INFRA TEMPORAL FOSSA  Irregularly shaped space deep & inferior to zygomatic arch, deep to ramus of mandible & posterior to maxilla  Communicates with temporal fossa through interval between (deep to) zygomatic arch & (superficial to) cranial bones  Temporal fossa is superior to zygomatic arch  In

1. DR. SUDIN KAYASTHA
RESIDENT, ORL HNS
NAMS
http://www.free-powerpoint-templates-design.com

2. INFRA TEMPORAL FOSSA
 Irregularly shaped space deep & inferior to
zygomatic arch, deep to ramus of mandible &
posterior to maxilla
 Communicates with temporal fossa through
interval between (deep to) zygomatic arch &
(superficial to) cranial bones
 Temporal fossa is superior to zygomatic arch
 Infra temporal fossa is inferior to zygomatic
arch

3. SECTION BREAK
Insert the title of your subtitle Here
BOUNDARIES

4. Infra
temporal
fossa

5. CONTENTS
 Muscle:
1) Inferior part of temporalis muscle.
2) Lateral & medial pterygoid muscles
 Ligaments:- Sphenomandibular ligament
 Vessels:-
1) Maxillary artery & branches.
2) Pterygoid venous plexus
 Nerves:-
1) Mandibular Nerve & branches.
2) Chorda tympani branch of facial nerve
3) Inferior alveolar, lingual, buccal nerve
 Otic parasympathetic ganglion

7. TEMPORALIS MUSCLE
Origin:- Temporal fossa and deep surface of
temporal fascia
• Insertion:- Medial surface, apex, ant. & post. Border
of coronoid process and ant. border of
ramus of the mandible
• Blood supply:- Deep temporal part of maxillary artery
• Nerve supply:- Deep temporal branches of anterior
mandibular nerve.
• Actions:- 1) Elevates & retracts mandible,
2) Side to side grinding movement.

8. Arise from 2 heads:
1) Upper head from infra temporal surface of
greater wing of sphenoid
2) Lower head from lateral surface of lateral
pterygoid plate
2 heads converge posteriorly into a tendon
which is inserted into neck of mandible, its
intra-articular disc and capsule.
Supplied by Mandibular Division of Trigeminal n.
Acts in opening mouth by pulling condyle forwards
LATERAL PTERYGOID

9. LATERAL PTERYGOID
 Superficial:
temporalis, masseter, ramus of mandible, maxillary
artery, buccal nerve
 Deep:
medial pterygoid, mandibular nerve, middle
meningeal artery, otic ganglion
 Emerging through its upper border:
deep temporal & masseteric nerves
 Emerging through its lower border:
lingual & inferior alveolar nerves + maxillary artery
 Emerging between its 2 heads:
buccal nerve, maxillary artery

10. MEDIAL PTERYGOID
ORIGIN:
Superficial head: Tuberosity of maxilla
Deep head: Medial surface of lateral pterygoid
plate
INSERTION: Medial surface of ramus & angle
of mandible
NERVE SUPPLY: From trunk of mandibular n.
ACTION:
1) Elevation of mandible
2) Protrusion of mandible
(when muscles on both sides act together)
3) Side-to-side movement
(when both sides actalternatively)

13. Maxillary Artery

14. Maxillary Artery

15. Maxillary Artery
Video

16. Pterygoid Plexus
 Lies within and on lateral surface of lateral pterygoid muscl
e, and receives tributaries corresponding to branches of max
illary artery
 Plexus  short, large maxillary veins  join
superficial temporal vein retromandibular vein
 Pterygoid venous plexus has 3 communicating veins
1. Inferior ophthalmic veininferior orbital fissurefacial vein
2. A connecting vein passes vertically down from cavernous
sinus via foramen ovale or foramen of Vesalius
3. Deep facial vein join anterior facial vein

17. Mandibular Nerve
 Passes through foramen ovale, and after a short
course just deep to upper head of Lateral Pterygoid
muscle, main trunk divides into anterior and posterior
divisions
 Before this division main trunk gives of sensory
nervus spinosus which reenter middle cranial fossa
through foramen spinosum and motor nerve to
medial pterygoid

18. Mandibular Nerve
Trunk: Motor: nerve to medial pterygoid
Sensory: nervus spinosus
Anterior Division:
Motor : Temporalis,
Lateral Pterygoid,
Masseter,
Sensory: Long Buccal Nerve
Posterior Division:
Motor: Mylohyoid nerve
Sensory: Auriculotemporal nerve
Inferior alveolar nerve
Lingual nerve

19. Otic Ganglion
 Lies close to mandibular nerve just below foramen
ovale, between the nerve and tensor palati muscle
 Relays secretomotor fibres for parotid gland which
it receives by way of lesser superficial petrosal nerve
and transmit to auriculotemporal nerve

21. LIGAMENTS
01
02
Stylo mandibular ligament
Joins styloid process to angle of
the mandible & is a thickened
part of parotid sheath..
Sphenomandibular ligament
Suspends mandible and
descends from spine of
sphenoid bone to lingula
of mandible.

