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To describe an ultrasound-guided suprazygomatic approach to the trigeminal nerve block in cat cadavers. Prospective descriptive study. Ten feline cadaver heads. A 25:75 methylene blue–iopamidol mixture (0.1 mL cm–1 cranium length) was injected into 10 cadaver heads using an ultrasound-guided suprazygomatic approach. A computed tomography (CT) scan was performed to identify contrast presence at the orbital fissure, foramen rotundum and ovale, followed by anatomical dissection to identify staining of the pterygopalatine fossa (PPF), extraconal retrobulbar area, mandibular and maxillary nerves. Descriptive statistics were used to summarize results. A total of 20 injections were performed. Of these, 1/20 misinjection occurred and excluded from further reporting. The volume of injectate was 0.9 (0.9–1.1) mL [median (range)]. Staining of the PPF, extraconal space, maxillary and mandibular nerves over more than 6 mm was achieved in 19/19 (100%), 18/19 (95%), 17/19 (89%) and 19/19 (100%) of injections, respectively. CT showed presence of contrast within 5 mm of the orbital fissure, foramen rotundum and ovale in 18/19 (95%), 19/19 (100%) and 19/19 (100%) of the injections, respectively. No intracranial migration was observed. This cadaver study illustrates that the suprazygomatic ultrasound-guided trigeminal nerve injection technique can successfully stain the PPF, retrobulbar cone extraconally, mandibular and maxillary nerves. Consequently, this technique has the potential to be used in vivo in cats to desensitize areas innervated by the trigeminal nerve. [ABSTRACT FROM AUTHOR]

We report a case of a 73-year-old woman presenting with intracranial and extracranial meningioma with perineural spread crossing the foramen rotundum and pterygopalatine fossa, primarily along the maxillary nerve. She visited our hospital with the chief complaint of the left cheek swelling. Subsequent magnetic resonance imaging revealed a well-demarcated mass containing intracranial (cavernous sinus, Meckel's cave, and middle cranial fossa) and extracranial components (pterygopalatine fossa, orbit, nasal cavity, ethmoid and sphenoid sinuses, infratemporal fossa, and buccal space) through the foramen rotundum. A biopsy specimen was obtained from the cheek mass, and the histopathological diagnosis was meningothelial meningioma. [ABSTRACT FROM AUTHOR]

Objective: Granulomatous invasive fungal sinusitis (GIFS) is a rare and life-threatening disease, whereas fungus ball (FB) is the most common form of noninvasive fungal sinusitis. Both GIFS and FB primarily develop in immunocompetent patients, with the former associated with higher mortality and morbidity. Methods: A chart review and review of the literature. Results: We present the case of a 77-year-old woman with mixed fungal sinusitis who was successfully treated with voriconazole. Conclusions: GIFS and FB can coexist in extremely rare cases, known as mixed fungal sinusitis; however, the diagnosis and subsequent treatment of mixed fungal sinusitis can be delayed because of a lack of awareness of the underlying concept. Therefore, it is crucial for clinicians to recognize the concept of mixed fungal sinusitis. [ABSTRACT FROM AUTHOR]

Adenoid cystic carcinoma (ACC) is an uncommon malignant neoplasm that predominantly arises from major and minor salivary glands, accounting for about 1% of head and neck malignancies. ACCs originating from the pterygopalatine fossa (PPF) are extremely rare. In this case report, we present a 77-year-old male patient who experienced a two-year hemi-facial numbness and mild trismus, with intact nasal mucosa. He underwent Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) which revealed opacification of the left PPF with extension to the left infratemporal fossa and osteolytic areas of the sphenoid bone. Histopathology, following blind biopsies, revealed ACC of the PPF, which was subsequently treated with combined therapy (radiotherapy and chemotherapy). Due to their slow and progressive growth, as well as their tendency for perineural invasion, ACCs should always be considered in the differential diagnosis of painless swelling or nerve dysfunction. To our knowledge, this case is the fifth described in the English literature. [ABSTRACT FROM AUTHOR]

