Endoscopic Study for the Pterygopalatine Fossa Anatomy: Via the Middle Nasal Meatus-Sphenopalatine Foramen Approach

Department of Otorhinolaryngology Head and Neck Surgery, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
The Journal of craniofacial surgery (Impact Factor: 0.68). 06/2009; 20(3):944-7. DOI: 10.1097/SCS.0b013e3181a2d9c8
Source: PubMed


The purposes of this study were to locate the constant anatomic landmarks, which are very important and helpful for endoscopic surgery and not well described for the pterygopalatine fossa (PPF) surgery via the middle nasal meatus-sphenopalatine foramen approach to establish a safe surgical mode.
Eight cases of adult skull specimens were selected for the simulated surgery. The Messerklinger surgical approach was used under the endoscope. The uncinate process was removed successively, and the anterior ethmoid sinus and posterior ethmoid sinus were opened. The opening of the maxillary sinus was identified and was expanded forward and backward. The ethmoidal crest was found and was used as an anatomic landmark to find the sphenopalatine foramen. The sphenopalatine artery was protected and was used as a guide to enter the PPF region. The sphenopalatine artery was followed conversely to anatomize the blood vessels and nerves in the PPF.
It was found that our surgical procedure provides a clear view of the constant anatomic landmark including ethmoidal crest and sphenopalatine foramen. By retrograde dissection, following the sphenopalatine artery, which runs out of the sphenopalatine foramen behind the ethmoidal crest, the internal maxillary artery (IMA) and the branches of the IMA in the PPF were exposed. Posterior to the sphenopalatine artery, the typical Y-shaped structure with the pterygopalatine ganglion as the center was visible when the IMA and its branches were moved downward and outward. The Y structure, which is consisted of the pterygopalatine ganglion, branches of the internal maxillary nerve, vidian nerve, and descending palatine nerve, served as the other anatomic landmark. By following the Y structure, it was easy to locate the pterygoid canal, foramen rotundum, and the infraorbital nerve, and the integrity of the nerve structure could be protected.
Endoscopic PPF surgery via the middle nasal meatus-sphenopalatine foramen approach is safe, and the ethmoidal crest, sphenopalatine foramen, and Y structure with the pterygopalatine ganglion in the center are important anatomic landmarks that can be referred to during the surgery.

26 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: The sphenoid bone seems to resemble a biblical angel. The angel had six wings, and used two to cover the eyes (lesser wings with optic canal representing the eyes), two to fly (greater wings), and two (broad lateral pterygoid plates) to cover the feet (medial pterygoid plates with hamulus). This illustration may help surgical trainees to conceptualise and understand the clinical implications of this wide-ranging bone.
    British Journal of Oral and Maxillofacial Surgery 07/2010; 48(5):e27-8. DOI:10.1016/j.bjoms.2010.04.006 · 1.08 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Vidian neurectomy has been used to manage intractable vasomotor rhinitis for decades. After the introduction of endoscopic sinus surgery in the 1980s, transnasal endoscopic vidian neurectomy (EVN) was subsequently reported. The most common problem in performing EVN was excessive bleeding from the pterygopalatine fossa. The complexity and vascularity of the pterygopalatine fossa can cause bloody surgical fields and prevent complete neurectomy. In response to this surgical problem, a procedure was developed to use powered instrumentation and coblation during EVN. There were eight cases of EVNs (16 neurectomies) assisted by power instrumentation and coblation from December 2011 to May 2012. The average blood loss of these cases was 37.5 mL (range, 25-50 mL). The average surgical time of each neurectomy was 27.4 minutes (range, 20-35 minutes). No complications occurred in any of the eight cases. Very limited bleeding and less thermal damage were noted while achieving a complete neurectomy.
    Journal of the Chinese Medical Association 06/2013; 76(9). DOI:10.1016/j.jcma.2013.05.012 · 0.85 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives Infraorbital nerve (ION) decompression, excision to remove intrinsic tumors, and resection with oncological margins in malignancies with perineural invasion or dissemination are usually accomplished with an open approach. The objective is to describe the surgical anatomy, technique, and indications of the endonasal endoscopic approach (EEA) to the ION with nasolacrimal duct preservation. DesignEleven sides of formalin-fixed specimens were dissected. An anterior maxillary antrostomy was performed. The length of the ION prominence within the sinus and anatomic features of the covering bone were studied. A 45-degree endoscope visualized the infraorbital prominence endonasally. An angled dissector and dural blade allowed for dissection and resection of the ION ipsilaterally and contralaterally. ResultsThe bone features of the ION prominence allowed for ipsilateral dissection in 10 out of 11 sides. In one case with the ION surrounded by thick cortical bone, the dissection could only be started by drilling contralaterally. The 45-degree endoscope visualized 92.2% and 100% of the length of the nerve using the ipsilateral and contralateral nostrils, respectively. Ipsilaterally, 83% of its length was resected, and 96.3% was resected contralaterally. Conclusion The ION can be approached using an ipsilateral EEA with nasolacrimal duct preservation in most cases. The contralateral approach provides a wider angle to access the ION. This technique is primarily indicated in cases where the EEA can be used for tumor resection and oncological margins within the ION.
    Journal of Neurological Surgery, Part B: Skull Base 12/2013; 74(6):393-8. DOI:10.1055/s-0033-1347372 · 0.72 Impact Factor