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Purpos: The location of infraorbital foramen (IOF) and the prevalence of accessory IOF vary among different populations. It may lead to infraorbital nerve (ION) blockage during surgery. This study aimed to assess the IOF location and AIOF frequency in Iranian people., Method: In this retrospective cross-sectional study, 500 paranasal sinus computed tomography scans of adults were examined using the INFINITT PACS system., Result: The distance from IOF to infraorbital margin (IOM), mid-pupillary line (MPL), midsagittal line (MSL), canine eminence (CE), and skin thickness (ST) was 8.97 ± 1.79, 5.73 ± 1.84, 24.86 ± 2.23, 20.39 ± 3.47, and 10.90 ± 2.59 mm, respectively. The vertical and transverse diameters of the foramen were 3.03 ± 0.65 and 3.71 ± 0.76 mm, respectively. In addition, the shape of 63.5% of the foramina was oval. The prevalence of AIOF was 9%, and its most common location was superomedial to IOF., Conclusion: We believe that in this study, landmarks like IOM, MPL, MSL, CE and ST could help the clinicians localize IOF and improve the ION anesthesia success rate. Furthermore, the occurrence of AIOF should be considered by physicians to reduce the chance of injuries to the infraorbital neurovascular complex., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Anatomical variations are a common feature of the human anatomy. Variation can explain some pathological conditions and is important to keep them in mind during surgical procedures. The relations between nerves and their adjacent arteries have been proposed to play a role in the generation of peripheral trigger migraines. Close opposition between nerves and arteries can lead to vascular compression of the nerve that triggers episodes of pain. We did a routine dissection of the infratemporal fossa and orbital floor by opening the maxillary sinus. Here we report a case where the infraorbital nerves form a nervous loop entrapping the infraorbital artery in the infraorbital channel. Similar cases of close nervous and arterial apposition are described for the auriculotemporal and occipital nerves. We think that accumulating knowledge of these rare variations could expand our understanding of rare conditions such as primary infraorbital neuralgia., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To develop and evaluate a transorbital endoscopic approach to the foramen rotundum to excise the maxillary nerve and infraorbital nerve branch., Methods: Cadaveric dissection study of 10 cadaver heads (20 orbits). This technique is predicated upon 1) an inferior orbital fissure release to facilitate access to the orbital apex and 2) the removal of the posterior maxillary wall to enter the pterygopalatine fossa (PPF). Angulations along the infraorbital nerve were quantified as follows: the first angulation was measured between the orbitomaxillary segment within the orbital floor and the pterygopalatine segment suspended within the PPF, while the second angulation was taken between the pterygopalatine segment and maxillary nerve as it exited the foramen rotundum. With refinement of the technique, the minimum amount of posterior maxillary wall removal was quantified in the final 5 cadaver heads (10 orbits)., Results: The mean distance from the inferior orbital rim to the foramen rotundum was 45.55 ± 3.24 mm. The first angulation of the infraorbital nerve was 133.10 ± 16.28 degrees, and the second angulation was 124.95 ± 18.01 degrees. The minimum posterior maxillary wall removal to reach the PPF was 11.10 ± 2.56 mm (vertical) and 11.10 ± 2.08 mm (horizontal)., Conclusions: The transorbital endoscopic approach to an en bloc resection of the infraorbital nerve branch up to its maxillary nerve origin provides a pathway to the PPF. This is relevant for nerve stripping in the context of perineural spread. Other applications include access to the superior portion of the PPF in selective biopsy cases or in concurrent orbital pathology., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: This research aims to enhance understanding of the anatomy of the supraorbital nerve (SON) and greater occipital nerve (GON), focusing on their exit points, distal trajectories, and variability, utilizing a novel 3D representation., Methods: Ten cadaveric specimens underwent meticulous dissection, and 3D landmarks were registered. Models were generated from CT scans, and a custom 3D method was employed to visualize nerve trajectories. Measurements, including lengths and distances, were obtained for the SON and GON., Results: The SON exhibited varied exit points, with the lateral branches being the longest. The GON showed distinct branching patterns, which are described relative to various anatomical reference points and planes. No systematic left-right differences were observed for either nerve. 3D analysis revealed significant interindividual variability in nerve trajectories. The closest approximation between the SON and GON occurred between lateral branches., Conclusion: The study introduces a novel 3D methodology for analyzing the SON and GON, highlighting considerable anatomical variation. Understanding this variability is crucial for clinical applications and tools targeting the skull innervation. The findings serve as a valuable reference for future research, emphasizing the necessity for personalized approaches in innervation-related interventions., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: In orbital floor reconstruction, fractures involving the slope of the posterior end of the orbital floor make it difficult to determine the best location for implant placement. Therefore, landmarks for reconstruction are desirable to perform safe and reproducible reconstruction surgery., Methods: We developed a surgical procedure that focuses on three orbital landmarks: the infraorbital nerve, the inferior margin of the greater wing of the sphenoid bone, and the posterior superior wall of the maxilla., Conclusions: Landmark-based orbital floor fracture reconstruction enables accurate reconstruction of fractures that extend to the slope of the posterior end of the orbital floor., (© 2022. The Author(s).)

The oculomotor nerve is the third cranial nerve, exiting the brainstem in the medial border of the cerebral peduncle, from where it crosses straight to the superior orbital fissure. It is a purely motor nerve responsible for the innervation of all the extraocular muscles, except the superior oblique and lateral rectus muscles. It also has parasympathetic pre-ganglionic fibers, responsible for the innervation of sphincter pupillae and ciliary muscles. Magnetic resonance imaging (MRI) is the best imaging exam to evaluate patients with clinical signs of third cranial nerve palsy. The oculomotor nerve can be affected by several diseases, such as congenital malformations, trauma, inflammatory or infectious diseases, vascular disorders, and neoplasms. This article aims to review the oculomotor nerve anatomy, discuss the best MRI techniques to evaluate each nerve segment, and demonstrate the imaging aspect of the diseases that most commonly affect it., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Reconstruction of orbitomaxillary defects poses many operative challenges because it requires consideration of cosmetic as well as functional elements: reestablishing facial symmetry while constituting the orbital volume and preserving involved neurovascular structures. The development of patient-specific polyetheretherketone implants have revolutionized complex craniofacial reconstruction due to its adaptability to anatomic constraints and accommodation of vital structures. Herein, we described 2 cases of orbitomaxillary reconstruction using PEEK implant with novel modifications to preserve the infraorbital nerve with optimal cosmetic outcomes and minimal postoperative morbidity., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Objective: The aim of this study was to learn about the morphological characteristics of the supraorbital foramen and to determine its precise position in relation to the surrounding anatomical landmarks in the adult population of Bosnia and Herzegovina., Material and Methods: For this purpose, 60 skulls from the Bosnia and Herzegovina population of known sex (32 males and 28 females), taken from the osteological collection of the Department of Human Anatomy of the Medical Faculty in Sarajevo, were subjected to morphological and morphometric analysis. Morphometric measurements were performed using a digital vernier caliper (Mitutoyo Corporation, Japan)., Results: The study showed that most supraorbital nerves exit the orbit through the supraorbital notch (73.8%) and the rest through the foramen (26.2%). Of this number, bilateral supraorbital notches were recorded in 58.33% of cases, a bilateral supraorbital foramen in 18.34% of cases, while in 23.33% of cases a notch was recorded on one side and a foramen on the contralateral side. Morphometric measurements performed to determine the exact position of the supraorbital foramen relative to the surrounding landmarks showed different values in males and females. An accessory foramen was also observed on the examined skulls in 16.67% of cases., Conclusion: Detailed knowledge of anatomical variations of the supraorbital foramen is required for safe and successful administration of regional anesthesia, in order to avoid iatrogenic nerve injuries during orbitofacial region surgery., (Copyright © 2022 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