22. Tissue Space associated
Temporal space: consists of superficial and deep components.
-Superficial temporal space lies on lateral surface of muscle, beneath
skin and superficial (temporal) fascia.
-Deep temporal space lies between medial (deep) surface of muscle &
adjacent temporal bone.
 Submasseteric space: series of spaces between lateral surface of ramus of
mandible and masseter muscle.
-form because fibres of masseter muscle have multiple
insertions onto lateral surface of ramus

23. Tissue Space associated
 Masticator tissue space: space enclosed by fascia ensheathing muscles of mastica
tion and ramus of mandible. It can be subdivided into pterygomandibular, infratempor
al, temporal and submasseteric tissue spaces.
 Pterygomandibular space: between ramus of mandible and MP muscle
has inferior alveolar and lingual nerves,
 Infratemporal space: is upper extremity of pterygomandibular space
lies behind the maxilla and
bounded medially by lateral pterygoid plate
above by the base of the skull
in continuity with the deep temporal space laterally.

24. PTERYGOPALATINE FOSSA

25. Pterygopalatine fossa
Small pyramidal space inferior to apex of orbit and medial to infratemporal fossa
Boundaries:
Posteriorly: Pterygoid process of sphenoid
Anteriorly: posterior aspect of maxilla
Medially: perpendicular plate of palatine bone
Roof: medial continuation of infra temporal surface of greater wing of sphenoid
Floor: pyramidal process of palatine bone

26. Contents
• Terminal (pterygopalatine or third) part of
maxillary artery, accompanying veins
• Maxillary nerve (CN V2), with which the
pterygopalatine ganglion is associated.
• Neurovascular sheaths of vessels and
nerves and fatty matrix occupy all remaini
ng space.

28. Pterygopalatine Ganglion
 In pterygopalatine fossa, maxillary nerve  two ganglionic branches to the pterygopal
atine ganglion (sensory roots of the pterygopalatine ganglion) suspend the ganglion.
 Pterygopalatine nerves convey general sensory fibers of maxillary nerve, which pass
through pterygopalatine ganglion without synapsing to supply nose, palate, and pharynx

31. Communications

33. SURGICAL CORELATIONS

34. Surgical Corelations
Transantral Approach to Pterygopalatine Fossa
 Surgical access to the deeply placed pterygopalatine fossa is gained through the
maxillary sinus.
 After elevating upper lip, maxillary gingiva and anterior wall of sinus are transversed
to enter sinus.
The posterior wall is then chipped away as needed to open anterior wall of pterygop
alatine fossa.
In case of chronic epistaxis (nose bleed), third part of maxillary artery may be ligated
in fossa to control the bleeding.

35. SOME SURGICAL LANDMARKS
 Infratemporal fossa is a space closed between lateral wall of nasopharynx and
medial surface of mandible.
 Superior constrictor muscle of pharynx which forms lateral wall of nasopharynx is
attached to medial pterygoid plate but ends about 2 cm below the base of the skull
 Mean distance of the medial pterygoid plate to the zygomatic arch was 4.78 cm
 In an adult the average distance between the root of the lateral pterygoid plate, i.e.
foramen ovale, and the zygomatic arch is 3.82 cm.

36. SOME SURGICAL LANDMARKS
 5 cm wide space between the nasopharynx and zygomatic arch is traversed by 4
muscles: from lateral to medial - temporalis, lateral pterygoid(LP), medial pterygoid
(MP) and superior constrictor of the pharynx.
 Between LP and temporalis muscles  vascular space [maxillary artery and branc
hes and pterygoid venous plexus] Haemangiomas to be found in this region.
 Between lateral and medial pterygoid muscles  Neural space [mandibular nerve
and its branches, and otic gangion]  Benign or malignant schwannomas or neurofi
bromas

37.  Space between medial pterygoid muscle and superior constrictor or lateral wall of
pharynx  extension of tumours originating in nasopharynx and sphenoid sinuses.
Juvenile angiofibroma, may extend through this path of least resistance. Carcinomas
often extend in this way.
 Meningiomas originating in middle cranial fossa extend to infratemporal fossa via
foramen ovale.
 Tumours originating in infratemporal space or extending to it from adjoining areas
may extend intracranially through foraminas.

38. Tumours directly or indirectly involve Eustachian tube which is superomedial to
medial pterygoid plate, leading to conductive hearing loss
Tumours originating in the pterygopalatine fossa or extending to it may spread to
infratemporal fossa. They may also extend superiorly and anteriorly pressing on
infraorbital nerve and causing symptoms of pressure behind the eye, exophthalmos
and diminution of vision

39. Tumours of the infratemporal fossa are classified into the following group:
1. Primary. Arise from structures within infratemporal fossa,
25–30% of tumours seen in the area.
2. Contiguous. By extension from adjoining areas such as maxilla, nasal cavity, naso
pharynx, sphenoid, mandible, parotid gland, external acoustic meatus and the cranial
cavity.
3. Metastatic. Spread of malignant tumour to infratemporal fossa by haematogenous
route is not common. Metastases from lung, ovary and breast carcinoma have been
reported.