Objective: Rhinosinusitis is one of the most common reasons for a visit to otolaryngology clinics. Some patients are candidates for sinus surgery. Infiltration of 1:100 000 adrenaline in the pterygopalatine fossa was studied, with the aim of evaluating the effect on bleeding in the surgical field. Methods: This double-blind clinical trial was conducted in 2021–2022 on 40 candidates for endoscopic sinus surgery. For each patient, one side of the pterygopalatine fossa was randomly selected to be infiltrated with a vasoconstrictor. Surgical field bleeding on each side was evaluated. Results: Blood loss was 35.8 ± 20.9 ml in the study group and 38.4 ± 23.7 ml for the control group, with no statistically significant difference between groups (p = 0.49). In addition, there was no difference between the two groups in terms of the surgical field based on Boezaart scores. Conclusion: Although there are some recommendations on the usage of vasoconstrictors via the pterygopalatine foramen, debate remains. [ABSTRACT FROM AUTHOR]

Objective We aimed to explore the clinical efficacy of precise electro-acupuncture stimulation in the pterygopalatine fossa for the treatment of chronic sinusitis. Methods In total, 40 patients with chronic sinusitis who visited the Xiyuan Hospital, China Academy of Chinese Medical Sciences between January 2022 and January 2023 were selected. The subjects were randomly divided into two groups: the treatment group (receiving precise electro-acupuncture in the pterygopalatine fossa) and the control group (receiving standard western medical treatment), with 20 cases in each groups. The treatments were administered twice a week for a period of 12 weeks. The effectiveness of the treatments was evaluated through computed tomography(CT) of the sinus changes and the Lund-Mackay scoring system. Results In cases of total opacity and partial opacity, there were significant differences between the two patient groups before and after treatment (P < 0.05). Intra-group comparison revealed statistically significant improvements in both groups before and after treatment (P < 0.05). The treatment group exhibited significant improvement in various sinus conditions (P < 0.05), while in the control group, a significant improvement was only observed in the left maxillary sinus (P < 0.05). Inter-group comparison also demonstrated that the treatment group's improvements were superior to those of the control group across multiple indicators (P < 0.05). Conclusion The precise electro-acupuncture stimulation technique in the pterygopalatine fossa demonstrated significant therapeutic effects in the treatment of chronic sinusitis, with superior outcomes with respect to radiological changes compared to standard western medicine treatment. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of the study is to analyze whether the volume of the pterygopalatine fossa will have a significant impact on the qualitative effect of local anesthesia or any other therapeutic procedures through this structure. Materials and Methods: It is a descriptive retrospective study with a single institutional setting. The study included subjects of age above 18 with quality cone beam computed tomography (CBCT) images taken from 2020 to 2023. Descriptive statistics were performed. Volume and sex associations were done through an independent t test, and volume and age associations were done through a Chi-square test. A P value of less than 0.05 was considered significant. Results: A study of 107 patients, excluding 53 females and 54 males, found a significant difference in the mean volumes of the pterygopalatine fossa (PPF) between males and females. The average capacity was 717±66.7 cc on the right side and 661±61.6 cc on the left, with a p value less than 0.001. Conclusion: Accurately assessing the volumetric capacity of the PPF is crucial for local anaesthetic and other therapeutic applications. Males have a significantly larger volume of PPF than females, and semiautomatic CBCT picture segmentation offers a practical and independently tested method. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to perform morphometric measurements of the pterygopalatine fossa (PPF), the transition zone to critical neurovascular structures. The second aim was to investigate the relationship between the volumes of the PPF and the paranasal sinuses and the effect of nasal septum deviation (NSD) types on all these measurements. Methods: We performed PPF's morphometry and all volume measurements on the CT images of 260 patients (130 male and 130 female, age range 18–79). Results: All volumetric measurements and the angle between foramen rotundum (FR) and pterygomaxillary fissure (PMF) were significantly higher in males than females. In contrast, the distance between sphenopalatine foramen (SPF) and PMF was considerably higher in females than in males. The PPF volume, the distance between the pterygoid canal (PC) and maxillary sinus, and the angle between FR and PMF were significantly higher on the right side than on the left. In contrast, the angle between PC and SPF and between greater palatine canal and PPF were considerably higher on the left side than on the right. The angle between PC and SPF decreased markedly with age. Only sphenoidal sinus volume was significantly smaller on the same side as the septal deviation. There was no correlation between PPF volume with maxillary and sphenoid sinus volumes from adjacent paranasal sinuses. Conclusions: Volumetric and morphometric data obtained from PPF and paranasal sinuses can aid clinicians in diagnosing and treating patients by guiding them in selecting the right surgical approach or tools, especially in endoscopic procedures. [ABSTRACT FROM AUTHOR]

