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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4368_Библиотеки_им_академика_М_И_Перельмана
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Jugular Foramen Approach
IX
ET
NP
ICA
LPP
MS
Fig. 23.12 The internal carotid artery (ICA) is exposed in
the poststyloid parapharyngeal space. The nasopharynx (NP),
V3 from the foramen ovale (FO), maxillary sinus fl oor (MS),
eustachian tube (ET), and lateral pterygoid plate (LPP) are all
shown to demonstrate the location of the internal carotid
artery relative to these anatomic landmarks.
JF
ICA
SC
XI
JF
X
XII
Fig. 23.14 Internal carotid artery (ICA), sympathetic chain
(SC), and CNs IX, X, XI, and XII are seen as they course between
the carotid artery and the jugular foramen (JF).
LVP M
JF
ICA
IX
ICA
X
APA
IX
X
a
b
Fig. 23.13 (a) The poststyloid space is dissected revealing the cranial nerves, and the jugular foramen (JF) is seen posterior and
lateral to the internal carotid artery (ICA). (a) Zoomed-out image which now demonstrates the ascending pharyngeal artery (APA)
coursing in close contact with the internal carotid artery. The levator veli palatini muscle (LVPM) is also seen coursing in the same
direction as the eustachian tube. IX, glossopharyngeal nerve; X, vagus nerve.
References
1. Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK.
Endoscopic cranial base surgery: classification of operative
approaches. Neurosurgery 2008;62(5):991–1002, discussion
1002–1005
2. Dallan I, Bignami M, Battaglia P, Castelnuovo P, Tschabitscher M.
Fully endoscopic transnasal approach to the jugular foramen:
anatomic study and clinical considerations. Neurosurgery
2010;67(3, Suppl Operative):ons1–ons7, discussion ons7–ons8
3. Lee DL, McCoul ED, Anand VK, Schwartz TH. Endoscopic endonasal access to the jugular foramen: defining the surgical approach. J
Neurol Surg B Skull Base 2012;73(5):342–351
4. Ho B, Jang DW, Van Rompaey J, et al. Landmarks for endoscopic approach to the parapharyngeal internal carotid artery: a radiographic and cadaveric study. Laryngoscope 2014;124(9):1995–2001
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Section 6
Pterygopalatine and
XXXXXXXX24 Endoscopic Endonasal
Approach to Pterygopalatine
Fossa 249
Infratemporal Fossa
25 Infratemporal Approach 259
26 Nasopharyngectomy 267
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Chapter 24
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24.1 Indications 250
Endoscopic Endonasal
Approach to
Pterygopalatine Fossa
24.2 Surgical Steps 250
24.3 Instruments Required 256
24.4 Complications 256
24.5 Case Example 256
24.6 Tips and Tricks 256
Endoscopic Endonasal Approach to Pterygopalatine Fossa
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24 Endoscopic Endonasal Approach to
Pterygopalatine Fossa
Paolo Battaglia, Mario Turri-Zanoni, Paolo Castelnuovo
Introduction
The pterygopalatine fossa (PPF) is a critical region located
behind the posterior wall of the maxillary sinus and
bordered by the pterygoid plates posteriorly, palatine
bone medially, and middle cranial fossa superiorly. It has
connections with the infratemporal fossa laterally through
the pterygomaxillary fissure, the posterior nasal cavity
medially through the sphenopalatine foramen (SPF), the
orbit superiorly through the inferior orbital fissure, and
the palate inferiorly through the palatine foramina.
this fact, the PPF represents the main pathway for the
spread of different inflammatory or neoplastic diseases
from the head and neck to the skull base.
1
Given
24.1 Indications
The endoscopic endonasal transantral approach can be
tailored according to the extension of the disease involving
the PPF and to the experience of the surgeon. The aim of
surgery could be to sample the lesion for diagnostic issue
or to treat it with a radical intent.
of pathologies involving the PPF can be diagnosed using
only clinical and radiologic assessment, performing the
biopsy and the complete resection of the lesion during
the same surgical procedure. For example, the biopsy of
the lesion is strongly contraindicated in case of highly
vascular lesions in young male patients for the suspect
of juvenile angiofibroma (JA). In the latter, a preoperative
intra-arterial angiography with embolization of the
hypervascularized component is recommended.