Objectives: The maxillary nerve courses very close to the globe, rendering cats - with their large eyes - at risk of globe penetration during infraorbital or maxillary nerve blocks. Therefore, the goals of the study were to compare the distribution and potential complications of three infraorbital or maxillary regional injection techniques., Methods: Twenty-three bilateral maxillae of cat cadavers were used in a randomised blinded trial. Each maxilla was injected with a 0.2 ml 1:1 mixture of lidocaine 2% and a contrast medium by one of three injection techniques: infraorbital foramen (IOF; n = 14); infraorbital canal (IOC; n = 16); or maxillary foramen (MF; transpalpebral approach; n = 16) using a 25 G 1.6 cm needle. CT imaging of each cadaver head was performed before and after injections. A radiologist scored injectate distribution (none [0], mild [1], moderate [2], large [3]) in four locations: rostral, central and caudal IOC, and at the MF, for which the distribution side was also determined. Comparisons were performed with ordinal logistic mixed effects ( P <0.05)., Results: The median (range) total distribution score of the IOC and MF technique were significantly higher compared with the IOF technique (6.5 [4-12], 4 [2-8] and 0 [0-10], respectively). The total IOC score was also significantly higher compared with the MF technique. Injectate distribution at the MF was significantly more central following IOC injection compared with MF injection, which distributed centrolaterally. None of the techniques resulted in intraocular injection., Conclusions and Relevance: The IOC and MF techniques produced a satisfactory spread of the mixture that could result in effective maxillary anaesthesia in cats. Further studies are required to determine the effectiveness and safety of these techniques.

We describe a case of an 18-year-old male who developed a supraorbital neuroma following facial trauma that occurred 2 years earlier. He presented with complaints of persistent facial pain and migraines despite successful laceration repair and removal of foreign bodies at the time of injury. A non-contrast computed tomography (CT) scan of the orbits revealed an enlarged supraorbital nerve with remodeling and expansion of the supraorbital notch, suggesting a neuroma. The patient underwent orbitotomy with excision of neuroma (confirmed histologically) and experienced a complete resolution of periorbital pain.

Purpose: The present study aimed to explore the glymphatic pathway in the intraorbital optic nerve (ON) using magnetic resonance imaging (MRI)., Methods: Following conventional MRI examination, a total of 89 outpatients underwent T2-weighted imaging in thin-sliced coronal and sagittal sections. Moreover, three injected cadaver heads were dissected., Results: In the cadaver specimens, differences in appearance between the central and peripheral parts of the ON were not observed. On the axial T2-weighted MRI performed in the initial examination, the central part of the intraorbital ONs was delineated as a well-demarcated, linear hyperintense area in 19% of patients. On the thin-sliced serial coronal images, the hyperintense areas were identified on both sides in 91% of patients. They were delineated as continuous hyperintense areas in the ONs with an inconsistent appearance even in the same nerve. In 12.4% of patients, the areas were divided into the upper and lower parts by a horizontal septum, while others showed variable morphologies, lacking a septum. On thin-sliced sagittal images, hyperintense areas were identified in 46% of patients., Conclusion: Hyperintense areas in the intraorbital ON detected on T2-weighted sequences may involve a glymphatic pathway with perivascular spaces of the ON and central retinal artery. These may be collapsed and difficult to identify on surgical and cadaver specimens., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature.)

Traumatic optic neuropathy is sinister sequelae of craniofacial trauma leading to vision loss. The decision between early medical or surgical intervention is usually individualised. Visual evoked potentials may guide the treatment plan. We describe a young male presenting 5 days after a road traffic accident with no perception of light vision in the right eye. He was managed medically with high dose of intravenous steroids. At the 3-month follow-up, he reported a reversal of vision loss with return of visual acuity to 3/60, which improved to 6/36 at 5 months and remained stable at 8 months., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The frontal nerve is the largest branch of the ophthalmic nerve. This nerve gives rise to two terminal branches, the supraorbital (SON) and supratrochlear nerves (STN). To the best of our knowledge, there are no reports describing the detailed proximal course of these nerves while inside the orbit. Therefore, the goal of this study was to clarify the anatomy of the SON and STN inside and at their exit from the orbit. Twenty sides from ten fresh-frozen cadavers were used in this study. Intra and extra orbital dissections were performed to observe the course of the SON and STN. Additionally, measurements of the nerves were made at these locations. The course of the SON and STN inside the orbit was classified into three groups depending on the STN branching pattern from the SON. The group without any branch from the SON and STN inside the orbit was the most common. The exit points of these nerves were via the supraorbital notch, foramen, or neither a notch nor foramen. A distinct fibrous band was consistently found tethering the nerve except in specimens with nerves traversing a bony foramen. The mean diameters of the SON and STN were 1.3 ± 0.2 and 0.7 ± 0.1 mm, respectively. The results of this study further our knowledge of the course and morphology of the SON and STN and might be useful for better understanding and potentially treating some forms of migraine headache due to SON or STN compression/entrapment. Clin. Anat. 33:332-337, 2020. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Background: The levator palpebrae superioris muscle (LPS) acts as the upper eyelid's major elevator and retractor and is innervated by the oculomotor nerve. The muscle's paralysis is manifested by ptosis., Material and Methods: 70 orbits were dissected. After removing the orbital roof, the LPS' shape and anatomical variations (i.e., the presence of accessory muscular bands or atypical formation of the muscle) were assessed. To visualize the distribution of the oculomotor nerve's intramuscular sub-branches, the isolated levator palpebrae superioris muscles were stained using Sihler's staining technique., Results: Several LPS anatomical variations were observed in the specimens examined, in seven of which (7/70; 10%) additional delicate muscular slips arose from the LPS' lateral border and reached the lacrimal gland. Histological examination confirmed the presence of striated skeletal muscle fibers in all those cases. In three other specimens (3/70; 4.28%), supernumerary muscular bands ("tensor trochleae") were found that linked the levator with the superior oblique muscle's trochlea. In the next case, the LPS' origin was double and the muscle was bipartite on its proximal half. In most cases (55/70; 78.6%), muscular branches formed a single bundle that wrapped around the superior rectus muscle's medial border to reach the levator's inferior surface. Intramuscular sub-branches were distributed largely within the proximal two-thirds of the LPS and formed an irregular, tree-like pattern. However, thin sub-branches and small retrograde sub-branches extended as far as the muscle's insertion., Conclusions: Plastic surgeons and ophthalmologists should be aware of the levator palpebrae superioris muscle's anatomic variations both in planning and conducting surgeries on the upper eyelid., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Background and Objective: The orbit is a structure of interest for many medical specialties. Surgical approaches to the orbit present significant difficulties for the general neurosurgeon. Whoever decides to practice orbital surgery must have vast anatomical knowledge of this structure. However, although many of the existing publications about orbital anatomy show the complexity of this structure in detail, they fail to facilitate their understanding. The purpose of this study was to systematise and simplify the anatomical study of the orbit from a surgical perspective, to facilitate its understanding., Materials and Methods: A review of the international literature on the subject was carried out, and the principle of the rule of 7was followed for its ordering. For illustration purposes, photographs of cadaveric preparations and digital drawings were used., Results: The orbits are 2cavities located symmetrically on both sides of the nose. They have a pyramidal shape, with 4sides, a posterior vertex, an anterior base and their axis established from the sagittal plane at a 20-degree angle. A distinctive feature of the orbit is that its elements are organised into groups of seven: 7bones, 7intraorbital extraocular muscles and 7nerves., Conclusion: A systematisation of the orbital anatomy was performed with clear illustrations to simplify its study. The understanding of the anatomy of the orbit is vital to classify lesions and provides a solid basis when choosing the most appropriate approach for their treatment., (Copyright © 2019 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

