Essam Saleh , MD Prof of Otolaryngology, Alex Univ. Forgotten Anatomy Anatomy

 Anterior: post.wall .  Posterior: Styloid, Carotid sheath, Condyle  Medial: Lat pterygoid plate & sup constrictor.  Lateral: Ramus of  Superior: Sphenoid Contents

Medial & Lateral Pterygoid muscles Contents

Maxillary artery Communications

 With the pterygopalatine through pterygo- maxillary fissure  With the through .  With the middle through F.O, F.R  With the neck & 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. Pathologies

Sarcoma V Neuroma Rhabdomyosarcoma Pathologies

Angiofibroma Meningioma Adenoidcystic carcinoma Problems  Deep 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. Management Anterior Approaches  Transpalatal  Lateral rhinotomy  Facial degloving. Anterolateral Approaches  Extended maxillotomy, maxillectomy, osteoplastic maxillotomy.  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, & 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 Approaches Advantages  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 Disadvantages  Sacrifice 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 ] -->1ry  Rhabdomyosarcoma 1 Infratemporal Fossa Tumors Extension 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 Tumors Total 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.