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Endoscopic Endonasal Approach to Pterygopalatine Fossa
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SS
ION
MA
Fig. 24.15 The periosteal layer of the PPF is incised and the
fat tissue is removed, exposing the maxillary artery and its
vascular network. ION, infraorbital nerve; MA, maxillary artery;
PG, pterygopalatine ganglion; SS, sphenoid sinus; V2, second
branch of the trigeminal nerve.
V2
PG
internal maxillary artery to avoid bleeding into the
surgical field. Behind the vascular network, the neural structures are now exposed. Blunt dissection is
performed to identify the neural network of the PPF,
composed of the V2 with the ION, the pterygopalatine
ganglion, and the greater and lesser palatine nerves
(Fig. 24.16). Whenever possible during the surgical dissection and if they appear to be macroscopically spared
from disease, these nerves have to be preserved to minimize the morbidity of the surgical procedure for the
patient.5 The descending palatine artery is identified,
cauterized, and cut, if necessary. Continuing the dissection posteriorly, the two heads of the lateral pterygoid
muscle (LPM) inserting on the lateral pterygoid plate
come into view (Fig. 24.17). If needed, the LPM can be
detached from its medial insertion on the pterygoids to
improve the dissection.
6
• Drilling out of the limiting bone. In selected cases, rad-
ical resection of the tumor is obtained only by drilling
out the limiting bone. In this respect, what seems to be
important for preventing recurrences of juvenile nasopharyngeal angiofibroma is drilling out the cancellous
bone of the pterygoid roots and basisphenoid, particularly around the vidian canal, to remove any residual disease that may not be immediately evident. This
technical note is relevant in case of malignancies as
well, where the pterygoid roots and/or pterygoid plates
are usually drilled out following the vidian canal, as far
as the anterior genu of the ICA.
3
SS
PG
MA
LPM
Fig. 24.16 The contents of the PPF. DPA, descending palatine
artery; LPM, lateral pterygoid muscle; MA, maxillary artery; NP,
nasopharynx; PG, pterygopalatine ganglion; PP, base of the
pterygoid plates; SS, sphenoid sinus.
PG
MA
LPM
Fig. 24.17 The descending palatine artery is divided and
the base of the pterygoids is drilled out to identify the medial
and lateral plates. LPM, lateral pterygoid muscle; LPP, lateral
pterygoid plate; MA, maxillary artery; MPP, medial pterygoid
plate; NP, nasopharynx; PG, pterygopalatine ganglion; PP, base
of the pterygoid plates.
DPA
LPP
PP
NP
PP
NP
MPP
255
Endoscopic Endonasal Approach to Pterygopalatine Fossa
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24.3 Instruments Required
• Both 0- and 45-degree rigid endoscopes (4 mm in
diameter) are essential for this surgical technique.
• Straight and curved diamond burr drills are useful to
approach the bony wall of the PPF.
• Straight and curved nasal bipolar cautery forceps
facilitate optimum visualization and access during the
surgical procedure, to control bleeding.
• Medium-sized vascular clips and its dedicated
positioning instrument have to be always available for
internal maxillary artery ligation.
• Angled and/or double-curved cutting, grasping, hold-
ing, and dissecting instruments are mandatory to
access laterally located structures.
• The magnetic neuronavigation system with computed
tomography/magnetic resonance imaging (CT/MRI)
fusion images or angio-CT scan is useful for better
illustration of surrounding structures.
• Intraoperative Doppler ultrasound is a helpful device
for detection of major vessels.
24.4 Complications
A key aspect to prevent complications is the acquisition
of three-dimensional anatomic knowledge that allows
the surgeon to achieve intraoperative orientation based
on the integration of macroscopic, radiologic, and tactile
perception.
fer an additional advantage to avoid complications, but
its use should never replace the anatomic and surgical
knowledge. Given this fact, the main anatomic landmarks must be constantly kept under control during
surgery to guarantee safe access to deep structures.