This study is aimed to determine the relationship between orbital fracture sites in each CT scan view and postoperative diplopia. Data for 141 patients of orbital wall fracture were analyzed retrospectively. One group of examiners reviewed sagittal, coronal and axial CT scans. Descriptive statistical analysis was used to assess each fracture area and its potential relationship with the occurrence of postoperative diplopia. Among the three anatomical views, sagittal sections were significantly associated with post-operative diplopia (PD) (p = 0.044). For orbital wall fractures in a single location, C1 (p = 0.015), A1 (p = 0.004) and S3 (p = 0.006) fractures were significantly related to PD. Orbital wall fractures found in more than one location resulted in a higher probability of PD in all sections:, C1 + C2 group (p = 0.010), C1 + C2 + C3 group (p = 0.005), A1 + A2 group (p = 0.034), A3 + A1 group (p = 0.005), S1 + S2 group (p < 0.001), S2 + S3 group (p = 0.006) and S1 + S2 + S3 group (p < 0.001). For combinations of two or three sections, we found that only fractures involving both coronal and sagittal sections led to a significantly increased risk of PD (p = 0.031). PD is the main posttreatment complication of orbital bone fracture reduction. In addition to the known myogenic cause (failure to relieve entrapment) of diplopia, both trauma and surgical manipulation can compromise ocular motor nerve function and possibly result in the development of neurogenic causes of diplopia. Careful assessment of patient symptoms (whether preoperative diplopia is present), and the location of orbital fractures (and the influence of related musculature, fat, and nerves) on CT scans are strongly related to surgical success.

Purpose: We describe the first case of a novel surgical technique of mini-invasive corneal neurotization (MICORNE) using the lateral antebrachial cutaneous nerve as a graft nerve and the contralateral supraorbital nerve as a donor nerve in a herpetic patient with a neurotrophic keratopathy (NK)., Methods: A MICORNE procedure was performed in a 32-year-old man with a 5-year history of herpes simplex virus (HSV)-related NK in the right eye (RE). Visual acuity and corneal sensation were assessed over 9 months of follow-up. HSV-1 and HSV-2 genomes were screened preoperatively and postoperatively in the patient's tears using the quantitative polymerase chain reaction technique. A high does of the oral antiviral prophylaxis was prescribed during the follow-up., Results: Preoperative best-corrected visual acuity was 20/200 in the RE. A Cochet-Bonnet esthesiometer revealed complete corneal anesthesia (<5 mm ie, >15.9 g/mm) in all quadrants in a scarred and neovascularized cornea. Twelve months after the procedure, the visual acuity of the RE was 20/80 and corneal sensitivity had increased to 40 mm, that is, 0.8 g/mm (superior quadrant), 35 mm, that is, 1 g/mm (inferior quadrant), 40 mm (temporal quadrant), 35 mm, that is, 1 g/mm (nasal quadrant), and 40 mm (centrally). We observed no clinical recurrence of herpes, and HSV was not detected in tears during the follow-up period., Conclusions: We report the first case of MICORNE, a novel surgical technique of corneal neurotization in a herpetic patient with NK. Despite the potential risk of viral recurrence, our patient showed dramatic improvement in corneal sensation and visual acuity.

Accurate eye movements are crucial for vision, but the development of the ocular motor system, especially the molecular pathways controlling axon guidance, has not been fully elucidated. This is partly due to technical limitations of traditional axon guidance assays. To identify additional axon guidance cues influencing the oculomotor nerve, an ex vivo slice assay to image the oculomotor nerve in real-time as it grows towards the eye was developed. E10.5 Isl MN -GFP embryos are used to generate ex vivo slices by embedding them in agarose, slicing on a vibratome, then growing them in a microscope stage-top incubator with time-lapse photomicroscopy for 24-72 h. Control slices recapitulate the in vivo timing of outgrowth of axons from the nucleus to the orbit. Small molecule inhibitors or recombinant proteins can be added to the culture media to assess the role of different axon guidance pathways. This method has the advantages of maintaining more of the local microenvironment through which axons traverse, not axotomizing the growing axons, and assessing the axons at multiple points along their trajectory. It can also identify effects on specific subsets of axons. For example, inhibition of CXCR4 causes axons still within the midbrain to grow dorsally rather than ventrally, but axons that have already exited ventrally are not affected.

BACKGROUND This study aimed to describe the topographical anatomy of the supraorbital and supratrochlear nerves. Anatomical variations of both the intraorbital course of the 2 nerves and their relation to the supraorbital margin were analyzed. MATERIAL AND METHODS The research material involved 50 isolated adult cadaveric hemi-heads and 25 macerated adult skulls. All studied specimens were of Caucasian origin. RESULTS Taking into account the location of the frontal nerve division, 2 main variants of the intraorbital course of the supraorbital and supratrochlear nerves were distinguished. The first variant (variant I, 42%) involved cases in which the supraorbital and supratrochlear nerves branched off from the frontal nerve in the distal half of the length of the orbit. In the second variant (variant II, 58%), the frontal nerve branched into the supraorbital and supratrochlear nerves in the proximal half of the orbit. Variant II was characterized by the presence of a thick supraorbital nerve and a long, tiny supratrochlear nerve. For variant I, 27.8% of the supraorbital nerves were divided into the medial and lateral branch within the orbit, whereas, for variant II, 75% of nerves were divided into the medial and lateral branch within the orbit (before crossing the supraorbital margin). Single passage was observed on the supraorbital margin in 80% of wet specimens and in 78% of orbits examined on the macerated skulls. CONCLUSIONS Both the intraorbital and extraorbital course of the branches of the supraorbital and supratrochlear nerves were highly diverse. These variations should be taken into account during medical procedures performed within the orbital and frontal regions.