Introduction The endoscopic endonasal transpterygoid approach (EETPA) with or without the addition of the endoscopic-assisted sublabial anterior transmaxillary approach (ESTA) has become increasingly utilized for lesions posterior to the pterygopalatine fossa (PPF), including infratemporal fossa (ITF), lateral recess of the sphenoid sinus, Meckel's cave, petrous apex, and parapharyngeal space. The main goal of this study is to develop an educational resource to learn the steps of the EETPA for trainees. Methods EETPA and ESTA were performed in 12 specimens by neurosurgery trainees, under supervision from the senior authors. One EETPA and one ESTA were performed on each specimen on opposite sides. Dissections were supplemented with representative cases. Results After a wide unilateral sphenoidotomy, ethmoidectomy, and partial medial maxillectomy, the anteromedial bone limits of the PPF were identified and drilled out. The pterygoid progress was modularly removed. By enlarging the opening of the posterior and lateral walls of the maxillary sinus through EETPA and ESTA, respectively, the neurovascular and muscular compartments of the PPF and ITF were better identified. The EETPA opens direct corridors to the PPF, medial ITF, middle cranial fossa, cavernous sinus, Meckel's cave, petrous apex, and internal carotid artery. If a more lateral exposure of the ITF is needed, the ESTA is an appropriate addition. Conclusion Despite the steep learning curve of the EETPA, granular knowledge of its surgical anatomy and basic surgical steps are vital for those advancing their learning in complex endoscopic approaches to the ventral skull base when expanding the approach laterally in the coronal plane. [ABSTRACT FROM AUTHOR]

Background: Bleeding is a common intraoperative complication in most of the surgeries and remains a challenge for the Surgeons. Despite the availability of many techniques, there is no definite method for controlling bleeding during endoscopic nasal surgeries. Objective: In this study, we evaluated the effectiveness of pterygopalatine fossa infiltration with lignocaine and adrenaline in controlling surgical field bleeding during endoscopic nasal surgery. Methods: Comparative observational study conducted in Department of ENT (Ear-Nose-Throat) of a tertiary care hospital. All patients who were diagnosed with chronic sinusitis, bilateral sinonasal polyposis, bilateral inferior turbinate hypertrophy supported by nasal endoscopy and computed tomography were considered for the study after fulfilling the inclusion and exclusion criteria. The effect of Pterygopalatine fossa infiltration was tested by injecting 2 mL of xylocaine with 1:100000 adrenaline in pterygopalatine canal on one side (test side), and saline on the control side. The surgical field was assessed and graded every 15 minutes on both sides according to Boezaart and Vander Merwe scoring system. Result: In our study, among the 22 patients who were infiltrated, 19 patients (86%) showed surgical field improvement on the infiltrated side, 3 patients (14%) had similar fields on both side (infiltrated and non-infiltrated side) and none of the patients had lesser bleed on the saline infiltrated side. The grading scale of surgical field was done using a scale called Boezaart and van der Merwe scale and the result was significantly better on the infiltrated side. (p value <0.001). Conclusion: This study finds a significant difference in surgical field bleeding, favouring the injection side. Since it is a simple technique with minimal complications, it can be routinely incorporated in all endoscopic nasal surgery. [ABSTRACT FROM AUTHOR]

