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Infratemporal fossa approaches

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TYPES OF APROACHES ,STEPS OF SURGERY

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Infratemporal fossa approaches

  1. 1.  Tumors arising from or extending into the ITF from neighboring regions provide a challenge as to how best to approach the area  Tumors within the ITF are rare, making up less than 1% of head and neck tumors  The ITF approaches are categorized as anterior (transfacial, transmaxillary, transoral, and transpalatal),  lateral (transzygomatic and lateral infratemporal), or  inferior (transmandibular and transcervical)
  2. 2.  The pioneers of the ITF were Conley and Barbosa  Barbosa indicated the ITF approach for advanced tumors into the maxillary sinus. 1960  n 1969, Terez et al used a craniofacial approach for tumors invading the pterygoid fossa but residual tumor could not be avoided.  In 1976, House and Hitselberger described a transcochlear approach for tumors that originated medially to the internal auditory canal or from the clivus.  In 1977, Fisch and coworkers reported the posterolateral ITF approach
  3. 3.  The postauricular infratemporal fossa approaches as described by Fisch  He has divided these techniques into three basic approaches  Type A  Type B  Type C
  4. 4.  indicated for meningiomas, cholesteatoma involving the internal carotid artery and petrous apex, for intratemporal neuromas of cranial nerves IX-XII and for lesions reaching the skull base from below (Carotid artery aneurysms, glomus vagale tumors etc).  Incisions and Skin Flaps  Anteriorly based periosteal flap elevation.  the tertiary branches of the facial nerve are identified and protected with periosteal flap.
  5. 5.  Closure of the External Auditory Canal  The cartilaginous canal skin is everted and sutured with absorbable sutures and reinforced medially with the periosteal flap elevated off the mastoid cortex
  6. 6.  Removal of External Auditory Canal Wall Skin and Tympanic Membrane  tympanic annulus is elevated, the incudostapedial joint is separated, the tensor tympani tendon is cut, and the neck of the malleus is nipped
  7. 7.  Cervical Dissection  Major structures, including the common, external, and internal carotid arteries, the internal jugular vein, and cranial nerves IX to XII, are identified  Division of the posterior belly of the digastric  Ligation of the occipital artery and ascending pharyngeal
  8. 8.  Extratemporal Facial Nerve Dissection  located deep to the midpoint of a line between the tragal pointer cartilage and the mastoid tip  by cutting overlying the parotid gland and freeing it from the underlying parotid tissues  required for anterior transposition in the type A approach
  9. 9.  Radical Mastoidectomy  removes the air cell tracts lateral and adjacent to the otic capsule  The stapes suprastructure is removed to prevent inner ear trauma  The eustachian tube is obliterated with bone wax
  10. 10.  FACIAL NERVE TRANSPOSITION  from the geniculate ganglion distal to the stylomastoid foramen  At the stylomastoid foramen, the facial nerve is densely adherent to the surrounding fibrous tissue  A new bony canal is drilled in the anterior wall of the epitympanum to receive the nerve  all medial attachments to the nerve should be sharply dissected to prevent stretch injury
  11. 11.  OCCLUSION OF THE SIGMOID SINUS  Bone is removed over the posterior fossa dura anterior and posterior to the sigmoid sinus to allow ligation  Dural vessels are coagulated  A small CSF leak may occur and is easily controlled with a sutured muscle plug
  12. 12.  EXPOSURE OF JUGULAR BULB AND INTERNAL CAROTID ARTERY  process is fractured and removed with the attached muscles.  The parotid gland is dissected from the tympanic bone, and a modified self-retaining laminectomy retractor is placed behind the ramus of the mandible to effect anterior subluxation  removal of bone over the carotid artery and beneath the otic capsule, the jugular fossa is exposed for tumor removal
  13. 13.  TUMOR REMOVAL  The jugular vein is ligated to prevent tumor and air embolism. Dissection begins by freeing the internal carotid artery and rotating the tumor posteriorly  The lateral wall of the sigmoid sinus is removed along with intraluminal tumor  The inferior margin of the tumor is elevated, and the extracranial tumor is removed  Profuse bleeding may occur from the entrances of the inferior petrosal sinus into the jugular bulb.
  14. 14.  the posterior fossa dura is opened, and the intracranial portion of the tumor is excised
  15. 15.  CLOSURE OF WOUND  Fascia lata provides the best material for reconstruction,  lyophilized dura can be used to seal the defect.  Abdominal fat is used to obliterate the dead space of the temporal bone, and the temporalis muscle is rotated inferiorly for reinforcement of the wound  The skin is closed routinely, and a bulky pressure dressing is applied for a minimum of 5 days to prevent leakage of CSF
  16. 16.  This provides access to the clivus and petrous apex and is applicable to glomus tumors involving the horizontal petrous carotid artery, clival chordoma, and congenital cholesteatoma of the petrous apex.  transposition of the nerve usually is not required  Reflection of the temporalis muscle still attached to the coronoid process and the zygoma allows the retractor to expose the superior infratemporal fossa  exposure in the type B approach are defined by the middle cranial fossa floor, mandibular condyle, and reflected temporalis muscle
  17. 17.  The middle meningeal artery and V3 branch of the trigeminal nerve require bipolar cauterization and transection  The carotid artery may be uncovered from its vertical segment to its anterior limit at the foramen lacerum after separation from the soft tissues around the eustachian tube  Elevation of the carotid artery permits additional access to the petrous apex and clivus.
