some
asymmetry between the rim on the right,
and the one on the left, perhaps due to
oblique projection during imaging. The
indicate a peculiar “basal lamella”.
In fact, this structure is nothing else but the
most posterior part of the middle turbinate.
Hence, passing beyond, the surgeon enters
the ethmoid labyrinth of the lamb’s head,
whereas in humans, exclusively enters the
posterior ethmoid. 72 73
Axial CT scan of a lower plane than in Fig. 72.
The infraorbital rim is clearly visible. The
refer to the maxillary sinuses, whereas
indicate the most inferior, residual ethmoid cells.
 Endoscopic Surgical Anatomy of the Lamb’s Head
74
Left half of the lamb’s head. The green oval indicates the region of the ethmoid
labyrinth that has just been emptied. The shows the endocranial space
(brain has been already removed). The bony posterior ethmoid wall is extremely
thin and appears translucent even for ambient light. indicates the “basal
lamella”, that is the inferior part of the middle turbinate.
76
Left half of the lamb’s head in the projection of the posterior part of the
maxillary sinus viewed from medially to laterally. The medial maxillary
sinus wall has been removed, so the exit point of the infraorbital nerve
is clearly visible ( ). The indicates the supero-anterior part of
the orbital wall, indicates the remaining (the deepest) part of the
lacrimal sinus, while the indicate the insertion of the ex bony plate
which otherwise demarcates the lacrimal sinus from both the maxillary
and palatinal sinuses. The refers to scarce remnants of the deepest
ethmoid cells maintaining close proximity to the skull base.
78
Postero-anterior view of the left cranial fossa following its complete
exposure. The anterior wall has an oval, large recess with a facet-like
appearance. In fact, the floor of this cavity is the cribriform plate. In case
the surgeon passes beyond any part of this region, particularly across
its middle part, the instruments would enter into the posterior ethmoid
labyrinth. indicates the crista galli.
37
75
The ethmoid labyrinth has been removed completely. The ambient light
shines through the cribriform plate (posterior ethmoid wall). The region
that borders the thinnest part of the bony skull base hence is located in
the bifurcated zone between the inferior margin ( ) of the middle
turbinate and its superior, free margin ( ).
77
Sagittal anatomic section through the lamb’s head. View of the left half.
The indicates the entrance to the palatinal and maxillary sinuses,
the black circle encloses the residual ethmoid cells, while the
indicates the intersphenoid synchodrosis (the junction between two
parts of the sphenoid bone – see Figs. 18b, 19 and 25). Proceeding with
removal of the ethmoid cells in the direction of the , the cribriform
plate would be directly approached.
79
Axial CT scan at the level of the ethmoid labyrinth. It is quite obvious how deep
the endocranium penetrates into the nasal cavity. The anatomic configuration
of this particular case resembles Keros type III in human anatomy. As a rule,
one should attempt to localize the posterior wall of the maxillary sinus, or
better said, the exit point of the infraorbital nerve, which serves as anatomic­al
landmark and helps to decide how deep one should go when exploring the
ethmoid labyrinth ( ). Apart from that, inadvertent penetration into the
endocranium can be prevented. – olfactory bulbs, bilaterally.
 38 Endoscopic Surgical Anatomy of the Lamb’s Head

1 sinus frontalis sinister 11 m. retractor bulbi 20 n. maxillaris 28 meatus 38 m. tensor veli palatini 48 pars nasalis pharyngis
2 septum sinuum 12 gl. lacrimalis 21 a. maxillaris ­naso­pharyngeus 39 m. masseter 49 n. glossopharyngeus
frontalium 13 labyrinthus ethmoidalis 22 vomer 29 n. buccalis 40 foramen mandibulae 50 m. hyopharyngeus
3 os frontale 14 corpus adiposum 23 periorbita 30 septum pharyngis 41 n. alveolaris inferior 51 a. lingualis
4 meatus ethmoidales intraperiorbitale 24 m. obliquus bulbi 31 os sphenoidale – 42 v. alveolaris inferior 52 corpus mandibulae
5 bulbus olfactorius 15 camera vitrea bulbi, ventralis ­processus pterygoideus 43 m. pterygoideus
6 cornea 32 os pterygoideum 53 n. hypoglossus
retina 25 corpus adiposum medialis
7 m. rectus bulbi 16 lens extraperiorbitale 33 m. temporalis 44 a. alveolaris inferior 54 arcus palatinus
medialis 17 m. rectus bulbi 26 m. pterygoideus 34 ramus mandibulae 45 ramus buccalis 55 gl. mandibularis
8 septum nasi osseus ventralis lateralis 35 v. buccalis ­ventralis ni. facialis 56 m. digastricus
9 sclera 18 sinus maxillaris 27 os zygomaticum – 36 m. levator veli palatini 46 mm. palati 57 m. omohyoideus
10 iris 19 bulla lacrimalis ­processus temporalis 37 n. lingualis 47 stylohyoideum 58 In. mandibularis
80
The ethmoid labyrinth ends posteriorly, at the level of the cribriform plate. The olfactory bulb (No. 5) is located just behind it. The medial parts of
the frontal sinuses’ “crown” are shown in this anatomical section. The ethmoid labyrinth stays in close proximity to the orbital walls. At least on the
left side of this anatomical section, the maxillary sinus can be seen (No. 18).
 Endoscopic Surgical Anatomy of the Lamb’s Head 39

1 os frontale 12 gl. lacrimalis 23 v. sphenopalatina 33 meatus 42 ramus buccalis 52 m. ceratohyoideus

2 sinus frontalis
3 concha nasalis dorsalis
4 cornea
5 corpus adiposum
intraperiorbitale
6 labyrinthus ethmoidalis
7 camera anterior bulbi
8 m. retractor bulbi
9 iris
10 camera vitrea bulbi,
retina
(ablatio a­ rte­ficialis)
11 sclera
13 cartilago septi nasi 24 os zygomaticum – ­naso­pharyngeus ­ventralis ni. facialis 53 thyreohyoideum
14 m. obliquus bulbi ­processus temporalis 34 m. masseter 43 n. lingualis 54 n. hypoglossus
ventralis – origo 25 a. sphenopalatina 35 os palatinum – lamina 44 palatum molle 55 m. digastricus
15 m. rectus bulbi 26 n. pterygopalatinus perpendicularis 45 tonsila paraepiglottica 56 m. sternohyoideus
ventralis 27 corpus adiposum 36 n. buccalis 46 m. stylopharyngeus 57 m. hyoepigloticus
16 a. infraorbitalis extraperiorbitale 37 m. temporalis rostralis 58 m. omohyoideus
17 n. maxillaris 28 m. pterygoideus 38 os pterygoideum – 47 stylohyoideum 59 a., v. et n. alveolaris
18 m. obliquus bulbi lateralis hamulus 48 epiglotis inferior
ventralis 29 septum pharyngis 39 m. pterygoideus 49 dens molaris III 60 corpus mandibulae –
19 sinus maxillaris 30 fossa pterygopalatina medialis ­mandibulae substantia compacta
20 bulla lacrimalis 31 mezenhim zubne 40 m. buccinator – 50 a. lingualis 61 gl. mandibularis
21 sulcus vomeris vrećice pars molaris 51 m. hyopharyngeus
22 vomer 32 gll. buccales dorsales 41 v. buccalis

81
The lateral parts of the frontal sinus “crown” are already visible, but their medial aspects are in a more posterior position, and therefore invisible on
this specific anatomical section. The large borderline between the maxillary sinus and orbit is marked by the .
40 Endoscopic Surgical Anatomy of the Lamb’s Head

82 83
shows the deepest portion of the pneumatized left superior Frontal sinus ( ).
turbinate. By proceeding in a supero-posterior direction one can reach
the frontal sinus proper. indicates the real floor of the ethmoid
labyrinth. On Fig.  84, at this very place, the olfactory bulb has been
exposed. The refers to the left maxillary sinus. shows part
of the orbital wall.

Figure 82 shows the appearance of the ex-ethmoid labyrinth

just after complete removal of the most posterior ethmoid cells
and upon creation of the middle antrostomy. The entrance of the
passageway toward the frontal sinus has been widely enlarged
through a pneumatized superior turbinate. In case d ­ issection
is continued in this direction, particularly when directed more
superiorly, the instrument tip would enter the frontal sinus
(Fig. 83).
Figure 84 shows the posterior wall of the ethmoid labyrinth. An
artificial opening has been created here to gain access to the
84 olfactory bulb.
The shows the olfactory bulb, the indicates the
passageway to the frontal sinus.

Endonasal Endoscopic CSF Leak Repair

Repair of a CSF leak can be trained effectively with the lamb’s head. Both onlay and
underlay techniques can be practiced.
The onlay technique involves that the graft be placed on the denuded bone of the
skull base defect from “outside”, instead of inserting it below the defect margins.
The point is to place the graft in such a way, that it fully covers the defect. As a rule
of thumb, the diameter of the graft should be fashioned 1–2 millimeters larger than
the defect itself. Once the graft has been placed successfully, we usually employ a
synthetic, thin ­bioresorbable patch, affixed with human fibrinogen. The patch should
always be placed in such a way that its active surface is in close contact with the
dura (the active surface should, under any circumstances, be clearly distinguishable,
preferably c
­ olor-coded, to make sure that it cannot be confused with the o­ pposite side
of the material). The size of this second layer is approximately 2–5 millimeters larger,
depending on the free space available to attach the platelet properly without wrinkling.
Wrinkles in CSF leak repairs are absolutely unacceptable b ­ ecause they are usually
associated with a failure of the procedure.
The onlay technique is used if the size of the defect is smaller than 5 millimeters in
­diameter, and if the leak is only of minor degree, or almost hardly visible. Besides, the
technique is suitable for the repair of CSF leaks in the sphenoid sinus area, p­ articularly
when located on its lateral wall. The sphenoid sinus is surrounded by a great variety of
vital structures (cavernous sinus, carotid artery, optic nerve, fronto­polar artery, basilar
artery), so underlay technique could be very dangerous and not very reasonable.
 Endoscopic Surgical Anatomy of the Lamb’s Head 41

85 86
Coronal CT scan of the lamb’s head. The green dotted line connects two Left lateral nasal wall. – plica recta (more anteriorly), i.e. superior
horizontal plates – the floors of the lacrimal sinuses. All of the structures turbinate (more posteriorly); – the head of the middle turbinate,
located in a superior level, belong to the ethmoid labyrinth (yellow – the head of the biggest and most anterior ethmoid cell; shows
circles). If the surgeon continues penetrating into this region, particularly the inferior turbinate, while the tetrahedron encloses the part of the
with the instrument directed mainly medially, the cribriform plate should ethmoid labyrinth that has to be removed when targeting the cribriform
be spotted very rapidly allowing the artificial defect to be created easily. plate.

87 88
The ethmoid sinus has been completely emptied. The cribriform plate The deepest part of the left ethmoid labyrinth. E – Posterior and lateral
seems to be almost transparent. Integrity of the middle turbinate, as the residual ethmoid cells. indicates the blind end of the superior
frame of the ethmoid labyrinth, has been completely preserved. turbinate, whereas the refers to the artificial opening at the
cribriform plate. A little amount of cerebrospinal fluid is visible at the
boundaries of the defect.

Conversely, if the surgeon is faced with a defect larger than 5 millimeters in diameter,
and particularly if discharge of cerebrospinal fluid is considerable, it is mandatory, that
the defect be managed in an underlay fashion, which involves that the graft be placed
in the epidural space below the margins of the bone defect, but still above the dura.
How to train such techniques on the lamb’s head?
First of all, the trainee creates an artifical defect in the skull base. This can be achieved
in the deepest parts of the ethmoid sinuses (Figs. 68, 70, 71, 74, 75, 77, 79, 80, 82
and 84). The best way to penetrate the endocranium is to advance into deeper layers
by removing the ethmoid cells, but without exceeding the level of an imaginary line
that connects the right and left horizontal plate of the (floor of the) lacrimal sinuses, i.e.
slightly superior to the inferior edge of the middle turbinate (Figs. 85–87).
Once the deepest ethmoid cells have been removed and the tip of the instrument
has reached as far as the cribriform plate, an artificial opening should be created so
as to prepare the “operating field” for a CSF leak repair (Figs. 88 and 89). Once the
onlay technique has been practiced several times, one can proceed with the underlay
­technique (Figs. 90–95 and 96). For training purposes, a maxillary periosteal graft
should be harvested because a flap from this “donor site” can be easily elevated
­allowing a piece of practically any size to be adequately shaped and trimmed as per
individual needs. The consistency of the flap is very similar to those used in human
surgery for repair of CSF rhinorrhea. Preparation of the flap is demonstrated in Figs.
97a–c).
42 Endoscopic Surgical Anatomy of the Lamb’s Head

89 90
The left olfactory bulb is visible ( ) just beneath the archnoid A previously fashioned layer of graft material is placed over the skull
membrane. base defect with a Blakesley forceps.

91 92
The patch is being adapted. A curved curette is used to fit in the patch until it assumes a proper
­position below the margins of the bone defect. The upper edge of the
patch has already adhered to the dura and brain, whereas the lower
edge still needs to be readjusted.

