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Objectives/hypothesis: Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications., Study Design: Anatomical study and retrospective clinical cohort study., Methods: Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies., Results: The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 ± 0.40 cm/9.3 ± 0.39 cm following standard harvest, 2.52 ± 0.61 cm/9.75±1.06 cm following SPA foramen release, 4.93 ± 0.89 cm/12.16 ± 0.54 cm following full IMAX dissection, and 6.18 ± 0.68 cm/13.41 ± 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients., Conclusions: Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting., Level of Evidence: 4 Laryngoscope, 130:18-24, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To propose a clinically applicable anatomic classification system describing three progressive endoscopic endonasal approaches (EEAs) to the infratemporal fossa (ITF) and their potential sequelae. Overall feasibility and outcomes of these approaches are presented through a consecutive case series., Study Design: Description of classification system for EEAs to the ITF and case series., Methods: A classification system of EEAs to ITF tumors was created based on the senior author's clinical experience and cadaveric dissection. A retrospective chart review of 21 child and adult patients with primary ITF tumors treated by these approaches from 2008 to 2012 at a tertiary-care academic medical center was conducted., Results: Three progressive EEAs to ITF tumors were defined: 1) a transpterygopalatine fossa approach, 2) a transmedial pterygoid plate approach, and 3) a translateral pterygoid plate approach. Twenty-one patients treated with these approaches were identified consecutively, with a mean age of 44.2 years (range, 11-79 years). Tumors primarily involving the pterygopalatine fossa and not the ITF were excluded. Pathology included three advanced juvenile nasopharyngeal angiofibromas, three adenoid cystic carcinomas, two recurrent inverted papillomas, two trigeminal schwannomas, and 11 other diverse skull base pathologies. No intraoperative or postoperative complications occurred, with a mean follow-up of 21.5 months (range, 1-55 months). Expected potential sequelae such as V2/palatal numbness, Eustachian tube dysfunction, and trismus occurred in 10/21 patients., Conclusions: EEAs to ITF tumors are technically feasible with low risk of complications for well-selected patients. The proposed classification system is useful for anticipating potential sequelae for each approach.

Objectives/hypothesis: In an effort to decrease morbidity, skull base surgeons have explored less invasive approaches to the infratemporal fossa, including endonasal-endoscopy, minicraniotomies, and transantral endoscopic and microscopic corridors. This project presents quantitative data that assesses the practicality, and volumetric exposure afforded by endonasal and open approaches to the infratemporal fossa., Study Design: First, the study defines the anatomy of endoscopic-endonasal and preauricular approaches to the infratemporal fossa. Subsequently, the study involved the calculation of anatomical volumes using cadaveric and virtual models., Methods: Computed tomography (CT) scanning of two anatomical specimens served to recreate computer simulations of the endonasal and preauricular approaches, allowing for the assessment of the infratemporal fossae volumes. In addition, the dissections served to identify and mark critical surgical landmarks and boundaries. A second CT scan, after the surgical dissection, allowed for a reanalysis of the data for a volumetric comparison of the surgical approaches., Results: Pre- and postdissection CT scans and computer simulations revealed that volumes in the open and endonasal approaches to the infratemporal fossa are strikingly similar, suggesting that volumes of surgical instrumentation and visualization may also be comparable. However, the entry gate for instrumentation differed significantly for each approach., Conclusion: This study suggests that, although the entry gate for instrumentation is greater during an open approach, contrary to intuition, an open approach does not create a substantially larger working space or visual field. Analysis of volumetric measurements facilitates a better understanding of the indications for each procedure., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Endoscopic endonasal approaches to the pterygopalatine and infratemporal fossae are technically challenging due to the complex anatomy of these areas. This project attempts to develop an anatomic and surgical model to enhance the understanding of these spaces from the endonasal endoscopic perspective., Methods: Eight pterygopalatine and infratemporal fossae were dissected in four adult human specimens in accordance with institutional protocols. All specimens were prepared with vascular injections using colored latex. Both the pterygopalatine and infratemporal fossae were accessed using a transpterygoid approach, which included a medial maxillectomy. Rod lens endoscopes (with 0°, 30°, and 45° lenses), surgical microscope, microsurgical and endoscopic instruments were used to complete the dissections., Results: Endoscopic endonasal approaches provided adequate access to the pterygopalatine and infratemporal fossae. Dissection of the internal maxillary artery and its terminal branches, and detachment of the medial and lateral pterygoid muscles were critical steps to access deeper structures of the infratemporal fossa. The lateral pterygoid plate was the most useful landmark to locate foramen ovale, and the mandibular branch of the trigeminal nerve. The Eustachian tube, medial pterygoid plate, and styloid process were the most useful landmarks to locate parapharyngeal poststyloid structures (parapharyngeal segment of the internal carotid artery, internal jugular vein, cranial nerves IX and X)., Conclusions: A medial maxillectomy coupled with a transpterygoid endoscopic approach, provides adequate access to the pterygopalatine and infratemporal fossae. The complex anatomy of the infratemporal fossa requires precise identification of surgical landmarks to assure preservation of neurovascular structures.