Moreover, complications can be minimized by excellent
exposure of the surgical field and meticulous dissection
of neurovascular structures contained into the PPF. SPA
bleeding usually does not represent a frightened complication because a dissection, cauterization, and cut of the
vessel can easily control it. In selected cases, identification and cauterization of vidian artery and palatovaginal
artery should be performed to reduce bleeding into the
surgical field, improving tumor dissection and removal.
On the other hand, hemorrhage of the internal maxillary
artery may represent the most challenging problem due
to the difficult surgical access between the pterygoid
muscles and to the significant blood flow. For this reason, careful dissection of the vessel and clip positioning
are recommended in every case before to dissect and
resect the tumor.
Moreover, nerves can be damaged either directly or
by injury to the vessels supplying them. Temporary or
permanent deficit is possible. Facial and hard palate
5
In this sense, neuronavigation systems of-
numbness ipsilateral to the lesion could result as injury
of V2 or its terminal branch (ION) and palatine nerves.
Dry eye syndrome is a possible complication occurring
sporadically when VN is encountered and cut. Other complications that may happen rarely are ascending bacterial
meningitis, infections of the paranasal sinuses or orbital
content, and nasal airway blockage due to the scarring of
the surgical corridor. To note, the majority of tumors encountered through the endoscopic endonasal transmaxillary approach to the PPF are extradural and so a cerebrospinal fluid leak is not a major problem for this approach.
24.5 Case Example
A 71-year-old woman presented with epistaxis and facial pain. The preoperative CT and contrast-enhanced
MRI scans demonstrated the presence of a hypervascularized tumor of the right PPF, compatible with a
schwannoma of the VN (Fig. 24.18a, b). The lesion was
resected using an endoscopic endonasal approach. The
surgical window was expanded inferiorly by removing the posterior half of the inferior turbinate together
with the posterior portion of the medial maxillary wall.
The final histology analysis confirmed the diagnosis of
schwannoma. The symptoms of the patient are completely solved after surgery. A 2-year MRI scan showed
the complete resection of the tumor without recurrence
of disease (Fig. 24.18 c, d).
24.6 Tips and Tricks
• Careful preoperative evaluation with imaging studies is
essential to determine the nature of the lesion affecting
the PPF and its relationship with the surrounding neurovascular structures.
• The posterior wall of the maxillary sinus can be
removed as much as needed, from medial to lateral
direction, generally as far as the sagittal plane passing
through the ION. In this phase, the periosteal layer surfacing the PPF has to be preserved.
• VN (medially) and V2 (superolaterally) could be easily
identified by laterally displacing the PPF content, enveloped in the “periosteal bag,” thus exposing of the base
of the pterygoid plates.
• Based on the biology and the extent of the tumor, it is
possible to identify, cauterize, and cut the palatovaginal, descending palatine, and vidian arteries, to reduce
bleeding during tumor dissection.
• A teamwork approach is essential. The treatment deci-
sion should be approved by a multidisciplinary group
so as to provide the patient with maximum benefit
from broad expertise.
5
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MS
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Endoscopic Endonasal Approach to Pterygopalatine Fossa
MCF
SS
MCF
TM
*
*
IT
a
cd
Fig. 24.18 Preoperative contrast-enhanced MR scan in sagittal (a) and coronal (b) views of a right pterygopalatine fossa
schwannoma arising from the vidian nerve. Postoperative MRI scan performed 2 years after surgery in sagittal (c) and coronal
(d) views, confi rming the radical resection of the tumor. The black asterisks indicate the descending palatine artery passing through
the palatine canal.
