INTRODUCTION TEMPORAL FOSSA Borders Clinical correlation Contents Temporalis and surgical aspects Temporal fascia and surgical aspects Deep temporal nerves and vessels, auriculotemporal nerve, superficial temporal artery TEMPORAL BONE AND TEMPORAL BONE FRACTURES CORONAL OR BI-TEMPORAL APPROACH TEMPORAL (GILLIES) APPROACH INFRATEMPORAL REGION Borders Contents LOCAL ANESTHESIA AND THE INFRATEMPORAL FOSSA INFECTION OF THE INFRATEMPORAL FOSSA REGION AND ITS SPREAD SURGICAL APPROACHES TO THE INFRATEMPORAL FOSSA PTERYGOPALATINE FOSSA / SPHENOPALATINE FOSSA Contents Relations Communications Clinical aspects

1. TEMPORAL AND
INFRATEMPORAL REGIONS
Presented by – Mahima
Shanker
(Department of oral and
maxillofacial surgery)

2. CONTENTS
 INTRODUCTION
TEMPORAL FOSSA
a. Borders
b. Clinical correlation
c. Contents
d. Temporalis and surgical aspects
e. Temporal fascia and surgical aspects
f. Deep temporal nerves and vessels,
auriculotemporal nerve, superficial temporal
artery
 TEMPORAL BONE AND TEMPORAL BONE FRACTURES
CORONAL OR BI-TEMPORAL APPROACH
TEMPORAL (GILLIES) APPROACH
INFRATEMPORAL REGION
a. Borders
b. Contents
LOCAL ANESTHESIA AND THE INFRATEMPORAL
FOSSA
INFECTION OF THE INFRATEMPORAL FOSSA REGION
AND ITS SPREAD
SURGICAL APPROACHES TO THE INFRATEMPORAL
FOSSA
PTERYGOPALATINE FOSSA / SPHENOPALATINE
FOSSA
a. Contents
b. Relations

3. INTRODUCTION
•Lateral side of the skull - divided into upper
temporal region and lower infratemporal region
(separated by zygomatic arch)
•Temporal region - area between temporal line and
zygomatic arch
•Infratemporal region - inferior to zygomatic arch,
deep to ramus of mandible and posterior to maxilla

4. TEMPORAL FOSSA
Depression on temporal region, one of the largest landmarks on the skull
BORDERS

5. CLINICAL CORRELATION

6. CONTENTS
• Temporalis muscles and its
covering fascia
• Middle temporal artery
• Auriculotemporal nerve
• Deep temporal nerves and
artery

7. TEMPORALIS
• Fan-shaped
• Arises - floor of temporal fossa
below inferior temporal line,
overlying temporal fascia
• Bony + fascial origins - bipennate
appearance
• Inserted - coronoid process, anterior
border of ramus
• Nerve supply - deep temporal branch
(mandibular nerve)
• Blood supply - deep temporal artery
(second part of maxillary artery)
• Actions - elevates the mandible,
helps in retraction of mandible, side-
to-side movement (grinding)

8. Ein, Liliana, Opeoluwa Daniyan, and Elizabeth Nicolli. "Temporalis muscle flap." Operative Techniques in
Otolaryngology-Head and Neck Surgery 30.2 (2019): 120-126.
1 2
3
4
5

9. Abubaker, A. Omar, and Mustafa B. Abouzgia. "The temporalis muscle flap in reconstruction of intraoral defects: an
appraisal of the technique." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 94.1 (2002):

10. TEMPORAL FASCIA
• Strong sheet of fascia - covers
temporalis above zygomatic arch
• Single layered in upper part and
attached to superior temporal line
• Lower part - splits into two layers -
attached to upper margin of zygomatic
arch
• Gap between the two layers - fat,
branches of superficial temporal
vessels, zygomaticotemporal nerve
• Deep surface - origin to temporalis
• Superficial surface - covered by
downward extension of epicranial
aponeurosis, origins to auricularis
anterior and superior muscles