93 94
View of the underlay graft which has now been fitted into its proper The image confirms that the overlap of the inserted patch exceeds the
position below the margins of the bone defect. No signs of wrinkles. free margins of the bone defect for at least 2 millimeters.
 Endoscopic Surgical Anatomy of the Lamb’s Head
95
Administration of fibrin glue.
97a
The circular incision has been made on the
periosteum covering the outer wall of the right
maxillary sinus. Using the curette or some
other appropriate instrument the periosteum
is detached from the bone taking care to
preserve integrity of the flap.
96
All recesses should be filled with fibrin glue to prevent recurrence of CSF
rhinorrhea.
97b
Elevation of the maxillary mucoperiosteal flap
is almost complete. The remaining portion
firmly adheres to the infraorbital nerve sheath.
The nerve can be transected, and the flap is
dissected free.
43
97c
The pale side of the flap, i.e. the one pressed by
the tip of the curette, should be placed over the
dural defect. The darker side should be faced to
the nasal cavity.
44 Endoscopic Surgical Anatomy of the Lamb’s Head

Endonasal Endoscopic Orbital Decompression (EEOD)

The relevant anatomical relationships in the lamb between ­the palatinal, m ­ axillary
and lacrim­al sinuses – and in particular between the ethmoid l­abyrinth and the orbit
– are very favorable for practicing endoscopic orbital decompression. In the author’s
­opinion, EEOD training is facilitated by this type of specimen, and, beyond any doubt,
pleasant, because a steep learning curve ­rewards the trainees for all the time and
effort put in to improve their surgical skills d ­ uring each step of dissection training.
None­theless, endoscopic orbital decompression, by all means, should not be the first
thing to do for beginners in this field. Figs. 49, 51, 57, 63, 69-73, 76, 79, 80–82 serve
to underpin this statement.
The trainee should be aware that the optic nerve canal in the lamb’s orbit is located
­inferiorly, coursing in a latero-medial direction through the skull base, arising from the
medial wall of the orbit, and ending, as in humans, at the optic chiasm (Fig. 98).
The first step of the EEOD procedure in the lamb specimen involves opening of the
­lacrimal sinus in order to entirely remove its floor, i.e., the almost horizontal lamina which
separates the lacrimal sinus from the maxillary and palatinal sinuses. ­Sub­sequently,
it is possible to clearly expose the rim of the infraorbital nerve canal, and the exit
point of the infraorbital nerve arising from the orbit. In reality, the ­infraorbital nerve
arises from anterior orbital wall. One should bear in mind that most part of the anterior
orbital wall in lamb is naturally covered by ethmoid cells (see Figs. 57, 58, 64, 75 –
Fig. 76 –  ), so once the three sinuses (lacrimal, palatinal and maxillary ­sinuses)
have been localized properly, the remaining adjacent ethmoid cells should be
­meticulously removed as well (Figs. 99 and 104).

98 99
View of the left half of the anterior skull base in lamb. FC – fossa cranii, Left half of the lamb’s head. The yellow ellipse encircles a group of
relates to the course of the optic nerve canal, the shows residual ethmoid cells superior to the orbital roof ( ). The black circle
the cribriform plate, labels the crista galli, whereas the encompasses the residual ethmoid cells located above the medial orbital
indicates the optic nerve at the level of its entrance to the optic chiasm. wall, the indicates the lateral part of the anterior orbital wall, which
in fact forms the posterior maxillary sinus wall (see Figs. 70-73),
indicates infraorbital nerve, the remnants of the posterior wall
of the lacrimal sinus, whereas the refers to the convexity
corresponding to the concavity of the most lateral aspect of the
anterior orbital wall (see Fig. 111, green arrow).

Always bear in mind that the proper endoscopic approach to

the orbit in the lamb specimen traverses the posterior wall of
the lacrimal, maxillary and palatinal sinuses. Following proper
identi­fication of the superior orbital wall, any residual ­ethmoid
cells are removed with meticulous care, making sure that any
iatrogenic damage to the cribriform plate and the skull base is
prevented. These structures can be easily localized just 1–2 cm
superiorly and about one centimeter medially, which is clearly
presented on Fig. 101.
After removal of the well-exposed bony walls of the orbit, one
has to perform the incisions over the periorbit. Three parallel
100
incisions are enough. It’s good to perform them cutting from
posterior to anterior, and from superior to inferior. After the
Most part of the superior orbital wall is visible. A thin blood vessel can be incisions of the periorbit have been completed, the surgeon
seen running over its surface. The remaining ethmoid cells are located
superiorly. They should be removed during the decompression as well. has to press the eyeball from outside. The retrobulbar fat tissue
The indicates the convexity corresponding to the concavity of the than comes into the operating field. The endonasal endoscopic
most lateral part of the anterior orbital wall, refers to the medial orbital orbital decompression is completed (Figs. 102 and 103).
wall, the indicates the maxillary sinus, SL – the lateral wall of the
lacrimal sinus.
 Endoscopic Surgical Anatomy of the Lamb’s Head 45

101 102
Left nasal cavity. Following extensive ethmoidectomy the entrance to Orbital decompression has been partly completed. So far, the lateral
the most anterior frontal sinus cell is visible ( ). The refers to ­portion has not been denuded ( ).
the perforated bone of the cribriform plate opening up the view of the – infraorbital nerve protruding from its canal. The mass of the
brain. The pale, semi-transparent circle encompasses the area of residual retrobulbar fat tissue is shown in the semi-transparent circle.
ethmoid cells that are left to be removed to obtain free access to the
medial aspect of the anterior orbital wall ( on Fig. 100), whereas the
refers to the lateral portion of the anterior orbital wall.

103 104
refers to the infraorbital nerve, the indicates the remnant of View of the left nasal cavity. The remaining posterior ethmoid cells are
the lacrimal sinus floor, whereas the semi-transparent ellipse highlights removed with a Blakesley punch forceps. The surgeon should keep as
the retrobulbar fat tissue following its partial exposure. lateral as possible to prevent penetrating the cribriform plate.
– the posterior aspect of the superior turbinate that has been
dissected off and ends blindly.

It is crucial to always keep in mind an essential rule that applies to periorbital i­ncisions:
such incisions should always be – with no exception – performed horizontally
and longitudinally in order to prevent inadvertent injury to the extraocular muscles
­(particularly regarding the medial rectus muscle).
In conclusion, just a few brief instructions that should be carefully followed during
the learning process required to build knowledge and skills needed to perform orbital
decompression:
Anatomical landmarks should be identified and respected at all costs in order to
­reduce to the lowest possible level the risk of iatrogenic damage. Today, training on
a lamb specimen – tomorrow, translating skills into practice in a real-patient setting.
While penetrating through the ethmoid labyrinth, it is highly recommended to stick to
the superior turbinate, mostly to its inferior half, whenever the bony orbital walls should
be broadly exposed (Fig. 104). As already mentioned in the chapter covering the
­ethmoid labyrinth, the posterior, pneumatized aspect of the superior turbinate is a very
important reference structure that should be utilized during endoscopic p ­ rocedures
in this area. This anatomical landmark serves as a specific guard which protects the
­surgeon from adopting the wrong path, i.e., too proceed too far superiorly, which
would involve heading towards the frontal sinus instead of the orbit.
46 Endoscopic Surgical Anatomy of the Lamb’s Head

Adopting a step-by-step strategy, which includes the identification of the lacrimal,

palatinal and maxillary sinuses, must not be underestimated (Figs. 51–56 and 105).
Proper identification of the infraorbital nerve and rim is of a paramount importance
since this nerve leads the surgeon directly to the anterior orbital wall.
The infraorbital nerve, therefore, similar to the posterior portion of the superior ­turbinate,
is another “bodyguard”, that plays a vital role in preventing inadvertent r­emoval of
anatomical structures that should be preserved at all costs (Figs. 105 and 106)
Once, the contours of the orbit have been clearly exposed, removal of bony f­ragments
should be initiated at the very medial part of the anterior orbital wall (Figs. 107 and
108).
Prior to performing endonasal endoscopic orbital d ­ ecompression in a lamb specimen,
it is very useful for beginners to remove the orbital contents from outside first. Once
the orbit has been completely exposed, maneuvering of the instrument tip is ­facilitated
by improved visualization during removal of the bony walls because the ambient
(natural or artificial) light in the operating room illuminates the orbital cavity and can
be observed endoscopically as transillumination through its bony walls (Fig. 169) and
vice versa, as shown on Fig. 112.
The procedure can be performed very quickly and easily. Since the lacrimal gland
is located superiorly, medially and posteriorly in the orbital cavity, it should be easily
visualized during the procedure (Fig. 81, No. 12, and Figs. 109 and 110).

105 106
Most of the ethmoid cells shown on Fig. 103 have been removed, so Removal of tissue remnants overlying the orbit. indicates the posterior
antrostomy, previously performed as step II (step I included opening of wall of the left palatine sinus. Shown above is the tip of the curette while
the lacrimal sinus and removal of its floor) is clearly shown. The infraorbital clearing out the infraorbital canal.
canal ( ) (following removal of the nerve) is clearly visible as well.
shows the posterior wall of the left palatine sinus.

107 108
The ball-shaped form of the left orbit can be easily recognized. The View of the left nasal cavity following complete removal of the medial
indicates the superior orbital wall, while refers to the lateral portion of the anterior orbital wall.
half of the anterior wall. Most of the medial wall has been removed
already. The orbital contents have been extracted from outside.
 Endoscopic Surgical Anatomy of the Lamb’s Head 47

109 110
Starting excision of the contents of the left orbit. – lacrimal gland. Most of the orbital contents have already been removed. View of the
scissors transecting the neurovascular bundle and the tendons of the
extraocular muscles. – lacrimal gland.

111 112
The refers to the entrance area of the nasolacrimal canal. The As shown here, the thinnest part of the anterior orbital wall (resembling
internal surface of the anterior orbital wall is meticulously enucleated the lamina papyracea in humans) can be determined by use of
with a curette. dia­phanoscopy. Light is emitted from the tip of the scope which has
been placed directly above the lacrimal sinus. The lacrimal sinus itself
is also illuminated ( ).

Once all orbital contents have been removed, the inner surface
of the bony orbital walls is enucleated meticulously (Figs. 111
and 112).
The next step is to remove the bony orbital walls, which can be
achieved most easily from inside, i.e., by endonasal insertion of
113 a Kerisson punch (Fig. 113).
Outside view of the tip of a Kerisson punch used to remove a bony
fragment from the anterior orbital wall, which is performed here in its
medial part.
48 Endoscopic Surgical Anatomy of the Lamb’s Head

Frontal Sinus
As mentioned above, the frontal sinus in the lamb specimen is located in an area, that,
on the basis of sagittal CT scans, in human anatomy would be called parietal, or in
rare cases, even occipital, rather than frontal (Fig. 114). Measured in the medio-sagittal
plane, volume is smallest in the most anterior frontal sinus cell (Fig. 115). Interestingly,
the frontal sinus is extensively developed above the orbit (Fig. 116). In fact, the frontal
sinus in lamb comprises a group of chambers that are arranged in a circular fashion
from anterior to posterior, with lateral compartments, altogether forming an array that
resembles a crown. The space bordered by this specific “crown” is not hollow, of
course, but is made up of hard bone directly overlying the brain (Fig. 119). Following
removal of this part of the cranial bone, the supraorbital frontal sinus chamber, in terms
of dimensions, gives a dominant impression. The contours of the orbit, particularly
those of its superior wall, are clearly presented as well.

114 115
Sagittal CT scan of the lamb’s head through the lacrimal sinus space. Medio-sagittal CT scan of the lamb’s nose. – extremely shallow
The indicates a part of the joint nasal cavity, relates to the most anterior frontal sinus cell, B – brain.
lacrimal sinus, – the inner space of the inferior turbinate, –
ethmoid labyrinth, O – orbit, – the contours of the pneumatized
posterior end of the superior turbinate, – frontal sinus (supraorbital
chamber), B – brain, – most posterior frontal sinus chamber.

116 117
Some artificial collection of air at the floor of the orbit can be seen. There Following removal of the anterior part of the cranial bone, the most
is also a real air space superior to the orbit (supraorbital chamber of the anterior frontal sinus chambers are clearly visible ( ). On their
frontal sinus). – orbit. ­posterior walls, the drainage openings are shown. The deep funnel
of the naso-frontal recess is demonstrated well ( ). The funnel
communicates with the superior nasal meatus region (see Fig. 118).
Pay attention to the supraorbital frontal sinus chamber indicated by
.
 Endoscopic Surgical Anatomy of the Lamb’s Head 49

1 os frontale 36 n. buccalis
2 sinus frontalis 37 m. temporalis
3 concha nasalis dorsalis 38 os pterygoideum –
4 cornea hamulus
5 corpus adiposum 39 m. pterygoideus medialis
­intra­periorbitale 40 m. buccinator –
6 labyrinthus ethmoidalis pars molaris
7 camera anterior bulbi 41 v. buccalis
8 m. retractor bulbi 42 ramus buccalis v­ entralis
9 iris ni. facialis
10 camera vitrea bulbi, 43 n. lingualis
retina (ablatio arte­ficialis) 44 palatum molle
11 sclera 45 tonsila paraepiglottica
12 gl. lacrimalis 46 m. stylopharyngeus
13 cartilago septi nasi rostralis
14 m. obliquus bulbi 47 stylohyoideum
­ventralis – origo 48 epiglotis
15 m. rectus bulbi ventralis 49 dens molaris III
16 a. infraorbitalis ­mandibulae
17 n. maxillaris 50 a. lingualis
18 m. obliquus bulbi 51 m. hyopharyngeus
ventralis 52 m. ceratohyoideus
19 sinus maxillaris 53 thyreohyoideum
20 bulla lacrimalis 54 n. hypoglossus
21 sulcus vomeris 55 m. digastricus
22 vomer 56 m. sternohyoideus
23 v. sphenopalatina 57 m. hyoepigloticus
24 os zygomaticum – 58 m. omohyoideus
­processus temporalis 59 a., v. et n. alveolaris
25 a. sphenopalatina inferior
26 n. pterygopalatinus 60 corpus mandibulae –
27 corpus adiposum substantia compacta
­extra­periorbitale 61 gl. mandibularis
28 m. pterygoideus lateralis
29 septum pharyngis
30 fossa pterygopalatina
31 tooth bud mesenchyme
32 gll. buccales dorsales
33 meatus naso­pharyngeus
34 m. masseter
35 os palatinum – lamina
perpendicularis
118
The zigzag blue line shows the drainage pathway of the frontal sinus from its starting point, the naso-frontal recess, which is located in most
superior aspects of the upper nasal meatus ( ), immediately above the still pneumatized tail of the superior turbinate (No. 3). The lateral
chambers are labelled as No. 2. The drainage bifurcates ( ), thus forming the niches No 3 and 4 in the recessus ostiarum.