However, the tissue biopsy could be useful for the
pretreatment work-up in selected cases of unclear
diagnosis, especially when malignant tumor is suspected.
For example, when lymphoproliferative disorder,
mesenchymal tumor (e.g., sarcoma), or poorly differentiated
cancer is suspected, surgery is performed only for a tumor
biopsy, obtaining the precise diagnosis that is essential
to properly orientate the medical treatments (different
protocols of radiotherapy and chemotherapy).
The diseases originating in or extending to the PPF
that can be resected radically with curative intent are as
follows:
• Fibro-osseous lesion (e.g., fibrous dysplasia).
• JA.
• Schwannoma arising from vidian nerve (VN), infraor-
bital nerve (ION), greater and lesser palatine nerve.
• Inverted papilloma.
• Cavernous hemangioma.
• Selected cases of sinonasal and skull base malignancies
(e.g., squamous cell carcinoma, adenocarcinoma, ade-
noid cystic carcinoma).
• Selected cases of nasopharyngeal cancers (e.g., undif-
ferentiated carcinoma).
2
The great majority
Contraindications for exclusive endoscopic endonasal
approach are related to the extension of disease to
selected anatomic compartments surrounding the
PPF not resectable through the transnasal corridor
and requiring external approaches or when the tumor
extension involves vital structures precluding the radical
resection of the lesion at all. The critical areas not
amenable for transnasal endoscopic resection include the
parapharyngeal spaces with encasement of the internal
carotid artery (ICA), the hard/soft palate, the cavernous
sinus, and the massive infiltration of the orbit.
3
24.2 Surgical Steps
The step-by-step surgical procedure is tailored to the
extension and histology of the lesion to be treated, as
follow:
• Exposure of the sinonasal corridor (Fig. 24.1). The low-
er portions of the middle and superior turbinate are
trimmed, preserving the olfactory mucosa. Anteroposterior ethmoidectomy, large maxillary antrostomy, and
sphenoidotomy are performed (Fig. 24.2).
• Identification of the surgical anatomic landmarks. A
subperiosteal dissection on the lateral nasal wall is
performed, starting approximately 1 cm anteriorly to
the tail of the middle turbinate. Just behind the crista
MT
*
NP
IT
Fig. 24.1 Endoscopic endonasal view of a right nasal cavity.
IT, inferior turbinate; MT, middle turbinate; NP, nasopharynx;
S, nasal septum. Black asterisk points out the medial wall of
the pterygopalatine fossa.
S
250
MT
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Endoscopic Endonasal Approach to Pterygopalatine Fossa
MS
S
SS
MT
S
MS
a
Fig. 24.2 Exposure of the sinonasal corridor (right side). (a) The middle turbinate is partially trimmed in its anterior part. The natural
ostium of the maxillary sinus is exposed after a total uncinectomy. The anterior ethmoid is visible. (b) Total ethmoidectomy and
sphenoidotomy are performed to identify anatomic landmarks. BE, bulla ethmoidalis; IT, inferior turbinate; MS, maxillary sinus; MT,
middle turbinate; NP, nasopharynx; S, nasal septum; SS, sphenoid sinus.
BE
NP
IT
b
ethmoidalis of the palatine bone, the sphenopalatine
artery (SPA) is identified, cauterized, and cut to expose
SS
the sphenopalatine foramen (SPF) (Fig. 24.3). The SPF
and the prominence of the ION, visible along the roof
of the maxillary sinus, served as consistent landmarks
to understand the position of the major neural structures of the PPF (Fig. 24.4). The sphenopalatine ganglion, together with the VN and maxillary nerve (V2),
will be located superior to the horizontal plane passing
through the SPF, while the greater and lesser palatine
SPA
nerves will be located inferiorly; all the neural elements of the PPF will be found medially to the virtual
sagittal plane passing through the ION. In this phase,
it is important to recognize the vascular network of
NP
S
the basisphenoid, including the palatovaginal artery
(Fig. 24.5) and the SPA with its branches (Fig. 24.6).
