Download Management of Infratemporal Fossa Lesions

Essam Saleh , MD
Prof of Otolaryngology, Alex Univ.
Forgotten Anatomy
Anatomy
 Anterior: post.wall
maxilla.
 Posterior: Styloid,
Carotid sheath, Condyle
 Medial: Lat pterygoid
plate & sup constrictor.
 Lateral: Ramus of
Mandible
 Superior: Sphenoid
Contents
Medial & Lateral Pterygoid muscles
Contents
Maxillary artery
Mandibular nerve
Communications
 With the pterygopalatine
fossa through pterygomaxillary fissure
 With the orbit through
inferior orbital fissure.
 With the middle cranial
fossa through F.O, F.R
 With the neck &
parapharyngeal space
behind post.border of
medial pterygoid
Pathologies
1ry:
Schwannoma, Rhabdomyosarcoma,
Fibrosarcoma, Chondrosarcoma,
Hemangiopericytoma, Lymphoma.
2ry extensions from adjacent areas:
Adenocarcinoma, Nasopharyngeal
angiofibroma, Nasopharyngeal Carcinoma,
Meningioma.
Pathologies
Sarcoma
V Neuroma
Rhabdomyosarcoma
Pathologies
Angiofibroma
Meningioma
Adenoidcystic
carcinoma
Problems
 Deep Location
 Difficult Access
 Extensions to more than one anatomical
compartment
 Relations to nearby vital structures:
 ICA
 Cavernous Sinus
 Orbit
Extensions
Problems
 Minimal symptoms  late diagnosis
 Difficult to attain preoperative
radiological diagnosis.
 Difficult to have preoperative biopsy.
Management
Anterior Approaches
 Transpalatal
 Lateral rhinotomy
 Facial degloving.
Anterolateral Approaches
 Extended maxillotomy, maxillectomy, osteoplastic
maxillotomy.
 Maxillary swing.
 Mandibular swing.
 Facial translocation.
Lateral Approaches
 Infratemproal fossa type C.
 Preauricular-infratemporal –subtemporal.
 Preauricular orbitozygomatic approach.
 Infratemporal fossa type D.
Anterior Approaches
 Valid only for limited tumor extension into
the infratemporal fossa.
 Minimal control of the vital structures
ICA
Cavernous sinus.
 Suitable for primary paranasal sinuses,
pterygopalatine fossa & midline clival
lesions with minimal lateral extension.
Anterolateral Approaches
 Extended maxillotomy, maxillectomy,
osteoplastic maxillotomy.
 Maxillary swing.
 Mandibular swing.
 Facial translocation.
Mandibular Swing
Facial Translocation
Extended maxillotomy
Anterolateral Approaches
Advantages:
 Direct access to nasopharynx, pterygopalatine
fossa, PNS and clivus.
Disadvantages
 Very extensive.
 High risk of osteoradionecrosis, oroantral fistula,
trismus.
 Need for tracheostomy.
 Transgressing contaminated field.
Lateral Approaches
 The preferred routes in our hospital.
 Concept: direct lateral access to the
infratemporal fossa through:
 Temporalis displacement
 Transzygomatic.
 Mandibular retraction and glenoid cavity
drilling.
Approaches
 Infratemporal fossa type C
 Preaucricular infratemporal
Infratemporal fossa
Infratemporal fossa C
Infratemporal fossa C
IFC-Clinical
Preauricular IF approach
Extensions to basic approach
 Transcervical
extension
 Craniotomy ±
transpetrous drilling
 Orbitozygomatic
osteotomy
Transcervical extension
Petrous apex drilling
Orbitozygomatic osteotomy
Preauricular IF Clinical
Trigeminal Neuroma
Preauricular IF Clinical
Recurrent NP Angiofibroma
Preauricular IF Clinical
Rhabdomyosaroma
Orbitozygomatic Approach
Orbitozygomatic Approach
O
T
Lateral Approaches
Advantages
 Excellent exposure of the infratemporal
fossa, pterygopalatine fossa, nasopharynx,
sphenoid sinus, posterolateral orbit and
inferolateral cavernous sinus.
 Excellent control of ICA.
 Can be combined with different approaches
transtemporal and transnasal approaches.
 No facial exposure.
Lateral Approaches
Disadvantages
 Sacrifice of the mandibular nerve.
 Significant CHL in the IF-C approach.
 Poor control of the other PNS and nasal
cavity.
 Lengthy procedure
Infratemporal Fossa Tumors
 11 cases (10 males & 1 Female)
 Age : 9-65 yrs (mean 32.6 yrs).
 Recurrent NP angiofibroma
 NP Carcinoma
 Meningioma
 Recurrent Chondrosarcoma
 Trigeminal Neuroma
 Rhabdomyosarcoma
4
2
2
1
1
1
]
-->1ry
Infratemporal Fossa Tumors
Extension
Pterygopalatine Fossa
Cavernous sinus
ICA
Orbit
Sphenoid sinus
Clivus (erosion)
PNS
Petrous apex
Parapharyngeal space
No(%)
7 (64%)
6 (55%)
5 (45%)
6 (55%)
5 (45%)
4 (36%)
4 (36%)
2 (18%)
2 (18%)
Approaches
 IFC
 Preauricular IF
 Preauricular IF + Orbitozygomatic
 Preauricular IF + Transcx
 Preauricular IF + Transcx + Transpalatal
 Preauricular IF + Transnasal
 Preauricular IF + MF-Transpetrous
 Transcochlear + Transtent + IF
2
2
2
1
1
1
1
1
Infratemporal Fossa Tumors
 Total removal 9 cases (one staged)
 Recurrence (one case)
 Post-op Radio ± chemotherapy 2 cases
 Frontal VII paresis 3 cases.
 No Mortality
Conclusions
 Infratemporal fossa tumors are difficult to diagnose
and manage.
 Anterolateral approaches afford a direct route with
little morbidity and can be combined with different
other procedures to achieve a safe and total
removal.
 Adequate knowledge of the anatomy is mandatory
before embarking on this difficult surgery.
 Recurrent irradiated nasopharyngeal tumors can be
managed surgically with excellent results for early
cases.