119
Axial CT scan at a very superior level of the lamb’s head which clearly
shows that the frontal sinus is made up of several chambers that are
arranged in a circular fashion around the thick, compact bone directly
overlying the brain. This specific configuration of the frontal sinus
chambers resembles very much the shape of a crown.
50 Endoscopic Surgical Anatomy of the Lamb’s Head

Fig. 120 clearly shows how close to each other are the posterior end of the
­ neumatized tail of the superior turbinate and the anterior wall of the most anterior
p
frontal sinus chambers. The blind end of the superior turbinate approaches the frontal
sinus from below (Fig. 121).
Furthermore, Figs. 122 and 123 clearly show that anterior and superior to the frontal
portion of the lamb’s brain there are some frontal chambers. But, just a couple of
centimeters posteriorly, the surgeon encounters a thick bone overlying the brain, and
without any chambers at all.
The key issue here relates to the communication pathways between all chambers of
the frontal sinus. It is obvious, that there are interconnections between the chambers
since they are adequately ventilated. The problem is to clearly identify the “­ openings”,
“ducts” or whatever morphological features the interconnections present. For
­endoscopic dissection training, this question, of course, is irrelevant, but it is good
to know that the dye, administer­ed into the supraorbital frontal sinus chamber from
outside, travels to the site that cor­
­ responds to the nasofrontal recess in human
anatomy (Figs. 124 and 125). The course of the dye is extremely difficult to observe
on a ­native specimen, but can be facilitated by uncapping a group of overlying frontal
sinus cells, so that the floor of each of these cells and the direction of the drainage
pathway ­becomes visible from outside and from above (Figs. 126–129).

120
Coronal CT scan of the lamb’s head showing that the posterior end of the
superior turbinate is still pneumatzied ( ). The overlying bone shows
discrete signs of incipient pneumatization of the most anterior frontal sinus
chambers, while those in lateral aspects, particularly the supraorbital
chamber, – the largest in the “crown”, – is already visible (semi-transparent
ellipses).
121
There are no more signs of pneumatization at the tail of the superior
turbinate, while at the same time, the most anterior frontal sinus
chambers are still well developed and pneumatized. Generally
speaking, the lateral chambers of the “crown” are larger than those
in medial aspects.

122
Coronal CT scan of the most anterior part of the brain shows that the
anterior frontal sinus chambers are still of considerable volume. However,
only 2–3 centimeters posterior, they become extremely shallow, and even
disappear, transforming into a compact bony mass immediately overlying
the brain. So, during dissection from outside and removal of this part of
the bony frame, the brain can be presented as it is shown in Fig. 124.
123
Once the cranial bone of the dome area, – which is resected down to
the level indicated by , – has been lifted off, the most posterior
frontal sinus chamber is widely exposed, enabling a view of the
superficial brain tissue. See Fig. 124.
 Endoscopic Surgical Anatomy of the Lamb’s Head
124
A few drops of dye have been administered into
the supraorbital frontal sinus chamber to exactly
trace the course along which it will be drained.
The indicates the space where the whole
group of chambers drain to, starting from the
supraorbital chamber and flowing in anterior
direction. The shows the most anterior
frontal sinus cells that drain themselves directly
into the third and fourth niches in the recessus
ostiarum. indicates the brain, refers
to the right supraorbital frontal sinus chamber,
while the shows the roof of the right orbit.
126
Most part of the frontal sinus chambers
and bony septa have been removed, which
considerably facilitates tracking the course
of the dye. Now, it becomes clear that the
chambers of the “crown” of the frontal sinus
in a lamb specimen are well interconnected
owing to a “state-of-the-art underground
sewage network”.
128
The bony septa dividing the lateral frontal
sinus chambers are removed in a piecemeal
fashion with a Blakesley punch forceps in
order to visualize the drainage pathway of the
dye. This dissection maneuver has already
been performed on the left side.
51
125
The dye has drained into the nasofrontal recess
through the openings that obviously serve as
interconnections between all these chambers.
Some of these openings are still invisible, but
may be made out indistinctly, owing to the blue
color of the dye recognizable through some of
the bony walls. Follwing removal of the walls,
the course of the dye’s drainage pathway is
shown clearly and can be easily tracked, as
depicted in Fig. 126.
127
The indicates a part of the bony roof
of one of the lateral frontal sinus chambers.
The superior refers to a small opening
through which the dye drains to the nose once
administered into the anterior frontal sinus
chambers. The inferior shows the same
opening, which on this side, apparently, is wider
than the contralateral one. Owing to this fact,
the course of the dye, emanating from the left
posterior supraorbital frontal sinus chamber, is
nicely presented.
129
The septum dividing the two most anterior
frontal sinus chambers is removed with a
Blakesley punch forceps. The maneuver is a
mandatory step prior to performing the Draf III
frontal sinus procedure, which will be discussed
in the following chapter.
52 Endoscopic Surgical Anatomy of the Lamb’s Head

130 131
The semi-transparent circle encloses the remnant of the left ethmoid indicates the blind end of the superior turbinate, while the tip
labyrinth. At the bottom of the circle there is a indicating the site of the instrument has already been advanced into the space of the left
where the surgeon can approach cribriform plate. The refers to the supraorbital chamber of the frontal sinus. The middle antrostomy 
blind end of the superior turbinate. The tip of the instrument has already ( ) serves here as a very good landmark.
been inserted in the supraorbital chamber of the frontal sinus “crown”.

Finally, the dye is seen to escape from the nose. It commonly appears very quickly in
the third and fourth niche of the recessus ostiarum (see Fig. 35).
In conclusion, we can say that, in practice, frontal sinus procedures typically involve
two interesting criteria:
 the first one involves that the frontal sinus area be identified properly, followed by
its meticulous ­exposure making use of the endonasal endoscopic technique. This
of course, in most of the cases, is targeted to access the lateral chambers of the
“crown” which involves passing through the superior parts of the ethmoid ­labyrinth
by referring meticulously to the superior turbinate as the best landmark that guide
the surgeon to the frontal sinus;
 the second criterion is related to all of the three frontal sinus endoscopic endonasal
procedures classified by Draf.
Regarding the first criterion, it has already been described as to where the frontal sinus
can be expected following removal of a great portion of the ethmoid labyrinth and after
completion of the middle meatal antrostomy. The lateral chambers of the frontal sinus
usually can be identified without difficulty (see also Fig. 120, semi-transparent, grayish
ellipses and Figs. 123, 130 and 131). The medial chambers, situated most a ­ nteriorly
and next to the blind end of the superior turbinate, are often so shallow, that it is
­seemingly impossible to create a window for access via an endoscopic approach.
The endonasal endoscopic frontal sinus procedures originally classified by Draf (Draf I,
Draf II and Draf III) will be described in the next chapter.

Endoscopic Endonasal Frontal Sinus Procedures

according to Draf
Endoscopic endonasal frontal sinus procedures according to Draf are not widely
­applied in clinical practice because of two reasons: – doctors often fail to establish the
indications for the specific type of procedure, and – they are not quite sure about how
to perform the procedure properly.
It seems, that there is a vicious circle between these two facts: surgical procedures
that are rarely performed, usually involve that the surgeon is not experienced and
skilled enough to safely perform them. If the surgeon is not skilled enough, e
­ stablishing
­indications usually becomes increasingly difficult. In fact, the Draf procedures have
a well-defined range of indications and validity when chronic inflammatory diseases
of the frontal sinus are concerned. Fortunately, for this specific purpose, the lamb
specimen can be used very effectively to train all three types of endoscopic endonasal
frontal sinus procedures according to Draf.
 Endoscopic Surgical Anatomy of the Lamb’s Head 53

Draf I
The scope of this procedure is minimal in comparison to types II and III. A type  I
procedure is indicated in patients suffering from unilateral, moderate pathology of the
frontal sinus, which stubbornly recurs, regardless of how precisely and ­successfully
previous procedures of whatever type have been performed. The main problem
here, ­apparently, is ­related to the degree of patency of the drainage pathways in the
­naso-frontal ­recess, particularly in cases p
­ reviously treated by means of endoscopic
sinus surgery technique.
The relevant factor in this context is that surgeons, in general, highly respect the area
of the anterior skull base, particularly its superior portion, which is where the bony
walls are thinnest.
Everybody knows that the dura in this area is particularly fragile and vulnerable, 132
and to make things worse, it adheres very firmly to the underlying bone, meaning
that in this area any bony lesion of even minor degree (infraction, for instance) can Postoperative coronal CT scan in a patient
­immediately induce an iatrogenic CSF leak. In case, the surgeon promptly realizes the who underwent a right-sided Draf I procedure.
Patency of the drainage pathways between
onset of a CSF leak, the successful outcome of surgery usually should not be ­affected the maxillary and frontal sinus is confirmed.
­adversely ­because the surgeon will swiftly attempt to close the dural defect, or a In human anatomy, the length of the cribriform
more ­ex­perienced surgeon will be called to assist in managing the critical situation. plate (much longer here, corresponding to a
The ­patient will immediately receive antibiotic prophylaxis and, in some cases, even a type-3 configuration in the Keros classification)
lumbar drainage for the next 72 hours. determines the depth of the olfactory fossa.
In these circumstances, the surgeon is usually
scarcely inclined to operate endoscopically,
since the lateral lamella of the olfactory fossa,
arising from the lateral margin of the cribriform
plate, is very thin, fragile and much longer,
meaning that the potential risk of iatrogenic
injury is elevated at this site.

133 134
indicates the left superior turbinate, a reliable guide to the most Middle turbinate has been pushed medially. The surgeon now has free
anterior wall of the frontal sinus. indicates the head of the middle approach to the middle meatus and to the recessus ostiarum. –
turbinate. Just above the arrow, a small formation resembling a nipple the posterior part, almost the tail already, of the superior turbinate.
can be seen. This is tuberculum Proversae. indicates tuberculum
Petradae. S indicates septum; – the third and fourth niche
region.

The situation is by far worse if a CSF leak goes unnoticed and no attempt is made to
close the defect without delay. The consequences, in such case, are usually ­serious
and much more difficult to manage. In conclusion, probably, all these factors, acting
together, account for the fact that endo­scopic sinus surgeons, not infrequently, have
reservations about surgical a­ pproaches in the area of the naso-frontal recess.
Ironically, the time required to perform a Draf I procedure in this area of predilection
to iatrogenic CSF rhinorrhea is usually longer than expected. The procedure requires
a ­meticulous ­radiological assessment of the related region which involves that high
quality multi-slice CT scans (MSCT) in coronal, axial and sagittal planes are obtained,
so as to have the thinnest lamellas and bony walls of the paranasal sinuses clearly
demonstrated and a ­ menable to detail detection prior to inspecting the area with the
scope and endoscopic instruments. Fig.  132 shows the postoperative coronal CT
scan three months after a right-sided Draf I procedure.
54 Endoscopic Surgical Anatomy of the Lamb’s Head

135 136
Close-up view of the left middle meatus and the recessus ostiarum. The back of the curette is in contact with the posterior wall of niche 4,
– niches 3 and 4 (see Fig. 35), the region of the frontal sinus (see Fig. 35).
drainage; – niche 2, (see Fig. 32) i.e. the site of lacrimal, palatinal
and maxillary sinus drainage.

137 138
Access to the naso-frontal recess has been obtained. Caution! The indicates the tail of the superior turbinate. – posterior
The most anterior frontal chamber is located far superiorly. It lies portion of the upper nasal meatus and naso-frontal recess (see Fig. 118
cranio­posterior to the tail of the superior turbinate indicated by . which describes frontal sinus drainage in detail).
– niche 2 (see Fig. 32).