• Opening the surgical window to approach the PPF.
The surgical approach should be tailored according
to the location and extension of the lesion into the
PPF. When the lesion is confined superiorly to the
virtual horizontal plane passing through the SPF, a
large maxillary antrostomy (preserving the integri-
Fig. 24.3 Identifi cation of the sphenopalatine foramen. NP,
nasopharynx; S, nasal septum; SPA, sphenopalatine artery;
SS, sphenoid sinus. The black arrow indicates the crista
ethmoidalis of the palatine bone (pointer).
ty of the inferior turbinate) should be sufficient for
removing the upper part of the posterior wall of the
maxillary sinus (medial to the ION) (Fig. 24.7). For
such a conservative approach, only the orbital and
sphenoidal processes of the palatine bone are drilled
4
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SS
ION
MS
PB
Fig. 24.4 Wide maxillary antrostomy with removal of the
medial wall of the maxillary sinus (superior portion). ION,
infraorbital nerve; MS, maxillary sinus; PB, palatine bone
(vertical segment); SPA, sphenopalatine artery; SS, sphenoid
sinus. The black arrow indicates the crista ethmoidalis of the
palatine bone (pointer).
SS
SPA
SS
sbSPA
PVA(in)
SPA
Fig. 24.5 Vascular network of the basisphenoid. The
palatovaginal artery is visible as it enters and goes out from
the palatosphenoidal canal. PVA(in), palatovaginal artery
entering the palatosphenoidal canal; PVA(out), palatovaginal
artery coming out from the canal and directed inferiorly to
vascularize the nasopharynx; S, nasal septum; sbSPA, septal
branches of the sphenopalatine artery; SPA, sphenopalatine
artery; SS, sphenoid sinus.
PVA(out)
S
PBo
MS
PBv
Fig. 24.6 Relationship between the palatine bone and the
sphenopalatine artery. MS, maxillary sinus; PBo, orbital process
of palatine bone; PBs, sphenoidal process of palatine bone;
PBv, vertical process of palatine bone; S, nasal septum; SPA,
sphenopalatine artery (two branches); SS, sphenoid sinus. The
black arrow indicates the crista ethmoidalis of the palatine
bone (pointer).
252
SPA
SPA
PBs
SS
S
ION
*
SPA
pwMS
IT
Fig. 24.7 The conservative approach to the upper part of the
PPF (black asterisk) is delimitated by a sagittal plane passing
through the infraorbital nerve and a horizontal one passing
through the sphenopalatine foramen. ION, infraorbital nerve;
IT, inferior turbinate; pwMS, posterior wall of maxillary sinus;
SPA, sphenopalatine artery; SS, sphenoid sinus. The black arrow
indicates the crista ethmoidalis of the palatine bone (pointer).
Endoscopic Endonasal Approach to Pterygopalatine Fossa
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SS
ION
V2
*
SPA
pwMS
Fig. 24.8 The rotundum foramen is located inferomedially
to the superior orbital fi ssure at the base of greater wing of
sphenoid. The black dotted line indicates the course of the
maxillary nerve through the rotundum foramen. The black
asterisk points out the PPF. ION, infraorbital nerve; pwMS,
posterior wall of maxillary sinus; SPA, sphenopalatine artery;
SS, sphenoid sinus; V2, second branch of the trigeminal nerve.
ION
pwMS
Fig. 24.10 The vidian nerve, medially (black arrowhead),
and the maxillary nerve, superolaterally, could be easily
identifi ed by displacing the PPF content, enveloped in the
“periosteal bag,” in an inferolateral direction, as far as the
base of the pterygoids is exposed. ION, infraorbital nerve; NP,
nasopharynx; PVA, palatovaginal artery; pwMS, posterior wall
of maxillary sinus; SS, sphenoid sinus; V2, second branch of the
trigeminal nerve.
V2
SS
PVA
NP
SS
ION
PSc
pwMS
Fig. 24.9 Once the sphenopalatine artery is divided and the
two processes of the palatine bone (orbital and sphenoidal) are
drilled out, the palatosphenoidal canal and the palatovaginal
artery running through (black dotted line) become visible.