Purpose : To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression. Methods : Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison's bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as "normal", 1 defined as "minimally reduced", 2 defined as "grossly reduced but perceptible", and 3 defined as "total loss". Results : The average follow-up after surgery was 16 months (range 13-48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively ( p  < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable ( p  > 0.5). Conclusions : Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.

The surgical procedures directed to the orbit are invariably reported to be one of the most challenging procedures of the neurosurgery and it is very important to take measures to protect the ocular nerves. Many researchers have tried to identify safe approaches or safe regions in the orbit but the suggestions and results vary among published studies. The ocular motor nerves are under risk of injury during various approaches to the orbit. Simple but careful attention to potential variations in the origin and anatomical course of the ocular nerves and their relationships to the orbit may help to define "safe zones" during various approaches, thus, help to enhance clinical outcomes. The objective of this review, therefore, is to discuss the surgical anatomy of the orbit with special emphasis on oculomotor, trochlear, and abducens nerves and further emphasize their relationships with a surgical point of view during various approaches directed to the orbit. Anat Rec, 302:568-574, 2019. © 2018 Wiley Periodicals, Inc., (© 2018 Wiley Periodicals, Inc.)

The supraorbital notch/foramen involving the segment of the supraorbital nerve (SON) and the supraorbital artery (SOA) has little been explored with magnetic resonance imaging (MRI). Therefore, we explored these structures using MRI. A total of 90 patients underwent thin-sliced contrast MRI. In addition, eight sides of the orbits were dissected in four cadaveric heads. Cadaver dissections showed that the SOA coursed consistently beneath and in close proximity to the SON and reached the supraorbital notch/foramen. On axial MRI images, the supraorbital notch/foramen was identified in 98% on the right side and in 99% on the left. The distance from the midline to the midpoint of the supraorbital notch/foramen and depth from the skin surface to the supraorbital foramen/exit were measured. The median distance was 22.6 ± 3.08 mm on the right side and 22.8 ± 3.07 mm on the left, whereas the depth was 7.7 ± 1.39 mm on the right and 7.7 ± 1.43 mm on the left. Eighty percent of the sagittal images showed well-developed diploic veins in the supraorbital rim. Of these, 8.3% had anastomotic channels with the subcutaneous veins through the anterior wall of the supraorbital rim, 11.8% through the inferior wall, and 9% through the SOF. The SON and SOA segments passing through the supraorbital exit can be reliably located using contrast MRI. The supraorbital rim may function as the intracranial to extracranial anastomotic channel., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To describe a novel ultrasound-guided posterior extraconal block in the dog., Study Design: Prospective experimental cadaveric study., Animals: A total of 13 Beagle Cross cadaver heads., Methods: After describing the ultrasound bony landmarks and posterior extraconal local regional technique in one head, 12 heads were used to evaluate the spreading of contrast and evaluate potential complications. A 5-8 MHz microconvex ultrasound probe was positioned caudal to the orbital ligament, with the beam orientated transversely, and then tilted caudally until the orbital fissure was visualized. After identifying the bony structures consistent with the orbital fissure, a needle was advanced using an in-plane technique and 0.5 mL of a 50:50 mixture of iohexol and methylene blue was injected. Computed tomography (CT) and dissection were used to evaluate successful injections and potential complications. The injection was considered successful if radiopaque contrast medium was 5 mm from the orbital fissure. Potential complications were defined as the presence of radiopaque contrast within the globe or the intracalvarial tissues., Results: The CT images confirmed contrast at the target site in 15/24 (63%) of the injections. Only two injections were found in the temporalis muscle; the rest of the injections were located in the extraconal space. No potential complications such as intracranial spreading of contrast, intravascular or intraocular injection were found., Conclusions and Clinical Relevance: The technique can deliver contrast close to the main nerves which provide sensory and motor innervation to the eye. Further studies are needed to evaluate this technique in clinical cases., (Copyright © 2018 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Purpose: Introduction of a novel sensory grading system to assess the incidence and long-term recovery of infraorbital hypesthesia following orbital floor and inferior orbital rim fractures., Methods: Patients who presented for evaluation of orbital floor and/or zygomaticomaxillary complex (ZMC) fractures between January 2015 and April 2016 were analyzed. Two-point subjective infraorbital sensory grading in 5 discrete anatomic areas was performed. Fractures were repaired based on traditional criteria; hypesthesia was not an indication for surgery. The sensory grading system was repeated a mean 21.7 months (range 18-28) after initial fracture., Results: Sixty-two patients (mean 41.8 years) participated in the initial symptom grading, and 42 patients (67.7%) completed the 2-year follow-up. Overall, 20 of 42 patients (47.6%) had some infraorbital hypesthesia. There were fewer with isolated orbital floor fractures versus ZMC fractures (31.8% vs. 68.4%; p = 0.019). Two years postinjury, 9.1% and 40.0% with isolated floor and ZMC fractures, respectively, had persistent sensory disturbance (p = 0.0188). Of patients with sensory disturbance on presentation, 71.4% with isolated floor fractures and 38.5% with ZMC fractures experienced complete sensory recovery (p = 0.1596). Patients with isolated floor fractures had improved recovery after surgery (100% vs. 33.3% recovery; p = 0.0410). Patients with ZMC fractures showed no difference in sensory prognosis between those repaired and observed., Conclusions: In this pilot study, isolated orbital floor fractures carried a good infraorbital sensory prognosis, further improved by surgical repair. Zygomaticomaxillary complex fractures portended a worse long-term sensory outcome, unaffected by management strategy. This study validates the novel sensory grading system in post-fracture analysis.