It must be emphasized that anatomical relationships ­between

neighbouring structures in this region are of complex nature.
That is why endoscopic surgical approaches to the front­al sinus
have been extensively analyzed and described in the literature.
The surgeon must pay particular attention to the a ­natomical
­variability of the vertical insertion of the uncinate process: it may
be attached to the lamina papyracea, to the cribriform plate
­itself, or occasionally, to the anterior skull base. The most critical
configuration is, of course, when the uncinate process attaches
to the cribriform plate. It is absolutely clear that dissection
­training on an animal model will not solve all these dilemmas,
since they are related to human medicine, and to solve them
properly, a great deal of knowledge, experience and painstaking
care is needed, involving that any therapeutic decision-making
be determined on a case-to-case basis. Nonetheless, t­raining
these types of surgical procedures on the lamb specimen
can help the surgeon-in-training to feel more comfortable and
139 ­confident during maneuvering of instruments, also in terms of
The shows the part of the ethmoid labyrinth that will be removed how and when to use them in a space that is very much similar
­meticu­lously in the next step. indicates the large artificial opening to that in man. The only difference is that, with a lamb’s head,
at the floor of the most anterior frontal sinus chamber. there is no danger at all. Figs. 133–139 show how to perform a
The Draf I procedure has been completed. Draf I procedure on a lamb specimen.
 Endoscopic Surgical Anatomy of the Lamb’s Head 55

Draf II
Compared to the type-I procedure, Draf type II is more complicated, but still ­unilateral.
In human medicine, it is employed in patients suffering from severe, chronically
­recurring, unilateral pathology of the frontal sinus, refractory to previous treatment, both
conservative and surgical therapeutic modalities.
The Draf I procedure refers to the area that stretches from the lamina papyracea to
the lateral surface of the middle turbinate, i.e. it still remains within the boundaries
of the ostiomeatal complex. Most part of the middle turbinate must be preserved.
However, Draf II involves the removal of its most anterior portion. In ­human medicine,
the initial step of the procedure involves clear identification of the first (most anterior)
olfactory fiber, which is considerably facilitated if the surgeon removes a strip from the
­anterior margin of the middle turbinate. Following exposure of this anatomical detail,
the ­surgeon should be able to exactly determine the extent of retrograde ­removal
of the frontal sinus floor in order to avoid close proximity to the cribriform plate.
The space that is usually left behind following a Draf II procedure e ­ xtends from the 140
lamina ­papyracea to the nasal septum, owing to the fact that the ­anterior portion of the Coronal CT scan secondary to a bilateral
middle turbinate has been resected. Fig. 140 is a CT-radiographic image taken after Draf II procedure in a human patient.
­completion of a Draf II procedure. indicate the remnants of the middle turbinates.
demonstrates restored patency and
The Draf II procedure on a lamb specimen is described in Figs. 141–145. course of drainage pathways of both frontal
sinuses.

141 142
View of the left nasal cavity in the lamb specimen showing The most anterior frontal sinus cell comes into view. The anterior wall
the upper half of the still pneumatized posterior end of the superior seems to be fragmented, very thin, almost transparent ( ).
turbinate. The instrument tip is advanced in posterosuperior direction The anterior half of the middle turbinate has been removed.
as far as the anticipated site of the anterior wall of the most anterior
frontal sinus cell. Once the over­lying tissue has been removed, access
to the frontal sinus is obtained. This is another type of approach to the
frontal sinus, more directly than the one previously described, as it is
based on anatomical landmarks relevant for proper identification of the
frontal sinus: the posterior end and the tail of the superior turbinate.

143 144 145

The direct approach from inferior to the floor of
the frontal sinus, i.e. the anterior wall and part
of the floor of the anterior frontal sinus cell has
been achieved. Given proper removal, patency
of the drainage pathway is established in this
way.
A wide opening has been created in the
anterior wall of the most anterior frontal sinus
cell (semi-transparent circle). In the next step,
this cell will be connected to the supraorbital
cell ( ).
Upon completion of the Draf II procedure, a
passageway has been established joining the two
cells.
56 Endoscopic Surgical Anatomy of the Lamb’s Head

Draf III
Unlike the type-I and -II procedures, the Draf III procedure always involves b ­ ilateral
resection of the frontal sinus floor. There is no unilateral Draf III procedure. This type
of surgery is performed for the purpose of radical removal of frontal sinus p ­ athology,
as in Draf II, but on both sides. It also involves that most part of the superior half of
the nasal septum be removed so that both openings in the infero-anterior wall of the
frontal sinus in a human patient can be joined (e.g., with a diamond burr) to form one
large opening. Fig. 146 is a CT-radiographic image taken after completion of a Draf III
procedure.

146 147
The postoperative CT scan confirms bilateral absence of nasal septum, Draf II procedures have been performed bilaterally. We use the curette
frontal sinus floor ( ) and middle turbinate, demonstrating that one to make an incision in the nasal septum. Fortunately, nasal septum in
large cavity has been created. lamb is made up of cartilage only.

148 149
View of the right nasal cavity. The incised parts of the nasal septum The left frontal sinus has been opened completely ( ). The
have been removed with a Blakesley punch forceps directly or from the shows a large supraorbital frontal sinus cell. The yellow (?) refers to the
other nasal cavity, as shown above. region that will be surgically treated in the same way.
 Endoscopic Surgical Anatomy of the Lamb’s Head 57

After performing Draf II on both sides, the nasal septum must be removed in its most
superior aspects, which are in close proximity to the frontal sinus floor. Once this has
been accomplished, the septum between the left and right most anterior frontal sinus
cells can be seen. Next, the septum is removed as well.
The Draf III procedure on a lamb specimen is shown in Figs. 147–157.

150 151
A residual portion of the nasal septum along with a few pieces of pre- The surgical maneuver shown in Fig. 150 may also be accomplished
frontal tissue are left to be removed to provide unobstructed vision of by use of a circular punch.
the frontal sinus cells.

152 153
Another alternative option is to use a back-biting forceps, as shown shows the opening in the tail of the right superior turbinate.
above. The frontal sinus itself is located in superoposterior position ( ).
58 Endoscopic Surgical Anatomy of the Lamb’s Head

154 155
The left most anterior frontal sinus cell is clearly visible (right ). The The pointers refer to the right and left most anterior frontal
contours of the right cell have only just appeared. Next, the instrument sinus cells. A diamond burr is used to drill out the bony wall located in
will be used at this site to create a second wide opening here. between.
Subsequently, a medio-sagittal bony wall will stay behind in the area
labelled by the yellow . This wall divides the two most anterior frontal
)

sinus cells and should be removed until both cells have been joined to
form one large opening.

156
shows the right supraorbital frontal sinus cell. The bony wall
overlying the two anterior frontal sinus cells has been removed almost
completely by use of a diamond burr.
157
The bony wall has been successfully drilled away. The anterior skull
base is now clearly visible ( ). The last step that remains to be
taken in order to finish the Draf III procedure is to remove a small piece
of bone that obstructs vision of the left supraorbital frontal sinus cell.
 Endoscopic Surgical Anatomy of the Lamb’s Head 59

Endonasal Endoscopic Dacryocystorhinostomy

Unfortunately, this kind of procedure cannot be trained on a lamb specimen, simply
because there is no lacrimal sac at all. Evidence for this anatomical finding has been
provided by means of dacryocystography which clearly showed that both superior
and inferior canaliculi directly drain into the nasolacrimal duct. The superior canaliculus
drains at an angle of approximately 170°, whereas the inferior one joins the duct at an
almost perpendicular angle. Both angles are opened towards the snout (Fig. 158).
Based on dacryocystography images, it seems that the nasolacrimal duct ends
­somewhere in the middle portion of the inferior turbinate labyrinth (Figs. 159, 160 and
161).
However, anatomical dissections showed that the nasolacrimal duct is much longer,
i.e. that it reaches as far as the most anterior aspects of the nasal cavity (Fig. 160).
This was clearly confirmed by injection of methylen-blue dye (Figs. 161, 162 and 163).
The nasolacrimal duct in lamb is quite a long structure. It measures approximately 158
76 millimeters, and runs in an almost horizontal direction. The pointers refer to the superior and
inferior canaliculi.
It seems that the distal part and the opening of the nasolacrimal duct is located below
the anterior portion of the inferior turbinate, just as in human anatomy (Fig. 164).

160 159
A Blakesley punch forceps is used to support the nicely exposed refers to the anticipated end of the nasolacrimal duct, while the
nasolacrimal duct from below. It seems that the duct ends like a fan. indicates the level of the anterior pole of the inferior turbinate.

161 162 163 164

At first sight, it seems that methylene After a short time, the dye spreads Methylene blue dye finally appears shows the anticipated
blue dye, – similarly to the contrast towards the anterior pole of the underneath the anterior pole of the open­ing of the nasolacrimal duct
agent used during dacryocysto­ inferior turbinate. inferior turbinate. beneath the anterior pole of the
graphy, – does not descend deeper inferior turbinate.
than half of the anticipated length of
the nasolacrimal duct.
60 Endoscopic Surgical Anatomy of the Lamb’s Head

165 166 167 168

View of the left lamb’s eye from
posterior to anterior. The eyeball
is medialized with the instrument
handle, allowing the entrance of
the nasolacrimal duct ( ) and
the infraorbital nerve ( ) to be
clearly presented.
The same view, but the orbital
contents have been extracted.
View of the internal part of the
anterior orbital wall. The
shows the entrance of the bony
canal, the bed of the nasolacrimal
duct. The opening below is relat­ed
to the infraorbital nerve. The
indicates the concavity found in
antero­lateral aspects of the orbit.
The corresponding convexity can
be visualized endoscopically, as
shown on Fig. 167.
Endoscopic endonasal view of the
anterior orbital wall. The convexity
to which the previous figure refers,
is indicated by .
This means that the most lateral
part of the anterior orbital wall is
endoscopic­ally acces­sible. The
shows the contours of the
bony canal of the nasolacrimal
duct. The indicates a deep,
orbital recess of the maxillary sinus
(recessus orbitalis sinus maxillaris
Tido).
Endoscopic endonasal view of the
left orbit. The bony nasolacrimal
canal has been opened ( )
from below using a diamond burr
or Blakesley punch forceps. The
duct has been removed in order to
inspect the intraluminal appearance
of the bony nasolacrimal canal.

169 170
Endonasal endoscopic view of the previously evacuated left orbit. The superior portion of the nasolacrimal canal can be resected by
The orbital cavity is illuminated exclusively by the diffuse light from drilling away bone. The course of the canal is indicated by the .
the ceiling lamp in the operating room. As shown above, the The shows one of the most anterior ethmoid cells. Part of
transillumination effect allows to easily evaluate the thickness of the the antero-medial orbital wall can be seen at its floor. The tip of the
orbital wall. Note, that it is quite thin in close proximity to the ethmoid diamond burr has already excavated a deep niche in the related bone.
sinus labyrinth ( ), while it seems to be rather thick medially from
two bony canals: nasolacrimal and infraorbital ( ).
The indicates the entrance of the nasolacrimal canal. The bone
overlying the canal seems to be thick as well, and therefore can be
drilled away by use of a diamond burr, as shown in Fig. 170.
The white ellipse encompasses an area of increased bone thickness
where the maxillary and ethmoid sinuses merge, creating the crest
(crista ethmoidalis sinus maxillaries Zite; see Fig. 70).
 Endoscopic Surgical Anatomy of the Lamb’s Head 61

Even though we repeatedly attempted to access and localize several sites of p ­ articular
surgical interest belonging to the lacrimal system (in lamb specimen), our efforts proved
to be in vain, most probably because the junction between the lacrimal ­canalicula and
the nasolacrimal duct itself is located in a far lateral position (Figs. 165 and 166).
Accordingly, endonasal endoscopic exposure of anatomical fine structures of
the lacrim­al system in the lamb specimen requires the use of a drill, because the
­surrounding bony structures are quite thick. The bone in this particular area has to be
drilled away until amenable to further endoscope-assisted dissection (Figs. 169, 170,
171 and 172).

171 172
The floor of the excavated niche has a bluish appearance ( ) The tip of the curette is clearly visible. It has been inserted through the
which undoubtedly suggests that the remaining bone is thin enough. orbital entrance to the nasolacrimal canal.
The shows the previously evacuated, bony nasolacrimal canal.
The indicates a part of the orbital wall at the floor of the deep
ethmoid cell.
62 Endoscopic Surgical Anatomy of the Lamb’s Head

MLADINA Head Holder

280130

280130 MLADINA Head Holder, bowl-shaped, tiltable,

with screwable pins for fixation of the specimen

It is recommended to check the suitability of the product for the intended procedure prior to use.
Endoscopic Surgical Anatomy of the Lamb’s Head 63

HOPKINS® Telescopes
for Diagnosis, Surgery and Treatment of Nose and Paranasal Sinuses, diameter 4 mm, length 18 cm

7230 AA – CA

7230 AA HOPKINS® Straight Forward Telescope 0°,

enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: green

7230 BA HOPKINS® Forward-Oblique Telescope 30°,

enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: red

7230 FA HOPKINS® Forward-Oblique Telescope 45°,

enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: black

7230 CA HOPKINS® Lateral Telescope 70°,

enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: yellow

7229 AA – CA

7229 AA HOPKINS® Straight Forward Telescope 0°,

enlarged view, diameter 2.7 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: green

7229 BA HOPKINS® Forward-Oblique Telescope 30°,

enlarged view, diameter 2.7 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: red

7229 FA HOPKINS® Forward-Oblique Telescope 45°,

enlarged view, diameter 2.7 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: black

7229 CA HOPKINS® Lateral Telescope 70°,

enlarged view, diameter 2.7 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: yellow
64 Endoscopic Surgical Anatomy of the Lamb’s Head

FESS Instruments
Accessories

723770 STAMMBERGER Telescope Handle, flat,

standard model, length 11 cm, for use with
HOPKINS® ­Straight Forward Telescopes 0°
with diameter 4 mm and length 18 cm

723772 STAMMBERGER Telescope Handle, round,

standard model, length 11 cm, for use with
HOPKINS® Telescopes 30° – 120°
with d
­ iameter 4 mm and length 18 cm

723774 STAMMBERGER Telescope Handle, round,

length 11 cm, for use with HOPKINS®
Telescopes with diameter 1.9/2.7 mm
and length 18 cm

723750 A Protection Tube, for HOPKINS® Telescopes

with length 11 cm

723750 B Protection Tube, for HOPKINS® Telescopes

with length 18 cm

723005 A Trocar and Cannula for Sinuscopy, ­

fenestrated beak, outer diameter 5 mm,
length of the cannula 8.5 cm, for use with
HOPKINS® Telescopes with diameter 4 mm

723005 B Trocar and Cannula for Sinuscopy,

Oblique beak, outer diameter 5 mm,
length of the cannula 8.5 cm, for use with
HOPKINS® Telescopes with diameter 4 mm

