The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave

Clinical article

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Object

In this paper the authors' goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base.

Methods

Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin.

Results

A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy.

Conclusions

An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.

Abbreviations used in this paper: ITF = infratemporal fossa; PPF = pterygopalatine fossa.

Article Information

Address correspondence to: Theodore H. Schwartz, M.D., Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525 East 68th Street, Box #99, New York, New York 10021. email: schwarh@med.cornell.edu.

Please include this information when citing this paper: published online November 20, 2009; DOI: 10.3171/2009.10.JNS09157.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bone landmarks and foramina encountered during the transmaxillary, transpterygoid approach. C = clivus; FR = foramen rotundum; PC = pterygoid canal; PMF = pterygomaxillary fissure; PP = pterygoid process; PWMS = posterior wall of the maxillary sinus; SOF = superior orbital fissure; SS = sphenoid sinus.

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    Schematic diagrams of the key steps and exposure of the transmaxillary, transpterygoid approach. A: Once the uncinectomy is performed and the ethmoidectomy and sphenoidotomy are performed, the ostium of the maxillary sinus is enlarged to expose the posterior wall. The sphenopalatine artery (SPA) emerges through the crista ethmoidalis (CE), and the optic nerve (ON) can be seen in the superior aspect of the field adjacent to the lamina papyracea (LP). B: The contents of the PPF include the internal maxillary artery (IMA), which gives rise to the sphenopalatine artery (SPA) and descending palatine artery (DPA) as well as the posterosuperior alveolar artery (PSAA). The pterygopalatine ganglion can be found at the intersection of the greater palatine nerve (GPN) and the second division of the trigeminal nerve (V2). The infraorbital nerve (ION) and ITF can be seen laterally. C: Removal of the pterygoid process and crista ethmoidalis also provides exposure to the region medial and posterior to the PPF covered by the lateral wall of the sphenoid sinus. Removal of this bone reveals the medial wall of the cavernous sinus (CS) as well as the second (V2) and third (V3) divisions of the trigeminal nerve and the vidian nerve (VN), often used as a landmark to identify the petrous internal carotid artery (ICA). PG = pituitary gland.

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    A and B: Case 5. Preoperative (A) and postoperative (B) contrast-enhanced coronal MR images obtained in a patient with an angiofibroma arising from the PPF. C and D: Case 2. Preoperative (C) and postoperative (D) contrast-enhanced axial MR images obtained in a patient with a nasal glioma in the Meckel cave. E and F: Case 13. Preoperative (E) and postoperative (F) contrast-enhanced coronal MR images obtained in a patient with an angiofibroma originating from the PPF.

  • View in gallery

    A: Case 1. Preoperative axial CT scan obtained in a patient with an encephalocele in the lateral recess of the sphenoid sinus. B: Case 3. Preoperative axial metrizamide CT scan obtained in a patient with an encephalocele in the lateral recess of the sphenoid sinus. C: Case 11. Preoperative coronal CT scan obtained in a patient with a cholesteatoma of the petrous apex. D: Case 12. Preoperative coronal CT scan obtained in a patient with a lymphoma in the PPF.

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