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Infratemporal and pterygopalatine fossae (ITF and PPF) represent two complex paramedian skull base areas, which can be defined as jewelry boxes, containing a large number of neurovascular and osteomuscular structures of primary importance. They are in close communication with many craniofacial areas, such as nasal/paranasal sinuses, orbit, middle cranial fossa, and oral cavities. Therefore, they can be involved by tumoral, infective or inflammatory lesions spreading from these spaces. Moreover, they can be the primary site of the development of some primitive tumors. For the deep-seated location of ITF and PPF lesions and their close relationship with the surrounding functional neuro-vascular structures, their surgery represents a challenge. In the last decades, the introduction of the endoscope in skull base surgery has favored the development of an innovative anterior endonasal approach for ITF and PPF tumors: the transmaxillary-pterygoid, which gives a direct and straightforward route for these areas. It has demonstrated that it is effective and safe for the treatment of a large number of benign and malignant neoplasms, located in these fossae, avoiding extensive bone drilling, soft tissue demolition, possibly unaesthetic scars, and reducing the risk of neurological deficits. However, some limits, especially for vascular tumors or lesions with lateral extension, are still present. Based on the experience of our multidisciplinary team, we present our operative technique, surgical indications, and pre- and post-operative management protocol for patients with ITF and PPF tumors.

BackgroundSuperb knowledge of anatomy and techniques to remove the natural barriers preventing full access to the most lateral aspect of the skull base determines the ease of using the transpterygoid approach (ETPA) as the main gateway for all the coronal planes during endonasal surgeries.MethodsThroughout stepwise image-guided cadaveric dissections, we describe the surgical anatomy and nuances of the ETPA to the pterygopalatine fossa (PPF) and upper parapharyngeal space (UPPS).ConclusionThe ETPA represents a lateral extension of the midline corridor and provides a valuable route to access the PPF/UPPS. Major landmarks for this EEA are the infraorbital canal, sphenopalatine foramen, and vidian nerve. It comprises the removal of the palatine bone, posterior wall of the maxillary sinus, and PPF transposition to drill the pterygoid process.

Background and ObjectivesThis study aimed to describe and assess the accuracy and feasibility of a novel technique for ultrasound-guided maxillary nerve block using the lateral pterygoid plate (LPP) approach via the pterygopalatine fossa (PPF) in a soft cadaveric model.MethodsTen soft cadavers were studied. The curved array ultrasound transducer probe was applied over 1 side of the face of the cadavers in the open-mouth posture. It was placed transversely below the zygomatic arch for identifying the border of the maxillary tuberosity and the LPP. We tilted the curve probe from the caudal to the cranial direction until the uppermost part of the PPF was identified. The in-plane needle approach was used from the anterior-to-posterior and lateral-to-medial directions through the fossa, and 3 mL of methylene blue dye was injected.ResultsThe spread of injectate after ultrasound-guided maxillary nerve block using the LPP approach was successfully performed in all cadavers as demonstrated by visualized moderate to marked traces of methylene blue within the PPF. No accidental injections in the maxillary arteries or facial nerves were observed.ConclusionsThis cadaveric study suggests that ultrasound-guided maxillary nerve block using the LPP approach via the PPF has a high degree of accuracy and feasibility. Further studies are required to confirm its efficacy and safety for clinical application.

Abstract Objectives Large-scale procedural safety data on pterygopalatine fossa nerve blocks (PPFBs) performed via a suprazygomatic, ultrasound-guided approach are lacking, leading to hesitancy surrounding this technique. The aim of this study was to characterize the safety of PPFB. Methods This retrospective chart review examined the records of adults who received an ultrasound-guided PPFB between January 1, 2016, and August 30, 2020, at the University of Florida. Indications included surgical procedures and nonsurgical pain. Clinical data describing PPFB were extracted from medical records. Descriptive statistics were calculated for all variables, and quantitative variables were analyzed with the paired t test to detect differences between before and after the procedure. Results A total of 833 distinct PPFBs were performed on 411 subjects (59% female, mean age 48.5 years). Minor oozing from the injection site was the only reported side effect, in a single subject. Although systolic blood pressure, heart rate, and oxygen saturation were significantly different before and after the procedure (132.3 vs 136.4 mm Hg, P < 0.0001; 78.2 vs 80.8, P = 0.0003; and 97.8% vs 96.3%, P < 0.0001; respectively), mean arterial pressure and diastolic blood pressure were not significantly different (96.2 vs 97.1 mm Hg, P = 0.1545, and 78.2 vs 77.4 mm Hg, P = 0.1314, respectively). Similar results were found within subgroups, including subgroups by sex, race, and indication for PPFB. Discussion We have not identified clinically significant adverse effects from PPFB performed with an ultrasound-guided suprazygomatic approach in a large cohort in the hospital setting. PPFBs are a safe and well-tolerated pain management strategy; however, prospective multicenter studies are needed.

