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Objectives: We sought to define the surgical endoscopic anatomy of the pterygopalatine fossa (PPF) and infratemporal fossa (ITF) through endoscopic cadaver dissections and radiographic imaging analysis., Methods: Eleven fresh cadavers were submitted to computed tomography (CT) and endoscopic dissection. We used 3-dimensional (3-D) CT reconstruction and endoscopic video imaging for analysis of the bony and soft tissue landmarks. One fixed cadaver head was grossly dissected to confirm the endoscopic anatomic findings., Results: The CT and 3-D CT reconstruction measurements between the pterygoid canal and the foramen rotundum averaged 4.36 mm and 5.09 mm, respectively. An osseous ridge (pterygoid ridge) was identified on the anterior face of the pterygoid process as a novel identifiable anatomic landmark in all of the specimens. The average length of the pterygoid ridge on 3-D CT reconstruction was 7.84 mm. The internal maxillary artery entered the PPF posteromedial to the temporalis tendon and anterolateral to the lateral pterygoid muscle. The average distance from the anterior edge of the lateral pterygoid plate to the foramen ovale was 17.1 mm., Conclusions: The pterygoid ridge is a novel and reliable osseous landmark that could assist surgeons during endoscopic surgery on the PPF and ITF. The neurovascular and muscular anatomic relationships were characterized for both the PPF and the ITF.

Objective: To evaluate the efficacy of combining an endonasal endoscopic skull-base approach and repair with a transcranial orbitozygomatic approach for spheno-orbital meningiomas (SOMs)., Methods: Three patients with recurrent SOMs underwent combined orbitozygomatic and endonasal endoscopic surgery. In 2 patients both procedures were done in 1 operation and in 1 patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity, and mortality were evaluated., Results: Gross total resection was achieved in 1 patient and near total resection in the other 2 patients with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8, whereas the patient having only the endonasal component on a later date was discharged on day 2., Conclusions: A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective 2-stage surgery for resecting SOMs invading into the sinuses and paranasal compartments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of postoperative cerebrospinal fluid leak., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: This study aimed to examine the feasibility of an endonasal, transmaxillary, transpterygoid approach to the foramen ovale by examining key anatomical, radiological and surgical landmarks., Method: Measurements were taken from 183 patients' computed tomography scans using BrainLAB iPlan 1.1 Cranial software. Endoscopic dissection was then carried out on a cadaver to assess surgical viability., Results: We found that the distances from the posterior maxillary wall to the foramen ovale and from the anterior nasal spine to the foramen ovale were statistically significantly larger in men than women. The distance from the base of the lateral pterygoid plate to the foramen ovale, and the angle between the foramen ovale, the anterior nasal spine and the sphenoid rostrum, were constant between the sexes. The importance of the lateral pterygoid plate in locating the foramen ovale was demonstrated., Conclusion: With the increasing popularity of image guidance and assisted navigation in endoscopic surgery, these findings increase anatomico-radiological understanding of the surgical approach investigated.

Objective: To sum up and analyze the results of surgical removal of Schwannoma in the pterygopalatine and infratemporal fossa (PPF and ITF) through postero-lateral wall via prelacrimal recess approach (PLRA). The surgical technique and indications were presented and discussed., Methods: Six patients aged from 29-59 year-old with Schwannoma in the PPF and ITF, who received the tumor resection via PLRA under endoscope, were enrolled in this paper. Three were female and 3 were male. All of them received preoperative CT and MRI. The PPF and ITF were approached via prelacrimal recess endoscopically under general anesthesia. Schwannoma was histopathologically confirmed after surgery. The postoperative periodical CT and MRI follow up was conducted., Results: The tumors were removed completely in these 6 patients. No recurrence was found during 19.3 months follow up on the average. Three patients had obvious numbness in the V2 innervation area 1 or 2 weeks after operation and disappeared afterwards. Only 1 patient had mild altercation numbness at the end of follow up., Conclusions: Schwannoma involved PPF and ITF can be removed endoscopically via PLRA. The lateral wall of nasal cavity might be kept intact. It is a novel minimally transnasal invasive approach to PPF and ITF with less damage and complications.

Background: Patients presenting with facial pain often have ineffective pain relief with medical therapy. Cases refractory to medical management are frequently treated with surgical or minimally invasive procedures with variable success rates. We report on the use of ultrasound-guided trigeminal nerve block via the pterygopalatine fossa in patients following refractory medical and surgical treatment., Objective: To present the immediate and long-term efficacy of ultrasound-guided injections of local anesthetic and steroids in the pterygopalatine fossa in patients with unilateral facial pain that failed pharmacological and surgical interventions., Setting: Academic pain management center., Study Design: Prospective case series., Methods: Fifteen patients were treated with ultrasound-guided trigeminal nerve block with local anesthetic and steroids placed into the pterygopalatine fossa., Results: All patients achieved complete sensory analgesia to pin prick in the distribution of the V2 branch of the trigeminal nerve and 80% (12 out of 15) achieved complete sensory analgesia in V1, V2, V3 distribution within 15 minutes of the injection. All patients reported pain relief within 5 minutes of the injection. The majority of patients maintained pain relief throughout the 15 month study period. No patients experienced symptoms of local anesthetic toxicity or onset of new neurological sequelae., Limitations: Prospective case series., Conclusion: We conclude that the use of ultrasound guidance for injectate delivery in the pterygopalatine fossa is a simple, free of radiation or magnetization, safe, and effective percutaneous procedure that provides sustained pain relief in trigeminal neuralgia or atypical facial pain patients who have failed previous medical interventions.