Abstract Background Tumors in the pterygopalatine fossa (PPF) and infratemporal fossa (ITF) are still challenging to surgeons because of their deep location and proximity to various arteries and cranial nerves. This study aimed to evaluate the access to infratemporal fossa and pterygopalatine fossa through anterior transmaxillary, modified endoscopic transnasal transmaxillary approaches. The study was a prospective comparative study conducted on 20 patients having a mass in pterygopalatine or infratemporal fossa. History, examination, computed tomography, and magnetic resonance imaging were performed for all patients. Nine patients were operated with anterior transmaxillary approach and eleven patients were operated with endoscopic transnasal transmaxillary approach. The operative duration, intraoperative blood loss, and operative difficulty were assessed. Patients were assessed 1 week postoperatively using a nasal surgical questionnaire for postoperative nasal symptoms. Endoscopic assessment of the nose was done 1 week postoperative to assess the degree of crusting and 4 weeks postoperative to assess nasal adhesions. Postoperative complications were assessed for both groups. Results There was a significant difference between the two groups regarding operative duration and blood loss favoring the endoscopic group. There was a non-significant difference between the two groups regarding operative difficulty. There was a significant difference between the two groups regarding nasal obstruction, crustation, bleeding, sneezing, secretion, and nasal pain. There was a significant difference between the two groups regarding the endoscopic assessment for nasal crusting and adhesions. Facial swelling and numbness of the face were significantly more in the open group compared with the endoscopic group. Conclusion Endoscopic endonasal transmaxillary approach had less trauma and lower complication rate while anterior transmaxillary was technically feasible and offered excellent surgical access with easy lateral expansion toward the infratemporal fossa. Both approaches had comparable operative difficulty and acceptable postoperative quality of life.

Objective To investigate the microsurgical treatment of giant osteochondroma in pterygopalatine fossa. Methods The clinical data of 1 patient with giant osteochondroma in pterygopalatine fossa admitted to Department of Neurosurgery, General Hospital of the Eastern War Zone in March 2022 was analyzed retrospectively. The relevant literature were reviewed. The patient was admitted due to right facial numbness with decreased olfactory function. The skull CT and MRI examination showed that there was a giant osteoma in the right pterygopalatine fossa, and there were bone changes in right sphenoid pterygoid process, greater sphenoid wing, temporal bone and mastoid process. According to the examination results, osteochondroma of the right pterygopalatine fossa was considered, and the lesions was resected through the infratemporal fossa approach. Results The lesion was completely removed in the operation, and the patient had no obvious complications after the operation. The skull CT showed that the lesion was completely resected postoperatively, and the pathology indicated osteochondroma. Conclusions Osteochondroma of pterygopalatine fossa is rare. Combination of skull CT and MRI is helpful for diagnosis. Resection of osteochondroma in pterygopalatine fossa via infratemporal fossa approach has the advantages of complete resection, less trauma and rapid recovery. [ABSTRACT FROM AUTHOR]

Despite growing interest in the endoscopic endonasal approach (EEA) to the medial orbital apex (OA), a comprehensive description of the multilayer topology lying at the intersection of the regional compartments is missing. An EEA to the OA, pterygopalatine fossa, and cavernous sinus was performed in 20 specimens. A 360° layer-by-layer dissection was performed taking into consideration relevant anatomical aspects of the interface and documented with 3-dimensional technologies. Endoscopic landmarks were analyzed to provide an outline of the compartments and identify critical structures. Additionally, the consistency of a previously described reference called orbital apex convergence prominence was analyzed and a method to identify its position was introduced. The orbital apex convergence prominence was an inconsistent finding (15%). However, a craniometric method introduced in this study proved to be reliable to reach the orbital apex convergence point. Additional structures such as the sphenoethmoidal suture and a 3-suture junction (sphenoethmoidal-palatoethmoidal-palatosphenoidal) helped to identify the posterior limit of the OA and define a keyhole to access the compartments of the interface. We defined the bone limits of the "optic risk zone," an area where the optic nerve is more susceptible to damage. Furthermore, an orbital fusion line (periorbita-dura-periosteum) was identified and divided into 4 segments according to adjacent structures: optic, cavernous, pterygopalatine, and infraorbital. Understanding cranial landmarks and the folds of the layers covering the orbito-cavernous-pterygopalatine interface can facilitate tailoring an EEA to the medial orbital space and avoid unnecessary exposure of sensitive anatomy in the vicinity. [ABSTRACT FROM AUTHOR]