b
References
1. Isaacs SJ, Goyal P. Endoscopic anatomy of the pterygopalatine
fossa. Am J Rhinol 2007;21(5):644–647
2. DelGaudio JM. Endoscopic transnasal approach to the pterygopalatine fossa. Arch Otolaryngol Head Neck Surg 2003;129(4):
441–446
3. Battaglia P, Turri-Zanoni M, Lepera D, et al. Endoscopic transnasal approaches to pterygopalatine fossa tumors. Head Neck
2016;38(Suppl 1):E214–E220
4. Karligkiotis A, Volpi L, Abbate V, et al. Palatovaginal (pharyngeal)
artery: clinical implication and surgical experience. Eur Arch Otorhinolaryngol 2014;271(10):2839–2843
5. Castelnuovo P, Lepera D, Turri-Zanoni M, et al. Quality of life following endoscopic endonasal resection of anterior skull base cancers. J Neurosurg 2013;119(6):1401–1409
6. Abuzayed B, Tanriover N, Gazioglu N, Cetin G, Akar Z. Extended
endoscopic endonasal approach to the pterygopalatine fossa: anatomic study. J Neurosurg Sci 2009;53(2):37–44
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Chapter 25
5
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25.1 Indications 260
Infratemporal
Approach
25.2 Infratemporal Fossa Limits 260
25.3 Surgical Steps 260
25.4 Case Examples 263
25.5 Complications 263
25.6 Tips and Tricks 265
Infratemporal Approach
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25 Infratemporal Approach
Lee A. Zimmer, Almaz Kurbanov
Introduction
The “infratemporal approach” explores the anatomic
steps in performing endoscopic skull base surgery of the
infratemporal fossa (ITF). A detailed anatomic description of
the steps is provided. Critical landmarks for safe dissection
are described and common instrumentation to access this
region is provided. From this knowledge, we are able to
predict functional outcomes for the patient and prepare
for management of postoperative deficits. Common tips
learned from the author’s experience are provided to
perform safe and minimally disabling surgery for the patient
while obtaining the oncologic goals of surgery.
25.1 Indications
• Juvenile nasopharyngeal angiofibroma.
• Trigeminal neurilemmoma.
• Meningioma.
• Lymphoproliferative disorders (biopsy only).
• Sinonasal malignancy.
• Nasopharyngeal carcinoma.
• Palliative debulking of malignancies.
• Diagnostic biopsy.
25.2 Infratemporal Fossa Limits
• Medial: The lateral pterygoid plate.
• Lateral: The ramus of the mandible.
• Posterior: The articular tubercle of the temporal bone,
spina angularis of the sphenoid bone, and carotid
sheath.
• Anterior: The infratemporal surface of the maxilla.
• Superior: The greater wing of the sphenoid bone and
under surface of the temporal squama containing the
foramen ovale.
• Inferior: The medial pterygoid muscle attaching to the
mandible.
25.3 Surgical Steps
The patient is placed in a supine position on the operating
table. After the application of general anesthesia and secured
intubation, pledgets soaked in oxymetazoline, a selective
-1 agonist and partial -2 agonist, are guided into the nasal
cavity for topical decongestion. Following decongestion, 1%
lidocaine with 1:100,000 epinephrine is injected into the
septum, middle turbinate, uncinate, inferior turbinate, the
inferior border of the third basal lamella, and the mucosa
overlying the canine fossa (if Caldwell-Luc is utilized)
ipsilateral to the lesion to decrease mucosal bleeding. It is
recommended to allow several minutes for decongestion
prior to surgery; during this time, images for surgical
guidance are loaded onto the preferred hospital system and
the patient is registered for neuronavigation.
The standard endoscopic infratemporal approach at the
author’s institution is through a uninostril endoscopic
approach with the possible assistance of a Caldwell-Luc
approach (described later). Some institutions also perform a Denker’s approach to improve ease of instrumentation and surgical access.
endoscope (e.g., Karl Storz or Medtronic), the middle turbinate is medialized and then subtotally removed with
nasal sinus scissors (Medtronic) with special attention
not to injure the lateral lamella at the cribriform plate
(Fig. 25.1a–c). The uncinate is removed in its entirety
with a back-biting forceps, allowing access to the natural ostium of the maxillary sinus (Fig. 25.2a–c). A large
maxillary antrostomy is performed with rongeurs and
4.0-mm microdebrider; the inferior turbinate is removed
with nasal sinus scissors for access to the inferior extent
of the approach (Fig. 25.3). This step allows visual access
of the posterior wall of the maxillary sinus corresponding
to the anterior wall of the pterygopalatine fossa (PtPF).