Introduction: Class II, anterior open bite and/or a steep mandibular plane angle are frequently considered a contraindication to the use of surgically assisted rapid palatal expansion (SARPE). Nevertheless, few studies have investigated the maxillary and mandibular effects after SARPE on the sagittal and vertical planes, with dissimilar results and small samples of patients.The aim of the current study was to evaluate the sagittal and vertical effects after SARPE., Methods: Twenty-one consecutive adult patients (7 males, 14 females; mean age, 25.6 ± 6.3 years) who required SARPE were included in this study. All patients were subjected to subtotal LeFort I osteotomy with pterygomaxillary disjunction. Lateral cephalometric radiographs were taken during the preoperative assessment (T0) and 6 months after the end of the expansion (T1). Cephalometric measurements were realized at T0 and T1 for all the patients. Independent-sample t test and analysis of variance were used., Results: Statistically significant changes were observed only in upper incisor^NA (P = 0.04). No skeletal sagittal or vertical variation was found after SARPE., Conclusions: Class II, anterior open bite and/or a steep mandibular plane angle cannot be considered an outright contraindication to its use. Upper incisor palatal inclination could result after SARPE.

Objectives: The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency., Methods: One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative., Results: There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (resolved in 6 months) and transitory diplopia with immediate deficit of the medial rectus muscle in 2 patients (completely resolved in 1 month)., Conclusions: With the use of this technique, the surgeon can precisely identify the position of the surgical instrument without losing his or her way, thereby significantly reducing the rate of complications.

Electrical stimulation of the cervical vagus nerve reduces infarct size by approximately 50% after cerebral ischemia in rats. The mechanism of ischemic protection by vagus nerve stimulation (VNS) is not known. In this study, we investigated whether the infarct reducing effect of VNS was mediated by activation of the parasympathetic vasodilator fibers that originate from the sphenopalatine ganglion (SPG) and innervate the anterior cerebral circulation. We examined the effects of electrical stimulation of the cervical vagus nerve in two groups of rats: one with and one without SPG ablation. Electrical stimulation was initiated 30 min after induction of ischemia, and lasted for 1h. Measurement of infarct size 24h later revealed that the volume of ischemic damage was smaller in those animals that received VNS treatment (41.32±2.07% vs. 24.19±2.62% of the contralateral hemispheric volume, n=6 in both; p<0.05). SPG ablation did not abolish this effect; the reduction in infarct volume following VNS was 58% in SPG-damaged animals, 41% in SPG-intact animals (p>0.05). In both SPG-intact and SPG-damaged animals VNS treatment resulted in better motor outcome (p<0.05 vs. corresponding controls for both). Our findings show that VNS can protect the brain against acute ischemic injury, and that this effect is not mediated by SPG projections., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The anterior and the lateral approach for resecting an invading tumor in the pterygopalatine fossa region were compared. An anterior approach was applied for resecting a malignancy that originated from the maxillary tuberosity, upper hard plate, and maxillary sinus, and a lateral approach was applied for resecting a malignancy that originated from the upper gingiva and buccal mucosa. The anterior approach was capable of exposing the whole maxilla, although it was difficult to achieve such exposure by the lateral approach. However, the submandibular incision technique used in the Dingman approach was useful for upper neck dissection as well as for exposure of the artery and vein to anastomose them for reconstruction. The anterior approach should be useful for resection of the pterygopalatine fossa concomitant with total maxillectomy. On the other hand, the lateral approach might have an advantage in terms of its cosmetic effects.