Background: For aggressive maxillary sinus and pterygopalatine fossa (PPF) tumors, an en‐bloc pterygomaxillectomy may be indicated. Methods: Five head specimens were used to study the feasibility of an en‐bloc pterygomaxillectomy. Eighty‐five non‐pathological CT scans were used to compare the superior edge of the inferior turbinate (IT) and the middle turbinate tail (MT) as landmarks for the pterygoid osteotomy. Results: Through a combined sublabial–subperiosteal incision and transoral route, a mid‐sagittal osteotomy through the hard palate and an axial osteotomy below the infraorbital foramen were performed. For the endoscopic pterygoid osteotomy, an infra‐vidian transpterygoid approach was performed, subsequently removing the pterygomaxillectomy en‐bloc. As landmarks, the osteotomies at the level of the MT tail and IT resected the pterygoid plates completely, but the IT osteotomy was further away from the vidian canal (7.5 vs. 6 mm). Conclusions: The endoscopic‐assisted en‐bloc pterygomaxillectomy is feasible. The IT landmark is safe and ensures complete resection of the pterygoid plates. [ABSTRACT FROM AUTHOR]

ObjectiveIn this paper, the goal of the authors is to present the anatomic nuances and their clinical experience with lesions of the pterygopalatine fossa and infratemporal fossa using an endoscopic transnasal prelacrimal recess transmaxillary approach (PLRMA).MethodsAn endoscopic anatomical dissection of three fresh cadaveric heads was performed bilaterally to evaluate the feasibility of the PLRMA. Prior to dissection, stereotactic computed tomography scans were obtained for each head to obtain anatomical measurements. The area of exposure on the posterior wall of the maxillary sinus was determined using stereotaxis. The cases of six patients with schwannomas or epidermoid cysts who underwent the transnasal PLRMA were illustrated.ResultsThe mean area of exposure on the posterior wall of the maxillary sinus was 9.55 cm2. Total resection was achieved in all six patients. The mean follow-up time was 16 months, and one patient complained of postoperative facial numbness, which resolved gradually. No cases of chronic sinusitis were reported.ConclusionsThe endoscopic transnasal PLRMA provides efficient operative exposure to the pterygopalatine fossa and infratemporal fossa. Preserving the integrity of the mucosa on the nasal lateral wall is an advantage of this approach.

Schwannomas are rarely seen in pterygopalatine fossa (PPF). PPF is a complex anatomical location and is often difficult to assess. This tumor arises from the branches of the trigeminal nerve. Initially, this tumor at the PPF is removed by conventional extra-nasal technique. The open-access traditional method for removal of the tumor from PPF is often associated with morbidity. However, the advancement of an expanded endonasal approach enables the skull base surgeons to reach into PPF via a transnasal nasal approach. A 22-year-old female was presented with a headache on the right side for 1 month and right-side facial numbness for 15 days. Computed tomography scan and magnetic resonance imaging confirmed the tumor at the PPF. The patient underwent endoscopic removal of the tumor and the biopsy confirmed the diagnosis of schwannoma. The endoscopic transnasal approach provides adequate access to the PPF, therefore, it enables the removal of the tumor safely with little or no morbidity than the conventional approach. [ABSTRACT FROM AUTHOR]

Background: Schwannomas are neoplasms that are rarely found in the sinonasal tract and pterygopalatine fossa (PPF). The objective of this study is to evaluate the schwannoma in the sinonasal tract and PPF including its effectiveness of endoscopic surgical excision of the lesion. Methods: This retrospective study was done between March 2018 and April 2022. There were nine cases of benign schwannomas found in the nasal cavity, the nasal ethmoid and the PPF. All patients had undergone endoscopic endonasal removal of the tumour. Results: All the patients successfully underwent endonasal endoscopic excision of the schwannoma from the sinonasal tract and PPF. Out of nine patients, one showed recurrence after 1 year during follow-up check-ups. None of the patients showed any major vascular complications during surgery. At follow-up, one patient presented with a persistent sensory deficit in the facial area. Conclusions: The endonasal endoscopic approach for schwannoma at the sinonasal tract and PPF is a safe and effective method for biopsy and treatment. This approach is highly effective for visualisation and has the potential to reduce complications. Pre-operative imaging is an important step before successful treatment by endoscopic endonasal removal of the schwannoma. [ABSTRACT FROM AUTHOR]