  18. 18.  Transcochlear approach to the petrous apex.  A, Posterior translocation of the facial nerve. GSPN, greater superficial petrosal nerve.  B, Subtotal petrosectomy with removal of the otitic capsule  Tumors of the clivus, such as chordomas, up to the parasellar area may be removed through the type B approach
  19. 19.  Type C Approach  posterolateral access to the rostral clivus, cavernous sinus, sphenoid sinus, peritubal space, pterygopalatine fossa, and nasopharynx  used primarily for extensive juvenile nasopharyngeal angiofibroma and radiation failure squamous cell carcinoma.  The base of the pterygoid process is removed to approach the sphenoid sinus and cavernous sinus
  20. 20.  approach to nasopharyngeal exposure.  Removal of pterygoid process and lateral wall of the nasopharynx exposing the opposite torus tubarius.
  21. 21.  Sen and Sekhar and colleagues  can expose the upper cervical segment (without facial nerve transposition) and the intrapetrous segment of the internal carotid artery  permits access to the petrous apex, clivus, and superior infratemporal fossa and may be extended to include the nasopharynx, parasellar area, pterygopalatine fossa, and anterior infratemporal fossa
  22. 22.  Advantage of preauricular approach preserving hearing  Facial .n need not to b rerouting  Disadvantage inability to access tumours extending temporal bone and posterior fossa  The Fisch C and D approaches both provide excellent access to structures within the ITF, as well as the basisphenoid, clivus, and entire intratemporal course of the internal carotid artery.  adverse outcomes include dysfunction of the facial nerve, conductive hearing loss, and dental malocclusion.
  23. 23.  large middle meatal antrostomy and complete sphenoethmoidecto my  endoscopic medial maxillectomy was performed.  The inferior turbinate was crushed and cut with a scissors
  24. 24.  A mucosal incision was made from the cut inferior turbinate onto the floor of the nasal cavity and was extended posteriorly to the back of the inferior turbinate.
  25. 25.  the lower half of the middle turbinate was removed to achieve full visualization of the nasal component of the tumour
  26. 26.  This allows the second surgeon to keep the operating field clear of blood, even if there is profuse bleeding present, or to place traction on the tumor, allowing the primary surgeon to dissect around the tumor, freeing it from its attachments in areas such as the infraorbital fissure and the lateral extensions into the ITF
  27. 27.  Lack of formal control of the internal carotid artery or internal jugular vein.  this technique is not suitable for tumors with invasion or encasement of these structures.  In addition, if there is tumor extension through the dura into the middle cranial fossa or laterally into the masseteric space and inferiorly into the parapharyngeal space,
  28. 28.  Several anterior approaches to the infratemporal fossa  Transoral, Transantral, Transpalatal, Transmaxillary, Extended maxillotomy, Maxillary swing, Transmandibular, Transzygomatic , Facial translocation, Transcranial, Combined  These approaches allow good access to the anteromedial ITF, nasopharynx , basisphenoid, and middle cranial fossa.  may result in facial deformity, facial and infraorbital nerve dysfunction, and lacrimal dysfunction
  29. 29.  The superior gingivolabial sulcus posteriorly is close to the tuberosity of the maxilla and provides access to the lower part of the infratemporal fossa.  An approach through this area does not provide enough exposure for removal of tumours,  the view is obstructed by fatty tissue and there is no vascular control.  However, the recess provides access for biopsy purposes especially if the lesion is located low in the infratemporal fossa.  Occasionally a benign tumour may be removed through this approach.
  30. 30.  The antral cavity is entered through a sublabial incision, extending from the level of the canine to the first molar tooth and the mucoperiosteal flap is elevated until the infraorbital foramen, so as to preserve the infraorbital vessels and  A window is made into the anterolateral wall of the antrum large enough to provide good exposure of the complete posterior wall of the maxillary sinus.  The roots of the canine and premolars are preserved.  The antral mucosa on the posterior wall is incised at its junction with the medial, lateral and superior walls, and the mucoperiosteal flap is reflected down.
  31. 31.  The periosteum on the outer surface of the posterior wall is incised along its medial, lateral and superior border and reflected downwards.  At the end of the procedure the bony posterior wall and the mucoperiosteal flap are replaced.  This approach is not suitable for tumour excision by itself, but may be combined with other approaches. It is invariably employed for the purpose of obtaining a biopsy.