11. Rajurkar SG, Makwana R, Ranadive P,
Deshpande MD, Nikunj A, Jadhav D. Use
of temporalis fascia flap in the treatment
of temporomandibular joint ankyloses
Contemp Clin Dent 2017;8:347-51

12. DEEP TEMPORAL NERVES AND VESSELS
• Deep temporal nerves - two in number (branches of anterior division of mandibular
nerve)
• Run between fossa and the temporalis - supply
• Deep temporal arteries accompany nerve (second part of maxillary artery)
AURICULOTEMPORAL NERVE
• Branch of posterior division of mandibular nerve - emerges from the parotid gland
behind TMJ - crosses posterior root of the zygoma - appears in temporal region
behind the superficial temporal artery and in front of auricle
• Supplies - skin of auricle, external acoustic meatus, scalp of temporal region
SUPERFICIAL TEMPORAL ARTERY
• Smaller, more direct terminal branch of the ECA
• Runs vertically upward crossing preauricular point where its pulsations are felt

13. Pair of temporal bones - one on each side of skull extending to base
PARTS
TEMPORAL BONE
Mastoid part
Petrous part

14. TEMPORAL BONE FRACTURES
(Skull base fracture)
1. Basavaraju, Umamaheshwari, et al. "Temporal Bone Fractures and its Classification: Retrospective Study of Incidence,
Causes, Clinical Features, Complications and Outcome." (2017).
2. Diaz, Rodney C et al. “Treatment of Temporal Bone Fractures.” Journal of neurological surgery. Part B, Skull base vol.
• 30 to 70% of skull fractures in head trauma
• Complex anatomy - critical structures in close
relation to it - cranial nerves V, VI, VII, VIII, ICA, MMA,
sigmoid sinus, jugular bulb, inner ear structures
• High energy head trauma
• Asymptomatic or complications - hearing loss,
balance dysfunction, perilymphatic fistulas, CSF leaks,
facial nerve paralysis, vascular injury
• Radiological Evaluation – computed tomography (CT)

15. • Traditionally - classified relative to the plane of petrous ridge
• Newer classification of fractures -
Longitudinal temporal bone
fracture
Oblique temporal bone fracture
CLASSIFICATION

16. TREATMENT
• Initially - closed head injury - conservative
• Prophylactic antibiotics - 4 weeks
• Myringotomy and insertion of ventilation tube - serious otitis that persists after one
month
• Residual hearing deficits - hearing aids
• Sometimes there is also an opportunity to restore hearing - middle ear surgery - the
ossicles can be cemented back - which is ossiculoplasty
• Surgical management
a. Facial nerve decompression
b. CSF leak- extracranial transmastoid approach
- transcranial middle fossa approach

17. Aftercare following management of temporal bone
fractures

18. Akbar, Z., and O. Saif. "Myringoplasty using temporalis fascia and its clinical outcome." Int J
Otorhinolaryngol Head Neck Surg 5 (2019): 1539-42.

19. General consideration
• Used to expose anterior cranial vault, forehead, and upper and middle regions of facial
skeleton
• The extent and position of the incision depends on surgical procedure and area of
interest
• Placed remotely - avoid visible facial scars
Access areas
• Entire calvarial vault
• Anterior and lateral skull base
• Frontal sinus/Ethmoid sinus
• Zygoma, Zygomatic arch
• Orbit
• Nasal dorsum
• TMJ
• Condyle and subcondylar region
CORONAL OR BI-TEMPORAL
APPROACH

20. LOCATING THE SCALP INCISION LINE

21. INFERIOR EXTENT OF INCISION LINE

22. DESIGN OF INCISION
HEMOSTATIC TECHNIQUES

23. INCISION AND CORONAL FLAP ELEVATION

24. INCISION OF THE SUPERFICIAL TEMPORAL
FASCIA FOR EXPOSURE OF THE ZYGOMATIC
ARCH
EXPOSURE OF THE TEMPORAL
FOSSA
CLOSURE

25. TEMPORAL (GILLIES) APPROACH
(INDIRECT APPROACH TO THE ZYGOMATIC ARCH)
SKIN INCISION DEEP DISSECTION

26. EXPOSURE WOUND CLOSURE

27. INFRATEMPORAL REGION
Below middle cranial fossa and between pharynx and ramus of
the mandible
BORDERS
• Superiorly - greater wing of the
sphenoid bone
• Inferiorly - medial pterygoid muscle
• Anteriorly - maxilla
• Posteriorly - styloid and condylar
processes
• Medially - sphenoid and palatine
bones
• Laterally - ramus and coronoid
processes of the mandible

28. CONTENTS
• The lateral and medial pterygoid muscles
• The mandibular division of the trigeminal nerve
• The chorda tympani branch of the facial nerve
• The otic parasympathetic ganglion

29. LOCAL ANESTHESIA AND THE
INFRATEMPORAL FOSSA
MAXILLARY ANESTHESIA
NERVE BLOCKS IN THE INFRATEMPORAL REGION -
• Posterior superior alveolar NB
• Maxillary NB - two intra oral techniques, one extra oral technique
POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK
• PSA nerve runs within pterygopalatine fossa - enters posterior aspect of the maxilla
(and the infratemporal fossa) as a single nerve or as several branches
• Descend within maxilla - posterior aspect of the maxillary antrum - supplying
sensation to antrum and then to the posterior aspects of superior dental plexus

31. COMPLICATIONS
• Remarkably safe
• Pterygoid venous plexus lies within
and around LP muscle - damaged if
needle is inserted too deeply or
laterally
• If positive (venous) aspiration is
observed during this procedure -
withdrawal will disengage the needle
with minimal bleeding
• Injecting into friable plexus causes
disruption - haematoma formation,
postoperative trismus

32. MAXILLARY NERVE BLOCK
Blockade of complete maxillary nerve - rarely indicated - useful for extensive surgery of
maxilla,
treatment of acute trigeminal neuralgia, differential diagnosis of facial pain
INTRAORAL TECHNIQUES
1. Buccal or tuberosity approach (posterior aspect of the maxilla)
2. Via greater palatine canal
1
2

33. COMPLICATIONS
• Tuberosity approach - inserting needle more deeply to enter the pterygomaxillary fissure -
needle not kept close to posterior (infratemporal) aspect of maxilla - pterygoid venous plexus
can be damaged
• Maxillary artery close to injection site - significant (arterial) aspiration is noted - needle
should be withdrawn a few mm - aspiration repeated before injecting solution
• If artery lacerated - haematoma
• Anesthetic solution can diffuse to affect orbital structures - temporary diplopia, rare occasions
may affect brainstem (more likely after extra oral approaches)
• Greater palatine canal - greater palatine nerve frequently damaged - palatal sensory
disturbance

34. EXTRA ORAL APPROACH
Rarely indicated - diagnostic blocks when the patient has trismus
COMPLICATIONS
• Inaccuracy - when techniques are practiced infrequently
• Reported success - in 84% of cases
• In addition to the problems relating to intraoral techniques - brainstem anesthesia, orbital
involvement

35. MANDIBULAR ANESTHESIA
NERVE BLOCKS IN INFRATEMPORAL FOSSA
• Inferior alveolar (and lingual) NB - two intraoral techniques, one extra oral
approach
• Mandibular NB - one intraoral technique, one extra oral approach
INFERIOR ALVEOLAR NERVE BLOCK
INTRAORAL TECHNIQUES
• Routine open-mouth direct method
• Closed mouth technique
EXTRA ORAL APPROACH

36. COMPLICATIONS
• Inaccuracy - inadequate
depth of anesthesia
• Common cause of inaccuracy
from open mouth procedure
- injecting too deeply
(complications such as facial
paralysis)
• Closed mouth technique -
deposits solution higher in
pterygomandibular space
• Trismus - less frequent as
MP diverges from mandible
towards its origins, less
likely to be encountered
• As solution deposited away
from neurovascular bundle -
reduced rate of positive
aspirations, higher failure of

37. EXTRA ORAL APPROACH
acute infection in the intraoral tissues, intraoral techniques failed to produce adequate
anesthesia (usually in trismus)
COMPLICATIONS
• Main difficulty - ensuring that solution deposited within pterygomandibular space and
not within MP muscle
• Injection into muscle - failure of anesthesia, trismus

38. MANDIBULAR NERVE BLOCK
THE INTRAORAL ‘HIGH CONDYLE’ (GOW-GATES) TECHNIQUE
Solution deposited high in pterygomandibular space - at the level of
neck of condyle

39. COMPLICATIONS
• High in the pterygomandibular space – solution deposited at neck of condyle just
below insertion of LP
• Solution therefore deposited some distance from neurovascular bundle - with a
slower onset and sometimes inadequate depth of anesthesia
• Main advantage - simultaneous block of all the mandibular nerve branches (does not
always occur)
• Maxillary artery or vein - may be encountered - injections directed to neck of condyle
• Inaccuracy can result in facial paralysis

40. EXTRA ORAL APPROACH
Few occasions - useful in diagnosis of facial pain, controlling acute trigeminal neuralgia
affecting mandibular division
• Success rate of 91% reported

41. INFECTION OF THE INFRATEMPORAL
FOSSA REGION AND ITS SPREAD
CERVICOFACIAL CELLULITIS / PERI-MANDIBULAR INFECTIONS
• Cellulitis - spreading infection of CT -
characterized by inflammatory exudate,
edema, fever, toxemia - may be severe
• Characteristics - diffuse brawny swelling,
pain, fever, malaise
• Swelling – tense, tender with board-like
firmness
• Overlying skin - taut and shiny
• Pain and swelling - difficulty in opening
mouth, swallowing
• Pyrexia, toxemia, leukocytosis
• Regional LN - swollen and tender
• Respiratory distress - if not rapidly
relieved - asphyxia - tracheostomy may

42. • Organisms - beta-hemolytic streptococci, variety of anaerobes
• Virulent periapical infection of mandibular third molar tooth - penetrate lingual plate of
mandible, entrance to several fascial spaces
• Anteriorly - submandibular, sublingual spaces
• Posteriorly - pharyngeal, pterygomandibular spaces
• Cellulitis - complication of acute osteomyelitis of jaws due to spread of virulent
infection
• No barriers running horizontally - to tissue spaces in neck
• Infection entering third molar region - rapidly spreads down the neck and may enter
thorax
AETIOLOGY AND PATHOLOGY

43. LUDWIG’S ANGINA
• Ludwig’s angina - severe form of cellulitis (arises from mandibular second or third
molar tooth)
• Involves - sublingual and submandibular tissue spaces bilaterally (almost
simultaneously)
• Readily spreads into pharyngeal and pterygomandibular spaces
• Spread of swelling towards midline of neck and below the chin - involvement of
submental tissue space
CLINICAL FEATURES
• Characterized by - rapid development of sublingual and submandibular cellulitis
with painful, brawny
swelling of upper part of the neck, floor of the mouth on both sides
• Parapharyngeal tissue space involved - swelling tracks down the neck, edema
spreads into loose CT around the rima glottidis - increasing respiratory obstruction
- seriously ill, fever, headache, malaise
• Difficulty in swallowing, mouth opening limited, tongue may be pushed up against

44. MANAGEMENT
• Brawny swelling of the mouth or neck, fever, malaise - admitted to hospital
• Vigorous use of antibiotics – IV penicillin (not less than 600 mg), every 6 hours
• Swelling - incised at an early stage to relieve pressure of exudate - forces tongue into
airway
• When draining such swellings - neck laid open widely, all tissue spaces opened with
sinus forceps, multiple corrugated drains inserted
• GA - hazardous in later stages - patient relying on conscious effort to maintain airway
• Muscle relaxant given - airway lost – if rapid intubation is not possible - emergency
tracheostomy necessary - opens up further tissue planes to infection therefore surgical
drainage undertaken early in course of infection before respiratory obstruction develops
• Tooth from which infection started - extracted as soon as patient’s condition allows

46. CAVERNOUS SINUS THROMBOSIS
• Serious complication - arise from spread of infection from upper canine tooth
• Infected thrombi in facial vein, pterygoid plexus of veins - communicate with
cavernous sinus through ophthalmic veins or emissary veins passing through foramen
ovale
• Infection may also spread via facial vein from infected boils on upper lip or exterior
nares
CLINICAL FEATURES
• Gross edema of eyelids + pulsatile exophthalmos due to venous obstruction - also
leads to cyanosis
• Superior orbital fissure syndrome - rapidly develops
• Facial vein is dilated, conjunctiva edematous, papilloedema, multiple retinal
haemorrhages
• Patient is seriously ill - meningitis with rigors, high swinging pyrexia
• Initially - one side affected
• Without treatment - both sides become infected due to spread via the midline inter
cavernous sinuses

47. MANAGEMENT
• Combination of anticoagulants, antibiotics, drainage of pus, elimination of source of
infection essential
• 50% mortality - of those who survive - half will lose the sight of one or both eyes
BILATERAL ORBITAL SIGNS

48. SURGICAL APPROACHES TO THE
INFRATEMPORAL FOSSA
IDEAL SURGICAL APPROACH
• Increased, more direct exposure of pathology and adjacent neurovasculature
 a short straight line between surgeon and pathology
 a wide arc of exposure in three dimensions
• Be extensile (capable of being extended preoperatively)
• Minimize brain retraction where exposure of intracranial contents is required
• Have minimal morbidity (functionally or cosmetically)
• Result in minimal increase in overall operating time
• Avoid facial skin incisions

49. TRANSMANDIBULAR APPROACH - EXTENDED MANDIBULAR SWING
Three separate elements -
• Incision to divide lower lip and chin
• division of the mandible anterior to mental foramen - preserving ipsilateral lower lip
sensation
• dissection of tissues in floor of the mouth, submandibular region and neck
Outline of midline lower lip
splitting incision
Mucosal incision extends into
gingivobuccal sulcus
Cheek flap is elevated
directly over outer cortex

50. Outline of proposed angled mandibulotomy

51. Retraction of halves
of mandible exposes
mylohyoid muscle
MP muscle exposed on further
retraction of halves of divided
mandible
LP muscle is exposed

53. MAXILLARY SWING APPROACH
Modified Weber-Ferguson
incision
Skin incision deepened up to bone
with
Orbicularis oculi muscle expose

54. Planned osteotomies of the maxilla Mucosal incision on hard and soft
palate
outlined

55. Mucoperiosteal flap of hard palate
elevated beyond midline
Maxilla swung laterally with
anterior soft tissues of cheek
attached
Mini plates and screws are
used
for fixation of maxilla
Skin incision is closed in

56. TRANSORAL APPROACH

57. Trans oral approach exposing
medial surface of the mandible
and MP muscle
Exposure of IAN and
lingual
nerve in ITF
Well-defined, encapsulated
tumor is revealed via blunt
dissection
Torres-Gaya, Jorge, et al. "Transoral endoscopic
approach for benign tumours in the
infratemporal fossa." BMJ Case Reports CP 12.1

58. Comparison between classic open approaches and contemporary endoscopic
approaches to the ITF

59. TRANSANTRAL APPROACH EXTENDED MAXILLOTOMY APPROAC

60. TRANSPALATAL APPROACH

61. LE FORT I OSTEOTOMY
APPROACH OR
TRANSMAXILLARY APPROACH

62. FISCH
APPROACHES
TYPE A
Permits access to -
• jugular bulb
• vertical petrous carotid
• posterior infratemporal fossa
TYPE B
Explores
• Skull base
• superior infratemporal fossa
TYPE C
• nasopharynx
• peritubal space
• pterygopalatine fossa
• antero superior infratemporal fossa

63. • Incisions and
skin flap
• Closure of the
EAC
TYPE A

64. Removal of EAC wall skin and
tympanic membrane
Cervical dissection Radical
mastoidectomy

65. Facial nerve
transposition
Occlusion of the
sigmoid sinus
Exposure of jugular bulb, ICA

66. Tumor removal Closure of wound

67. TYPE B

68. TYPE C

69. PTERYGOPALATINE FOSSA /
SPHENOPALATINE FOSSA
• Cone-shaped paired depression -
deep to ITF, posterior to maxilla
• Located between - pterygoid
process and maxillary tuberosity
• Contents
 Maxillary nerve
 Third part of maxillary artery
 Pterygopalatine ganglion
 Nerve of pterygoid canal