Objective: To investigate the efficacy and safety of injecting onabotulinum toxin A (BTA) towards the sphenopalatine ganglion (SPG) using the MultiGuide® in patients with persistent idiopathic facial pain (PIFP). Methods: This cross-over, exploratory study compared the injection of 25 units BTA versus placebo in patients who met modified ICDH-3 criteria for PIFP. Daily pain diaries were registered for a 4-week baseline, a 12-week follow-up after each injection, and an 8-week conceptual washout period in between. The primary efficacy endpoint was the change from baseline to weeks 5–8 in average pain intensity using a numeric rating scale. Adverse events were recorded. Results: Of 30 patients who were randomized to treatment, 29 were evaluable. In weeks 5–8, there was no statistically significant difference in average pain intensity between BTA versus placebo (0.00; 95% CI = −0.57 to 0.57) (P = 0.996). Following both BTA and placebo injections, five participants reported at least a 30% reduction in average pain during weeks 5–8 (P = 1.000). No serious adverse events were reported. Post-hoc analyses indicated a possible carry-over effect. Conclusions: Injection of BTA toward the SPG with the MultiGuide® did not appear to provide a reduction in pain reduction at 5–8 weeks, although this finding may be influenced by a carry-over effect. The injection appears to otherwise be safe and well-tolerated in patients with PIFP. Trial Registration: The study protocol is registered in ClinicalTrial.gov (NCT03462290) and EUDRACT (number: 2017-002518-30). [ABSTRACT FROM AUTHOR]

Schwannomas are rarely seen in pterygopalatine fossa (PPF). PPF is a complex anatomical location and is often difficult to assess. This tumor arises from the branches of the trigeminal nerve. Initially, this tumor at the PPF is removed by conventional extra-nasal technique. The open-access traditional method for removal of the tumor from PPF is often associated with morbidity. However, the advancement of an expanded endonasal approach enables the skull base surgeons to reach into PPF via a transnasal nasal approach. A 22-year-old female was presented with a headache on the right side for 1 month and right-side facial numbness for 15 days. Computed tomography scan and magnetic resonance imaging confirmed the tumor at the PPF. The patient underwent endoscopic removal of the tumor and the biopsy confirmed the diagnosis of schwannoma. The endoscopic transnasal approach provides adequate access to the PPF, therefore, it enables the removal of the tumor safely with little or no morbidity than the conventional approach.

Background: Schwannomas are neoplasms that are rarely found in the sinonasal tract and pterygopalatine fossa (PPF). The objective of this study is to evaluate the schwannoma in the sinonasal tract and PPF including its effectiveness of endoscopic surgical excision of the lesion. Methods: This retrospective study was done between March 2018 and April 2022. There were nine cases of benign schwannomas found in the nasal cavity, the nasal ethmoid and the PPF. All patients had undergone endoscopic endonasal removal of the tumour. Results: All the patients successfully underwent endonasal endoscopic excision of the schwannoma from the sinonasal tract and PPF. Out of nine patients, one showed recurrence after 1 year during follow-up check-ups. None of the patients showed any major vascular complications during surgery. At follow-up, one patient presented with a persistent sensory deficit in the facial area. Conclusions: The endonasal endoscopic approach for schwannoma at the sinonasal tract and PPF is a safe and effective method for biopsy and treatment. This approach is highly effective for visualisation and has the potential to reduce complications. Pre-operative imaging is an important step before successful treatment by endoscopic endonasal removal of the schwannoma.

Abstract Background This study aimed to assess the effect of pterygopalatine fossa injection via greater palatine canal with xylocaine and adrenaline on intra-operative surgical field bleeding and overall blood loss during FESS. Methods We are doing this randomized blinded study on 60 patients who underwent FESS. Infiltration with 2 ml of xylocaine 2% with 1:100,000 adrenaline was slowly injected on one side and the surgeon was asked to assess the surgical field using a Boezaart scale. Results Operative time is significantly less in injected cases than the other cases with a P value < 0.001. blood loss in injected side was significantly less than Non-injected side with a P value < 0.001. Conclusion There was a significant decrease in blood loss, duration of surgery, and improvement in visual field using Boezaart score in injection group (cases) who underwent pterygopalatine fossa injection of xylocaine/adrenaline compared to the other non-injected group.