  32. 32.  The authors Kornfehl et al. have basically described a transpharyngeal approach via the palate.  The nasopharynx is reached via an ‘S'-shaped incision running vertically on the soft palate and on to the anterior pharyngeal arch towards the side of the lesion.  The mucosa of the lateral wall of the nasopharynx is incised vertically, the superior constrictor muscle of the pharynx is split to enter the most medial part of the infratemporal fossa.  Kornfehl et al. employed this approach to extirpate a cavernous haemangioma close to the lateral pterygoid muscle which had been shown not to have any feeding vessels.  This is not a safe approach for tumour excision.  The internal carotid artery is close to the pharyngeal wall and it is not possible to obtain any control on the vessel.
  33. 33.  It was originally described by Langenbeek in 1859 as an osteoplastic technique for tumours of the pterygopalatine fossa.  An incision is placed in the buccal sulcus above the attached gingivae between the maxillary second premolars.  the incision is placed half a centimetre above the apices of tooth to ensure the viability of the teeth.  A mucoperiosteal flap is raised. The nasal septum is separated from the anterior nasal spine and the maxillary crest and the facial soft tissue are retracted cranially.
  34. 34.  An osteotomy incision is placed, using an electric burr from one maxillary tuberosity to the other.  The incision passes just under the zygomatic buttress and divides the anterior nasal aperture.  An osteotomy of the medial wall of the maxilla is performed through the inferior meatus to the palatine canal. At this stage the palate and the inferior portion of the maxilla remain attached by the pterygomaxillary suture, the thin posterior wall of the maxillary sinus and the bone forming the canal of the palatine vessels.  Using a curved osteotome the maxilla is separated and disimpacted downwards.  The buttress of bone anterolaterally and at the piriform nasal aperture are preserved so that they can be approximated at closure.
  35. 35.  This is essentially a transantral approach with an extended sublabial incision taken from the midline to the maxillary tuberosity and carried down to the periosteum.  The posterior wall of the maxillary sinus is widely excised allowing access to the pterygomaxillary portion of the tumour.  The medial wall of the maxillary sinus and the nasopharynx is removed. Lateral extension of the tumour can be exposed by removing the lateral wall of the antrum.  It can also be combined with a transpalatal approach. It was described by Krause and Baker who used it mainly for surgical treatment of nasopharyngeal angiofibroma.
  36. 36.  The concept of approaching the retromaxillary area through a mandibulotomy is not new and has been advocated by Conley and Barbosa. The infratemporal fossa communicates inferiorly with the neck.  If the mandible is laterally retracted and the medial pterygoid muscle is detached from its mandibular attachment the infratemporal space can be reached.  This approach provides good control of the vessels and nerves and en bloc resection of nasopharynx, posterior maxilla, infratemporal fossa structures, mandibular ramus and parotid gland can be performed.  The procedure has been modified by Attia et al. to obtain wide field exposure without sacrifice of either mandibular function or the sensory supply of the face and oral cavity.
  37. 37.  The mandibular osteotomies are arranged to spare the inferior alveolar nerve and vessels and are positioned under the intercondylar notch above the opening of the mandibular canal and just medial to the mental foramen.  Detachment of the medial and lateral pterygoid muscles and the sphenomandibular ligament allows the mandibular segment to be reflected superiorly .  This provides direct access to the infratemporal fossa; osteosynthesis of the mandible and intermaxillary fixation is performed. The procedure preserves function, exposure is good and is cosmetically acceptable.
  38. 38.  Incision – Weber Ferguson incision without gingivolabial component  Bilateral tarsorraphy should be performed  Inverted “U” shaped incision is marked out on the hard palate  After deepening the facial incision the lacrimal sac should be skeletonized and sectioned at its lower end.  Infra orbital nerve should be sectioned as it comes out of infraorbital foramen.  Periosteum of the inferior orbital wall should be elevated.  Osteotomies should be performed on the frontal process of maxilla and at the maxillo zygomatic suture.  The maxillo ethmoidal junction should be separated using a straight osteotome.
  39. 39.  The mucoperiosteum over the hard palate should be elevated based on the contralateral greater palatine vessels. The ipsilateral greater palatine vessels were cauterized and sectioned.  A straight osteotome should be placed between the arms of a v shaped notch located on the anterior nasal spine and hammered in order to separate the maxilla down the middle.  Now the whole maxilla with its attached cheek tissue can be swung like a door laterally exposing the whole of nasopharynx.  Mass in the naso pharynx can now be removed under direct vision.  Maxilla can be repositioned after surgery and secured in position by using miniplate and screws.
  40. 40.  Radical excision of tumours and the 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 and the best opportunity for surgical excision.

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