723103 B Trocar and Cannula for Sinuscopy,

oblique beak, outer diameter 3.3 mm,
length of the cannula 7.5 cm, for use with
HOPKINS® Telescopes with diameter 2.7 mm
Endoscopic Surgical Anatomy of the Lamb’s Head 65

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

456000 B – 456003 B

456000 B BLAKESLEY RHINOFORCE® II

456000 B – 456003 B 456000 B Nasal Forceps, straight, size 0,
with cleaning connector,
working length 13 cmm
456001 B Same, size 1
456001 B 456002 B 456003 B 456002 B Same, size 2
456003 B Same, size 3

456500 B BLAKESLEY-WILDE RHINOFORCE® II

456500 B – 456502 B 456500 B Nasal Forceps, 45° upturned, size 0,
with cleaning connector,
working length 13 cm
456501 B Same, size 1
456501 B 456502 B 456502 B Same, size 2

456801 B BLAKESLEY-WILDE RHINOFORCE® II

456801 B – 456803 B 456801 B Nasal Forceps, 90° upturned, size 1,
with cleaning connector,
working length 13 cm
456802 B Same, size 2
456802 B 456803 B 456803 B Same, size 3

456601 B

456601 B BLAKESLEY-WILDE RHINOFORCE® II

456601 B 456601 B Nasal Forceps, 45° upturned,
handle in right horizontal position, size 1,
with cleaning connector,
working length 13 cm
66 Endoscopic Surgical Anatomy of the Lamb’s Head

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

451000 B – 451010 B

451000 B GRÜNWALD-HENKE RHINOFORCE® II Nasal Forceps, straight,

through-cutting, tissue-sparing, BLAKESLEY shape, size 0,
width 3 mm, with cleaning connector, working length 13 cm
451001 B Same, size 1, width 3.5 mm
451002 B Same, size 2, width 4 mm

451500 B GRÜNWALD-HENKE RHINOFORCE® II Nasal Forceps,

45º upturned, through-cutting, tissue-sparing,
BLAKESLEY shape, size 0, width 3 mm, with cleaning connector,
working length 13 cm
451501 B Same, size 1, width 3.5 mm
451502 B Same, size 2, width 4 mm

452001 B MACKAY-GRÜNWALD RHINOFORCE® II Nasal Forceps,

through-cutting, tissue-sparing, straight, delicate, 8 x 3 mm,
size 1, with cleaning connector, working length 13 cm
Size 1
452002 B Same, 11.5 x 3.5 mm, size 2

Size 2

452501 B MACKAY-GRÜNWALD RHINOFORCE® II Nasal Forceps,

through-cutting, tissue-sparing, 45º upturned, delicate, 8 x 3 mm,
size 1, with cleaning connector, working length 13 cm
Size 1 452502 B Same, 11.5 x 3.5 mm, size 2

Size 2

455010

455010 STRUYCKEN RHINOFORCE® II Nasal Cutting Forceps,

with cleaning connector, working length 13 cm
Endoscopic Surgical Anatomy of the Lamb’s Head 67

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

459012

459010 STAMMBERGER RHINOFORCE® II Antrum Punch,

upside backward cutting, with cleaning connector,
working length 10 cm

459011 Same, right side backward cutting

459012 Same, left side backward cutting

459016

459016 STAMMBERGER RHINOFORCE® Antrum Punch,

backward cutting, sheath 360° rotatable,
with fixing screw, take apart, working length 10 cm,
for use with cleaning adaptor 459015 LL

459015 LL Cleaning Adaptor

68 Endoscopic Surgical Anatomy of the Lamb’s Head

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

459030

459030 STAMMBERGER RHINOFORCE® II Antrum Punch,

small pediatric size, slender, upside backward c
­ utting,
with cleaning connector, working length 10 cm

459031 Same, right side backward cutting

459032 Same, left side backward cutting

459036

459036 STAMMBERGER RHINOFORCE® Antrum Punch,

small pediatric size, slender, backward cutting,
sheath 360° rotatable, with fixing screw, take apart,
working length 10 cm,
for use with cleaning adaptor 459015 LL

459015 LL Cleaning Adaptor

Endoscopic Surgical Anatomy of the Lamb’s Head 69

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

459051
459052

459051 STAMMBERGER Antrum Punch,

right side downward and forward cutting,
working length 10 cm

459052 Same, left side downward and forward cutting

449201–
449203

449201 RHINOFORCE® II Nasal Scissors,

straight, with cleaning connector,
working length 13 cm

449202 Same, curved to right

449203 Same, curved to left

70 Endoscopic Surgical Anatomy of the Lamb’s Head

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

651050 STAMMBERGER Punch, circular cutting,

for sphenoid, ethmoid and choanal atresia,
with cleaning connector,
working length 18 cm,
diameter 4.5 mm
651055 Same, diameter 3.5 mm
651055

651060 STAMMBERGER Punch, circular cutting,

65° upturned, for frontal sinus/recess,
with cleaning connector, working length 17 cm,
diameter 3.5 mm

651065 Same, diameter 4.5 mm

651061 STAMMBERGER Punch, tip egg-shaped,

circular cutting, 65° upturned, for frontal sinus / recess,
with cleaning connector, working length 17 cm,
diameter 3.5 mm

651066 Same, diameter 4.5 mm

651050 R
651050 R Cleaning Tool, for circular cutting punches type
651050 / 651055 / 60 / 65, double-ended, length 14 cm

651010

651010 STAMMBERGER RHINOFORCE® II Forceps, ­

cupped jaws, vertical opening, 65° upturned,
­with cleaning connector, working length 12 cm,
cupped jaws diameter 3 mm

651020 STAMMBERGER RHINOFORCE® II Forceps,

­cupped jaws, horizontal opening, 65° upturned,
with cleaning connector, working length 12 cm,
cupped jaws diameter 3 mm
 Endoscopic Surgical Anatomy of the Lamb’s Head 71

Nose Sinuses
Microscopic/Endoscopic Surgery in the Area of Paranasal Sinuses, Skull Base and Pituitary Surgery

662102-662104

662102 KERRISON Micro Punch, ­detachable rigid, 90° upbiting,

not through-cutting, size 2 mm, w
­ orking length 17 cm

662104 KERRISON Punch, detachable ­rigid, 90° upbiting,

not t­hrough-cutting, size 4 mm, ­working length 17 cm

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

628001 Sickle Knife, pointed, length 19 cm

628002 Same, round, double-cutting

628001 223300 PLESTER Sickle Knife, double-cutting,

­standard model, slightly curved,
length 16 cm

629820 Probe, double-ended,

maxillary sinus ostium seeker,
ball-shaped ends d­ iameter 1.2 and 2 mm,
628002
length 19 cm

629850 MLADINA Elevator, curved backwards 40°,

6 mm x 6 mm,
for atraumatic retrograde elevation,
length 21 cm

474000 FREER Elevator, double-ended,

length 20 cm
628001 – 223300 629820 629850 474000
628002
72 Endoscopic Surgical Anatomy of the Lamb’s Head

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

629826

629826 KUHN Frontal Sinus Seeker, double-ended,

No. 2, both sides curved 90°, one tip straight,
one tip reverse angle, length 22 cm

629830 KUHN Frontal Ostium Seeker, double-ended,

No. 6, b
­ oth sides curved 77°, one tip straight,
other tip reverse angle, length 22 cm

628702 Antrum Curette, oblong,

small size, length 19 cm,

628712 KUHN-BOLGER Frontal Sinus Curette,

small, oblong, 55° curved, ­forward ­cutting,
628712 length 19 cm
628714 Same, 90º curved

628714

628702 628712 628714

Endoscopic Surgical Anatomy of the Lamb’s Head 73

FESS Instruments
for Endoscopic Diagnosis, Surgery and Postoperative Treatment of Paranasal Sinuses and Anterior Skull Base

586325 – 529305 –
586340 529309

586325 v. EICKEN Antrum Cannula, LUER-Lock, long curved,

outer diameter 2.5 mm, working length 11 cm, l­ength 15 cm
586330 Same, outer diameter 3 mm
586340 Same, outer diameter 4 mm

529305 FRAZIER Suction Tube, with mandrin and ­cut-off hole,

with distance markings at 5 – 9 cm, 5 Fr., working length 10 cm
529307 Same, 7 Fr.
529309 Same, 9 Fr.
74 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB/UNIDRIVE® S III ECO

The multifunctional unit for ENT

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

II
III

I
ECO RIVE ® S
ENT RIVE ® S
SCB

UNID
UNID
Special Features:

Touch Screen: Straightforward function selection via touch screen l –

Set values of the last session are stored l l

Optimized user control due to touch screen l –

Choice of user languages l –

Operating elements are single and clear to read due to color display l –

One unit – multifunctional:

– Shaver system for surgery of the paranasal sinuses and anterior skull base
– INTRA Drill Handpieces (40,000 rpm and 80,000 rpm)
– Sinus Shaver l l
– Micro Saw
– STAMMBERGER-SACHSE Intranasal Drill
– Dermatome
– High-Speed Handpieces (60,000 rpm and 100,000 rpm) l –

Two motor outputs: Two motor outputs enable simultaneous connection of two motors:
l l
For example, a shaver and micro motor
Soft start function l –

Formulated error messages l –

Integrated irrigation and coolant pump:

– Absolutely homogeneous, micro-processor controlled irrigation rate throughout
l l
the entire irrigation range
– Quick and easy connection of the tubing set

Easy program selection via automated motor recognition l l

Continuously variable revolution range l l

Maximum number of revolutions and motor torque: Microprocessor-controlled revolutions
l l
per minute. Therefore the preselected parameters are maintained all the time during drilling
Maximum number of revolutions can be preset l l
SCB model with connections to the KARL STORZ Communication Bus
l –
(KARL STORZ-SCB)
Irrigator rod included l –
 Endoscopic Surgical Anatomy of the Lamb’s Head 75

Motor Systems
Specifications

System specifications

Mode Order No. rpm

Shaver mode oscillating

Operation mode: in conjunction with Handpiece:
Max. rev. (rpm): DrillCut-X® II Shaver Handpiece 40 7120 50 10,000*
DrillCut-X® II N Shaver Handpiece 40 7120 55 10,000*

Sinus burr mode rotating

Operation mode: in conjunction with Handpiece:
Max. rev. (rpm): DrillCut-X® II Shaver Handpiece 40 7120 50 12,000
DrillCut-X® II N Shaver Handpiece 40 7120 55 12,000

High-speed drilling mode counterclockwise or clockwise

Operation mode: in conjunction with:
Max. rev. (rpm): High-Speed Micro Motor 20 7120 33 60,000/100,000

Drilling mode counterclockwise or clockwise

Operation mode: in conjunction with:
Max. rev. (rpm): micro motor
and connecting cable [ 20 7111 73]
20 7110 33 40,000/80,000

Micro saw mode in conjunction with:

Max. rev. (rpm): micro motor
and connecting cable [ 20 7111 73]
20 7110 33 15,000/20,000

Intranasal drill mode in conjunction with:

Max. rev. (rpm):

micro motor
and connecting cable [ 20 7111 73]
20 7110 33 60,000

Dermatome mode in conjunction with:

Max. rev. (rpm):

micro motor
and connecting cable [ 20 7111 73]
20 7110 33 8,000

Power supply: 100 – 240 VAC, 50/60 Hz

Dimensions: 300 x 165 x 265 mm

(w x h x d)

Two outputs for parallel connection of two motors

Integrated irrigation pump:

Flow: adjustable in 9 steps

* Approx. 4,000 rpm is recommended as this is the most efficient suction/performance ratio.