If a second port of access is needed for instrumentation or increased lateral access, a Caldwell-Luc
incision is placed under the ipsilateral lip over the
canine fossa. This incision, approximately 4 cm in
length, is made preserving at least a 5-mm cuff of
1
Using a 0-degree rigid nasal
U
a b c
Fig. 25.1 Endoscopic, endonasal view with a 4-mm 0-degree endoscope of the right nasal cavity and middle meatus. (a) View of the right
middle meatus after the middle turbinate is retracted medially with a caudal elevator. The uncinate and ethmoid bulla are clearly visualized.
(b) View of the right nasal cavity and middle meatus after resection of the middle turbinate (arrows = cut edge of middle turbinate near the
skull base and lateral lamella) with an endoscopic scissors. (c) The resected middle turbinate is preserved for possible use as a mucosal free
graft to cover exposed bone or assist in cerebrospinal fl uid leak repair. B, bulla; MT, middle turbinate; S, septum; U, uncinate.
260
B
B
U
MT
S
Infratemporal Approach
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B
B
U
S
a
Fig. 25.2 Endoscopic, endonasal view of the right nasal cavity with a 4-mm 0-degree endoscope and steps for fi nding the natural
ostium of the maxillary sinus. (a) View of the right uncinate process being resected with a back-biting forceps. (b) View of the
resulting window through the uncinate allowing access into the infundibulum. (c) View after complete resection of the uncinate bone
(dashed line) with back-biting forceps or a 4-mm microdebrider allowing visualization of the natural ostium of the maxillary sinus
(arrow). B, bulla; S, septum; U, uncinate.
b
B
U
B
S
c
Fig. 25.3 Endoscopic endonasal view of the right maxillary
sinus after completion of the maxillary antrostomy and inferior
turbinate resection (if needed). Note wide view of posterior
maxillary sinus (circle). B, bulla.
inferior gingivobuccal tissue for closure at the end of
the surgery. The incision is carried down through the
periosteum. The periosteum is then elevated over the
limit is the inferior alveolar nerve and canal. The medial
limit is the piriform aperture. The lip is retracted with
self-retaining instruments with wet gauze padding
protecting the lip from injury (Fig. 25.4). The anterior
wall of the maxillary sinus is then removed, allowing
full sinus access. In case an endoscopic Denker or
Sturmann-Canfield approach is chosen, the piriform
aperture is removed laterally with rongeurs.
With a 0-degree endoscope through the ipsilateral
nostril, the mucosa lying on the medial surface of the
crista ethmoidalis is elevated, allowing visualization
of sphenopalatine artery (SPA) exiting its canal. This is
Fig. 25.4 Photomicrograph of view of a right-sided CaldwellLuc approach to the maxillary sinus.
usually centrally located at the lateral attachment of the
basal lamella (for more details, please check Chapter 8).
A 2-mm Kerrison rongeur is used to remove the bone
from the posterior bone wall of the maxillary sinus
exposing the PtPF. A 3-mm high-speed diamond drill
with continuous saline irrigation can be used to remove
thick bone particularly in the inferior posterior quarter
and lateral bone of the maxillary sinus.
The periosteum overlying the soft-tissue contents of the
PtPF is removed with Kerrison rongeurs or sharp microscissors exposing the course of the SPA (Fig. 25.5a, b). Often
the SPA has a random course through the PtPF. To prevent
inadvertent vascular injury and to increase exposure, care is
taken to place titanium vascular clips on the most proximal
segment of the artery accessible with an endoscopic clip
applier (Fig. 25.5c).
