This document provides an overview of the anatomy of the infratemporal fossa. It describes the boundaries, contents, neurovasculature, and communications of the infratemporal fossa. Key structures discussed include the maxillary artery and its branches, the mandibular nerve and its branches, the otic ganglion, and muscles such as the temporalis, lateral pterygoid, and medial pterygoid. Surgical approaches and nerve blocks related to the infratemporal fossa are also summarized.
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Maxillectomy and craniofacial resection Mamoon Ameen
all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Anatomy of the Temporal region & Temporomandibular jointRafid Rashid
Provides a detailed description of the gross anatomy of the temporal fossa, infratemporal fossa & temporomandibular joint. The boundaries & the structures present in the temporal & infratemporal fossa, the formation & movements of the TMJ & also includes branches of the mandibular nerve & maxillary artery.
Located on the side of the head
Extends from the superior temporal lines to the zygomatic arch.
Communicates with the infratemporal fossa deep to the zygomatic arch.
Contains a numbers of structures that include a muscle, nerves, blood vessels
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Anatomy of the Temporal region & Temporomandibular jointRafid Rashid
Provides a detailed description of the gross anatomy of the temporal fossa, infratemporal fossa & temporomandibular joint. The boundaries & the structures present in the temporal & infratemporal fossa, the formation & movements of the TMJ & also includes branches of the mandibular nerve & maxillary artery.
Located on the side of the head
Extends from the superior temporal lines to the zygomatic arch.
Communicates with the infratemporal fossa deep to the zygomatic arch.
Contains a numbers of structures that include a muscle, nerves, blood vessels
Infratemporal fossa a systematic approachAugustine raj
infratemporal fossa is a irregular space with numerous neurovascular structures. an attempt has been made by me to decode all the boundaries and structures in a systematic way. sincere thanks to Dr. Viren Karia for his awesome video.
INFRATEMPORAL FOSSA AND PTERYGOPALATINE FOSSA NEW.pptxSudin Kayastha
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
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Surgical anatomy of Infratemporal fossa. by Dr. Aditya Tiwari
1. “Anatomy of infratemporal
fossa & various surgical
approaches to it”
By..
Dr. Aditya Tiwari,
Junior Resident,
Dept. of E.N.T.
Date: 14/07/2015
2. INTRODUCTION
• The infratemporal fossa is an anatomic space of
great importance to neurological surgeons
specializing in skull base surgery.
• Multiple neural and vascular structures enter & exit
the infratemporal fossa via foramina in the skull
base.
• Knowledge of these calrelationships is extremely
important to neurological surgeons, neuro-
otologists, craniofacial, and head and neck surgeons.
4. INFRATEMPORAL FOSSA
• Irregularly shaped space deep & inferior to zygomatic arch, deep to
ramus of mandible & post. To maxilla.
• Communicates with temporal fossa through interval bwt (deep to)
zygomatic arch & (superficial to) cranial bones.
• Temporal fossa is superior
to zygomatic arch,
• Infratemporal fossa is
Inf. to zygomatic arch.
5. BOUNDARIES
• Sup: Inf. surface of greater
wing of the sphenoid
• Inf: Where the medial pterygoid
muscle attaches to mandible near its
angle.
• Ant: Post aspect of the maxilla
• Post: Tympanic plate ,mastoid &
styloid processes of temporal bone,
ant. aspect
• Med: Lateral pterygoid plate
• Lat: Ramus of the mandible
6.
7. OSTEOLOGY
• F. ovale & spinosum open on its roof.
• Alveolar canals open on its anterior wall.
• At its upper & medial part are 2 fissures Form T-shaped fissure,
horizontal limb is inf. orbital, & vertical limb is pterygomaxillary.
8. APPROXIMATE LOCATION OF
INFRATEMPORAL SPACE
A Temporalis muscle
B Masseter muscle
C Lateral pterygoid muscle
D Medial ptaerygoid muscle
E Superficial temporal space
F Deep temporal space
G Submasseteric space,
H Pterygomandibular space,
11. Temporalis muscle
• Origin:-Temporal fossa & 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 ant. mandibular nerve.
