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Luigi M. Cavallo, Andrea Messina, Paul Gardner, Felice Esposito, Amin B. Kassam, Paolo Cappabianca, Enrico de Divitiis and Manfred Tschabitscher

Object

The pterygopalatine fossa is an area located deep in the skull base. The microsurgical transmaxillary–transantral route is usually chosen to remove lesions in this region. The increasing use of the endoscope in sinonasal functional surgery has more recently led to the advent of the endoscope for the treatment of tumors located in the pterygopalatine fossa as well.

Methods

An anatomical dissection of three fresh cadaveric heads (six pterygopalatine fossas) and three dried skull base specimens was performed to evaluate the feasibility of the approach and to illustrate the surgical landmarks that are useful for operations in this complex region.

The endoscopic endonasal approach allows a wide exposure of the pterygopalatine fossa. Furthermore, with the same access (that is, through the nostril) it is possible to expose regions contiguous with the pterygopalatine fossa, either to visualize more surgical landmarks or to accomplish a better lesion removal.

Conclusions

In this anatomical study the endoscopic endonasal approach to the pterygopalatine fossa has been found to be a safe approach for the removal of lesions in this region. The approach could be proposed as an alternative to the standard microsurgical transmaxillary–transantral route.

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: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum Amin Kassam Carl H. Snyderman Arlan Mintz Paul Gardner Ricardo L. Carrau 7 2005 19 1 1 7 10.3171/foc.2005.19.1.5 FOC.2005.19.1.5 Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations Luigi M. Cavallo Andrea Messina Paul Gardner Felice Esposito Amin B. Kassam Paolo Cappabianca Enrico de Divitiis Manfred Tschabitscher 7 2005 19 1 1 7 10.3171/foc.2005.19.1.6 FOC.2005.19.1.6 Expanded endonasal approach: fully endoscopic, completely

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Domenico Solari, Francesco Magro, Paolo Cappabianca, Luigi M. Cavallo, Amir Samii, Felice Esposito, Vincenzo Paternò, Enrico de Divitiis and Madjid Samii

, Gardner P , Esposito F , Kassam AB , Cappabianca P , : Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E5 , 2005 10 Choi J , Park HS : The clinical anatomy of the maxillary artery in the pterygopalatine fossa . J Oral Maxillofac Surg 61 : 72 – 78 , 2003 11 Couldwell WT , Weiss MH , Rabb C , Liu JK , Apfelbaum RI , Fukushima T : Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended

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Daniel M. Prevedello, Francesco Doglietto, John A. Jane Jr., Jay Jagannathan, Joseph Han and Edward R. Laws Jr.

, Tschabitscher M : Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study . Neurosurgery 56 : 2 Suppl 379 – 389 , 2005 22 Cavallo LM , Messina A , Cappabianca P , Esposito F , de Divitiis E , Gardner P , : Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E2 , 2005 23 Cavallo LM , Messina A , Gardner P , Esposito F , Kassam AB , Cappabianca P , : Extended endoscopic endonasal approach to the pterygopalatine

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Franco DeMonte and Ehab Hanna

, Gardner P , : Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E2 , 2005 4 Cavallo LM , Messina A , Gardner P , Esposito F , Kassam AB , Cappabianca P , : Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E5 , 2005 5 Chummun S , McLean NR , Kelly CG , Dawes PJ , Meikle D , Fellows S , : Adenoid cystic carcinoma of the head and neck . Br J Plast Surg

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Luigi Maria Cavallo, Andrea Messina, Felice Esposito, Oreste de Divitiis, Mateus Dal Fabbro, Enrico de Divitiis and Paolo Cappabianca

synthetic materials have been proposed for the repair of these relatively large skull base defects ( Table 1 ). 11 , 13 , 17 , 20 , 29 , 32 , 34 , 35 , 37 Unfortunately, all of them have some variable complexity, and an increased rate of postoperative CSF leakage has resulted compared with the rate associated with the standard transsphenoidal approach to the sellar region. 4 , 8 , 10 , 42 On the basis of our experience with the extended endoscopic endonasal approach to the planum sphenoidale, we describe 21 consecutive cases in which different techniques were used to

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Ilya Laufer, Jeffrey P. Greenfield, Vijay K. Anand, Roger Härtl and Theodore H. Schwartz

Divitiis E , : The extended endoscopic endonasal approach to the clivus and craniovertebral junction: anatomical study . Childs Nerv Syst 23 : 665 – 671 , 2007 7 Fraser JF , Anand VK , Schwartz TH : Endoscopic biopsy sampling of tophaceous gout of the odontoid process. Case report and review of the literature . J Neurosurg Spine 7 : 61 – 64 , 2007 8 Frempong-Boadu AK , Faunce WA , Fessler RG : Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction . Neurosurgery 51 : 5 Suppl S60 – S66 , 2002 9

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Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz

craniopharyngiomas using an endoscopic endonasal approach. Six of the 10 cases were suprasellar tumors without sellar involvement. De Divitiis and coworkers 14 recently (2007) described their experience with extended endoscopic endonasal approaches in 21 patients, including 7 with craniopharyngiomas. Five of these tumors were purely suprasellar lesions. All of these patient series demonstrated extraordinary results: excellent resection indices, progressively decreasing rates of CSF leaks over time (67%, 40 30%, 20 and 14%, 14 respectively), excellent visual outcomes, and no

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Giorgio Carrabba, Amir R. Dehdashti and Fred Gentili

: Combined transpetrosal-subtemporal craniotomy for clival tumors with extension into the posterior fossa . Laryngoscope 105 : 975 – 982 , 1995 4 Cappabianca P , Cavallo LM , de Divitiis E : Endoscopic endonasal transsphenoidal surgery . Neurosurgery 55 : 933 – 941 , 2004 5 Cappabianca P , Cavallo LM , Esposito F , De Divitiis O , Messina A , De Divitiis E : Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery . Adv Tech Stand Neurosurg 33 : 151 – 199 , 2008 6 Cloward

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Roberto Faggin, Luigi Pentimalli, Maurizia Grazzini, Roberto Saetti, Paola Drigo and Domenico d'Avella

literature. A spontaneous sphenoidal encephalocele is a rare entity. 3 In the case of an intrasphenoidal encephalocele, most defects are temporosphenoidal and occur in the lateral wall of the sphenoid sinus. We propose the extended endoscopic endonasal approach as a new, minimally invasive surgical approach to this deep location. We have suggested a rational approach that should be always coordinated by a combined team including otolaryngology specialists who are skilled in endoscopy procedures and neurosurgeons. An intracranial approach is controversial in literature