Hydatid cyst disease is a rare parasitic infestation caused by larvae of Echinococcus granulosus. Although larval stage of this parasite can thrive in any part of the body, especially lungs and liver; head and neck involvement is rare. Pterygopalatine fossa involvement is reported in two cases in the literature. In this report we represent a case with solitary, secondary pterygopalatine fossa hydatid cyst extending in to the maxillary sinus, orbita, sphenoid sinus and skull base., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine the three-dimensional virtual anatomical features of the sphenoid sinus and adjacent structures during virtual surgery and explore their relevance to actual transsphenoidal surgery., Methods: CT images of the sphenoid sinus and surrounding structures from 28 Chinese adult patients were measured using a 16-slice helical CT scanner. Image analysis was performed using the volume-rendering method. Two experienced neurosurgeons wearing stereoscopic glasses performed virtual transsphenoidal surgery by the transnasal approach., Results: The virtual anatomical features of the sphenoid sinus and the adjacent structures during virtual surgery were described. The distance from the sphenopalatine foramen to the left and right sphenoid ostium was 10.1 ± 2.7 mm and 10.5 ± 3.2 mm, respectively, to the left and right sphenoidal crest 12.9 ± 2.0 mm and 12.8 ± 2.2 mm, respectively, and to the left and right uncinate process 24.0 ± 1.9 mm and 23.9 ± 2.0 mm, respectively. The distance from the uncinate process to the medial and lateral edge of the most prominent part of the anterior bend of the cavernous internal carotid artery (ICA) was 33.7 ± 3.7 mm and 34.8 ± 3.7 mm, respectively, and the angle between the two lines was 9.7 ± 1.9°., Conclusion: The study provides virtual anatomical information about the sphenoid sinus and important surrounding structures that is essential for successful real life transsphenoidal surgery., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

This study assessed the incidence, presenting symptoms, diagnosis, and management of patients with life-threatening postoperative haemorrhage after total Le Fort I osteotomy and surgically assisted rapid palatal expansion (SARPE). The medical records of 750 consecutive Le Fort I osteotomies and 376 consecutive SARPEs, both of which involved pterygomaxillary separation with a curved osteotome and a mallet, were analysed prospectively. Two cases of life-threatening haemorrhage were observed in the Le Fort I osteotomy group, both initiated on postoperative day 7. Anterior and posterior nasal packing were successful in one patient; the other required two embolizations for bleeding control (incidence of life-threatening postoperative haemorrhage: 2/750; confidence interval: 0.03-0.96%). In the SARPE group, one brisk epistaxis on the first postoperative day was controlled with anterior and posterior nasal packing under general anaesthesia. This haemorrhage was not considered life threatening (incidence of life-threatening postoperative haemorrhage: 0/376; confidence interval: 0-0.98%). In no case could the source of bleeding be established during re-explorative surgery or during diagnostic arteriography. The authors conclude that life-threatening haemorrhage is an exceptional finding after Le Fort I osteotomy; the observed incidence was 2/750, and life-threatening haemorrhage was not observed after SARPE in this series, despite the use of identical pterygomaxillary separation., (Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To assess the success and marginal bone loss, after 1 year of loading, of implants placed in anatomic buttresses of atrophic maxillae to rehabilitate patients with combination syndrome., Materials and Methods: A case series retrospective study of 22 patients with combination syndrome who were treated with implants in anatomic buttresses in the atrophic maxilla was performed. The inclusion criteria were Classes IV and V Cawood and Howell maxillary atrophy, rehabilitation with implants placed in anatomic buttresses, the presence of anterior remnant teeth in the mandible, and a minimum follow-up of 12 months after implant loading. The criteria of Buser et al were used to evaluate implant success, and marginal bone loss was measured on periapical radiographs. Statistical analysis was performed to relate implant success and marginal bone loss to gender, degree of maxillary atrophy, implant technique, and prosthesis type., Results: A total of 18 patients fulfilled the inclusion criteria. A total of 117 implants were placed; 32 were placed with the conventional technique in the alveolar ridges with enough height and width, 35 were positioned palatally, 30 were tilted in the frontomaxillary buttress, 10 were placed in the pterygomaxillary area, 6 were placed in the nasopalatine canal, and 4 were zygomatic implants. The follow-up ranged from 1 to 7 years after implant loading. Of the 117 implants, 7 failed, for an implant success rate of 94%. The mean marginal bone loss was 0.63 mm. A statistically significant relation was found between bone loss and implant placement technique and the level of maxillary atrophy, being greater in tilted implants and in Class V Cawood and Howell maxillary atrophy., Conclusions: Implants in anatomic buttresses allow rehabilitation of atrophic maxillae in patients with combination syndrome. The implant success rate was high, and a mean marginal bone loss of 0.63 mm was recorded., (Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Basal cell adenocarcinoma (BCAC) is a rare malignant neoplasm in the salivary glands and BCAC of the minor salivary glands is exceedingly rare. Only nine cases of palatal BCACs of the minor salivary gland have been reported. BCAC is a low-grade malignant tumour which shares many histologic characteristics with basal cell adenoma. Histological differentiation between the two is difficult and they are often discriminated only by invasion of local structures or by perineural or vascular invasive figures. The authors describe the case of a 69-year-old man with a massive BCAC of a palatal minor salivary gland that progressed into the nasal cavity and pterygopalatine fossa and was treated by a subtotal maxillectomy. This is a highly locally advanced case which required a wider surgical excision range than other previously reported BCAC cases of the palatal minor salivary glands. In this case, the proper diagnosis could not be made by local biopsy alone. It should be kept in mind that it may be difficult to distinguish BCAC from basal cell adenoma by microscopic examination of biopsy specimens alone., (Copyright © 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: The aim of this work, based on a recent review of the literature, is to update the surgical techniques for endoscopic vidian neurectomy (EVN)., Recent Findings: Traditionally, vidian neurectomy was performed on the orifice of the vidian canal on the posterior surface of the pterygopalatine fossa (PPF) through an open approach. A major advance in vidian neurectomy is to transect the vidian nerve endoscopically. In the past 2 decades, EVN has been developed and has replaced the traditional open approach because of improved visualization of the vidian nerve and the less invasive procedure. In addition, computed tomographic (CT) scanning has become a routine evaluation tool for EVN., Summary: In the past decade, there has been renewed interest in the procedure of vidian neurectomy because endoscopic techniques have greatly improved. The recent evolution of EVN improves the surgical visualization of the vidian nerve and minimizes surgical complications. Preoperative CT imaging is a key element in determining the surgical approach. This study reviews the literature and summarizes the preferred vidian nerve exposure, recent technical refinements, and our current surgical approach.