PurposeThe pterygopalatine fossa is a deep viscerocranial space containing the maxillary artery and nerve, the pterygopalatine ganglion, and the nerve of the pterygoid canal (vidian nerve). The endoscopic approach to this area relies on adequate preoperative imaging, such as computed tomography (CT). The aim was to determine the morphometric characteristics of the pterygopalatine fossa and its communications, including several previously unpublished measurements.Methods100 CT scans (56 male and 44 female patients) were analyzed. The axial, coronal, and sagittal slices, together with the three-dimensional reconstructions, were used in the study.ResultsThe central diameter and the length of the foramen rotundum, the vertical diameter and the length of the pterygoid (vidian) canal, and the diameter of the sphenopalatine foramen were significantly larger in men. The central diameters of the foramen rotundum and the vidian canal were significantly smaller than their anterior and posterior transverse diameters. The vidian canal length of 12.1 mm indicates the presence of the type 3 VC with a sensitivity of 83% and a specificity of 85%.ConclusionSeveral new descriptions of the pterygopalatine fossa are presented here (such as the angle between the sphenopalatine foramen and the vidian canal, a new aspect in the understanding of the FR, and the distance between the posterior wall of the maxillary sinus to the vidian canal and the foramen rotundum), which might prove useful in the comprehension of the anatomy of the pterygopalatine fossa.

Background Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal. Methods This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement. Results Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6–11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p  = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p  = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min. Conclusions PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.

IntroductionThe greater palatine canal (GPC) connects the pterygopalatine fossa to the greater palatine foramen and houses vital neurovascular structures, which provide sensory innervation and circulation to the gums, palate, and nasal cavity. The GPC is of great clinical importance to various medical specialties; however, the anatomical variability of the GPC poses a risk of iatrogenic injury and complications. Therefore, understanding the normal anatomy and variations of the GPC is crucial for identifying vital structures and minimizing risks in clinical practice.PurposeThe aim was to fill a gap in the current literature by focusing on the prevalence of GPC medial wall dehiscence, a lesser-known anatomic variation, in radiological scans.MethodsA total of 200 head and neck CT scans were examined, where 71 scans met the inclusion criteria. Statistical significance for incidence of GPC medial wall dehiscence, in reference to sex and side, was measured.ResultsThe GPC medial wall dehiscence was observed in 69% of scans. Bilateral dehiscence was seen in 57.7% of scans, while right-sided and left-sided unilateral dehiscence were found in 14.1% and 11.3%, respectively. Significant difference was found between the incidence of bilateral dehiscence compared to the absence of dehiscence.ConclusionPrevious studies have highlighted the potential risks associated with invasive procedures involving the GPC. The clinical relevance of GPC medial wall dehiscence lies in the increased risk of transecting the contained neurovascular bundle. The presence of dehiscence emphasizes the need for meticulous preoperative radiologic analysis to tailor surgical approaches to individual patient anatomy.

Rhinosinusitis is one of the most common reasons for a visit to otolaryngology clinics. Some patients are candidates for sinus surgery. Infiltration of 1:100 000 adrenaline in the pterygopalatine fossa was studied, with the aim of evaluating the effect on bleeding in the surgical field. This double-blind clinical trial was conducted in 2021-2022 on 40 candidates for endoscopic sinus surgery. For each patient, one side of the pterygopalatine fossa was randomly selected to be infiltrated with a vasoconstrictor. Surgical field bleeding on each side was evaluated. Blood loss was 35.8 ± 20.9 ml in the study group and 38.4 ± 23.7 ml for the control group, with no statistically significant difference between groups ( = 0.49). In addition, there was no difference between the two groups in terms of the surgical field based on Boezaart scores. Although there are some recommendations on the usage of vasoconstrictors via the pterygopalatine foramen, debate remains.

BackgroundEndoscopic transorbital approach (eTOA) has been announced as an alternative minimally invasive surgery to skull base. Owing to the inferior orbital fissure (IOF) connecting the orbit with surrounding pterygopalatine fossa (PPF), infratemporal fossa (ITF), and temporal fossa, the idea of eTOA to anterolateral skull base through IOF is postulated. The aim of this study is to access its practical feasibility.MethodsAnatomical dissections were performed in five human cadaveric heads (10 sides) using 0-degree and 30-degree endoscopes. A stepwise description of eTOA to anterolateral skull base through IOF was documented. The anterosuperior corner of the maxillary sinus in the horizontal plane of the upper edge of zygomatic arch was defined as reference point (RP). The distances between the RP to the foramen rotundum (FR), foramen ovale (FO), and Gasserian ganglion (GG) were measured. The exposed area of anterolateral skull base in the coronal plane of the posterior wall of the maxillary sinus was quantified.ResultsThe surgical procedure consisted of six steps: (1) lateral canthotomy with cantholysis and preseptal lower eyelid approach with periorbita dissection; (2) drilling of the ocular surface of greater sphenoid wing and lateral orbital rim osteotomy; (3) entry into the maxillary sinus and exposure of PPF and ITF; (4) mobilization of infraorbital nerve with drilling of the infratemporal surface of the greater sphenoid wing and pterygoid process; (5) exposure of middle cranial fossa, Meckel’s cave, and lateral wall of cavernous sinus; and (6) reconstruction of orbital floor and lateral orbital rim. The distances measured were as follows: RP-FR = 45.0 ± 1.9 mm, RP-FO = 55.7 ± 0.5 mm, and RP-GG = 61.0 ± 1.6 mm. In comparison with the horizontal portion of greater sphenoid wing, the superior and inferior axes of the exposed area were 22.3 ± 2.1 mm and 20.5 ± 1.8 mm, respectively. With reference to the FR, the medial and lateral axes of the exposed area were 11.6 ± 1.1 mm and 15.8 ± 1.6 mm, respectively.ConclusionsThe eTOA through IOF can be used as a minimally invasive surgery to access whole anterolateral skull base. It provides a possible resolution to target lesion involving multiple compartments of anterolateral skull base.