Essam Saleh , MD

Prof of Otolaryngology, Alex Univ.

Forgotten Anatomy

Anatomy

Anterior: post.wall maxilla.

Posterior: Styloid, Carotid sheath, Condyle

Medial: Lat pterygoid plate & sup constrictor.

Lateral: Ramus of Mandible

Superior: Sphenoid

Contents

Medial & Lateral Pterygoid muscles

Contents

Mandibular nerveMaxillary artery

Communications

With the pterygopalatine fossa through pterygo-maxillary fissure

With the orbit through inferior orbital fissure.

With the middle cranial fossa through F.O, F.R

With the neck & parapharyngeal space behind post.border of medial pterygoid

Pathologies

1ry: Schwannoma, Rhabdomyosarcoma,

Fibrosarcoma, Chondrosarcoma, Hemangiopericytoma, Lymphoma.

2ry extensions from adjacent areas:

Adenocarcinoma, Nasopharyngeal angiofibroma, Nasopharyngeal Carcinoma, Meningioma.

V Neuroma Rhabdomyosarcoma

Pathologies

Sarcoma

Angiofibroma Meningioma Adenoidcystic carcinoma

Pathologies

ProblemsDeep Location

Difficult Access

Extensions to more than one anatomical compartment

Relations to nearby vital structures:

ICA

Cavernous Sinus

Orbit

Extensions

Problems

Minimal symptoms late diagnosis

Difficult to attain preoperative radiological diagnosis.

Difficult to have preoperative biopsy.

ManagementAnterior Approaches

Transpalatal

Lateral rhinotomy

Facial degloving.

Anterolateral Approaches

Extended maxillotomy, maxillectomy, osteoplasticmaxillotomy.

Maxillary swing.

Mandibular swing.

Facial translocation.

Lateral Approaches

Infratemproal fossa type C.

Preauricular-infratemporal –subtemporal.

Preauricular orbitozygomatic approach.

Infratemporal fossa type D.

Anterior Approaches

Valid only for limited tumor extension into the infratemporal fossa.

Minimal control of the vital structures

ICA

Cavernous sinus.

Suitable for primary paranasal sinuses, pterygopalatine fossa & midline clival lesions with minimal lateral extension.

Anterolateral Approaches

Extended maxillotomy, maxillectomy, osteoplastic maxillotomy.

Maxillary swing.

Mandibular swing.

Facial translocation.

Mandibular Swing

Facial Translocation

Extended maxillotomy

Anterolateral Approaches

Advantages:

Direct access to nasopharynx, pterygopalatine fossa, PNS and clivus.

Disadvantages

Very extensive.

High risk of osteoradionecrosis, oroantral fistula, trismus.

Need for tracheostomy.

Transgressing contaminated field.

Lateral Approaches

The preferred routes in our hospital.

Concept: direct lateral access to the infratemporal fossa through:

Temporalis displacement

Transzygomatic.

Mandibular retraction and glenoid cavity drilling.

Approaches Infratemporal fossa type C

Preaucricular infratemporal

Infratemporal fossa

Infratemporal fossa C

Infratemporal fossa C

IFC-Clinical

Preauricular IF approach

Extensions to basic approach Transcervical

extension

Craniotomy ±transpetrous drilling

Orbitozygomatic osteotomy

Transcervical extension

Petrous apex drilling

Orbitozygomatic osteotomy

Preauricular IF Clinical

Trigeminal Neuroma

Preauricular IF Clinical

Recurrent NP Angiofibroma

Preauricular IF Clinical

Rhabdomyosaroma

Orbitozygomatic Approach

Orbitozygomatic Approach

O

T

Lateral ApproachesAdvantages

Excellent exposure of the infratemporal fossa, pterygopalatine fossa, nasopharynx, sphenoid sinus, posterolateral orbit and inferolateral cavernous sinus.

Excellent control of ICA.

Can be combined with different approaches transtemporal and transnasal approaches.

No facial exposure.

Lateral Approaches

DisadvantagesSacrifice of the mandibular nerve.

Significant CHL in the IF-C approach.

Poor control of the other PNS and nasal cavity.

Lengthy procedure

Infratemporal Fossa Tumors

11 cases (10 males & 1 Female)

Age : 9-65 yrs (mean 32.6 yrs).

Recurrent NP angiofibroma 4

NP Carcinoma 2

Meningioma 2

Recurrent Chondrosarcoma 1

Trigeminal Neuroma 1

Rhabdomyosarcoma 1] -->1ry

Infratemporal Fossa TumorsExtension No(%)

Pterygopalatine Fossa 7 (64%)

Cavernous sinus 6 (55%)

ICA 5 (45%)

Orbit 6 (55%)

Sphenoid sinus 5 (45%)

Clivus (erosion) 4 (36%)

PNS 4 (36%)

Petrous apex 2 (18%)

Parapharyngeal space 2 (18%)

Approaches IFC 2

Preauricular IF 2

Preauricular IF + Orbitozygomatic 2

Preauricular IF + Transcx 1

Preauricular IF + Transcx + Transpalatal 1

Preauricular IF + Transnasal 1

Preauricular IF + MF-Transpetrous 1

Transcochlear + Transtent + IF 1

Infratemporal Fossa TumorsTotal removal 9 cases (one staged)

Recurrence (one case)

Post-op Radio ± chemotherapy 2 cases

Frontal VII paresis 3 cases.

No Mortality

Conclusions

Infratemporal fossa tumors are difficult to diagnose and manage.

Anterolateral approaches afford a direct route with little morbidity and can be combined with different other procedures to achieve a safe and total removal.

Adequate knowledge of the anatomy is mandatory before embarking on this difficult surgery.

Recurrent irradiated nasopharyngeal tumors can be managed surgically with excellent results for early cases.