Background: The pterygopalatine fossa (PPF) can be entered endoscopically, but the endoscopic landmarks to localize the bony structures in the PPF are not well described. This study aimed to investigate the anatomy of the sphenopalatine foramen (SPF), vidian canal (VC), and foramen rotundum (FR) with regard to an endoscopic endonasal approach to the PPF using three-dimensional reconstruction of computed tomography (CT) scans., Methods: The CT scans of 98 patients were retrospectively evaluated. The morphology of the SPF, VC, and FR as well as the spatial relationship between the SPF and VC were measured on a three-dimensional model., Results: The mean diameters of the SPF, VC, and FR were 5.3 ± 1.3 mm, 2.4 ± 0.7 mm, and 2.8 ± 0.5 mm, respectively. The mean distance between the VC and posteroinferior margin of SPF was 3.8 ± 1.0 mm. The mean vertical and horizontal distances on the surface plane of sphenoid bone between the VC and FR were 5.8 ± 1.9 mm and 8.5 ± 1.9 mm, respectively. The whole or partial margin of the VC was above the inferior margin of the SPF in 92% (180/196) of the VC and lateral to the posterior margin of the SPF in 98% (195/196) of the VC. The distance between the VC and SPF had a positive correlation with the distances between the VC and FR., Conclusion: The endoscopic endonasal approach to the PPF will be performed with greater accuracy and safety through comprehension of the spatial relationships between the SPF, VC, and FR.

Myxomas are benign mesenchymal tumors of uncertain etiology. They can arise from odontogenic tissue, as well as from the sinonasal tract and from the facial and temporal bones, apparently from nonodontogenic mesenchyme. Although histologically benign, myxomas are locally invasive. Histopathology demonstrates a characteristically hypocellular lesion with loose stellate cells. We describe the case of a 48-year-old woman with a nonodontogenic maxillary sinus myxoma that invaded the sphenoid sinus and pterygopalatine fossa. We removed the mass via a combined endoscopic and gingivobuccal approach. The rarity of a nonodontogenic sinonasal myxoma extending into the sphenoid sinus and pterygopalatine fossa is the basis for our presentation of this case.

Aims: Survey the clinical symptoms, radiological features, management, and long-term outcomes of sinonasal and anterior skull base schwannomas., Patients and Methods: Retrospective review of patients with sinonasal schwannomas treated from June 2001 through January 2010 at two academic institutions., Results: There were 4 women and 3 men in this study. The mean age was 46 years (range 17-68). The mean tumor size was 2.4 cm (range 1.4-3.8 cm). Tumor locations included ethmoid sinuses (3), nasal cavity (2) and pterygopalatine fossa (2). Six patients had endoscopic resections, while 1 was approached and resected via a lateral rhinotomy. The mean follow-up was 2.8 years. There were no tumor recurrences during the study period., Conclusions: Schwannomas of the paranasal sinuses and nasal cavity are uncommon tumors that can usually present with vague and nonspecific symptoms. Magnetic resonance imaging can suggest the diagnosis; however, a definitive diagnosis is made by correlation with histopathological findings. Treatment is complete surgical resection. This study illustrates the effectiveness of the endoscopic endonasal approach in the treatment of these benign tumors., (Copyright © 2011 S. Karger AG, Basel.)

Background: Endonasal and infrazygomatic pterygopalatine ganglion (PPG) block for facial pain provides pain relief in a broader area than expected on anatomic grounds. The aim of this study was to search for neural structures in the pterygopalatine fossa (PPF) that could explain unexpected pain relief after PPG blockage., Methods: The neural PPF content was explored through human cadaver study and nerve-specific staining. Five human PPF specimens were dissected as whole-mount preparations with the aid of an operation microscope and stained for acetylcholinesterase. One of these specimens was partially sectioned and analyzed through nitric oxide synthase (NOS) immunohistochemistry., Results: A previously unknown nerve was identified. The nerve runs between the PPG and the ophthalmic nerve and was identified in all five specimens. NOS-containing nerve fibers were present but did not occupy the complete nerve area., Conclusion: Because it is likely that the nerve contains sensory fibers, our findings may provide an anatomic basis for unexplained pain relief in the ophthalmic area after PPG blockage.