• Actions:- 1) Elevates & retracts mandible,
2) Side to side grinding movement.
12. LATERAL PTERYGOID
• ORIGIN:
• Upper head: Infratemporal surface of greater wing of sphenoid
• Lower head: Lateral surface of lateral pterygoid plate
• INSERTION: Pterygoid fovea (in front of neck of mandible) +
capsule & articular disc of TMJ
• NERVE SUPPLY: Ant. division of mandibular nerve
• ACTION: 1) Side-to-side movement.
2) Pulls condylar process forward to depress .
13. RELATIONS OF 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
14. 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 nerve
• ACTION: 1) Elevation of mandible
2) Protrusion of mandible (when muscles on both sides act together)
3)Side-to-side movement (when muscles on both sides act alternatively)
15. LIGAMENTS
• Stylomandibular ligament:- Joins styloid process to angle of the
mandible & is a thickened part of parotid sheath.
• Sphenomandibular ligament:- Suspends mandible & descends from
spine of sphenoid bone to lingula of mandible.
• Pterygospinous ligament:- Join spine of sphenoid bone to post. border
of lat. pterygoid plate.
16. Neurovasculature of Infratemporal fossa
• The maxillary artery is larger of 2 terminal branches of ECA.
• Arises post. to neck of mandible & is divided into 3 parts based on its
relation to lat. pterygoid muscle.
• 1st (Mandibular) part: Deep to condyle of mandible.
• 2nd (Pterygoid) part: Neighbourhood of lat. pterygoid muscle.
• 3rd (Pterygopalatine) part: Into pterygopalatine fossa.
17. Branches of the 1st part: 1) Deep auricular To ext. acoustic meatus.
2) Anterior tympanic artery To tympanic membrane.
3) Middle meningeal artery To dura mater & calvaria.
4) Accessory meningeal artery To cranial cavity.
5) Inf. alveolar artery To mandibular gingiva & teeth.
In first & third parts, five branches all enter foramina in bones.
From second part, none of branches go through bony foramina.
18. Branches of the 2nd part:
1) Deep temporal art (to temporal muscle)
2) Pterygoid artery(to pterygoid muscles)
3) Masseteric artery (to masseter muscle)
4) Buccal artery (to buccinator muscle)
Branches of the 3rd part:
1) Deep auricular (da),
2) Ant. tympanic (at)
3) Middle meningeal (mm)
4) Acc. middle meningeal (amm)
5) Inf. alveolar (ia), buccal (b)
6) Deep temporal (dt)
7) Post. Sup. alveolar (psa)
8) Desc. palatine (dp)
9) Infraorbital (io), sphenopalatine (sp)
19. Variation of Maxillary Artery
As superficial (a) & deep (b) A/C to
lat. pterygoid (LP) (referenced
from Putz & Pabst, 2001). ST, sup.
temporal artery; EC, ext. carotid
artery.
A/C to part of pterygopalatine (ref. from Morton &
Khan, 1991). SP, sphenopalatine artery; DP,
descending palatine artery
20. PTERYGOID VENOUS PLEXUS
• Lies around & within lat. pterygoid muscle.
• Tributaries correspond to branches of maxillary artery.
• Plexus drained by maxillary vein which begins at post. end of plexus
& unites with sup. temporal vein Form retromandibular vein.
• Maxillary vein accompanies only 1ST part of maxillary artery.
• It communicates with a) Inf. ophthalmic vein via inf. orbital fissure
b) Cavernous sinus via emissary veins & c) Facial vein through deep
facial vein.
21. Clinical notes of venous drainage
• Anastomoses of pterygoid venous plexus with facial
vein & cavernous sinus is important potential
pathway for spread of infection.
• Normally, blood from medial angle of eye, nose &
lips drains down via facial vein.
• Veins in head, including of pterygoid venous plexus,
do not have valves.
• Infections reverse the flow of blood into cavernous
sinus, results in meningeal infections.