ION, infraorbital nerve; PBv, vertical process of palatine bone;
PSc, palatosphenoidal canal; pwMS, posterior wall of maxillary
sinus; SS, sphenoid sinus.
PBv
out, exposing therefore the foramen rotundum
(Fig. 24.8) and the palatosphenoidal canal (Fig. 24.9).
The SPA and the palatovaginal artery are cauterized
and divided. During this surgical step, the periosteum behind the posterior wall of the maxillary sinus,
surfacing the PPF, has to be carefully preserved. In
this way, the VN (medially) and the V2 (superolaterally) can be identified easily by displacing the PPF
content, enveloped in the “periosteal bag,” in an inferolateral direction (Fig. 24.10). For lesions localized
or extended inferiorly to the horizontal plane passing through the SPF, the surgical window has to be
expanded inferiorly by drilling out also the vertical
plate of the palatine bone as well and by removing
the posterior half of the inferior turbinate together
with the posterior portion of the medial maxillary
wall (Fig. 24.11). Also in this case, the posterior wall
of the maxillary sinus can be removed as much as
required using Kerrison rongeurs, in a medial-to-lateral direction, generally as far as the sagittal plane
and passing through the ION (Fig. 24.12). By removing the vertical process of the palatine bone, the descending palatine artery and the palatine nerve are
visible inside to the palatine canal (Fig. 24.13). When
the VN and artery are divided, the PPF content enveloped in the periosteal layer is gently lateralized to
expose the base of the pterygoids (Fig. 24.14).
Dissection within the PPF. Once the periosteal lay-
er containing the PPF has been incised, the fibrofatty
tissue surrounding the internal maxillary artery and
its branches is exposed (Fig. 24.15). A medium-sized
vascular clip is positioned on the lateral aspect of the
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SS
PVA
ION
SS
pwMS
NP
IT
Fig. 24.11 For expanded approaches to the PPF, the surgical
window has to be extended inferiorly to the horizontal plane
passing through the sphenopalatine foramen by removing
the posterior half of the inferior turbinate together with the
posterior portion of the medial maxillary wall. IT, inferior
turbinate; NP, nasopharynx; PVA, palatovaginal artery; pwMS,
posterior wall of maxillary sinus; SS, sphenoid sinus. The black
arrowhead indicates the vidian nerve.
SS
pwMS
DPA
IT
Fig. 24.12 The posterior wall of the maxillary sinus is
completely removed, from medial to lateral direction, as far as
the sagittal plane passing through the infraorbital nerve (black
dotted line). The vertical process of the palatine bone is drilled
out, exposing the descending palatine artery. In this phase, the
periosteal layer surfacing the pterygopalatine fossa has to be
preserved. DPA, descending palatine artery; ION, infraorbital
nerve; IT, inferior turbinate; PVA, palatovaginal artery; pwMS,
posterior wall of maxillary sinus; S, nasal septum; SS, sphenoid
sinus. The black arrowhead indicates the vidian nerve.
PVA
S
254
PVA
DPA
GPA
Fig. 24.13 The descending palatine artery (DPA) branches
off of the maxillary artery in the PPF and descends through
the palatine canal (black arrow) along with the palatine nerves
arising from the pterygopalatine ganglion. The DPA produces
two branches: the greater palatine artery (GPA) to supply the
hard palate and the lesser palatine artery (LPA) to supply the
soft palate. NP, nasopharynx; PVA, palatovaginal artery; SS,
sphenoid sinus. The black arrowhead indicates the vidian nerve.
LPA
NP
ION
V2
*
PP
Fig. 24.14 The vidian nerve is divided and the PPF content
(black asterisk) is displaced laterally to expose the base of
the pterygoid plates. ION, infraorbital nerve; PP, base of the
pterygoid plates; PVA, palatovaginal artery; SS, sphenoid
sinus; V2, second branch of the trigeminal nerve. The black
arrowhead indicates the vidian canal.
SS
PVA
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