Background: The accessory infraorbital foramen (AIOF) is an anatomical variation associated with the infraorbital foramen (IOF) and nerve (ION). Its occurrence and neural contents have clinical implications regarding failure of loco-regional anesthesia and risk of neural damage during surgical interventions involving the maxillary region. Thus, morphologic characterization of the AIOF and neural contents as well as the spatial relationships to the IOF are potentially useful for optimizing surgical procedures. Additionally, predictive features of the AIOF based on its relationship to IOF morphology could enable the surgeon to anticipate its presence and proceed accordingly. The purpose of this study was to determine whether the presence of an AIOF and its neural contents affected the size, shape, and composition of the IOF and ION. The specific hypothesis tested was that the topography and fascicular composition of the ION and IOF differs between individuals possessing an AIOF and those lacking this anatomical variant., Methods: Gross topographic features of the IOF (42 crania) were compared between specimens possessing (test) or lacking (control) an AIOF. Nerve fascicles of ION (60 cadaveric sides) were examined histologically and compared morphometrically between specimens presenting or lacking an AIOF. An additional sample of 30 crania was subjected to cone-beam computed tomography (CBCT) analysis to determine the course of the canal leading to the AIOF., Results: The AIOF incidence was 47.6% (20 crania) and 32.1% of the sides (27 sides). A single AIOF was observed in 24 sides and double AIOF in three sides. The AIOF occurred bilaterally in 7 specimens (16.7%). The majority of AIOF (86.7%) were located superomedial to IOF. A slightly higher frequency of the AIOF was found in left side compared to the right. Using CBCT, a patient sample showed an AIOF incidence in 21 sides of 16 patients (65.6%). A single AIOF was observed in 19 sides. Only 1 double AIOF was found in the scans, whereas 3 were found in the dry skull group. The AIOF occurred bilaterally in 3 scans (10%). The majority of AIOF (90.4%) were located superomedial to the IOF based on the CBCT scans. The AIOF was consistently seen connected to the infraorbital canal and progressed superiorly and medially from the infraorbital canal to the maxillary surface. The size of the ION without an AIOF was not significantly different than the ION in the presence of an AIOF (1.45 × 10/1.32 × 10 μm, P < 0.35) based on fascicular area. However, the number of ION fascicles was greater in specimens without an AIOF compared to those showing this feature (15.15/12.71, P < 0.04) CONCLUSION:: Results indicate that the area of the ION is not affected by an AIOF, suggesting that the field of innervation of this area is not modified by its occurrence. However, the ION appears to divide more proximally into its component branches when the AIOF is present.

Our aims were to document the occurrence of neurosensory disturbances of the infraorbital nerve six months after operation for an orbital blow-out fracture, and to find out whether dexamethasone facilitates neurosensory regeneration. Patients were randomly assigned to one of two groups: the study group was given a total of dexamethasone 30mg, whereas the control group were given neither glucocorticoid nor placebo. Each patient's infraorbital neurosensory state was recorded preoperatively, immediately postoperatively, and six months later. A total of 18 patients were included, eight of whom had neurosensory disturbances six months after the initial trauma that was not affected by dexamethasone. Six of the seven patients who had a delay of seven days or more between trauma and operation had significantly prolonged disturbance at the 180-day clinical follow up compared with those in whom it was less than seven days (p=0.005). Other possible predictors made no significant difference. Although dexamethasone did not facilitate sensory recovery, its benefits in the management of pain and reduction of swelling may justify its use in the management of facial trauma in selected patients., (Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Importance: Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options., Objective: To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment., Design, Setting, and Participants: Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle., Interventions: Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group., Main Outcomes and Measures: Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year., Results: In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery., Conclusions and Relevance: Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher., Level of Evidence: 3.

Background: Neurosurgeons who operate in and around the pathway of the ocular nerves should have good knowledge of not only their normal anatomy but also their variations., Case Description: During routine dissection of the orbits in an adult cadaver, an aberrant branch of the right trochlear nerve continued on to innervate the orbicularis oculi muscle. In this case, the trochlear nerve also provided a branch to the supratrochlear nerve., Conclusions: Surgeons who operate along the pathway of the trochlear nerve such as the cavernous sinus should be aware of such an anatomic variant in order to avoid unwanted complications such as weakness of the orbicularis oculi muscle., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Infraorbital nerve blocks are often performed for the management of postoperative pain associated with cleft lip correction. Infraorbital nerve block procedures depend on the identification of the infraorbital foramen; however, there is little information regarding the infraorbital foramen location in the pediatric population., Aims: The aim of this study was to identify the location of the infraorbital foramen in the pediatric population relative to a midpoint between the nasospinale and jugale., Methods: The study assessed the location of 152 infraorbital foramina relative to a midpoint between the nasospinale and J on dry crania. Crania were from individuals ranging in age-at-death from 6-month fetal to 18 years. The population was subdivided into fetal/infant (≥6 months fetal age-<2 years), child (≥2-<12 years), and adolescent (≥12-≤18 years) groups for comparison., Results: The average distance of the infraorbital foramen from the nasospinale-to-jugale midpoint was 1.55 ± 0.78 mm (Mean ± SD) in the fetal/infant group, 0.80 ± 0.91 mm in the child group, and 1.31 ± 1.68 mm in the adolescent group. Furthermore, infraorbital foramina tended to be located medial to the nasospinale-to-jugale midpoint in the fetal/infant population, directly upon or superomedial to the nasospinale-to-jugale midpoint in the child population, and directly upon or superior/superolateral to the nasospinale-to-jugale midpoint in the adolescent population., Conclusions: The infraorbital foramen was located within 2 mm, on average, from the nasospinale-to-jugale midpoint regardless of age group. Therefore, the nasospinale-to-jugale midpoint may serve as useful means of identifying the location of the infraorbital foramen in the pediatric population and aid in optimizing infraorbital nerve block procedures. The information in this report is valuable in general, but may be particularly useful in developing countries where there is a lack of ultrasound training and availability for health care providers; or places where infraorbital nerve block may be the sole anesthetic modality for cleft lip surgery, even among adolescent patients., (© 2018 John Wiley & Sons Ltd.)

The zygomaticofacial branch (ZFb) of the zygomatic nerve passes through the lateral wall of the orbit anterolaterally and traverses the zygomaticofacial foramen (ZFFOUT). However, in terms of intraorbital course, only a few studies have focused on the orbital opening of the ZFb (ZFFIN) and related canal. Therefore, this study aimed to locate the orbital opening and exit of the ZFb of the zygomatic nerve. Twenty sides from 10 fresh frozen cadaveric Caucasian heads were used in this study. The vertical distance between inferior margin of the orbit and ZFFIN (V-ZFFIN), the horizontal distance between the lateral margin of the orbit and ZFFIN (H-ZFFIN), diameter of the ZFFIN (D-ZFFIN), the vertical distance between the inferior margin of the orbit and ZFFOUT (V-ZFFOUT), the horizontal distance between the lateral margin of the orbit and ZFFOUT (H-ZFFOUT), and the diameter of the ZFFOUT (D-ZFFOUT) were measured, respectively. The ZFFIN were located 5.1 ± 2.0 mm superior to the inferior margin of the orbit and 4.3 ± 1.6 mm medial to the lateral margin of the orbit. The ZFFOUT was located 1.2 ± 2.9 mm inferior to the inferior margin of the orbit and 1.1 ± 3.0 mm lateral to the lateral margin of the orbit. The diameter of the ZFFOUT was significantly larger than that of the ZFFIN. Additional knowledge of the zygomatic nerve and its branches might decrease patient morbidity following invasive procedures around the inferolateral orbit.

