Zygomatic-transmandibular approach for giant tumors of the infratemporal fossa and parapharyngeal space.
ABSTRACT The surgical anatomy of the infratemporal fossa and parapharyngeal space is often not properly understood by neurosurgeons, because these areas are more related to other medical disciplines. This article provides a detailed description of the infratemporal fossa and parapharyngeal space anatomy in cadaveric specimens and offers a neurosurgical perspective on a surgical approach that allows wide exposure and complete resection of giant tumors in this location.
Ten cadaveric specimens were prepared for anatomic study. Dissections were performed to emphasize the relationship between bone, muscles, and neurovascular structures and to simultaneously expose the middle cranial fossa, the infratemporal fossa, and the parapharyngeal space. Ten patients with giant lesions in these areas (with maximum tumor diameter >8 cm) were treated via this approach.
The main obstacles to approaching the infratemporal fossa and the parapharyngeal space are the zygomatic arch, the parotid gland, the facial nerve, and the ascending ramus of the mandible. Thus, by combining a pterional-zygomatic craniotomy with transmandibular access, working up and down the parotid gland, the exposure is wider and safer. Among the 10 patients treated, tumors were totally resected in 7, subtotally resected in 2, and partially resected in 1. Morbidity was unremarkable, and, in 8 patients, clinical status improved dramatically.
The zygomatic-transmandibular approach allows resection of giant lesions in the middle cranial base, when they are invading the infratemporal fossa and parapharyngeal space, with a low morbidity rate.
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ABSTRACT: Trigeminal schwannomas extending into the deep parapharyngeal space are relatively rare, and a surgical approach to such tumors has not been well established. We report four cases in which the tumors were completely removed by using a combination of three approaches. Four patients with trigeminal schwannomas extending into the extracranial space were surgically treated using a combination of the transcervical approach, anterolateral retromaxillar pathway via gingivobuccal sulcus, and epi and interdural middle fossa approach. The maximum diameters of the tumors ranged from 4 to 7 cm. Three tumors extended beyond the lower end of the maxillary sinus. All tumors were completely excised. The Karnofsky performance scales after surgery were more than 90% in all patients. Although the tumors extending to the deep parapharyngeal space are difficult to completely remove via a single approach, a combined approach is useful in these huge extracranial extensions.Acta Neurochirurgica 03/2009; 151(4):335-40. · 1.55 Impact Factor
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ABSTRACT: The surgical strategy for tumors located in or extending from the intracranial space to the infratemporal fossa was analyzed in 12 cases with various pathologies. A case of mandibular nerve schwannoma, which extended 1 cm below the external orifice of the foramen ovale, was completely removed via the epidural subtemporal approach without zygomatic osteotomy with partial removal of the middle cranial base. The inferior margin of infratemporal tumor could be accessed via the transcranial route with zygomatic or orbitozygomatic osteotomy without complications including facial nerve injury in nine cases, and the lowest level of the infratemporal tumors was approximately 4.5 cm below the outer surface of the middle cranial base. In five of these 9 cases (2 schwannomas, 1 myxoma, 1 chondrosarcoma, and 1 malignant peripheral nerve sheath tumor), the tumors were localized in the infratemporal fossa, and in the other 4 cases (2 meningiomas, 1 glioblastoma, and 1 ameloblastoma), the tumors extended to both the intracranial space and the infratemporal fossa. In two cases (recurrent jugular schwannoma and mandibular osteosarcoma), a combined transcranial and transcervical approach (mandibular swing approach) was essential, because the resection line of the lower margin was too far from the middle cranial base. These results indicate that the transcranial approach, with or without zygomatic or orbitozygomatic osteotomy (zygomatic infratemporal fossa approach), is safe and effective for removal of some infratemporal tumors, and that a combined transcranial and transcervical approach is useful for removing infratemporal tumors with extensive downward extension.Neurologia medico-chirurgica 12/2009; 49(12):580-6. · 0.49 Impact Factor
- Neurologia Medico-chirurgica - NEUROL MED-CHIR. 01/2009; 49(12):580-586.