22. Mandibular Nerve
• Represents the mandibular division (v3) of trigeminal nerve (CN V)
Passes through F. ovale & descends into ITF.
• Origin: Gasserian ganglion of CN V.
• Located in lat. wall of cavernous sinus MIXED NERVE
• Lies superficial to medial pterygoid & deep to lat. pterygoid muscle.
23. • Branches within infratemporal fossa is divided into 3 groups:
Branches from trunk:-
1) Spinous nerve
2) Medial pterygoid nerve
Anterior branches:-
1) Buccal nerve
2) Masseteric nerve
3) Deep temporal nerves
4) Lateral pterygoid nerve
Posterior branches:-
1) Auriculotemporal nerve
2) Lingual nerve
3) Inferior alveolar nerve
24. • Spinous nerve Pass via spinous foramen & enters cranium
Sensory nerve innervating the dura mater.
• Medial pterygoid nerve Innervates med. pterygoid, tensor veli
palatini & tensor tympani muscle.
• Buccal , masseteric, deep temporal, lat. pterygoid nerve Innervate
muscles with the same name except buccal nerve.
• Buccal nerve is sensory and innervates the inner surface of the cheek.
25. Auriculotemporal nerve
• Supplies sensory fibers to auricle, temporal region & TMJ.
• Conveys postsynaptic parasympa. secretomotor fibers from otic
ganglion to parotid gland.
• Frey syndrome also c/a Auriculotemporal syndrome, Baillarger
syndrome, Dupuy syndrome, Salivosudoriparous syndrome, Gustatory
sweating syndrome.
26. • Its U/L hyperhidrosis, flushing of malar region & pinna on
eating or drinking that stimulates the parotid gland to
produce saliva.
• Occurs 2-13 mnths after surgery, open trauma, or infection
of parotid gland.
• Caused by improper regeneration of sympathetic &
parasympathetic nerves subserving parotid gland & affected
anatomic areas.
• Diagnostic test:- Minor Iodine-Starch Test.
• T/t:- 1) Symptomatic T/t. 2) Inj. Botulinum A toxin.
3) Med. T/t:- Anticholinergics, Antihydrotics
4) Surg.T/t:- Excision & muscle flap interposition.
27. • Inf. alveolar nerve Mandibular foramen
Mandibular canal, forming inf. dental plexus
Sends branches to all mandibular teeth on its side.
• Terminal branch of inf. alveolar nerve is Mental
nerve Mental foramen.
29. Chorda tympani nerve
• A branch of CN VII carrying taste fibers from ant. 2/3rd of tongue.
• CT nerve Int. acoustic canal Middle ear Petrotympanic
fissure Joins lingual nerve in ITF.
• Carries secretomotor fibers for submandibular & sublingual salivary
glands.
30. Otic ganglion (Parasympathetic)
• Located in ITF inferior to F.ovale.
• Presynaptic parasympathetic fibers, derived mainly from via lesser
petrosal nerve synapse in otic ganglion.
• Postsynaptic parasympathetic fibers, secretory to parotid gland, pass
from otic ganglion to this gland through the auriculotemporal nerve.
31. COMMUNICATIONS
The infratemporal fossa communicates with………..
1) Temporal fossa Via space below zygomatic arch.
1) The orbit Via inferior orbital fissure.
2) The middle cranial fossa Via foramen spinosum, ovale, lacerum
3) The pterygopalatine fossa Via pterygomaxillary fissure
33. • The post. Sup. alveolar artery runs with nerve(s), but
is no more likely to be damaged than arteries in
other neurovascular bundles.
• The pterygoid venous plexus should not be damaged
unless the needle is inserted too deeply or laterally.
• If a positive (venous) aspiration is observed during
this procedure, withdrawal will disengage the needle
with minimal bleeding resulting—injecting into the
friable plexus causes disruption which can lead to
haematoma formation and postoperative trismus.
34. APPROACHES TO INFRATEMPORAL FOSSA
• There are several surgical approaches to the ITF.
• They are grouped as……
A) Anterior = Transoral, Transantral, Transpalatal,
Transmaxillary, Exteded transmaxillary, Maxillary
swing, Transfacial.