In this study, details of the infraorbital nerve's (ION's) anatomical course variants were compared using computed tomography (CT), and relationships between the variants and fracture patterns in the orbital floor were investigated. Fifty-two normal individuals and 50 patients with unilateral isolated orbital floor fractures were enrolled in this study. Four measurements in normal individuals and five measurements in fracture patients were obtained in parasagittal sections. The anatomical variations of the ION were categorized into three types according to the classification by Ferences et al. Among the normal individuals, 42 orbits were classified as type 1 ION, 48 orbits as type 2, and 14 orbits as type 3. The distance from the inferior orbital rim to the upper border of the inferior orbital foramen and the length of descension portion of the ION in type 1 ION were significantly shorter than in type 2 and type 3 IONs. In patients with orbital floor fractures, the distance from the inferior orbital rim to the upper border of the inferior orbital foramen was positively correlated with herniation level of bone and soft tissue. The ION had three anatomical variants according to the degree of descension in the anterior portion of the orbit. When fracture of the orbital floor occurs in patients with type 1 ION, inferior displacement of the fractured orbital bone and orbital soft tissue may be less severe than in patients with other ION types., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Identification of the infraorbital foramen is important in infraorbital nerve block and the prevention of iatrogenic injury of the infraorbital nerve in maxillofacial surgeries. This study assessed the location of 887 infraorbital foramina from 518 adult crania of varied sex and population. The study assessed the midpoint of a line segment spanning from nasospinale to jugale (NS-J) relative to the infraorbital foramen. The mean distance of the NS-J midpoint from the infraorbital foramen was 2.1 ± 1.9 mm (mean ± SD) with a mode of 0 mm (266:887; 30%). The NS-J midpoint was located in the same plane or inferior to the infraorbital foramen in 98.4% of sides (873:887). There were no significant differences between sexes, populations, or sides with regard to the NS-J midpoint to infraorbital foramen distance. The NS-J midpoint can be used to locate the infraorbital foramen in both females and males of varied populations regardless of craniofacial diversity. The results of this study will aid in infraorbital nerve block procedures and maxillofacial surgery.

The aim of this study was to elucidate the sensory territory of the trigeminal nerve on the upper eyelid.Eight hemifaces from Korean cadavers were dissected. The frontal nerve (FN), supraorbital nerve (SON), supratrochlear nerve (STN), infratrochlear nerve (ITN), and lacrimal nerve (LN) were traced.The terminal branches to the eyelid margin of FN were distributed between 1/6 and 2/5 of the palpebral fissure width lateral to the medial canthus and 1/6 of the eyebrow height from eyelid margin. The SON was distributed between 2/5 and 9/10 of the eye width lateral to the medial canthus, at 1/3 of the eyebrow height. The STN was distributed between -1/4 and -1/5 of the eye width medial to the medial canthus, at 1/5 of the eyebrow height. The ITN was distributed at -1/4 and 1/10 of the eye width medial to the medial canthus, and at 1/5 of the eyebrow height. The LN was distributed between approximately 3/5 and 13/10 of the eye width lateral to the medial canthus, and at 1/4 of the eyebrow height. The main branches of FN and SON ran deep to the orbicularis from the supraorbital notch to the upper border of the tarsal plate. In the pretarsal area, they were between the orbicularis and tarsal plate. The STN and ITN were between the orbicularis and the skin. The LN was observed between the orbicularis and the tarsal plate.Upper eyelid was mainly supplied by SON and FN. The medial extremity was supplied by STN and ITN, and the lateral extremity by LN.

The association between immunoglobulin IgG4 and autoimmune pancreatitis was first shown in 2001. Since then many previously established fibrosclerotic diseases demonstrating synchronous or metachronous multiorgan involvement have been included within the ambit of IgG4-related disease. Diagnostic criteria have been proposed involving 1) serum IgG4 level elevated beyond 135 mg/dL, 2) IgG4+ to IgG+ plasma cell ratio > 40% and >10 IgG4+ cells per high power field of biopsy sample and 3) a constellation of imaging features which involve a variety of organ systems. We present a pictorial essay demonstrating the spectrum of imaging findings for IgG4-related disease, including dacryosialadenitis, variety of renal lesions, tumefactive thickening of the extraocular muscles and orbital nerve, sclerosing cholangitis, and type I pancreatitis. Imaging plays an important role in diagnosis, screening for multiorgan involvement, and follow-up of the disease.

To investigate the behavioral and biomolecular similarity between neuralgia and depression, a trigeminal neuralgia (TN) mouse model was established by constriction of the infraorbital nerve (CION) to mimic clinical trigeminal neuropathic pain. A mouse learned helplessness (LH) model was developed to investigate inescapable foot-shock-induced psychiatric disorders like depression in humans. Mass spectrometry was used to assess changes in the biomolecules and signaling pathways in the hippocampus from TN or LH mice. TN mice developed not only significant mechanical allodynia but also depressive-like behaviors (mainly behavioral despair) at 2 weeks after CION, similar to LH mice. MS analysis demonstrated common and distinctive protein changes in the hippocampus between groups. Many protein function families (such as cell-to-cell signaling and interaction, and cell assembly and organization,) and signaling pathways (e.g., the Huntington's disease pathway) were involved in chronic neuralgia and depression. Together, these results demonstrated that the LH and TN models both develop depressive-like behaviors, and revealed the involvement of many psychiatric disorder-related biomolecules/pathways in the pathogenesis of TN and LH.

Purpose: To review the radiological findings of frontal nerve schwannoma of the orbit and determine distinguishing imaging features., Design: Retrospective interventional case series., Methods: Setting: Single tertiary institution., Period: September 1996 to December 2016., Patient Population: Thirteen patients with orbital frontal nerve schwannoma., Intervention: Patients underwent surgical excision following preoperative imaging., Main Outcome Measures: Imaging characteristics on computed tomography (CT) and magnetic resonance imaging (MRI)., Results: There were 13 patients with histopathologically proven schwannoma of the frontal nerve. Mean age was 44.4 years and 61.5% were male. The majority (84.6%) of frontal nerve schwannomas extended between the supraorbital notch and superior orbital fissure. The most common shape seen in our patients with frontal nerve schwannoma was a multilobulated "beaded" appearance (46.2%), followed by a dumbbell (30.8%), oval (15.4%), and fusiform (7.7%) shape. On CT imaging, all patients had bony remodeling. Target sign, fascicular sign, and cystic degeneration were seen in 76.9%, 35.8%, and 46.2% of patients, respectively. On radiological-pathologic correlation, the zone of tightly packed cellular solid portion (Antoni A pattern) corresponded to the hypointense area on T2-weighted MRI and the hyperintense area on gadolinium-enhanced T1-weighted MRI., Conclusion: Frontal nerve schwannoma should be considered as a differential diagnosis for any superior orbital mass. Our study describes several radiological findings that would point toward its diagnosis, including its multilobulated beaded or dumbbell shape, as well as additional signs such as the target sign, fascicular sign, and cystic degeneration., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Normal variations in the paranasal sinus region are well documented in literature. We present five cases of a little known normal variant, which can have serious implications for the patient as well as the operating surgeon. An ectopic infra orbital nerve canal coursing through the maxillary sinus has rarely been described in imaging literature. This may sometimes be mistaken for a simple septum in the maxillary sinus and may cause serious complications during Functional Endoscopic sinus surgery (FESS) surgeries. We describe the imaging findings and present a brief review of the previous publications on the same subject.