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Infratemporal Approach
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IMAX
IMAX
S
SPA
a
posterior wall of the maxillary sinus. (a) View of the contents of the right pterygopalatine fossa in a cadaver (circle). (b) Same
endoscopic view of the pterygopalatine fossa in a case approaching a meningioma of the right infratemporal fossa. (c) Same
endoscopic view of the right pterygopalatine fossa after lateral placement of titanium clips on the internal maxillary. IMAX, internal
maxillary artery; S, septum; SPA, sphenopalatine artery.
LPtP
a
Fig. 25.6 Endoscopic endonasal view of the anteromedial portion of the right infratemporal fossa with a 4 mm 0-degree endoscope
after removal of the posterior wall of the maxillary sinus. (a) View of a Frazier suction retracting the lateral pterygoid muscle in a
lateral direction exposing the lateral pterygoid plate (black arrow). Note the titanium clip on the lateralized internal maxillary artery
(white arrow). (b) Same endoscopic view after resection of meningioma along the undersurface of the greater wing of the sphenoid
bone. Image guidance confi rms the medial border of the foramen rotundum and third branch of trigeminal nerve. (c) Corresponding
endoscopic endonasal view of the right infratemporal fossa in the cadaver. GWSp, greater wing of the sphenoid bone; LPtP, lateral
pterygoid plate; PtM, pterygoid muscle; V3, mandibular nerve.
b
b
SPA
GWSp
V3
c
GWSp
V3
PtM
c
LPtP
S
Fat within the PtPF may be removed with a rongeurs,
Frazier suction, or soft-tissue ultrasonicator to allow
visualization of the inferior orbital nerve, pterygopalatine
ganglion, vidian nerve, and descending palatine nerve. It
is important to preserve these structures when possible
to avoid postoperative paresthesias of the ipsilateral
midface and palate.
The anterolateral surface of the lateral pterygoid plate
is then identified with palpation and image guidance.
The attachments of the lateral pterygoid muscle are
then elevated from the plate with a caudal elevator
(Fig. 25.6a). Sometimes, use of a 3-mm high-speed
diamond drill with irrigation helps to obtain this plane.
Depending on the tumor type, the lateral pterygoid muscle
may be resected to gain further exposure. In these cases,
patients often suffer from trismus and an asymmetric
bite requiring postoperative physical therapy. Following
the lateral edge of the pterygoid plate and greater wing of
the sphenoid leads to foramen ovale and the mandibular
262
nerve (Fig. 25.6b, c). Nerve injury or sacrifice will cause
paresis and/or paralysis of the muscle of mastication and
paresthesias, numbness, and/or pain of the lower third of
the face and ipsilateral tongue.
2
Posterior and lateral to foramen ovale is the foramen
spinosum with the middle meningeal artery. Careful
placement of a titanium clip or pistol-grip, bipolar cautery
can control this vessel. Avoid cauterizing too close to the
foramen to avoid intracranial retraction and subsequent
epidural hematoma. The cervical segment of the carotid
artery (C1) is posterior and lateral to foramen spinosum
(Fig. 25.7a, b). Although not in the ITF, care must be
taken to inspect the course of the C1 segment due to the
random course this artery may take in the neck prior to
entering the skull base.3 The greater wing of the sphenoid
bone limits superior exposure of the ITF. The floor of the
maxilla containing the dental roots of the molars limits
inferior access. The medial and lateral borders of the ITF
should be easily accessible.
Infratemporal Approach
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GWSp
V3
V3
PtM
*
a
ab
b
*
GWSp
Fig. 25.7 Endoscopic endonasal view
of the right infratemporal fossa. (a)
Broad view of the right infratemporal
fossa in the cadaver with the mandibular
nerve retracted to show the carotid
artery (*) posterior and lateral to
the nerve. (b) Higher magnifi cation
view showing the relationship of
the mandibular nerve to the middle
meningeal artery entering foramen
spinosum (white arrowhead) and the
carotid artery (*). GWSp, greater wing
of the sphenoid bone; PtM, pterygoid
muscle; V3, mandibular nerve.