Ballistic traumas among civilians are usually from low velocity, low calibre weapons such as soft air guns. The facial skeleton is an area of high aesthetic/functional value, and therefore, this is a showcase for technical description of a minimally invasive endoscopic approach for the removal of a bullet from the pterygopalatine fossae. [ABSTRACT FROM AUTHOR]

The pterygopalatine fossa (PPF) is a covert neurovascular pathway in the skull base and connects with numerous intracranial and extracranial spaces. The aim of this study was to explore the magnetic resonance imaging (MRI) features of PPF invasion in patients with nasopharyngeal carcinoma (NPC). The medical records of 88 patients with stage T3 or T4 NPC were retrospectively analyzed. The 3-Dimensional (3D) volumetric images of MRI were reconstructed for the tiny connecting conduits of the invaded PPFs in the NPC patients. The infiltration incidence of conduits and connected further structures were calculated. Forty-six PPFs from 37 patients were invaded by NPC. The proportions of stage T4 NPC and intracranial extension were higher in patients with PPF invasion than that without PPF invasion (P < 0.05). Each connecting conduit of the PPF had corresponding optimal reconstructed orientation based on 3D volumetric MRI images. The first three most common infiltrated conduits were palatovaginal canal, vidian canal and sphenopalatine foramen, which were adjacent to the nasopharynx. Among the conduits connecting with further structures, the most common infiltrated conduit was pterygomaxillary fissure, followed by foramen rotundum and inferior orbital fissure. Furthermore, The NPC lesions involved stage T4 structures via the conduits from 19.6% of the invaded PPFs. The application of high-quality reconstruction images based on 3D sequence of MRI in NPC patients proved to be feasible and beneficial for the manifestation of the invaded PPFs and connecting conduits. [ABSTRACT FROM AUTHOR]

Objectives: The aim of our study was to describe a surgical access to pterygopalatine fossa and Vidian canal using an endonasal endoscopic approach. We also intend to reveal the anatomical relations of the neurovascular structures in the surgical corridors and to determine the relationships between previously defined reference points in order to prevent surgical complications during surgical access to these regions. Methods: Our study was carried out between October-December 2016 in Cerrahpaşa Faculty of Medicine Microneurosurgery and Neuroanatomy Laboratory. A total of 7 silicon dye-injected cadavers (4 males and 3 females) were studied. 3D images were obtained by photographing the approaches applied to the pterygopalatine fossa and Vidian canal and related anatomical structures. Results: We succeeded in exposing and examining the pterygopalatine fossa and Vidian canal endoscopically in all samples. First, the posterior wall of the maxillary sinus was opened to reach the pterygopalatine fossa. The pterygopalatine fossa was divided into 3 anatomical compartments. The first layer encountered was the periosteum covering the pterygopalatine fossa. After removing the periosteum, the fat layer was revealed. Under the fat layer, the vascular compartment and finally the neural compartment were encountered. Conclusion: Our study revealed three-dimensional anatomical data related to the surgical margins involved in approaches to the pterygopalatine fossa and Vidian canal; and specifically defined various neurovascular structures encountered in these approaches. Our study provides information to decrease potential complications that may develop during endonasal endoscopic surgery. We conclude that as the anatomy of the pterygopalatine fossa and Vidian canal is known in details, the endonasal endoscopic approach is likely to become the standard method to access lesions in these regions. [ABSTRACT FROM AUTHOR]

Adenoid cystic carcinoma (AdCC) is a rare epithelial neoplasm of the head and neck, most commonly found in the salivary glands. Orbital AdCC is an uncommon clinical entity arising from the lacrimal glands, however primary orbital AdCC has been previously described in a small number of case reports. The exact origin of the neoplasm with uninvolved lacrimal gland in the orbit is unknown, however it may arise from ectopic lacrimal or salivary gland tissue, or extension from nearby epithelial structures. We describe the clinical characteristics, investigations and management of a 55-year-old man presenting with vertical diplopia, found to have left posterior orbital AdCC invading the skull base with intracranial extension involving the inferotemporal fossa, pterygopalatine fossa, left carotid artery, cavernous sinus and temporal lobe dura, without clinical or radiological lacrimal gland involvement or systemic metastases. [ABSTRACT FROM AUTHOR]