A 53-year-old Afghan man presented with a 12-month history of left proptosis, diplopia and facial swelling 20 years after a bomb blast injury. Magnetic resonance and computed tomography imaging revealed a well-circumscribed lesion centred within the left inferior orbit/superior maxillary sinus along with left orbital fracture. Histopathology and immunostaining of the debulked lesion were consistent with traumatic neuroma of the infraorbital nerve. Infraorbital neuromas have developed following orbital decompression surgeries but have not been reported previously following non-surgical trauma.

Background Although the peripheral and central sensitizations of trigeminal nervous system may be one of the important factors of migraine, the precise mechanism is not fully understood. In this study, we examined the influence of the sensitization of the second division of the trigeminal nerve (V2) by chronic constriction injury (CCI) of the infraorbital nerve (ION) on migraine headache, using the capsaicin-induced migraine model. Methods Male Sprague-Dawley rats were assigned to four groups: (a) sham surgery and topical-dural vehicle application (Sham + Vehicle) group, (b) CCI-ION and topical-dural vehicle application (CCI-ION + Vehicle) group, (c) sham surgery and topical-dural capsaicin application (Sham + Capsaicin) group, (d) CCI-ION and topical-dural capsaicin application (CCI-ION + Capsaicin) group. Behavioral testing and immunohistochemical staining were performed. Results In the behavioral test, the Sham + Capsaicin group showed significantly longer duration of immobilization and shorter duration of exploration compared with the Sham + Vehicle group, which is similar to clinical features of migraine patients. Moreover, CCI-ION enhanced these effects in the CCI-ION + Capsaicin group. Immunohistochemical staining for phospho-extracellular signal-related kinase (pERK) in the trigeminal ganglion (TG) containing first and second divisions of the trigeminal nerve and the trigeminocervical complex (TCC) revealed that pERK expression was significantly increased in the CCI-ION + Capsaicin group compared with the other groups. However, comparing between effects of the peripheral and central sensitizations (in the TG and TCC), from our results, peripheral sensitization would play a much less or not significant role. Conclusions These data demonstrate that the sensitization of V2 could influence the activation and the sensitization of the first division of the trigeminal nerve in the TCC, subsequently exacerbating pain sensation and pain-related behaviors. We have shown for the first time that the existence of the central sensitization of V2 can be an exacerbating factor for migraine related nociceptive thresholds/activation.

Periorbital nerve enlargement commonly indicates perineural invasion of malignancy or inflammatory conditions. This study reviews the role of supraorbital and infraorbital nerve biopsies in patients presenting with radiographic enlargement and to elucidate the surgical technique involved. A retrospective chart review (1997-2014) was performed at a single tertiary center. Patients with radiographic confirmation of enlarged supraorbital/infraorbital nerves that underwent biopsy were included. Charts were reviewed for: patient demographics and history, clinical symptoms and findings, radiographic findings, surgical method, and treatment. Five patients (4 female, 1 male) met inclusion criteria. Average age was 72.4 years (range 36-90). Four patients had history of cutaneous malignancy. All presented with diplopia and/or dysesthesias. Clinical examination confirmed decreased V1 and/or V2 sensation for 4 patients. Imaging revealed enlargement of V1, V2, and/or V3 in all patients. Infraorbital nerve biopsies were performed in 3 patients via transconjunctival fornix-based orbitotomy with subperiosteal dissection along orbital floor followed by unroofing of infraorbital canal. The remaining 2 underwent supraorbital nerve biopsy via sub-brow incision onto superior orbital rim with reflection of periosteum. Biopsies confirmed squamous cell carcinoma(3), mucoepidermoid carcinoma(1), and idiopathic orbital inflammation(1). Three patients initiated treatment in <1 month. One decided to follow-up closer to home, one was lost to follow-up. For patients presenting with enlarged supraorbital/infraorbital nerves, biopsy can rapidly confirm the underlying condition and facilitate early treatment. A sub-brow approach offers direct access to supraorbital nerve while transconjunctival fornix-based anterior orbitotomy with canal unroofing allows access to infraorbital nerve.

Purpose: To elucidate the course of the supraorbital nerve (SON) with reference to the lacrimal caruncle in order to facilitate safer direct browplasty by preventing nerve injury., Methods: Thirty-four hemifaces from 18 embalmed Korean cadavers were dissected. A vertical line through the upmost point of the lacrimal caruncle and a horizontal line through the supraorbital margin were used as the horizontal and vertical reference positions, respectively. The course of the SON in the frontal view and the point at which it pierced the overlaying musculature were examined., Results: The SON divides into a superficial branch and a deep branch just after exiting the orbit. In all cases, the deep SON remains in the subgaleal plane deep to the corrugator and frontalis muscles. The superficial SON travels under the corrugator muscle dividing into three branches (medial, intermediate and lateral) and pierced the frontalis muscle at 19-32 mm above the supraorbital margin. However, in 11 cases (32%) the medial branch of the superficial SON pierced the lower portion of the corrugator muscle at 3.6 mm above the supraorbital margin and ran in front of the muscle along with the vertical line through the upmost point of the lacrimal caruncle., Conclusions: One-third of the medial branch of the superficial SON without corrugator muscle protection is vulnerable to iatrogenic injury during direct browplasty. Therefore, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the vertical line through the upmost point of the lacrimal caruncle in order to avoid nerve injury., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives/hypothesis: To examine by intraoperative electric stimulation which peripheral facial nerve (FN) branches are functionally connected to which facial muscle functions., Study Design: Single-center prospective clinical study., Methods: Seven patients whose peripheral FN branching was exposed during parotidectomy under FN monitoring received a systematic electrostimulation of each branch starting with 0.1 mA and stepwise increase to 2 mA with a frequency of 3 Hz. The electrostimulation and the facial and neck movements were video recorded simultaneously and evaluated independently by two investigators., Results: A uniform functional allocation of specific peripheral FN branches to a specific mimic movement was not possible. Stimulation of the whole spectrum of branches of the temporofacial division could lead to eye closure (orbicularis oculi muscle function). Stimulation of the spectrum of nerve branches of the cervicofacial division could lead to reactions in the midface (nasal and zygomatic muscles) as well as around the mouth (orbicularis oris and depressor anguli oris muscle function). Frontal and eye region were exclusively supplied by the temporofacial division. The region of the mouth and the neck was exclusively supplied by the cervicofacial division. Nose and zygomatic region were mainly supplied by the temporofacial division, but some patients had also nerve branches of the cervicofacial division functionally supplying the nasal and zygomatic region., Conclusions: FN branches distal to temporofacial and cervicofacial division are not necessarily covered by common facial nerve monitoring. Future bionic devices will need a patient-specific evaluation to stimulate the correct peripheral nerve branches to trigger distinct muscle functions., Level of Evidence: 4 Laryngoscope, 127:1288-1295, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