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

Touch Screen: 6,4" / 300 cd/m2

Weight: 5.2 kg 4.7 kg

Certified to: IEC 601-1 CE acc. to MDD IEC 60601-1

Available languages: English, French, German, numerical codes

Spanish, Italian, Portuguese, 
Greek, Turkish, Polish, Russian
76 Endoscopic Surgical Anatomy of the Lamb’s Head

Motor Systems
Special features of high-performance EC micro motor II
and of the high-speed micro motor

Special features of high-performance EC micro motor II:

l Self-cooling,
brushless high-performance ## INTRA coupling enables a wide variety
EC micro motor of applications
l Smallest possible dimensions ## Maximum torque 4 Ncm
l Autoclavable ## Number of revolutions can be continuously
l Can be processed in a cleaning machine adjusted up to 40.000 rpm
l Detachable connecting cable ## Provided a suitable handle is used, the number
of revolutions can be continuously adjusted up
to 80,000 rpm

20 7110 33

20 7110 33 High-Performance EC Micro Motor II, for use with

UNIDRIVE® II/UNIDRIVE® ENT/OMFS/NEURO/ECO
and Connecting Cable 20 7110 73, or for use with
UNIDRIVE® S III ENT/ECO/NEURO and Connecting
Cable 20 7111 73

20 7111 73 Connecting Cable, to connect High-Performance

EC Micro Motor 20 7110 33 to UNIDRIVE® S III
ENT/ECO/NEURO

Special Features of the high-speed micro motor:

l Brushless high-speed micro motor ## Maximum torque 6 Ncm
l Smallestpossible dimensions ## Number of revolutions can be continuously
l Autoclavable adjusted up to 60.000 rpm
l Can be processed in a cleaning machine ## Provided a suitable handle is used, the number
of revolutions can be continuously adjusted up
l Maximum torque 6 Ncm
to 100,000 rpm

20 7120 33

20 7120 33 
High-Speed Micro-Motor, max. speed 60,000 rpm,
including connecting cable, for use with UNIDRIVE® S III
ENT/NEURO
Endoscopic Surgical Anatomy of the Lamb’s Head 77

UNIDRIVE® S III ENT SCB n

UNIDRIVE® S III ECO
Recommended System Configuration

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

40 7016 20-1 40 7014 20

40 7016 01-1 
UNIDRIVE® S III ENT SCB, motor control unit with color display,
touch screen, two motor outputs, integrated irrigation pump and
SCB module, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
Irrigator Rod
Two-Pedal Footswitch, two-stage, with proportional function
Silicone Tubing Set, for irrigation, sterilizable
Clip Set, for use with silicone tubing set
SCB Connecting Cable, length 100 cm
Single Use Tubing Set*, sterile, package of 3

40 7014 01 UNIDRIVE® S III ECO, motor control unit with two motor outputs and
integrated irrigation pump, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
Two-Pedal Footswitch, two-stage, with proportional function
Silicone Tubing Set, for irrigation, sterilizable
Clip Set, for use with silicone tubing set

Specifications:
Touch Screen UNIDRIVE® S III ENT SCB: 6,4"/300 cd/m2 Dimensions w x h x d 300 x 165 x 265 mm
Flow 9 steps Weight 5.2 kg
Power supply 100-240 VAC, 50/60 Hz Certified to EC 601-1, CE acc. to MDD

* mtp medical technical promotion gmbh,

Take-Off GewerbePark 46, D-78579 Neuhausen ob Eck, Germany
78 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

UNIDRIVE® S III ECO
System Components

Silicone Tubing Set

Two-Pedal Footswitch

20 0166 30

20 7116 40

U N I T S I D E

PATIENT SIDE

High-Speed Micro-Motor High-Performance EC Micro Motor II DrillCut-X® II Shaver Handpiece, DrillCut-X® II N Shaver Handpiece,
for use with UNIDRIVE® S III optional adaptability to
ECO/ENT/NEURO Shaver Tracker, for use with
UNIDRIVE® S III ECO/ENT/NEURO

20 7110 33
20 7120 33 20 7111 73 40 7120 50 40 7120 55

High-Speed Handpiece INTRA Drill Handpiece

Shaver Blade

41201 KN
252660 – 252692 252575 – 252590
Shaver Blade, curved
Intranasal Drill

41302 KN

Sinus Burr
660000

41305 DN
Endoscopic Surgical Anatomy of the Lamb’s Head 79

Optional Accessories
for UNIDRIVE® S III ENT SCB and UNIDRIVE® S III ECO

280053 Universal Spray, 6x 500 ml bottles – HAZARDOUS GOODS – UN 1950

including:
Spray Nozzle

280053 C Spray Nozzle, for the reprocessing of INTRA burr handpieces,

for use with Universal Spray 280053 B

031131-10* Tubing Set, for irrigation, for single use, sterile,

package of 10

*
mtp medical technical promotion gmbh,
Take-Off GewerbePark 46, D-78579 Neuhausen ob Eck, Germany
80 Endoscopic Surgical Anatomy of the Lamb’s Head

DrillCut-X® Shaver Handpieces n

Special Features

40 71 ut-X ® II N
40 71 t-X ® II

20 55
20 50
u

DrillC
DrillC
Special Features:

Max. 10,000 rpm for shaver blades, max. 12,000 rpm for sinus shaver l l

Straight suction channel l l

Integrated irrigation channel l l

Powerful motor, also suitable for harder materials l l

Absolutely silent running, no vibration l l

Completely immersible and machine-washable l l

LOCK allows fixation of shaver blades and sinus shavers l l

Extremely lightweight design l l

Optional, ergonomic handle, detachable l l

Can be adapted to navigation tracker – l

40 7120 50

40 7120 50 DrillCut-X® II Shaver Handpiece,

for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 55

40 7120 55 DrillCut-X® II N Shaver Handpiece,

optional adaptability to Shaver Tracker 40 8001 22,
for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS
Endoscopic Surgical Anatomy of the Lamb’s Head 81

DrillCut-X® II Shaver Handpiece n

Special Features:
## Powerful motor ## The versatile DrillCut-X® II Shaver Handpiece can
## Absolutely silent running be adapted to individual needs of the user
## Enhanced ergonomics ## Easy hygienic processing, suitable for use in
washer and autoclavable at 134° C
## Lighweight design
## Quick coupling mechanism facilitates more
## Oscillation mode for shaver blades,
rapid exchange of work inserts
max. 10,000 rpm
## Proven DrillCut-X® blade portfolios can be used
## Rotation mode for sinus shavers, max. 12,000 rpm
## Straight suction channel and
integrated irrigation

40 7120 50

40 7120 50 DrillCut-X® II Shaver Handpiece,

for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 90

40 7120 90 Handle, adjustable, for use with DrillCut-X® II 40 7120 50

and DrillCut-X® II N 40 7120 55

Optional Accessory:

41250 RA

41250 RA Cleaning Adaptor, LUER-Lock,

for cleaning DrillCut-X® shaver handpieces
82 Endoscopic Surgical Anatomy of the Lamb’s Head

DrillCut-X® II Shaver N Handpiece n

Special Features:
## Powerful motor ## Easy hygienic processing, suitable for use in
## Absolutely silent running washer and autoclavable at 134° C
## Enhanced ergonomics ## Quick coupling mechanism facilitates more rapid
exchange of working inserts
## Lighweight design
## Proven DrillCut-X® blade portfolios can be used
## Oscillation mode for shaver blades,
## Optional adaptability to Shaver Tracker 40 8001 22
max. 10,000 rpm
## Rotation mode for sinus shavers, ## Allows shaver navigation when used with
max. 12,000 rpm NPU 40 8000 01
## Straight suction channel and integrated irrigation
## The versatile DrillCut®-X II Shaver N Shaver
Handpiece can be adapted to the individual needs
of the user

40 7120 55

40 7120 55 DrillCut-X® II N Shaver Handpiece,

optional adaptability to Shaver Tracker 40 8001 22,
for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 90

40 7120 90 Handle, adjustable, for use with DrillCut-X® II 40 7120 50

and DrillCut-X® II N 40 7120 55

Optional Accessory:

41250 RA

41250 RA Cleaning Adaptor, LUER-Lock,

for cleaning DrillCut-X® shaver handpieces
 Endoscopic Surgical Anatomy of the Lamb’s Head 83

Handle for DrillCut-X® II Shaver Handpiece n

for use with DrillCut-X® II 40 7120 50 and DrillCut-X® II N 40 7120 55

Special Features:
## Ergonomic design ## The adjustable handle can be mounted to
## Ultralight construction DrillCut®-X II or -X II N Shaver Handpiece
## Easy handle control allows individual adjustment ## Easy fixation via rotary lock
## Sterilizable

40 7120 90

40 7120 90 Handle, adjustable, for use with DrillCut-X® II 40 7120 50

and DrillCut-X® II N 40 7120 55
84 Endoscopic Surgical Anatomy of the Lamb’s Head

Shaver Blades, straight

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41201 GN

Shaver Blades, straight, sterilizable

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

serrated cutting edge,

41201 KN diameter 4 mm,
color code: blue-red

double serrated cutting edge,

41201 KK diameter 4 mm,
color code: blue-yellow

concave cutting edge,

41201 GN ­oval cutting window, diameter 4 mm,
color code: blue-green

concave cutting edge, oblique

41201 LN cutting window, diameter 4 mm,
color code: blue-black

straight cutting edge,

41201 SN diameter 4 mm,
color code: blue-blue

serrated cutting edge,

41201 KSA diameter 3 mm,
color code: blue-red

double serrated cutting edge,

41201 KKSA diameter 3 mm,
color code: blue-yellow

double serrated cutting edge,

41201 KKSB diameter 2 mm,
color code: blue-yellow

concave cutting edge, oblique

41201 LSA cutting window, diameter 3 mm,
color code: blue-black

Optional Accessory:
41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner
and outer blades of reusable Shaver Blades 412xx
 Endoscopic Surgical Anatomy of the Lamb’s Head 85

Shaver Blades, curved

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41204 KKB

Shaver Blades, curved 35°/40°, sterilizable

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

curved 35°, ­cutting edge serrated

41202 KN backwards, diameter 4 mm,
color code: blue-red

curved 40°, cutting edge serrated

forwards, double serrated,
41204 KKF
diameter 4 mm,
color code: blue-yellow

curved 40°, cutting edge serrated

backwards, ­double serrated,
41204 KKB
diameter 4 mm,
color code: blue-yellow

curved 40°, cutting edge serrated

forwards, double serrated,
41204 KKFA
diameter 3 mm,
color code: blue-yellow

curved 40°, cutting edge serrated

backwards, double serrated,
41204 KKBA
diameter 3 mm,
color code: blue-yellow

Optional Accessory:
41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner
and outer blades of reusable Shaver Blades 412xx
86 Endoscopic Surgical Anatomy of the Lamb’s Head

Shaver Blades, curved

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41203 KKF

Shaver Blades, curved 65°, sterilizable

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

curved 65°, cutting edge serrated

41203 KNF forwards, diameter 4 mm,
color code: blue-red

curved 65°, cutting edge serrated

41203 KNB backwards, diameter 4 mm,
color code: blue-red

curved 65°, cutting edge serrated

forwards, double serrated,
41203 KKF
diameter 4 mm,
color code: blue-yellow

curved 65°, cutting edge serrated

backwards, double serrated,
41203 KKB
diameter 4 mm,
color code: blue-yellow

curved 65°, cutting edge serrated

forwards, double serrated,
41203 KKFA
diameter 3 mm,
color code: blue-yellow

curved 65°, cutting edge serrated

backwards, double serrated,
41203 KKBA
diameter 3 mm,
color code: blue-yellow

curved 65°, concave cutting edge,

oval cutting window, forward
41203 GNF
opening, diameter 4 mm,
color code: blue-green

curved 65°, concave cutting edge,

oval cutting window, backward
41203 GNB
opening, diameter 4 mm,
color code: blue-green

Optional Accessory:
41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner
and outer blades of reusable Shaver Blades 412xx
 Endoscopic Surgical Anatomy of the Lamb’s Head 87

Shaver Blades, straight

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41301 KK

Shaver Blades, straight, for single use , sterile, package of 5

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

serrated cutting edge,

41301 KN diameter 4 mm,
color code: blue-red

double serrated cutting edge,

41301 KK diameter 4 mm,
color code: blue-yellow

concave cutting edge, ­oval cutting

41301 GN window, diameter 4 mm,
color code: blue-green

concave cutting edge, oblique

41301 LN cutting window, diameter 4 mm,
color code: blue-black

straight cutting edge,

41301 SN diameter 4 mm,
color code: blue-blue

serrated cutting edge,

41301 KSA diameter 3 mm,
color code: blue-red

double serrated cutting edge,

41301 KKSA diameter 3 mm,
color code: blue-yellow

double serrated cutting edge,

41301 KKSB diameter 2 mm,
color code: blue-yellow

concave cutting edge, oblique

41301 LSA cutting window, diameter 3 mm,
color code: blue-black
88 Endoscopic Surgical Anatomy of the Lamb’s Head

Shaver Blades, curved

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41302 KN

Shaver Blades, curved 35°/40°, for single use , sterile, package of 5

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

curved 35°, ­cutting edge

serrated backwards,
41302 KN
diameter 4 mm,
color code: blue-red

curved 40°, cutting edge

serrated forwards, double
41304 KKF
serrated, diameter 4 mm,
color code: blue-yellow

curved 40°, cutting edge

serrated backwards, ­double
41304 KKB
serrated, diameter 4 mm,
color code: blue-yellow

curved 40°, cutting edge

serrated forwards, double
41304 KKFA
serrated, diameter 3 mm,
color code: blue-yellow

curved 40°, cutting edge

serrated backwards, double
41304 KKBA
serrated, diameter 3 mm,
color code: blue-yellow
 Endoscopic Surgical Anatomy of the Lamb’s Head 89

Shaver Blades, curved

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41303 KKB

Shaver Blades, curved 65°, for single use , sterile, package of 5

for use with
Shaver Blade
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

curved 65°, cutting

edge serrated forwards,
41303 KNF
diameter 4 mm,
color code: blue-red

curved 65°, cutting edge

serrated backwards,
41303 KNB
diameter 4 mm,
color code: blue-red

curved 65°, cutting edge

serrated forwards, double
41303 KKF
serrated, diameter 4 mm,
color code: blue-yellow

curved 65°, cutting edge

serrated backwards, double
41303 KKB
serrated, diameter 4 mm,
color code: blue-yellow

curved 65°, cutting edge

serrated forwards, double
41303 KKFA
serrated, diameter 3 mm,
color code: blue-yellow

curved 65°, cutting edge

serrated backwards, double
41303 KKBA
serrated, diameter 3 mm,
color code: blue-yellow

curved 65°, cutting

edge concave forwards,
41303 GNF oval cutting window,
diameter 4 mm,
color code: blue-green

curved 65°, cutting edge

concave backwards,
41303 GNB oval cutting window,
diameter 4 mm,
color code: blue-green
90 Endoscopic Surgical Anatomy of the Lamb’s Head

