essam saleh , md prof of otolaryngology, alex...
TRANSCRIPT
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.