B) Inferior = Transmandibular, Transcervical.
C) Lateral = Transzygomatic, Lateral infratemporal.
D) Other = Fisch types A, B, C, and D, Facial
translocation, Transcranial, Combined
35. TRANSORAL APPROACH
• Sup. gingivolabial sulcus posteriorly is close to
tuberosity of the maxilla & provides access to lower
part of the ITF.
• Does not provide enough exposure for removal of
tumours,
• View obstructed by fatty tissue
& there is no vascular control.
• Access for biopsy purposes
if lesion low in ITF.
• Benign tumour may be
removed via this.
36. TRANSANTRAL APPROACH
• Antral cavity entered via sublabial incision, from canine to 1st molar.
• Mucoperiosteal flap elevated till infraorbital foramen To preserve
infraorbital vessels.
• Window on anterolateral wall of antrum For exposure of complete
post. wall of maxillary sinus.
• Roots of canine & premolars are preserved.
• Antral mucosa of post. wall incised at its junction with med, lat & sup
walls mucoperiosteal flap reflected down
37. 1.infraorbital nerve;
2.posterior wall maxilla
3.maxillary artery
4.lat. pterygoid plate
5.lat pterygoid muscle
6.lat. pterygoid muscle
7.nasal cavity;
8.eyeball & optic nerve.
• At the end, bony posterior wall & mucoperiosteal flap are replaced.
• It is not suitable for tumour excision by itself, but may be combined
with other approaches.
• Used for the purpose of obtaining a biopsy.
38. TRANSPALATAL APPROACH
• Kornfehl et al. described transpharyngeal approach via palate.
• Nasopharynx reached via ‘S'-shaped incision vertically on soft
palate & on to ant. pharyngeal arch towards side of lesion.
• Mucosa of lat. nasopharynx incised vertically, sup. constrictor
muscle of pharynx split to enter medial part of ITF.
39. Limitations:-
• Not a safe approach for tumour excision.
• Internal carotid artery is close to pharyngeal wall &
inot possible to obtain any control on vessel.
• Limited exposure of tumor.
40. TRANSMAXILLARY APPROACH
• By Langenbeek in 1859 Osteoplastic technique for tumours of
pterygopalatine fossa.
• An incision placed in buccal sulcus above attached gingivae bwt
maxillary second premolars.
• Incision placed half cm. above apices of tooth to ensure viability of
teeth.
• Mucoperiosteal flap raised. Nasal septum separated from ant. nasal
spine & maxillary crest. Facial soft tissue retracted cranially.
41. • Osteotomy incision from one maxillary tuberosity to other.
• The incision passes just under zygomatic buttress & divides ant
nasal aperture.
• Medial maxilla wall osteotomy done via inf. meatus to palatine
canal. At this stage the palate & inf. portion of maxilla remain
attached by the pterygomaxillary suture, thin post. wall of
maxillary sinus & bone forming canal of palatine vessels.
• Using a curved osteotome, maxilla separated & disimpacted
downwards.
• The buttress of bone anterolaterally & at piriform nasal aperture
are preserved so that they can be approximated at closure.
42. EXTENDED MAXILLOTOMY APPROACH
• Transantral approach with extended sublabial incision, from
midline to maxillary tuberosity & carried down to
periosteum.
• Post. wall of maxillary sinus widely excised Access to
pterygomaxillary portion of the tumour.
43. • The medial wall of the maxillary sinus and the
nasopharynx is removed.
• Lateral extension of tumour exposed by removing
the lateral wall of antrum.
• Combined with a transpalatal approach.
• Krause & Baker 1ST used for surgical treatment of
nasopharyngeal angiofibroma.
44. TRANSMANDIBULAR APPROACH
• 1st done by Conley & Barbosa. ITF communicates inf. with neck.
• If mandible lat. retracted & med. pterygoid muscle detached from its
mandibular attachment, ITF reached.
• Good control of vessels & nerves & en bloc resection of nasopharynx,
post. maxilla, ITF , mandibular ramus & parotid gland.