Sinus Burrs, curved

for Nasal Sinuses and Skull Base Surgery

For use with DrillCut-X® II and DrillCut-X® II N

41305 RN

Sinus Burrs, curved 70°/55°/40°/15°, for single use , sterile, package of 5

for use with
Sinus Burr
Detail 40 7120 50 DrillCut-X® II Handpiece length 12 cm
40 7120 55 DrillCut-X® II N Handpiece

curved 40°, cylindric,

drill diameter 3 mm,
41304 W
shaft diameter 4 mm,
color code: red-blue

curved 55°, cylindric,

drill diameter 3.6 mm,
41303 WN
shaft diameter 4 mm,
color code: red-blue

curved 15°, bud drill,

drill diameter 4 mm,
41305 RN
shaft diameter 4 mm,
color code: red-black

curved 15°, diamond head,

drill diameter 3 mm,
41305 DN
shaft diameter 4 mm,
color code: red-yellow

curved 15°, diamond head,

drill diameter 5 mm,
41305 D
shaft diameter 4 mm,
color code: red-yellow

curved 40°, diamond head,

drill diameter 5 mm,
41305 DW
shaft diameter 4 mm,
color code: red-yellow

curved 70°, diamond head,

drill diameter 3.6 mm,
41303 DT
shaft diameter 4 mm,
color code: red-yellow
Endoscopic Surgical Anatomy of the Lamb’s Head 91

Accessories for Shaver

39550 A

39550 A Wire Tray, provides safe storage of accessories for

KARL STORZ paranasal sinus shaver systems during
cleaning and sterilization
for storage of:
– Up to 7 shaver attachments
– Connecting cable

Please note: The instruments displayed are not included in the sterilizing and storage tray.
92 Endoscopic Surgical Anatomy of the Lamb’s Head

INTRA Drill Handpiece

for Surgery in Ethmoid and Skull Base Area

Special Features:
## Tool-free closing and opening of the drill ## Lightconstruction
## Right/left rotation ## Operates with little vibrations
## Max. rotating speed up to ## Low maintenance
40,000 rpm / 80,000 U/min ## Can be processed in a cleaning machine
## Detachable irrigation channels ## Safe grip

252571 INTRA Drill Handpiece, angled, length 15 cm,

transmission 1:1 (40,000 rpm), for use with
252571 KARL STORZ high-performance EC micro
motor II and burrs
252574 Same, Transmission 1:2 (80.000 rpm)
252574 INTRA Drill Handpiece, straight, length 13 cm,
252591 
transmission 1:1 (40,000 rpm), for use with
KARL STORZ high-performance EC micro
motor II and burrs
252591

9.5 cm

649600 – 649770 G
Dia. Diamond
Detail Size mm Standard Diamond
coarse
014 1.4 649614 649714 –

018 1.8 649618 649718 –

023 2.3 649623 649723 649723 G

027 2.7 649627 649727 649727 G

031 3.1 649631 649731 649731 G

035 3.5 649635 649735 649735 G

040 4 649640 649740 649740 G

045 4.5 649645 649745 649745 G

050 5 649650 649750 649750 G

060 6 649660 649760 649760 G

070 7 649670 649770 649770 G

649600 Standard Straight Shaft Burr, stainless, size 014 – 070,

length 9.5 cm, set of 11
649700 Diamond Straight Shaft Burr, stainless, size 014 – 070,
length 9.5 cm, set of 11
649700 G Rapid Diamond Straight Shaft Burr, stainless, with coarse diamond
coating for precise drilling and abrasion without hand pressure and
generating minimal heat, size 023 – 070, length 9.5 cm, set of 9,
color code: gold
280033 Rack, for 36 straight shaft burrs with a length of 9.5 cm,
foldable, sterilizable, size 22 x 14 x 2 cm
 Endoscopic Surgical Anatomy of the Lamb’s Head 93

INTRA Drill Handpiece

for Surgery in Ethmoid and Skull Base Area

Special Features:
## Tool-free closing and opening of the drill ## Lightconstruction
## Right/left rotation ## Operates with little vibrations
## Max. rotating speed up to ## Low maintenance
40,000 rpm / 80,000 U/min ## Can be processed in a cleaning machine
## Detachable irrigation channels ## Safe grip

252572 INTRA Drill Handpiece, angled, length 18 cm,

transmission 1:1 (40,000 rpm), for use with
252572 KARL STORZ high-performance EC micro
motor II and burrs
252575 Same, transmission 1:2 (80,000 rpm)
252575 INTRA Drill Handpiece, straight, length 17 cm,
252592 
transmission 1:1 (40,000 rpm), for use with
KARL STORZ high-performance EC micro
252592 motor II and burrs

12.5 cm

649600 L – 649770 GL
Diamond
Standard Diamond
Dia. coarse
Detail Size mm
sterilizable sterilizable sterilizable

014 1.4 649614 L 649714 L –

018 1.8 649618 L 649718 L –

023 2.3 649623 L 649723 L 649723 GL

027 2.7 649627 L 649727 L 649727 GL

031 3.1 649631 L 649731 L 649731 GL

035 3.5 649635 L 649735 L 649735 GL

040 4 649640 L 649740 L 649740 GL

045 4.5 649645 L 649745 L 649745 GL

050 5 649650 L 649750 L 649750 GL

060 6 649660 L 649760 L 649760 GL

070 7 649670 L 649770 L 649770 GL

649600 L Standard Straight Shaft Burr, stainless, size 014 – 070,

length 12.5 cm, set of 11
649700 L Diamond Straight Shaft Burr, stainless, size 014 – 070,
length 12.5 cm, set of 11
649700 GL Rapid Diamond Straight Shaft Burr, stainless, with ­coarse diamond
coating for precise drilling and abrasion without hand pressure and
generating minimal heat, sizes 023 – 070, length 12.5 cm, set of 9,
color code: gold
280034 Rack, for 36 straight shaft burrs with a length of 12.5 cm,
foldable, sterilizable, size 22 x 17 x 2 cm
94 Endoscopic Surgical Anatomy of the Lamb’s Head

Accessories for Burrs

280033
280034

280043

280033 Rack, for 36 straight shaft burrs with a length of 9.5 cm,

foldable, sterilizable, size 22 x 14 x 2 cm
280034 Rack, for 36 straight shaft burrs with a length of 12.5 cm,
foldable, sterilizable, size 22 x 17 x 2 cm

n 280043 Rack, flat model, to hold 21 straight shaft burrs

with a length of 7 cm (6 pcs) and 9.5 cm (15 pcs),
folding model, sterilizable, size 17.5 x 11.5 x 1.2 cm

Please note: The burrs displayed are not included in the racks.
Endoscopic Surgical Anatomy of the Lamb’s Head 95

Accessories for Burrs

39552 B

Tray for small parts included

39552 A Wire Tray, provides safe storage of accessories for KARL STORZ

drilling/grinding systems during cleaning and sterilization,
includes tray for small parts, for use with Rack 280030, rack not
included
for storage of:
– Up to 6 drill handpieces
– Connecting cable
– EC micro motor
– Small parts
39552 B Wire Tray, provides safe storage of accessories for KARL STORZ
drilling/grinding systems during cleaning and sterilization, includes
tray for small parts, for use with Rack 280030, rack included
for storage of:
– Up to 6 drill handpieces
– Connecting cable
– EC micro motor
– Up to 36 drill bits and burrs
– Small parts

Please note: The instruments displayed are not included in the sterilizing and storage tray.
96 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

High-Speed Handpieces, angled, 100,000 rpm

For use with High-Speed Drills, shaft diameter 3.17 mm

100,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 7.5 mm

20 7120 33

53 mm

7.5 mm
252681

93 mm

7.5 mm
252682

High-Speed Handpiece, medium, angled, 100,000 rpm,

252681 
for use with High-Speed Micro-Motor 20 7120 33
High-Speed Handpiece, long, angled, 100,000 rpm,
252682 
for use with High-Speed Micro-Motor 20 7120 33
Endoscopic Surgical Anatomy of the Lamb’s Head 97

UNIDRIVE® S III ENT SCB n

High-Speed Handpieces, angled, 60,000 rpm

For use with High-Speed Drills, shaft diameter 2.35 mm

60,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 5.5 mm

20 7120 33

51 mm

5.5 mm
252661

71 mm

5.5 mm
252662

91 mm

5.5 mm
252663

High-Speed Handpiece, short, angled, 60,000 rpm,

252661 
for use with High-Speed Micro-Motor 20 7120 33
High-Speed Handpiece, medium, angled, 60,000 rpm,
252662 
for use with High-Speed Micro-Motor 20 7120 33
High-Speed Handpiece, long, angled, 60,000 rpm,
252663 
for use with High-Speed Micro-Motor 20 7120 33
98 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

High-Speed Handpieces, straight, 60,000 rpm

For use with High-Speed Drills, shaft diameter 2.35 mm

60,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 5.5 mm

20 7120 33

51 mm

5.5 mm
252691

71 mm

5.5 mm
252692

High-Speed Handpiece, short, straight, 60,000 rpm,

252691 
for use with High-Speed Micro-Motor 20 7120 33
High-Speed Handpiece, medium, straight, 60,000 rpm,
252692 
for use with High-Speed Micro-Motor 20 7120 33
Endoscopic Surgical Anatomy of the Lamb’s Head 99

UNIDRIVE® S III ENT SCB n

High-Speed Handpieces, malleable, slim, angled, 60,000 rpm

For use with High-Speed Drills, shaft diameter 1 mm

60,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 4.7 mm

The handpieces have malleable shafts that can be

bent up to 20° according to user requirements.

malleable

20 7120 33

108 mm

4.7 mm 252671

128 mm

252672
4.7 mm

High-Speed Handpiece, extra long, malleable, slim, angled,

252671 
60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33
High-Speed Handpiece, super long, malleable, slim, angled,
252672 
60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33
100 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

High-Speed Standard Burrs, High-Speed Diamond Burrs

For use with High-Speed Handpieces, 100,000 rpm

100,000 rpm
diameter 7.5 mm

252681 252682

High-Speed Standard Burrs, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium long

1 350110 M –

2 350120 M 350120 L

3 350130 M 350130 L

4 350140 M 350140 L

5 350150 M 350150 L

6 350160 M 350160 L

7 350170 M 350170 L

High-Speed Diamond Burrs, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium long

1 350210 M –

2 350220 M 350220 L

3 350230 M 350230 L

4 350240 M 350240 L

5 350250 M 350250 L

6 350260 M 350260 L

7 350270 M 350270 L
Endoscopic Surgical Anatomy of the Lamb’s Head 101

UNIDRIVE® S III ENT SCB n

High-Speed Diamond Burrs, High-Speed Acorn,
High-Speed Barrel Burrs, High-Speed Neuro Fluted Burrs

For use with High-Speed Handpieces, 100,000 rpm

100,000 rpm
diameter 7.5 mm

252681 252682

High-Speed Coarse Diamond Burrs, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium long

3 350330 M 350330 L

4 350340 M 350340 L

5 350350 M 350350 L

6 350360 M 350360 L

7 350370 M 350370 L

High-Speed Acorn, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium

7.5 350675 M

9 350690 M

High-Speed Barrel Burrs, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium

6 350960 M

9.1 350991 M

High-Speed Neuro Fluted Burrs, 100,000 rpm, for single use ,

sterile, package of 5

Diameter in mm medium long

1,8 350718 M 350718 L

3 350730 M 350730 L
102 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

High-Speed Standard Burrs, High-Speed Diamond Burrs

60,000 rpm
For use with High-Speed Handpieces, 60,000 rpm diameter 5.5 mm

252661 252662 252663

252691 252692

High-Speed Standard Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm short medium long

1 330110 S 330110 M –

2 330120 S 330120 M 330120 L

3 330130 S 330130 M 330130 L

4 330140 S 330140 M 330140 L

5 330150 S 330150 M 330150 L

6 330160 S 330160 M 330160 L

7 330170 S 330170 M 330170 L

High-Speed Diamond Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm short medium long

0.6 330206 S – –

1 330210 S 330210 M –

1.5 330215 S – –

2 330220 S 330220 M 330220 L

3 330230 S 330230 M 330230 L

4 330240 S 330240 M 330240 L

5 330250 S 330250 M 330250 L

6 330260 S 330260 M 330260 L

7 330270 S 330270 M 330270 L

Endoscopic Surgical Anatomy of the Lamb’s Head 103

UNIDRIVE® S III ENT SCB n

High-Speed Diamond Burrs, High-Speed Cylinder Burrs,
LINDEMANN High-Speed Fluted Burrs

For use with High-Speed Handpieces, 60,000 rpm

60,000 rpm
diameter 5.5 mm

252661 252662 252663

252691 252692

High-Speed Coarse Diamond Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm short medium long

3 330330 S 330330 M 330330 L

4 330340 S 330340 M 330340 L

5 330350 S 330350 M 330350 L

6 330360 S 330360 M 330360 L

7 330370 S 330370 M 330370 L

High-Speed Cylinder Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm short

4 330440 S

6 330460 S

LINDEMANN High-Speed Fluted Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Size in mm
short
(diameter x length)

Diameter 2.1/11 330511 S

Diameter 2.3/26 330526 S

104 Endoscopic Surgical Anatomy of the Lamb’s Head

UNIDRIVE® S III ENT SCB n

High-Speed Diamond Burrs

For use with High-Speed Handpieces, 60,000 rpm

60,000 rpm
diameter 4.7 mm

252671 252672

High-Speed Diamond Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm extra long super long

2 320220 EL 320220 SL

3 320230 EL 320230 SL

4 320240 EL 320240 SL

High-Speed Coarse Diamond Burrs, 60,000 rpm, for single use ,

sterile, package of 5

Diameter in mm extra long super long

2 320320 EL 320320 SL

3 320330 EL 320330 SL

4 320340 EL 320340 SL
 Endoscopic Surgical Anatomy of the Lamb’s Head 105

Navigation Panel Unit (NPU)

Straightforward and efficient support for ENT surgery and skull base

Similar to car navigation technology, surgery also ­requires danger zones. The system should always enable the
a tool that provides safe and secure orientation ­surgeon to determine the exact location of an instrument
towards a destination by means of a patient roadmap, in a patient’s body. The KARL STORZ Navigation Panel
uncomplicated surgical routes and a clear indication of Unit provides the surgeon with this ability.