40. SURGICAL APPROACH
 The medial boundary poses most difficulty for surgeons en-bloc resection
 Between Medial pterygoid muscle and superior constrictor muscle  a layer of
loose areolar tissuemedial boundary of resection for malignant tumours confined
to infratemporal fossa.

41. SURGICAL APPROACH
 Two prominent reference points for identification
of this critical medial plane of :
styloid process and pterygoid hamulus
 Foramen lacerum, carotid canal and jugular
foramen are situated medial to this plane.

42. SURGICAL APPROACH
 Infratemporal fossa and pterygopalatine fossa combine  ‘retromaxillary space’.
 Lateral pterygoid divides the infratemporal fossa into superior and inferior
compartments

43. SURGICAL APPROACH
 Resection of floor of middle cranial fossa is
required for tumours involving superior
compartment.
 The limit of medial resection margin in
such cases is the line running medial to foramen
rotundum, foramen ovale, foramen spinosum, &
lateral to internal carotid artery (foramen lacerum

44. ANTERIOR
1.Transmandibular
2. Transfacial
3. Intraoral
LATERAL
1. Transmandibular
2. Transzygomatic
COMBINED
SURGICAL APPROACH
These approaches may be combined with a fronto temporal craniotomy as necessary.

45. SURGICAL APPROACH
The ideal surgical approach to the infratemporal fossa should:
 Provide increased and more direct exposure of the pathology and the adjacent
neurovasculature
 Be extensile, i.e. capable of being extended peroperatively.
 Minimise 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.

46. ANTERIOR APPROACH
Transmandibular approach: extended mandibular swing
• an incision to divide the lower lip and chin
• division of the mandible anterior to the mental foramen—preserving ipsilateral lower
lip sensation
• dissection of the tissues in the floor of the mouth, submandibular region and neck
Transfacial approach
• mobilisation of pedicled bone flaps in which the midfacial bone segment remains
pedicled to the soft tissues of the cheek thereby retaining their blood supply.
• Maxillo cheek flap and Naso-maxillo cheek flap
Intraoral Approach
• Only in carefully selected cases in which the lesions are small, benign and well circu
mscribed. No role in the treatment of malignant pathology (Lefort I and Transpalatine)

47. Pleomorphic adenoma filling the
infratemporal fossa and the para
pharyngeal space
The tumour in this case was exposed
and resected via an MCF combined
with a mandibular cheek flap (extend
ed mandibular swing).

48. LATERAL APPROACH
Lateral transmandibular approaches
• Do not involve the lip-split incision described above for extended mandibular swing
approach. Avoid entering the oral cavity
Lateral transzygomatic approaches
• Disarticulation and inferior displacement of zygoma, usually pedicled to masseter
muscle, as well as displacement of temporalis muscle in superior or inferior direction
• Access to superior compartment of infratemporal fossa by removing lateral boundar
y

49. Fisch Approaches
The Fisch-described infratemporal fossa approach has three variations providing a
graded level of anterior and medial exposure.
Type A provides exposure to the region of the jugular foramen, the vertical segment
of the internal carotid artery (ICA), and the posterior infratemporal fossa.
Type B provides additional exposure to the petrous apex and horizontal ICA and the
clivus.
Type C provides an extension to the anterior infratemporal fossa, the nasopharynx,
the pterygopalatine fossa, and the cavernous sinus.

50. FISCH APPROACH

51. INFERIOR ALVEOLAR NERVE BLOCK
• By inserting the needle, lateral to pterygomandibular raphae, about 6-10mm above the
occlusal table of mandibular teeth, then sliding posteriorly along the medial aspect of
the ramus.
• Approach area of injection from contralateral premolar region ,with other hand thumb
retracting the buccal mucosa pressing on the coronoid process.
• Vicinity of mandibular foramen can be reached.
• Tongue and skin of chin are also anaesthetised d/t lingual and mental nerve blockade.

52. INFERIOR ALVEOLAR NERVE BLOCK

53. MANDIBULAR NERVE BLOCK
In the pterygomandibular space, at the level of the neck of the condyle

54. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK
 The site of the injection is about 1 cm above &
behind the apices of the maxillary third molar.
 Useful for procedures involving posterior aspects
of maxilla and maxillary antrum.
 Hematomas arising from laceration of posterior
superior alveolar artery or from damage to pterygoi
d venous plexus; this is uncommon.

55. MAXILLARY NERVE BLOCK
Blockade of complete maxillary nerve is rarely indicated,
but is useful for extensive surgery of the maxilla, or in the
treatment of acute trigeminal neuralgia of the maxillary
division.

56. Thank you