• Modified by Attia et al To obtain wide exposure without sacrifice
of mandibular function & sensory supply of face & oral cavity.
45. • Mandibular osteotomies To spare inf. alveolar nerve & vessels &
positioned under intercondylar notch, above the opening of
mandibular canal & medial to mental foramen.
• Detachment of med. & lat. pterygoid muscles & sphenomandibular
ligament allows mandibular segment to reflect sup.
• Provides direct access to ITF Intermaxillary fixation performed.
• Preserves function, exposure is good & cosmetically acceptable.
46. MAXILLARY SWING
• Incision – Weber Ferguson incision without gingivolabial component
• B/L tarsorraphy should be performed
• Inverted “U” shaped incision marked on hard palate
• After deepening facial incision, lacrimal sac skeletonized & sectioned
at its lower end.
• Infra orbital nerve sectioned as it comes out of infraorbital foramen.
• Periosteum of inf. orbital wall elevated.
47. • Osteotomy on frontal process of maxilla & maxillo zygomatic suture.
• Maxillo-ethmoidal junction separated.
• Hard palate mucoperiosteum elevated based on C/L greater palatine
vessels & I/L greater palatine vessels cauterized & sectioned.
• Straight osteotome placed bwt arms of v shaped notch on ant. nasal
spine & hammered To separate maxilla down middle.
• Whole maxilla with its attached cheek tissue swung like a door
laterally exposing whole of nasopharynx.
48. • Mass in nasopharynx can now be removed under
direct vision.
• Maxilla can be repositioned after surgery and
secured in position by using miniplate & screws.
49. Transzygomatic approach
1) Preauricular incision & ant. displacement of the flap.
2) Section of the zygomatic arch.
3) Masseter & zygomatic arch displaced inferiorly.
4) Coronoid process sectioned, displaced upward with temporal muscle.
1. masseter muscle;
2.deep temporal fascia;
3.coronoid process;
4.maxillary artery;
5.Lateral pterygoid
muscle (upper head
50. Fisch(1984) infratemporal fossa approach
• Type A= Access to temporal bone right up to petrous
apex Glomus jugulare tumours
• Type B= Cross petrous apex to
basiocciput & clivus Chordoma,
petrous apex cholesteatoma.
• Type C= Upto nasopharynx,
parasellar , retromaxillary &
paratubal regions.
• Type D= Upto lat. orbital wall,
infratemporal & PPF.
51. Le Fort I osteotomy approach
A) Proposed osteotomy site just
above the level of nasal floor.
B&C) Incisions & bone cuts along
anterolateral maxillary surface.
D) Separation of the nasal septum
with an osteotome.
E) Separation of maxilla from the
pterygoid plate with curved osteotome
F) Down-fracture of maxilla to allow
access to maxillary sinuses,
nasopharynx, and adjacent skull base.
52. COMBINATION OF APPROACHES
• Radical excision of tumours & relatively limited access
obtained by any single approach have made combined
approaches necessary.
• It offers the patients the maximum benefit of the technical
‘know-how’ of the surgical team & the best opportunity for
surgical excision.
• They are as follow………………..
53. • Combined infratemporal & PCF approach
• Subtemporal preauricular infratemporal fossa
approach
• Mid facial degloving approach.
• In 1969, Terez et al Craniofacial approach for
tumors invading pterygoid fossa.
• In 1976, House & Hitselberger Transcochlear
approach for tumors medial to the IAC or from the
clivus.
54. References
• Grays anatomy, Last anatomy.
• Atlas of human body- Netters.
• B.D. Chaurasia- Text book of anatomy.
• John d Langdon- Surgical anatomy of infratemporal fossa.
• Jatin shah- Head and Neck cancer.
• Scott Brown 6th edition.
• Cumming’s 6th edition.
• Original study ‘Microanatomy & Surgical Approaches to
the Infratemporal Fossa: An Anaglyphic Three-
Dimensional Stereoscopic Printing Study’- Gustavo
Rassier Isolan et al.
• Various journals.