Special Features:
## Mobile,space-saving system with intuitive ## Durable,sturdy and autoclavable navigation
handling instruments
## Easy assembly and flexible use in the OR ## Reduced costs through autoclavable
accessories and reduced duration of surgery
106 Endoscopic Surgical Anatomy of the Lamb’s Head

Navigation Panel Unit (NPU)

Straightforward and efficient support for ENT surgery and skull base

40 8000 01 Navigation Panel Unit NPU,

KARL STORZ SURGICAL COCKPIT® navigation system NPU,
including:
1x Navigation Panel
1x Optical Mouse
1x Navigation Camera
1x Electronic Box
1x Docking Adaptor
1x NPU Mobile Stand
1x Data Cable
1x Video Cable
1x Navigation Camera cable 250
1x Headband for Navigation, for single use
1x Patient Tracker II
1x Case Navigation
1x Navigation Probe
1x Mains Cord
Endoscopic Surgical Anatomy of the Lamb’s Head
Navigation Base Unit (NBU)
Space-saving integration in any operating room
The Navigation Base Unit NBU enables you to ­benefit
from a seamlessly integrated high-performance
­navigation solution. The basic unit can easily be
attached to a ceiling supply unit or integrated into an
equipment cart.
107
Mounted on a ceiling or an extension arm, the navigation
camera allows an easy setup and optimal visualization
of the surgical site combined with high flexibility. This
results in a “zero footprint” navigation solution.
Therefore the NBU is offered as a solution for the
f­unctional combination of all units in one place.
108 Endoscopic Surgical Anatomy of the Lamb’s Head

Navigation Base Unit (NBU)

Space-saving integration in any operating room

40 8100 01 Navigation Base Unit NBU, KARL STORZ

SURGICAL COCKPIT® Navigation System NBU,
including:
1x Navigation Base Unit
1x Optical Mouse
1x Navigation Camera
1x NBU Mobile Stand
1x Navigation Camera Cable 750
1x Headband for Navigation, for single use
1x Patient Tracker II
1x Transport Case Navigation
1x Navigation Probe
1x Mains Cord

Remark: Equipment cart and units are not delivered as a part of the NBU system
 Endoscopic Surgical Anatomy of the Lamb’s Head 109

Probe, Patient Tracker and Headband

for Navigation Panel Unit (NPU)

40 800110

40 8001 10 Navigation Probe, with glass marker spheres incorporated,

autoclavable, dimensions: 295 x 15 x 30 mm,
for use with KARL STORZ SURGICAL COCKPIT®
navigation systems

40 8000 87

40 8000 87 Patient Tracker II, with verification adaptor,

3 incorporated glass marker spheres and fixation screw,
autoclavable, dimensions: 80 x 60 x 12 mm
for use with KARL STORZ SURGICAL COCKPIT®
navigation systems

40 8000 83

40 8000 83 Headband for Navigation, for single use,

with plastic holder, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems

The autoclavable Probe 40 800110 with glass spheres for position tracking is a versatile,
basic instrument for navigation.

The autoclavable Patient Tracker 40 8000 87 ensures position tracking and orientation
of the patient.
110 Endoscopic Surgical Anatomy of the Lamb’s Head

Navigated Suction Tubes n

angular, curved downwards, curved upwards

40 8001 40

40 8001 40 FRAZIER Navigated Suction Tube, angular,

for right-handed use, with cut-off hole, 9 Fr.,
working length 9 cm, for use with KARL STORZ
SURGICAL COCKPIT® Navigation Systems

40 8001 50

40 8001 50 v. EICKEN Navigated Suction Tube, curved upwards,

for right-handed use, outer diameter 3 mm,
length 16.5 cm, for use with KARL STORZ
SURGICAL COCKPIT® Navigation Systems

40 8001 60

40 8001 60 v. EICKEN Navigated Suction Tube, curved downwards,

for right-handed use, outer diameter 3 mm,
length 16.5 cm, for use with KARL STORZ
SURGICAL COCKPIT® Navigation Systems

40 8001 40 L

40 8001 40 L FRAZIER Navigated Suction Tube, angular,

for left-handed use, 9 Fr., working length 9 cm,
total length 16 cm, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems
Endoscopic Surgical Anatomy of the Lamb’s Head 111

Navigated Suction Tubes n

angular, curved downwards, curved upwards

40 001 40 R

40 8001 40 R FRAZIER Navigated Suction Tube, angular,

for right-handed use, 9 Fr., working length 9 cm,
total length 16 cm, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems

40 8001 51

40 8001 51 v. EICKEN Navigated Suction Tube, curved upwards,

for left and right-handed use, outer diameter 3 mm,
length 16.5 cm, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems

40 8001 60 LM

40 8001 60 LM v. EICKEN Navigated Suction Tube, curved to left,

for left and right-handed use, outer diameter 3 mm,
length 16.5 cm, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems

40 8001 60 RM

40 8001 60 RM FRAZIER Navigated Suction Tube, angular,

for left-handed use, 9 Fr., working length 9 cm,
total length 16 cm, for use with KARL STORZ
SURGICAL COCKPIT® navigation systems
112 Endoscopic Surgical Anatomy of the Lamb’s Head

Instrument Tracker n
for Navigation Panel Unit (NPU)

The autoclavable instrument tracker is designed for the instrument tracker reduces the risk of collision and
the navigation of various instruments. The small size of ­ensures very good instrument maneuvrability.

Special Features:
## User-friendly handling thanks to optimized,
miniaturized design
## Can be used for various navigation instruments

40 8001 20

40 8001 20 Tool Tracker, for navigated instruments, autoclavable,

with 3 fix-mounted glass spheres, autoclavable,
dimensions: 70 x 50 x 14 mm,
for use with navigated instruments 40 800 14x,
40 800 15x, 40 800 16x and 40 800 17x
Endoscopic Surgical Anatomy of the Lamb’s Head 113

Wire Tray for Navigation Probe and Patient Tracker n

The wire tray ensures hygienic and secure sterilization,

cleaning and storage of standard navigation instrument sets.

39502 NAV1

39502 NAV1 Wire Tray with Lid, stackable,

with silicone knob mat and fixation system,
for the cleaning, sterilization and storage of one
navigation probe and one patient tracker,
external dimensions (w x d x h): 240 x 250 x 70 mm

Please note: The instruments displayed are not included in the rack.
114 Endoscopic Surgical Anatomy of the Lamb’s Head

Wire Tray for Suction Tubes and Instrument Tracker n

The wire tray ensures hygienic and secure sterilization,

cleaning and storage of the suction tube sets.

39502 NAV2

39502 NAV2 Wire Tray with Lid, stackable,

with silicone knob mat and fixation system,
for the cleaning, sterilization and storage of three
suction tubes and three instrument trackers,
external dimensions (w x d x h): 240 x 250 x 70 mm

Please note: The instruments displayed are not included in the rack.
Endoscopic Surgical Anatomy of the Lamb’s Head 115

IMAGE1 S Camera System n

Economical and future-proof
## Modular concept for flexible, rigid and ## Sustainable investment
3D endoscopy as well as new technologies ## Compatible with all light sources
## Forward and backward compatibility with video
endoscopes and FULL HD camera heads

Innovative Design
## Dashboard: Complete overview with intuitive
menu guidance
## Live menu: User-friendly and customizable
## Intelligent icons: Graphic representation changes
when settings of connected devices or the entire
system are adjusted
## Automatic light source control
## Side-by-side view: Parallel display of standard
­image and the Visualization mode
## Multiple source control: IMAGE1 S a ­ llows
the simultaneous display, processing and
­documentation of image information from
two c ­ onnected image sources, e.g., for hybrid
operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and

Visualization mode
116 Endoscopic Surgical Anatomy of the Lamb’s Head

IMAGE1 S Camera System n

Brillant Imaging
## Clear and razor-sharp endoscopic images in ## Reflection is minimized
FULL HD ## Multiple IMAGE1 S technologies for homogeneous
## Natural color rendition illumination, ­contrast enhancement and color
­shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

* SPECTRA  A : Not for sale in the U.S.

** SPECTRA  B : Not for sale in the U.S.
Endoscopic Surgical Anatomy of the Lamb’s Head 117

IMAGE1 S Camera System n

TC 200EN

IMAGE1 S CONNECT, connect module, for use with up to

TC 200EN*
3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S

IMAGE1 S CONNECT Module TC 200EN

TC 300

TC 300 IMAGE1 S H3-LINK, link module, for use with

IMAGE1 FULL HD three-chip camera heads,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz,
for use with IMAGE1 S CONNECT TC 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm

Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH 103, TH 104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S ­technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg

* SPECTRA  A : Not for sale in the U.S.

** SPECTRA  B : Not for sale in the U.S.
118 Endoscopic Surgical Anatomy of the Lamb’s Head

IMAGE1 S Camera Heads n

For use with IMAGE1 S Camera System
IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300
and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, autoclavable,
progressive scan, soakable, gas- and plasma-sterilizable,
with integrated Parfocal Zoom Lens, focal length
f = 15 – 31 mm (2x), 2 freely programmable camera head
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Endoscopic Surgical Anatomy of the Lamb’s Head 119

Monitors
9619 NB 19" HD Monitor,
color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 – 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord
9619 NB

9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image fomat 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord

9826 NB
120 Endoscopic Surgical Anatomy of the Lamb’s Head

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D l l
Fibre Optic – –
3G-SDI – l
RGBS (VGA) l l
S-Video l l
Composite/FBAS l l
Outputs:
DVI-D l l
S-Video l –
Composite/FBAS l l
RGBS (VGA) l –
3G-SDI – l
Signal Format Display:
4:3 l l
5:4 l l
16:9 l l
Picture-in-Picture l l
PAL/NTSC compatible l l

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (typ) 500 cd/m2 (typ)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
Endoscopic Surgical Anatomy of the Lamb’s Head 121

Cold Light Fountains and Accessories

495 NT Fiber Optic Light Cable,

with straight connector, diameter 2.5 mm,
length 180 cm
495 NTW Fiber Optic Light Cable,
diameter 2.5 mm, length 180 cm
with 90° deflection to the light source
495 NTX Same, length 230 cm

LED NOVA® 150, High-Performance LED Cold Light Fountain

20 1612 01 LED Nova 150, High-Performance

LED Cold Light Fountain
with one KARL STORZ light outlet,
power supply 100 - 240 VAC, 50/60 Hz
including:
Mains cord

Cold Light Fountain XENON NOVA® 175

20131501 Cold Light Fountain XENON NOVA® 175

power supply:
100–125 VAC/220–240 VAC, 50/60 Hz
including:
Mains Cord
20132026 XENON Spare Lamp, only,
175 watt, 15 volt

Cold Light Fountain XENON 300 SCB

20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 –125 VAC/220 –240 VAC, 50/60 Hz
including:
Mains Cord
Silicone Tubing Set, autoclavable, length 250 cm
SCB Connecting Cable, length 100 cm
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt
122 Endoscopic Surgical Anatomy of the Lamb’s Head

KARL STORZ AIDA® compact NEO advanced

Brilliance in documentation

AIDA compact NEO:
Recording screen
Data Acquisition
Still images, video sequences and audio comments can easily be recorded
during an examination or intervention by pressing the on-screen button,
activitating the footswitch, or pressing the camera head button.
All captured data are displayed on the right-hand side as a thumbnail
preview to ensure the data have been generated. Patient data can be
entered via an onscreen or standard keyboard. The system also offers the
possibility to transfer all relevant patient data via a DICOM worklist or a link
to the hospital information system (HIS) without requiring manual entry in
the patient entry screen.

AIDA compact NEO:
Patient data

Flexible Review, Data Storage and Efficient Data Export

Captured still images or video files can easily be viewed, edited, or deleted
on-screen before final storage. KARL STORZ AIDA® compact NEO efficiently
stores all recorded data on DVD, CD, USB stick, external/internal drive,
the relevant network and/or on a FTP server. It is also possible to save the
data directly on the PACS and/or HIS servers via HL7/DICOM. Data that
AIDA compact NEO: cannot be stored successfully remains in a cache until final archiving is
Review screen possible.

Special Features:
## SD and HD signal support:
– Y/C (S-Video)
– Composite input
– DVI-D input
## Picture-in-Picture function:
Display of channel 2 (SD) in channel 1 (FULL HD)
## Resolution:
– Still images 1920 x 1080 and SD
– Videos 1080p, 720p and SD
## Interface package (DICOM/H7) included
## NEO Secure security software
## Recommended applications:
– Universal (cart or OR1™ installation)

20 0409 13-EN* 
KARL STORZ AIDA® compact NEO advanced
Documentation system for digital storage of still images,
video sequences and audio files, power supply 115/230 VAC, 50/60 Hz

*  Available in the following languages:

DE, ES, FR, IT, PT, PL, RU, DK, SE, JP, CN
Endoscopic Surgical Anatomy of the Lamb’s Head 123

Equipment Cart

UG 220 Equipment Cart

wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220

UG 540 Monitor Swivel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180°, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx

UG 540
124 Endoscopic Surgical Anatomy of the Lamb’s Head

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,

200 V – 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,

200 V – 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or rigth,
turning radius approx. 320°, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
for usage with equipment carts UG xxx

UG 510
Endoscopic Surgical Anatomy of the Lamb’s Head 125

Notes:
126 Endoscopic Surgical Anatomy of the Lamb’s Head

Notes: