The Lateral Facial Approach to the Nasopharynx and Infratemporal Fossa

1988 ◽  
Vol 99 (3) ◽  
pp. 321-325 ◽  
Author(s):  
George A. Gates
Keyword(s):  
Single Case ◽  
Infratemporal Fossa ◽  
Operating Time ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Intracranial Extension ◽  
Surgical Access ◽  
Technical Control ◽  
Ethmoid Sinuses ◽  
And Control

Surgical access to the nasopharynx and infratemporal fossa is restricted by the bony structures that support and define these areas. Traditional surgical approaches to the nasopharynx for removal of benign neoplasms follow three directions: (1) the anterior route via the nasal cavity and the maxillary and, if necessary, the ethmoid sinuses; (2) the inferior route through the palate; and (3) the anterolateral retromaxillary pathway via the gingivobuccal sulcus into the pterygoid space. These approaches provide fair access, but limited visibility and little technical control of the neurovascular supply. For the small- to medium-sized tumor, the experienced surgeon is able to successfully manage the majority of cases using these approaches, singly or in combination. However, in patients with larger tumors—when recurrence is more common—approaches offering greater visualization have been developed, such as Panje's facial bifiap,1 Mann's transmaxillary,2 and Fisch's transtemporal.3 These provide better access and control at the cost of increased locoregional morbidity, long operating time, and considerable technical complexity. I have developed a simpler, more direct surgical approach that combines the exposure concepts of the head and neck surgeon with the microsurgical techniques of the otosurgeon. It has been applied to eight cases, with minimal morbidity and excellent results, and appears to be the procedure of choice for cases of angiofibroma with early intracranial extension. Subsequently, a similar approach, developed previously by Holliday,4 has been published in which access into the anterior temporal lobe, petrous apex, and clivus are gained. In this report, I describe and illustrate the anatomic and technical considerations of this approach and report a single case in which it was first applied.

Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques

2022 ◽  
Author(s):  
Tomasz Andrzej Dziedzic ◽  
Kumar Abhinav ◽  
Juan C. Fernandez-Miranda
Keyword(s):  
Human Head ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Cerebral Peduncle ◽  
Subtemporal Approach ◽  
Prepontine Cistern ◽  
Surgical Access ◽  
Anterior Petrosectomy ◽  
Tentorial Incisura ◽  
Selection Of

Abstract Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions. Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex. Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy. Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.

Transseptal Approach for Extended Endoscopic Resections of the Maxilla and Infratemporal Fossa

2009 ◽  
Vol 23 (4) ◽  
pp. 426-432 ◽  
Author(s):  
Richard J. Harvey ◽  
Patrick O. Sheehan ◽  
Nick I. Debnath ◽  
Rodney J. Schlosser
Keyword(s):  
Infratemporal Fossa ◽  
Preoperative Assessment ◽  
Infraorbital Nerve ◽  
Surgical Approaches ◽  
Skull Base Tumor ◽  
Anterior Maxilla ◽  
Surgical Access ◽  
Maxillary Surgery ◽  
Transseptal Approach ◽  
Medial Maxillectomy

Background Larger and more extensive lesions of the maxilla and infratemporal fossa are being successfully managed by entirely endoscopic approaches. There are still limitations in access, especially the anterolateral maxilla. The suitability of various surgical approaches was assessed in relation to surgical access achieved. Methods Surgical access was compared in 10 cadaver heads. Five zones were defined: zone 1, nasal cavity; zone 2, medial to infraorbital nerve (ION); zone 3, lateral to ION; zone 4, anterior maxilla; and zone 5, premaxillary tissue. Endoscopic maxillary surgery consisted of standard antrostomy, modified medial maxillectomy, or complete medial maxillectomy with lacrimal duct resection. Transseptal and ipsilateral approaches were compared in each surgical state. The degree of angulations and resection zone accessed were recorded from image-guided surgery. The limits of both straight and curved instrumentation were also compared. Results Transseptal access improved surgical access by 14.7 ± 2.5° when compared with ipsilateral approaches (p < 0.001) across all situations. The access to zone 3 across all specimens was significantly improved by 63.3–97.6% (χ2 = 20.83; p < 0.001) after all three surgical states. After complete medial maxillectomy, access to zone 4 increased from 25.0 to 85.0% (χ2 = 14.54; p < 0.001) with a transseptal approach. Conclusion Extended endoscopic maxillary surgery combined with a transseptal option enables additional access to previously considered challenging locations. Preoperative assessment of skull base tumor, papilloma and angiofibroma extent, and resection margin will dictate surgical approach.

scholarly journals Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances

2020 ◽  
Vol 2 (2) ◽  
pp. V16
Author(s):  
James K. Liu ◽  
Kevin Zhao ◽  
Alejandro Vazquez ◽  
Jean Anderson Eloy
Keyword(s):  
Infratemporal Fossa ◽  
Nasolacrimal Duct ◽  
Surgical Approaches ◽  
Intracranial Extension ◽  
Combined Approach ◽  
Lateral Extension ◽  
Endoscopic Endonasal ◽  
Direct Head ◽  
Surgical Corridor ◽  
Neurovascular Structures

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.The video can be found here: https://youtu.be/gy-pkjLdDgE.

Sphenooccipital Chordoma Presenting as a Nasopharyngeal Mass

1980 ◽  
Vol 89 (3) ◽  
pp. 271-275 ◽  
Author(s):  
Michael L. Eisemann
Keyword(s):  
Treatment Plan ◽  
Infratemporal Fossa ◽  
Clinical Signs ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
High Morbidity ◽  
Tumor Type ◽  
Axial Tomography ◽  
Transphenoidal Approach

While the nasopharynx is most commonly regarded by the otolaryngologist as a primary site of neoplastic involvement, it is also an avenue of spread of base-of-the-skull tumors presenting as bulging nasopharyngeal masses. The temporal sequence of clinical signs and symptoms may reliably predict the origin of a ventrally extending sphenooccipital chordoma seen on a nasopharyngeal examination. This tumor may cause extensive bony erosion of the petrous apex, sphenoid sinus, and clivus and may suggest a more rapidly growing and aggressive tumor type. The extent of the tumor may be accurately determined by conventional tomography, computerized axial tomography, and arteriography. Several surgical approaches including the infratemporal fossa approach, transoral transpalatal approach and rhinoseptal transphenoidal approach may be appropriately utilized singly or in combination to remove this tumor in whole or part; however, the rhinoseptal transphenoidal approach is emphasized and regarded as the most rational treatment plan for subtotal resection, recognizing the usual futility of an en bloc resection with its associated high morbidity.

Successful Implicit Vocabulary Intervention for Three Cantonese-Speaking Toddlers: A Replicated Single-Case Design

2020 ◽  
Vol 63 (12) ◽  
pp. 4148-4161
Author(s):  
Christine S.-Y. Ng ◽  
Stephanie F. Stokes ◽  
Mary Alt
Keyword(s):  
Single Case ◽  
Cross Cultural ◽  
Neighborhood Density ◽  
Expressive Vocabulary ◽  
Single Case Design ◽  
Vocabulary Intervention ◽  
Phonological Neighborhood Density ◽  
Phonological Neighborhood ◽  
And Control ◽  
Case Design

Purpose We report on a replicated single-case design study that measured the feasibility of an expressive vocabulary intervention for three Cantonese-speaking toddlers with small expressive lexicons relative to their age. The aim was to assess the cross-cultural and cross-linguistic feasibility of an intervention method developed for English-speaking children. Method A nonconcurrent multiple-baseline design was used with four baseline data points and 16 intervention sessions per participant. The intervention design incorporated implicit learning principles, high treatment dosage, and control of the phonological neighborhood density of the stimuli. The children (24–39 months) attended 7–9 weeks of twice weekly input-based treatment in which no explicit verbal production was required from the child. Each target word was provided as input a minimum of 64 times in at least two intervention sessions. Treatment feasibility was measured by comparison of how many of the target and control words the child produced across the intervention period, and parent-reported expressive vocabulary checklists were completed for comparison of pre- and postintervention child spoken vocabulary size. An omnibus effect size for the treatment effect of the number of target and control words produced across time was calculated using Kendall's Tau. Results There was a significant treatment effect for target words learned in intervention relative to baselines, and all children produced significantly more target than control words across the intervention period. The effect of phonological neighborhood density on expressive word production could not be evaluated because two of the three children learned all target words. Conclusion The results provide cross-cultural evidence of the feasibility of a model of intervention that incorporated a high-dosage, cross-situational statistical learning paradigm to teach spoken word production to children with small expressive lexicons.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

Irresectable tumours of the temporal bone

1987 ◽  
Vol 101 (5) ◽  
pp. 432-442 ◽  
Author(s):  
R. E. Quiney ◽  
L. M. Flood
Keyword(s):  
Temporal Bone ◽  
Case Reports ◽  
Sporadic Case ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Total Removal ◽  
Inaccessible Area ◽  
History Of ◽  
Petrous Temporal Bone

