Endoscopic transorbital approach to the infratemporal fossa and parapharyngeal space: a cadaveric study

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OBJECTIVE

The infratemporal fossa (ITF) and parapharyngeal space are anatomical regions that can be challenging to access without the use of complex, cosmetically disfiguring approaches. With advances in endoscopic techniques, a new group of surgical approaches to access the intracranial space through the orbit has been recently referred to as transorbital neuroendoscopic surgery (TONES). The objective of this study was to establish a transorbital endoscopic approach utilizing the inferior orbital fissure (IOF) to gain access to the ITF and parapharyngeal space and provide a detailed endoscopic anatomical description of this approach.

METHODS

Four cadaveric heads (8 sides) were dissected using a TONES approach through the IOF to reach the ITF and parapharyngeal space, providing stepwise dissection with detailed anatomical findings and a description of each step.

RESULTS

An inferior eyelid approach was made with subperiosteal periorbital dissection to the IOF. The zygomatic and greater wing of the sphenoid were drilled, forming the boundaries of the IOF. The upper head of the lateral pterygoid muscle in the ITF and parapharyngeal space was removed, and 7 distinct planes were described, each with its own anatomical contents. The second part of the maxillary artery was mainly found in plane 1 between the temporalis laterally and the lateral pterygoid muscle in plane 2. The branches of the mandibular nerve (V3) and middle meningeal artery (MMA) were identified in plane 3. Plane 4 was formed by the fascia of the medial pterygoid muscle (MTM) and the tensor veli palatini muscle. The prestyloid segment, found in plane 5, was composed mainly of fat and lymph nodes. The parapharyngeal carotid artery in the poststyloid segment, found in plane 7, was identified after laterally dissecting the styloid diaphragm, found in plane 6. V3 and the origin of the levator and tensor veli palatini muscles serve as landmarks for identification of the parapharyngeal carotid artery.

CONCLUSIONS

The transorbital endoscopic approach provides excellent access to the ITF and parapharyngeal space compared to previously described complex and morbid transfacial or transcranial approaches. Using the IOF is an important and useful landmark that permits a wide exposure.

ABBREVIATIONS EEA = endonasal endoscopic approach; ICA = internal carotid artery; IOF = inferior orbital fissure; ITF = infratemporal fossa; MMA = middle meningeal artery; MTM = medial pterygoid muscle; SOF = superior orbital fissure; TMJ = temporomandibular joint; TONES = transorbital neuroendoscopic surgery.
Article Information

Contributor Notes

Correspondence Theodore H. Schwartz: Weill Cornell Medicine, New York, NY. schwarh@med.cornell.edu.INCLUDE WHEN CITING Published online November 1, 2019; DOI: 10.3171/2019.7.JNS191743.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Almeida JPOmay SBShetty SRChen YNRuiz-Treviño ASLiang B: Transorbital endoscopic eyelid approach for resection of sphenoorbital meningiomas with predominant hyperostosis: report of 2 cases. J Neurosurg 128:188518952018

    • Search Google Scholar
    • Export Citation
  • 2

    Almeida JPRuiz-Treviño ASShetty SROmay SBAnand VKSchwartz TH: Transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern: an anatomical study. Acta Neurochir (Wien) 159:189319072017

    • Search Google Scholar
    • Export Citation
  • 3

    Chen HIBohman LELoevner LALucas TH: Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg 120:142814362014

    • Search Google Scholar
    • Export Citation
  • 4

    Ciporen JNMoe KSRamanathan DLopez SLedesma ERostomily R: Multiportal endoscopic approaches to the central skull base: a cadaveric study. World Neurosurg 73:7057122010

    • Search Google Scholar
    • Export Citation
  • 5

    Dallan IDi Somma APrats-Galino ASolari DAlobid ITurri-Zanoni M: Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study. J Neurosurg 127:6226292017

    • Search Google Scholar
    • Export Citation
  • 6

    De Battista JCZimmer LARodríguez-Vázquez JFFroelich SCTheodosopoulos PVDePowell JJ: Muller’s muscle, no longer vestigial in endoscopic surgery. World Neurosurg 76:3423462011

    • Search Google Scholar
    • Export Citation
  • 7

    De Battista JCZimmer LATheodosopoulos PVFroelich SCKeller JT: Anatomy of the inferior orbital fissure: implications for endoscopic cranial base surgery. J Neurol Surg B Skull Base 73:1321382012

    • Search Google Scholar
    • Export Citation
  • 8

    Di Somma AAndaluz NCavallo LMde Notaris MDallan ISolari D: Endoscopic transorbital superior eyelid approach: anatomical study from a neurosurgical perspective. J Neurosurg 129:120312162018

    • Search Google Scholar
    • Export Citation
  • 9

    Di Somma AAndaluz NCavallo LMTopczewski TEFrio FGerardi RM: Endoscopic transorbital route to the petrous apex: a feasibility anatomic study. Acta Neurochir (Wien) 160:7077202018

    • Search Google Scholar
    • Export Citation
  • 10

    Di Somma ACavallo LMde Notaris MSolari DTopczewski TEBernal-Sprekelsen M: Endoscopic endonasal medial-to-lateral and transorbital lateral-to-medial optic nerve decompression: an anatomical study with surgical implications. J Neurosurg 127:1992082017

    • Search Google Scholar
    • Export Citation
  • 11

    Eloy JAMurray KPFriedel METessema BLiu JK: Graduated endoscopic multiangle approach for access to the infratemporal fossa: a cadaveric study with clinical correlates. Otolaryngol Head Neck Surg 147:3693782012

    • Search Google Scholar
    • Export Citation
  • 12

    Evans BTWebb AA: Post-traumatic orbital reconstruction: anatomical landmarks and the concept of the deep orbit. Br J Oral Maxillofac Surg 45:1831892007

    • Search Google Scholar
    • Export Citation
  • 13

    Falcon RTRivera-Serrano CMMiranda JFPrevedello DMSnyderman CHKassam AB: Endoscopic endonasal dissection of the infratemporal fossa: anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery. Laryngoscope 121:31412011

    • Search Google Scholar
    • Export Citation
  • 14

    Ferrari MSchreiber AMattavelli DBelotti FRampinelli VLancini D: The inferolateral transorbital endoscopic approach: a preclinical anatomic study. World Neurosurg 90:4034132016

    • Search Google Scholar
    • Export Citation
  • 15

    Fisch UFagan PValavanis A: The infratemporal fossa approach for the lateral skull base. Otolaryngol Clin North Am 17:5135521984

    • Search Google Scholar
    • Export Citation
  • 16

    Fortes FSSennes LUCarrau RLBrito RRibas GCYasuda A: Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model. Laryngoscope 118:44492008

    • Search Google Scholar
    • Export Citation
  • 17

    Gao ZChi FL: Anatomy relationship around internal carotid artery in the endoscopic surgery of nasopharynx: a study based on computed tomography angiography. J Neurol Surg B Skull Base 76:1761822015

    • Search Google Scholar
    • Export Citation
  • 18

    Hosseini SMRazfar ACarrau RLPrevedello DMFernandez-Miranda JZanation A: Endonasal transpterygoid approach to the infratemporal fossa: correlation of endoscopic and multiplanar CT anatomy. Head Neck 34:3133202012

    • Search Google Scholar
    • Export Citation
  • 19

    Hwang KSuh MSLee SIChung IH: Zygomaticotemporal nerve passage in the orbit and temporal area. J Craniofac Surg 15:2092142004

  • 20

    Komune NKomune SMatsushima KRhoton AL Jr: Comparison of lateral microsurgical preauricular and anterior endoscopic approaches to the jugular foramen. J Laryngol Otol 129 (Suppl 2):S12S202015

    • Search Google Scholar
    • Export Citation
  • 21

    Laleva LSpiriev TDallan IPrats-Galino ACatapano GNakov V: Pure endoscopic lateral orbitotomy approach to the cavernous sinus, posterior, and infratemporal fossae: anatomic study. J Neurol Surg B Skull Base 80:2953052019

    • Search Google Scholar
    • Export Citation
  • 22

    Locatelli DPozzi FTurri-Zanoni MBattaglia PSanti LDallan I: Transorbital endoscopic approaches to the skull base: current concepts and future perspectives. J Neurosurg Sci 60:5145252016

    • Search Google Scholar
    • Export Citation
  • 23

    Marcus KJTishler RB: Head and neck carcinomas across the age spectrum: epidemiology, therapy, and late effects. Semin Radiat Oncol 20:52572010

    • Search Google Scholar
    • Export Citation
  • 24

    Moe KSBergeron CMEllenbogen RG: Transorbital neuroendoscopic surgery. Neurosurgery 67 (3 Suppl Operative):ons16ons282010

  • 25

    Moreira-Gonzalez APieper DRCambra JBSimman RJackson IT: Skull base tumors: a comprehensive review of transfacial swing osteotomy approaches. Plast Reconstr Surg 115:7117202005