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.

Inflammatory myofibroblastic tumour (IMT) is a rare distinctive neoplasm of intermediate biological potential with a predilection for the abdominopelvic region and lung of children and young adults. It is histologically composed of spindle cells (myofibroblasts) in a myxoid to collagenous stroma with a prominent inflammatory infiltrate composed primarily of plasma cells and lymphocytes. Its pathogenesis is controversial. Arising most commonly in the lungs, only two cases of histopathologically confirmed IMT originating from the infratemporal and pterygopalatine fossae have been documented in the literature. Neither had orbital involvement. We now report the first case of IMT originating from the infratemporal fossa with orbital extension in a previously well 31-year-old woman. The patient presented with a 5-month history of intermittent right-sided headaches, progressive trismus and right lower lid swelling. She then developed right proptosis, diplopia and paraesthesia in the ophthalmic and maxillary divisions of her trigeminal nerve. Magnetic resonance imaging showed a soft tissue mass occupying most of the right infratemporal fossa with extension into pterygopalatine fossa and orbit. Provisional diagnosis from an open biopsy was nodular fasciitis. She underwent surgical debulking of the infratemporal fossa and lateral orbit through a coronal and trans-oral approach with trans-zygomatic access via total zygomatic osteotomy. Review of intraoperative specimens revised the diagnosis to IMT. Further management included systemic corticosteroids and adjuvant radiotherapy., (© 2010 The Authors. Journal compilation © 2010 Royal Australian and New Zealand College of Ophthalmologists.)

We expose the anatomical characteristics of the pterygopalatine fossa (FPP) and the pathology that can cause it. Below is the surgical experience in a case of schwannoma of FPP five centimeters in diameter that could be removed by transnasal endoscopic surgery, being unnecessary an external surgery. Schwannomas constitute the 8-10% of intracranial tumors, normally localized in the vestibular branch of the VIII cranial nerve. A schwannoma of a branche of the trigeminal lnerve in the pterigopalatine fossa is exceptional.

Introduction: Cluster headaches (CH) are primary headaches marked by repeated short-lasting attacks of severe, unilateral head pain and associated autonomic symptoms. Despite aggressive management with medications, oxygen therapy, nerve blocks, as well as various lesioning and neurostimulation therapies, a number of patients are incapacitated and suffering. The sphenopalatine ganglion (SPG) has been implicated in the pathophysiology of CH and has been a target for blocks, lesioning, and other surgical approaches. For this reason, it was selected as a target for an acute neurostimulation study., Methods: Six patients with refractory chronic CH were treated with short-term (up to 1 hour) electrical stimulation of the SPG during an acute CH. Headaches were spontaneously present at the time of stimulation or were triggered with agents known to trigger clusters headache in each patient. A standard percutaneous infrazygomatic approach was used to place a needle at the ipsilateral SPG in the pterygopalatine fossa under fluoroscopic guidance. Electrical stimulation was performed using a temporary stimulating electrode. Stimulation was performed at various settings during maximal headache intensity., Results: Five patients had CH during the initial evaluation. Three returned 3 months later for a second evaluation. There were 18 acute and distinct CH attacks with clinically maximal visual analog scale (VAS) intensity of 8 (out of 10) and above. SPG stimulation resulted in complete resolution of the headache in 11 attacks, partial resolution (>50% VAS reduction) in 3, and minimal to no relief in 4 attacks. Associated autonomic features of CH were resolved in each responder. Pain relief was noted within several minutes of stimulation., Conclusion: Sphenopalatine ganglion stimulation can be effective in relieving acute severe CH pain and associated autonomic features. Chronic long-term outcome studies are needed to determine the utility of SPG stimulation for management and prevention of CH.

Aim: To explore a method to obtain sub-millimeter data of the thin transverse section of the pterygopalatine fossa (PPF), and to study the thin transverse sectional anatomy of the adult pterygopalatine fossa and its communicating structure for providing anatomic gist for the imaging diagnosis and minimal invasive operation when PPF diseased., Material and Methods: Two heads of adult cadaver without macroscopic trauma (four sides of PPF) were selected to observe. Images of 0.6 mm-thick multi-planar construction (MPR) were obtained with multislice spiral CT (MSCT) based on the superior orbitomeatal line. Then, the specimens were sliced into 0.1 mm serial section on the transverse plane with the computerized milling machine, the figures were taken with digital camera and the sectional data were stored in the computer. Lastly, the thin transversal section of PPF was investigated and compared with multislice spiral CT images acquired by MPR technique to explore and discuss the anatomy of the thin transverse section of the internal structure of PPF., Results: PPF was divided into four portions: infrapterygopalatine portion, pterygopalatine ganglionic one, suprapterygopalatine one and roof of PPF according to the structural characteristics of the transverse section of PPF. The infrapterygopalatine portion communicated laterally with the infratemporal fossa through the pterygomaxillary fissure and communicated downwards with the oral cavity via palatine greater and lesser canals. The pterygopalatine ganglion was shown clearly in the pterygopalatine ganglionic portion, and its dimensions were 3.91x1.92 mm at the best layer. In the suprapterygopalatine portion, the sphenopalatine foramen and artery were obviously shown on the medial wall, while the palatovaginal canal and artery, the pterygoid canal and artery, and the foramen rotundum and maxillary nerve were shown from the inferiomedial to laterosuperior on the posterior wall. The vomerovaginal canal and artery were located at the slightly superior portion of the medial side of the palatovaginal canal., Conclusion: Figures of thin transverse section and multislice spiral CT have highly consistency for the display of PPF. Both of them can correctly identify the micro-structure, the complex relationship of the connectivity and the spatial localization in the narrow space of PPF. It can provide reference gist for the imaging diagnosis and minimal invasive operation.