70. Relations
• Anteriorly - maxilla
• Posteriorly - pterygoid process
• Medially - vertical plate of palatine
bone
• Laterally - pterygomaxillary fissure
• Superiorly - greater wing
• Inferiorly - pyramidal process -
palatine bone

71. Communicates with the nasal and oral cavities, infratemporal fossa, orbit, pharynx, and
middle cranial fossa through foramina
Pterygomaxillary
fissure
Foramen rotundum Pterygoid (Vidian) canal

73. CLINICAL ASPECTS
• Involved in the spread of tumors, infections, inflammations caused by neoplastic
diseases in the head and neck (such as juvenile nasopharyngeal angiofibroma,
nasopharyngeal carcinoma, bacterial sinusitis)
• Juvenile nasopharyngeal angiofibroma - tumor extends into the pterygopalatine fossa
through sphenopalatine foramen - spreads in multidirectional fashion into other
regions - sinuses, infratemporal fossa, orbit, cranial fossa
• Congestion of the nasal glands, lacrimal glands and palatine glands result in running
nose and lacrimation due to stimulation of Pterygopalatine ganglion - Hay fever
ganglion
• Mandibular nerve also innervates a portion of ear (by auriculotemporal branch) and
pain in infected lower tooth (by inferior alveolar branch) - referred to ear - Referred
otalgia
• Paresthesia of mandible, teeth and side of the face and paralysis of Masticatory
muscles, hearing aberrations and jaw jerk loss - Foramen ovale lesion

74. VIDIAN NEURECTOMY
• The vidian nerve - parasympathetic and sympathetic innervation to the nasal mucosa
• The principle of vidian neurectomy - severe preganglionic fibers that reach
sphenopalatine ganglion through vidian nerve
INDICATIONS
• Severe intractable rhinitis
• Senile nasal drip
• Severe recurrent nasal polyposis
Thiagarajan, Balasubramanian. (2012). Vidian Neurectomy. 10.13140/2.1.3775.4560.

75. TRANS ANTRAL APPROACH (GOLDING-WOOD APPROACH)
1. Maxillary antrum opened via Caldwell Luc approach
2. Posterior wall of maxilla is identified and removed
3. Internal maxillary artery - controlled using clips
4. Maxillary nerve - identified and traced up to foramen rotundum
5. This foramen - most important land mark in surgical procedure
6. Exiting from the foramen rotundum - maxillary nerve gives off branches to
sphenopalatine ganglion
7. Vidian nerve identified and resected here
8. According to Golding Wood - unilateral resection of vidian nerve provided relief on
both sides of nasal cavities

76. Elliptical posterior antral window
is made with chisel after
removing mucosa
Exposing maxillary
artery
Application of occluding
clips
Artery displaced
downwards Seek for
maxillary nerve and trace
Identify and follow
sphenopalatine
bundle medial to maxillary
nerve
and trace it up to medial
buttress

77. Sphenopalatine bundle
traced medially to find
ganglion -
diverges - descending
palatine, nasal branches
Sphenopalatine ganglion
found
8mm medial, inferior to
Hook slipped over
divergence of
sphenopalatine bundle
Knife passed beneath it to
cut vidian nerve emerging
from pterygoid canal
Mouth of canal -
coagulated with
diathermy

78. NERVE BLOCKS
• Inferior alveolar nerve block
• Maxillary nerve block
• Mandibular nerve block
APPROACHES TO PTERYGOPALATINE FOSSA
• Trans antral approach
• Trans nasal approach
• Trans palatal approach

79. REFERENCES
•Gray’s Anatomy - The Anatomical Basis of Clinical Practice
•Netter’s Clinical Anatomy
•Surgical Anatomy of the Infratemporal Fossa - John D Langdon
•Handbook of Local Anesthesia - Stanley F Malamed
•Jatin Shah’s Head and Neck Surgery and Oncology