Essam Saleh , MD

Prof of Otolaryngology, Alex Univ.

Forgotten Anatomy

Anatomy
Anterior: post.wall

maxilla.
Posterior: Styloid,
Carotid sheath, Condyle
Medial: Lat pterygoid
plate & sup constrictor.
Lateral: Ramus of
Mandible
Superior: Sphenoid

Contents

Medial & Lateral Pterygoid muscles

Contents

Maxillary artery

Mandibular nerve

Communications
With the pterygopalatine

fossa through pterygomaxillary fissure

With the orbit through
inferior orbital fissure.
With the middle cranial
fossa through F.O, F.R
With the neck &
parapharyngeal space
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,
pterygopalatine fossa & 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
NP Carcinoma
Meningioma
Recurrent Chondrosarcoma
Trigeminal Neuroma
Rhabdomyosarcoma

4
2
2
1
1
1

-->1ry

Infratemporal Fossa Tumors

Extension

Pterygopalatine Fossa
Cavernous sinus
ICA
Orbit
Sphenoid sinus
Clivus (erosion)
PNS
Petrous apex
Parapharyngeal space

No(%)

7 (64%)
6 (55%)
5 (45%)
6 (55%)
5 (45%)
4 (36%)
4 (36%)
2 (18%)
2 (18%)

Approaches
IFC
Preauricular IF
Preauricular IF + Orbitozygomatic
Preauricular IF + Transcx
Preauricular IF + Transcx + Transpalatal
Preauricular IF + Transnasal
Preauricular IF + MF-Transpetrous
Transcochlear + Transtent + IF

2
2
2
1
1
1
1
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.