In the last decade, a new surgical treatment modality was developed for frontal secondary headache, based on the assumption that the trigger of this pain entity is the entrapment of peripheral sensory nerves. The surgery entails a procedure, where an endoscopic approach is used to decompress the supraorbital and supratrochlear nerve branches, which are entrapped by the periosteum in the region of the corrugator supercilii muscle. Candidates for the surgery define their headache as moderate to severe persistent daily pressure or tension, localized in the frontal area, sometimes accompanied by symptoms of nausea and photophobia mimicking a primary headache-migraine. We created a step-by-step screening algorithm which is used to differentiate patients that have the highest chance for a successful surgical decompression. Up to now, published data regarding this type of surgery demonstrate long-lasting successful outcomes while adverse effects are minor. This article reviews and discusses from a surgeon's perspective decompression surgery for secondary headache attributed to supraorbital and supratrochlear nerve entrapment.

Purpose: The location of the infraorbital foramen and its variations are important during periorbital, dental, plastic, and oromaxillofacial surgeries. The aim of this study is to document the most practical anatomical soft tissue landmarks for defining the location of infraorbital foramen and infraorbital nerve for effective nerve blockade and to decrease its risk of injury during periorbital surgeries., Methods: Forty sides from 20 adult fixed cadavers were used for this study. The position of the infraorbital nerve was determined in reference to the lateral edge of the ala of the nose, medial and lateral palpebral commissures. All these three soft tissue landmarks were then connected to each other forming a triangular shaped region., Results: In 75 % of the cases the infraorbital foramen was located on the line which is connecting the lateral palpebral commissure to the ala of the nose. The closest distance of infraorbital foramen to the inferior orbital margin and to facial midline was also measured. The infraorbital foramen was located outside the previously defined triangular region in 20 % and inside the triangle in 5 %. The closest mean distance between the infraorbital foramen and the infraorbital margin was measured as 8.8 ± 1.0 mm and the distance between the medial wall of the infraorbital foramen and the facial midline was measured as 30.3 ± 2.7 mm., Conclusion: The triangular region and the soft tissue landmarks we offered in this study may facilitate prediction of the locations of the infraorbital foramen thus, the infraorbital nerve.

Orbital floor fractures commonly occur just medial to the junction of the infraorbital nerve and the inferior orbital fissure because the bone is thinner posteromedial to the infraorbital nerve than that lateral to the nerve. The authors previously reported 2 pediatric patients with an isolated orbital floor fracture lateral to the infraorbital nerve. The authors showed that, on the unaffected side of these patients, the lateral portion of the orbital floor was thinner than the medial portion. In the present study of 5 adult patients with an isolated orbital floor fracture lateral to the infraorbital nerve, the authors compared the thickness of the medial and lateral portions of the orbital floor with that of the infraorbital nerve on the unaffected side. Computed tomographic images showed that the bone lateral to the infraorbital nerve was somewhat thinner than bone in the medial portion. Because the orbital structures are generally symmetrical, our findings suggest that these 5 patients had partial anatomical weakness in the lateral portion of the infraorbital nerve on the affected side, resulting in an isolated orbital floor fracture lateral to the infraorbital nerve.

Orbital floor fractures are one of the most commonly encountered maxillofacial fractures due to their weak anatomical structure. Restoration of the orbital floor following a traumatic injury or a tumor surgery is often difficult due to inadequate visibility and lack of knowledge on its anatomical details. The aim of this study is to investigate the locations of the inferior orbital fissure (IOF), infraorbital groove (G), and infraorbital foramen (Fo) and their relationship with the orbital floor using a software. Measurements from the inferior orbital rim (IOR) using the Fo, the IOF, G, and the optic canal (OC) were calculated in 268 orbits as reference points. The surgical landmarks from the G and the OC, the G and the IOF, the G and the intersection point were measured as 31.6 ± 6, 12.9 ± 4, and 12 ± 5 mm, respectively. The mean distances between the G and the IOR, the Fo and the IOF, and the Fo and the OC were found as 8.3 ± 2.1, 28.7 ± 3.5, and 53.6 ± 5.9 mm, respectively. The mean angles were calculated as OC-IOF-G 68.1° ± 16.4°; intersection-G-IOF as 61.4° ± 15.8°; IOF-OC-G as 19° ± 5.5°; OC-G-intersection as 31.5° ± 11.9°, G-intersection-OC as 129.5°, IOF-intersection-G as 50.5°. Furthermore, variable bony changes on the orbital floor which may lead to the differences at intersection point of the G and Fo were determined. In 28 specimens (20.9 %), unilateral accessory Fo (AcFo) was present. In 27 specimens, AcFo was situated supermaedially (96.4 %) on the main aperture. In one specimen, two intraorbital canals and Fo emerged from different points and coursed into different apertures. The measured mean distances of the AcFo-IOR and the AcFo-Fo were as 7 ± 2 and 7.3 ± 3.2 mm, respectively. The primary principle in the oculoplastic treatment of orbital floor reconstructions must be repositioning the herniated orbital aperture by maintaining the infraorbital artery and the nerve in the orbital floor. The IOF and the G were recommended as the more reliable oculoplastic surgical landmarks for identifying the orbital floor. To avoid pinching of the orbital floor structures, the triangle (IS-G-IOF) should be equilateral with an exigence of a 70° angle within it. Among each distance of the intersection-IOF, IOF-G, G-intersection should be equal. With the help of certain software, this study made possible to investigate the variability of the orbital floor structures, observe the variety in measurements and calculate the parameters which are crucial in implementing personalized reconstruction and implanting support.

This study reports the first case of abducens nerve duplication along its entire intracranial course, ending within the orbit. A distinct abducens nerve duplication reaching the common tendinous ring (annulus of Zinn), as well as another split within the intraconal segment of the nerve have been revealed. Additionally, two groups (superior and inferior) of abducens nerve sub-branches to the lateral rectus muscle were visualised using Sihler's stain. The analysed anatomical variation has never been reported before and it seems to be in the middle of the spectrum between the cases of duplication occurring only within the intracranial segments of the abducens nerve found in the literature and those continuing throughout the whole course of the nerve. Abducens nerve duplication may be treated as a relic of early stages of ontogenesis. Such a variant might result from alternative developmental pathways in which axons of the abducens nerve, specific for a given segment of the lateral rectus muscle, run separately at some stage, instead of forming a single stem.