Cluster headache is a primary neurovascular headache. It is a strictly unilateral head pain that is associated with cranial autonomic symptoms and usually follows circadian and circannual patterns. Chronic cluster headache, which accounts for about 10% to 15% of patients with cluster headache, lacks the circadian pattern and is often resistant to pharmacological management. The sphenopalatine ganglion (SPG), located in the pterygopalatine fossa, is involved in the pathophysiology of cluster headache and has been a target for blocks and other surgical approaches. Percutaneous radiofrequency ablation of the SPG was shown to have encouraging results in those patients with intractable cluster headaches.

Objective: Classic surgical exposures of the infratemporal fossa region, including the adjacent intracranial space, temporal bone, and sinonasal region, require the extensive exposure associated with the transcranial, transfacial, and transmandibular approaches with their inherent neurological and cosmetic morbidities. In this study, we evaluated the feasibility and exposure afforded by combining 2 endoscopic transmaxillary approaches, endonasal and Caldwell-Luc supplement, to the infratemporal fossa., Methods: Endoscopic transmaxillary dissection was performed in 4 formalin-fixed cadaver heads (8 sides). We quantified the extent of exposure achieved within the pterygopalatine and infratemporal fossae after our initial dissection, which was endonasal with a medial antrostomy, and after addition of a Caldwell-Luc incision with an anterior antrostomy. Complementing this anatomic study, we report on a patient in whom this endoscopic transmaxillary approach combining the endonasal and Caldwell-Luc approaches was used for resection of a trigeminal schwannoma in the infratemporal fossa., Results: The combination of these 2 endoscopic transmaxillary approaches enabled visualization of the entire region of the pterygopalatine fossa and anteromedial aspect of the infratemporal fossa. Additional posterolateral exposure of the infratemporal fossa requires significant traumatic traction on the nose. Addition of the Caldwell-Luc transmaxillary approach exposed the remainder of the infratemporal fossa, including the mandibular nerve and branches, middle meningeal artery, and even the distal cervical portion of the internal carotid artery., Conclusion: Endoscopic exposure of the infratemporal fossa is feasible. Using the combination of the endonasal and Caldwell-Luc approaches for direct transmaxillary access significantly extended exposure, allowing safe and effective resection of infratemporal fossa lesions.

Objective: To provide a new approach for the treatment of tumor in Meckel's cave, by dissecting adjacent structures of the nasal cavity-maxillary sinus-pterygopalatine fossa-Meckel's cave approach., Methods: Fifteen adult cadaver heads (30 sides) were dissected and the correlated anatomic landmarks were observed, measured and analyzed in an operative route., Results: The approach was divided into 3 steps: entering the maxillary sinus, the later pterygopalatine fossa and the final Meckel's cave. Safe access to Meckel's cave could be achieved by tracing the vidian neurovascular bundles and dissecting the quadrangular space (QS). The distances from the nasal columella to the apertura maxillaries, the sphenopalatine foramen, and the anterior foramen of the pterygoid canal were (44.08+/-2.61) mm, (64.83+/-2.42) mm, and (70.43+/-2.94) mm, respectively. The angles between the horizontal plate of the palatine bone and the link from nasal columella to apertura maxillaries, between the horizontal plate of the palatine bone and the link from nasal columella to sphenopalatine foramen were (38.10+/-2.46) degrees and (26.15+/-2.26) degrees , respectively., Conclusion: The endoscopic approach of transnasal maxillary sinus-pterygopalatine fossa-Meckel's cave (ENMPA) is a safe and direct way to access Meckel's cave, and could be employed for the treatment of tumor in Meckel's cave.