AbstractSporadic case reports and the few published series of expanding lesions of the deep petrous temporal bone propose a variety of surgical approaches to ensure excision. All such surgery represents a compromise between exposure adequate for total removal and avoidance of further neurological deficit. Unfortunately pathology in the petrous apex evolves relatively silently and diagnosis is delayed. In many cases total excision is impossible. We present a series of patients presenting with advanced tumours of the deep petrous temporal bone in order to illustrate the spectrum of disease encountered, the limited role of surgery and the natural history of irresectable pathology in this remote and inaccessible area.

scholarly journals Effects of two different deep digital flexor tenotomy techniques on distal articular angles of equine cadaver forelimbs

2012 ◽  
Vol 42 (11) ◽  
pp. 2005-2010
Author(s):  
Antonio Cezar de Oliveira Dearo ◽  
Vitor Bruno Bianconi Rosa ◽  
Peter Reichmann ◽  
Milton Luis Ribeiro de Oliveira
Keyword(s):  
Quantitative Data ◽  
Statistical Significance ◽  
Surgical Approaches ◽  
Control Groups ◽  
Before And After ◽  
Distal Interphalangeal ◽  
The Difference ◽  
And Control ◽  
Flexor Tenotomy

Deep digital flexor (DDF) tenotomy is a technique employed for years to treat selected disorders of the musculoskeletal system in horses. Although two different surgical approaches (i.e. mid-metacarpal and pastern) have been described for performing the procedure, in vitro quantitative data regarding the modifications induced by either technique on the distal articular angles is lacking. Therefore, the purpose of the study reported here was to investigate the viability of a proposed biomechanical system of induced-traction used to compare the two DDF tenotomy techniques by measuring the distal articular angles of equine cadaver forelimbs. Ten pairs of forelimbs were collected and mounted to a biomechanical system developed to apply traction at the toe level. Dorsal articular angles of the metacarpophalangeal (MP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were determined by geometric lines on radiographs taken before and after performing each technique. Comparisons between each tenotomy group and its own control, for each joint, and between the two tenotomy groups using as variable the difference between the tenotomy and control groups were tested. Despite the lack of statistical significance, the DDF tenotomy technique at the pastern level produced extension, to a lesser and greater extent, of the PIP and DIP joints, respectively when compared to the mid-metacarpal level. No remarkable differences could be observed for the MP joint. The developed traction-induced biomechanical construct seemed to be effective in producing valuable quantitative estimations of the distal articular angles of equine cadaver forelimbs subjected to different DDF tenotomy techniques.

scholarly journals Analysis of Approaches in the Microsurgical Treatment of 102 Cases of Petroclival Meningioma in a Single Center

2021 ◽  
Vol 12 ◽  
Author(s):  
Yazhou Lin ◽  
Qiang Gao ◽  
Huiping Jin ◽  
Nana Wang ◽  
Dingkang Xu ◽  
...  
Keyword(s):  
Attachment Site ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Karnofsky Performance Scale ◽  
Therapeutic Effects ◽  
Single Center ◽  
Petroclival Meningioma ◽  
Tumor Subtypes ◽  
Significant Difference

Objectives: We identified the optimal approaches for treating the diverse tumor subtypes of petroclival meningioma (PM) by analyzing the clinical benefits of various surgical approaches adopted for each subtype.Methods: Tumors in 102 PM patients from a single center who underwent surgical treatment were classified as upper clivus (UC), cavernous sinus (CS), tentorium (TE), or petrous apex (PA) types based on the attachment site of the tumor base and the displacement of the trigeminal nerve. The therapeutic effects of different surgical approaches among the subtypes were evaluated according to the patient outcomes.Results: The subtemporal (33.33%), retrosigmoid (16.67%), and Kawase approaches (50%) were used for the UC type. Simpson I/II resection was achieved in 46.66% of patients with the Kawase approach. Significant differences were found between the other two approaches (P = 0.044) and in the follow-up Karnofsky performance scale (KPS) scores (P = 0.008). The subtemporal (60%) and Kawase approaches (40%) were used for the CS type; neither approach achieved Simpson I/II resection. The retrosigmoid (25.81%) and Kawase approaches (74.19%) were used for the TE type. The Simpson I/II resection rates of the two approaches were 55.55 and 86.95%, respectively, and a significant difference was observed between them (P = 0.039). The retrosigmoid (43.75%) and Kawase approaches (56.25%) were used for the PA type. The Simpson I/II resection rates of the two approaches were 31.25 and 50%, respectively. The resection degrees of the two approaches and the KPS scores at follow-up were significantly different (P = 0.034).Conclusion: The individual microsurgical approaches adopted for the various PM tumor subtypes can provide maximal safe resection and good KPS scores. The Kawase approach is more suitable for PM, especially for UC- and PA-type PM tumors.

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