Fig. 25.8 Case example of pre- and
postoperative CT images following
endoscopic endonasal resection of a
recurrent maxillary sinus squamous
cell carcinoma. (a) Preoperative axial
CT scan showing recurrent tumor in
the left maxillary sinus, PtPF, and ITF
(white circle). (b) Preoperative coronal
CT showing tumor fi lling the PtPF
extending into the ITF (white circle).
(c) Postoperative axial CT showing
surgical defect with gross total
resection. (d) Postoperative coronal
CT showing surgical defect with gross
total resection. ITF, infratemporal
fossa; PtPF, pterygopalatine fossa.
cd
25.4 Case Examples
25.4.1 Case 1
A 71-year-old Caucasian man presented with a 6-month
history of left-sided facial pain and occasional epistaxis.
Computed tomography (CT) imaging revealed a mass
in the left maxillary sinus involving the lateral and
posterior wall. With the diagnosis of sinus squamous cell
carcinoma, he completed a full course of chemotherapy
and radiation, but his symptoms did not resolve. Repeat
CT imaging was performed, revealing tumor in the
posterior and lateral maxillary sinus involving the PtPF
and ITF (Fig. 25.8a, b). Palliative chemotherapy was
recommended and an outside surgical consultation
was performed. The patient went to the operating room
for an endoscopic endonasal resection of tumor with
Caldwell-Luc assistance. He tolerated the procedure
well. Intraoperative findings and postoperative imaging
suggest gross total resection (Fig. 25.8c, d). He is
currently undergoing postoperative surveillance with
no evidence of recurrence.
25.4.2 Case 2
A 30-year-old woman presented with a chief complaint
of left midface paresthesias and left ear fullness. Exam
in the office revealed decreased sensation of the left
midface and left middle ear serous otitis media. Magnetic
resonance imaging revealed a left infratemporal
schwannoma (Fig. 25.9a). As with the prior case, the
patient went to the operating room for a left endonasal
endoscopic resection. A Caldwell-Luc approach was
added for increased access and instrument manipulation
(Fig. 25.9b). Pathology confirmed a schwannoma and
postoperative imaging confirmed gross total resection
of tumor (Fig. 25.9c). Note that image-guided surgery
was utilized to confirm position in the ITF (Fig. 25.10).
25.5 Complications
• Epistaxis:
– Epistaxis is a possible major complication after sur-
gery. The internal maxillary artery (IMAX) takes
a complicated course through the ITF and can be
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Fig. 25.9 Case example of a
trigeminal schwannoma of the left
infratemporal fossa. (a) Preoperative,
postcontrast, T1 coronal magnetic
resonance image showing
enhancement in the left ITF (white
circle). (b) Postoperative, postcontrast,
T1 coronal MR image showing
gross total resection of tumor. ITF,
infratemporal fossa.
a
b
Fig. 25.10 Example of use of image
guidance during resection of the
trigeminal schwannoma in Fig. 25.9.
Coronal (upper left), sagittal (upper
right), and axial (lower left) CT images
confi rm location of the image guidance
probe (lower right).
inadvertently injured causing delayed epistaxis.
Careful blunt dissection, identification, and control
with arterial clips are critical. Branches of the artery
should also be cauterized with bipolar cautery.
Delayed arterial bleeding from a pseudoaneurysm
may occur without proper vascular control of the
IMAX. Epistaxis from pseudoaneurysms may occur
weeks after surgery with sudden onset.
– Although not in the ITF, carotid injury during surgery
could lead to a rapidly fatal outcome. Due to limited
access, immediate packing and transport to interventional radiology for control is warranted.
264
• Musculoskeletal:
– Tumor access to the ITF requires some extent of dis-
section of the pterygoid muscles from the skull base.
Postoperative complications include asymmetric
bite and trismus. Early intervention with physical
therapy by a speech language pathologist can help
correct this injury.
• Neurologic:
– Superolateral dissection of the posterior wall of the
maxillary sinus may injure the inferior orbital nerve.
This may result in complete numbness, paresthesias,
or neuralgia of the midface and upper dentition and
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