Objective: Esthesioneuroblastoma is a rare, malignant neoplasm arising from the olfactory neuroepithelium in the upper nasal cavity. Even more rare is ectopic esthesioneuroblastoma developing from the region outside the olfactory epithelium. In addition, tumors occurring in the pterygopalatine fossa (PPF) are uncommon, and the endoscopic transnasal approach for the resection of malignant tumors in this region is also uncommon., Clinical Presentation: We describe an esthesioneuroblastoma arising from the left maxillary sinus and PPF. The tumor was resected using the endoscopic transnasal approach, followed by treatment with radiotherapy. The patient showed no evidence of recurrence 12 months postoperatively., Technique: The endoscopic transnasal approach could be successfully used for the complete removal of malignant tumors in the PPF., Conclusion: The PPF is an anatomic area that is difficult to access. The endoscopic transnasal approach improves access and visualization; it also has the potential to reduce complications compared with the open approach. The endoscopic transnasal approach might become the treatment of choice for malignant tumors in the PPF.

Background: Adenoid cystic carcinomas (ACC) in sinunasal compartments are often not completely resectable. We discuss both, surgical margins and functional results preoperatively and postoperative options for adjuvant therapy. The former opinion of a resistance of ACC towards chemotherapy or irradiation seems to be outdated, even though consensus about therapeutic strategies is still missing., Material and Methods: We discuss therapeutic options and compare data from literature regarding the best adjuvant therapy with the case of a 25-year-old patient with an advanced ACC of the left fossa pterygopalatina. Further we discuss alternative therapeutic options like neutron irradiation, chemotherapy or targeted therapy. Following the advice from literature, we performed an eye saving tumor resection by a left transmaxilloethmoidale sphenoidectomy via combined trans- und extranasal approach. We accepted close surgical margins for the benefit of the abandonment of dismembering measures and performed an adjuvant radiochemotherapy with taxol and carboplatin., Results: With the described therapeutic strategy we reached an optimal local tumor control with unlimited visus and without functional and cosmetic restrictions up to now. Periodic staging did not show any local tumor progress or metastatic spread hitherto., Conclusion: Organ preserving surgery and adjuvant radiochemotherapy even in combination with taxol and carboplatin seems to be a sufficient therapeutic option in treating advanced sinunasal ACC, and might not have any prognostic disadvantages to radical surgery., (Georg Thieme Verlag KG Stuttgart, New York.)

En bloc resection of maxillary sinus tumors that extend through the posterior wall necessitates resection of maxilla along with pterygopalatine and infratemporal fossae contents. This cannot be readily performed by conventional anterior maxillectomy approaches. The objective of this study is to evaluate the effectiveness of transmandibular approach for the excision of maxillary sinus tumors extending to pterygopalatine and infratemporal fossae. This is a retrospective review of 15 consecutive patients who underwent maxillectomy with transmandibular approach for tumors with posterior extension, between January 2004 and February 2008. The principal outcome parameter was the margin status on final histopathology report. In addition, evaluable patients were reviewed to assess the morbidity of the procedure using pre-defined parameters. All the patients had negative margins at the infratemporal fossa region. Varying degree of trismus was present in all patients. The cosmetic outcome of the procedure was excellent. Other anterior and transcranial approaches could be combined with this procedure when indicated. We conclude that transmandibular approach is an effective technique for resection of maxillary tumors with posterior extension to the pterygopalatine and infratemporal fossae. The procedure has acceptable morbidity and the aesthetic and functional results are satisfactory.

Aim: Our aim in this study was to recognize the endoscopic anatomy of the pterygopalatine fossa (PPF) and the anatomic variations of the related neurovascular structures, to define the endoscopic endonasal approach to this region., Methods: Six fresh adult cadavers were studied (N=6) by endoscopic endonasal approach. To reach the pterygopalatine fossa endonasally, we performed the middle meatus transpalatine approach in 2 cadavers, the middle meatus transnasal approach in 2 cadavers and the inferior turbinatectomy transnasal approach in 2 cadavers. The superior and posterior walls of the maxillary sinus were defined and studied. The sphenopalatine foramen is widened by drilling the orbital process of the foramen and the sphenopalatine artery was exposed. The posterior wall of maxillary sinus was opened to expose the pterygopalatine fossa and its neurovascular contents, which were studied and documented., Results: The PPF was easily approached by endoscopic transnasal transmaxillary approach. The PPF region was best exposed by the middle meatus tranasal approach. In the PPF; infraorbital nerve, vidian nerve, major palatine nerve, the infraorbital artery, internal maxillary artery, sphenopalatine artery, descending palatine artery, posterior superior alveolar artery and buccal artery were exposed. According Morton and Khan morphologic classification of the third portion of the internal maxillary artery we found intermediate type in 2 cadavers (33.3%), M' type in 2 cadavers (33.3%), T' type in 1 cadaver (16.7%) and Y' type in 1 cadaver (16.7%). Also, according to Chio and Park classification of the branching type of the infraorbital artery, posterior superior alveolar artery and deep palatine artery, we found type I in 4 cadavers (66%) and type II in 2 cadavers (33%)., Conclusions: During the endoscopic transnasal transmaxillary approach to the PPF, it is possible to face wide range of variations in every phase of the approach. Understanding the anatomy of this region and the neurovascular relations from the endoscopic view by cadaver dissections will help us to performed more controlled and safe surgery.