    • Search Google Scholar
    • Export Citation
  • 26

    Nossek ECostantino PDEisenberg MDehdashti ARSetton AChalif DJ: Internal maxillary artery-middle cerebral artery bypass: infratemporal approach for subcranial-intracranial (SC-IC) bypass. Neurosurgery 75:87952014

    • Search Google Scholar
    • Export Citation
  • 27

    Obwegeser HL: Temporal approach to the TMJ, the orbit, and the retromaxillary-infracranial region. Head Neck Surg 7:1851991985

  • 28

    Paullus WSPait TGRhoton AI Jr: Microsurgical exposure of the petrous portion of the carotid artery. J Neurosurg 47:7137261977

  • 29

    Priddy BHNunes CFBeer-Furlan ACarrau RDallan IPrevedello DMS: A side door to Meckel’s cave: anatomic feasibility study for the lateral transorbital approach. Oper Neurosurg (Hagerstown) 13:6146212017 [Erratum in Oper Neurosurg (Hagerstown) 13:650 2017)

    • Search Google Scholar
    • Export Citation
  • 30

    Ramakrishna RKim LJBly RAMoe KFerreira M Jr: Transorbital neuroendoscopic surgery for the treatment of skull base lesions. J Clin Neurosci 24:991042016

    • Search Google Scholar
    • Export Citation
  • 31

    Raza SMQuinones-Hinojosa ALim MBoahene KD: The transconjunctival transorbital approach: a keyhole approach to the midline anterior skull base. World Neurosurg 80:8648712013

    • Search Google Scholar
    • Export Citation
  • 32

    Ricketts SChew HFSunderland IRKiss AFialkov JA: Transection of inferior orbital fissure contents for improved access and visibility in orbital surgery. J Craniofac Surg 25:5575622014

    • Search Google Scholar
    • Export Citation
  • 33

    Robert RLegent FRogez JMMeiner YHéloury YPatra P: The infratemporal fossa: a trial clarification. Surg Radiol Anat 11:3073111989

    • Search Google Scholar
    • Export Citation
  • 34

    Sabit ISchaefer SDCouldwell WT: Modified infratemporal fossa approach via lateral transantral maxillotomy: a microsurgical model. Surg Neurol 58:21312002

    • Search Google Scholar
    • Export Citation
  • 35

    Sekhar LNSchramm VL JrJones NF: Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 67:4884991987

    • Search Google Scholar
    • Export Citation
  • 36

    Shibuya TYDoerr TDMathog RHBurgio DLMeleca RJYoo GH: Functional outcomes of the retromaxillary-infratemporal fossa dissection for advanced head and neck/skull base lesions. Skull Base Surg 10:1091172000

    • Search Google Scholar
    • Export Citation
  • 37

    Standring S (ed): Gray’s Anatomy: The Anatomical Basis of Clinical Practice. Edinburgh: Elsevier Churchill Livingstone2005

  • 38

    Taniguchi MKohmura E: Endoscopic transnasal transmaxillary transpterygoid approach to the parapharyngeal space: an anatomic study. Minim Invasive Neurosurg 53:2552602010

    • Search Google Scholar
    • Export Citation
  • 39

    Theodosopoulos PVGuthikonda BBrescia AKeller JTZimmer LA: Endoscopic approach to the infratemporal fossa: anatomic study. Neurosurgery 66:1962032010

    • Search Google Scholar
    • Export Citation
  • 40

    Tiwari RQuak JEgeler SSmeele LWaal IVValk PV: Tumors of the infratemporal fossa. Skull Base Surg 10:192000

  • 41

    Van Rompaey JSuruliraj ACarrau RPanizza BSolares CA: Access to the parapharyngeal space: an anatomical study comparing the endoscopic and open approaches. Laryngoscope 123:237823822013

    • Search Google Scholar
    • Export Citation
  • 42

    Wang XLi YMHuang CGLiu HCLi QCYu MK: Endoscopic transmaxillary transMüller’s muscle approach for decompression of superior orbital fissure: a cadaveric study with illustrative case. J Craniomaxillofac Surg 42:1321402014

    • Search Google Scholar
    • Export Citation
  • 43

    Werther JR: Cutaneous approaches to the lower lid and orbit. J Oral Maxillofac Surg 56:60651998

  • 44

    Youssef ACarrau RLTantawy AIbraheim ASolares ACOtto BA: Endoscopic versus open approach to the infratemporal fossa: a cadaver study. J Neurol Surg B Skull Base 76:3583642015

    • Search Google Scholar
    • Export Citation
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