Introduction: Myoepithelial tumours are rare clinicopathological identity. It has been found in parotid glands and salivary glands but never reported in infratemporal fossa or other sites of lateral skull base region., Discussion: Unlike its benign counterpart, myoepithelial carcinoma is biologically very aggressive and prone to recur even after adequate therapy., Case Report: Here, a rare case of myoepithelial carcinoma arising from infratemporal fossa has been described along with its treatment options and outcome.

Objective: To explore the rules about the pathway and branch patterns of the internal maxillary artery in pterygopalatine fossa, provide the anatomic basis for treating the internal maxillary artery during the transnasal endoscopic surgery., Method: Ten adult cadaveric skull base were dissected, the sphenopalatine artery and its branches were observed. The pterygopalatine fossa was opened through trans-maxillary sinus endoscopic approach, all the branches of the internal maxillary artery in pterygopalatine fossa were exposed. The concave of the maxillary sinus posterior-medial wall was defined as point A, the cross point of the horizontal line pass through the infraorbital foramen, the maxillary sinus anterior wall and posterior-lateral wall as point B, the cross point of the maxillary sinus anterior wall, floor and posterior-lateral wall as point D, the midpoint of BD as C, the C' denoted the first branch root of internal maxillary artery in pterygopalatine fossa. Observed the pterygopalatine segment of internal maxillary artery based on the marking points., Result: The distance between the sphenoid sinus os and the sphenopalatine fossa was (5.88 +/- 2.21) mm. The C' point locate on AC at 13 sides specimen, locate on AB at 5 sides specimen, locate on AC at 1 side specimen, higher than AB at 1 side specimen., Conclusion: Being familiar with the pathway and branch patterns of the internal maxillary artery in pterygopalatine fossa is important for treating the uncontrol epistaxis and endoscopic pterygopalatine fossa surgery, the rules described by A, B, C, D in our experiments will be helpful in ligation of internal maxillary artery during the endoscopic transnasal/maxillary-pterygopalatine fossa surgery.

Objective: To provide morphologic data for the operation of pterygopalatine fossa (PPF) region by measuring the bony landmarks and dissecting vessel and nerve., Method: The shape, size and adjacent important structures of PPF were observed in 20 dry skulls (forty sides). Ten (twenty sides) skulls were fixed in 4% paraformaldehyde and their arteries were perfused with red lacteprene. The pterygopalatine fossa was exposed from the middle sagittal section dissected to inner wall of maxillary sinus and PPF and observed the course of trigeminal nerve and arteria maxillaris under the operating microscope. To investigate the related surgical anatomy approaches of the maxillary sinus and pterygopalatine fossa., Result: The pterygopalatine fossa shows a long and narrow cleft. PPF communicate with nasal cavity, oral cavity, pharynx, orbit, infratemporal fossa and middle cranial fossa. The pterygopalatine segment of maxillary artery and accompanying vein, the maxillary nerve and sphenopalatine ganglion are the most important structures. There are two layers of tissue in the pterygopalatine fossa, they are nervous layer and vessel layer., Conclusion: (1) To deal with lesion, the approach of maxillary sinus can de used, the cross point of the upper wall, the inner wall and the back wall can be thought as important landmark. (2) Safe scope could be acquired in endoscopic transnasal surgery in pterygopalatine fossa, pterygoid canal and foramen rotundum could be thought as an important landmark.

Objective: To provide anatomic data of pterygopalatine fossa(PPF) for endoscopic PPF surgery., Method: Fifteen wet adult skull specimen fixed in 10% formaldehyde were studies. From center the skulls were sawed, the middle and inferior turbinate were resected, the anterior and posterior ethmoid sinuses were resected. Then after punch out perpendicular part of palatine bone and posterior wall of maxillary,the pterygopalatine fossa were showed and some related measurements were made., Result: This pathway can lead to a good view of pterygopalatine fossa. The main soft structures in PPF were maxillary artery and nerve with their branches. The diameter of artery branches was smaller than 3 mm., Conclusion: The endoscopic PPF surgery is safe and practical from the anatomic data.

Objective: To provide endoscopic anatomic bony structures of pterygopalatine fossa for skull base surgery., Methods: The bony structures of the pterygopalatine fossa were observed in ten dry skulls under endoscope., Results: The pterygopalatine fossa showed a long and narrow cleft composed of the body and pterygoid process of sphenoid bone, the lamina perpendicular of palatine bone, and the posterior wall of maxillary sinus. The pterygopalatine fossa is (21.4 +/- 0.8) mm x (5.2 +/- 0.3) mm x (3.2 +/- 0.3) mm, with seven paths communicating with nasal cavity, mouth cavity, pharynx, orbit, infratemporal fossa and middle cranial fossa. Under endoscope,the whole pterygopalatine fossa could be observed., Conclusions: Endoscopic anatomic study of the pterygopalatine fossa is important to endoscopic endonasal skull base surgery. Under endoscope,the whole pterygopalatine fossa can be observed.