The pterygopalatine fossa (PPF) is a challenging space and pathological processes in this anatomical space are uncommon. This report presents a case of glomus tumor right PPF in a 65 years old female patient who underwent tumor removal by endoscopic transnasal-transmaxillary approach with preoperative selective embolization of the right internal maxillary artery. [ABSTRACT FROM AUTHOR]

Schwannomas of the sinonasal compartment are rare benign neoplasms of peripheral nerve sheath origin and constitute ~ 4% of all head and neck schwannomas. The presentation may simulate a range of benign and intermediate grade pathologies. Management involves surgical excision via open or endoscopic approach. To describe the clinico-epidemiological characteristics and surgical outcomes in sinonasal region schwannoma patients operated at our institute. The study is a descriptive case series of patients with sinonasal region schwannomas treated at our institution. A retrospective search of electronic database of the Department of ENT and Head and Neck Surgeries and Department of Pathology was conducted from January 2013 to January 2019. The various demographic and clinical details of the patients were extracted. A total of four patients operated for sinonasal region schwannoma were identified. The involved sites were nasal dorsum, nasal cavity, pterygopalatine fossa and infratemporal fossa. The mild, non-specific symptoms resulted in patients ignoring their symptoms for a while initially and presenting late. The nasal dorsum lesion was revealed as a surprise during open rhinoplasty for correction of nasal deformity. Complete excision was achieved in all the cases and no recurrence has been noticed during the follow up (varying from 6 months to 6 years) till date. The diverse clinical manifestations and approaches to the treatment of schwannomas in this specific region are discussed. The surgical excision is the standard of care in dealing with these neoplasms. This series highlights the rarity of this pathology in the sinonasal area, diagnostic surprises and the decision making to choose the correct surgical approach for complete excision. Once excised completely, recurrence is not expected. [ABSTRACT FROM AUTHOR]

This video article aims to describe the surgical technique and effectiveness of a combined endoscopic transnasal and pre-lacrimal recess approach for paramedian V2 schwannoma., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Hemangiomas are rare and benign tumors originating from the pterygopalatine fossa (PPF). In this study, we report a rare case of PPF hemangioma in a 66-year-old male, for which he underwent surgical resection via the anterior nasolacrimal recess after preoperative arteria maxillaris embolization. To enhance our understanding on this rare condition, we conducted a comprehensive review of existing literature on this disease to discuss its clinical characteristics, differential diagnoses, and potential treatment approaches., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes., Methods: This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings., Results: An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%)., Conclusions: This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis., (Copyright © 2024 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Purpose: Choroidal dysfunction is implicated in various ocular pathologies. The parasympathetic pterygopalatine ganglion (PPG) innervates orbital vessels supplying the choroid. While PPG stimulation has been shown to dilate cerebral blood flow, its effects on the choroid, particularly in human subjects, require further elucidation. This study aimed to investigate the short-term influence of PPG stimulation via electroacupuncture on choroidal structure., Methods: In this crossover study, 22 healthy adults received PPG electrical stimulation and sham stimulation for one session each on two separate days in a randomized order. Measurements including choroidal thickness (ChT), choroidal vascularity index (ChVI), central subfield thickness, axial length, anterior chamber depth, and lens thickness were recorded before and at intervals (0, 15, 30, 45, and 60 minutes) postintervention., Results: The ChT on the side receiving PPG stimulation demonstrated a sustained increase, peaking at 15 minutes poststimulation (17.2 µm, P < 0.001) and persisting for up to 60 minutes. Conversely, the ChVI exhibited a more immediate response, with a peak increase immediately poststimulation (3.8%, P = 0.003), followed by a gradual return to baseline. ChT and ChVI in the contralateral eye showed a nonsignificant trend to decrease. Additionally, a notable reduction in ipsilateral axial length was observed at specific time points poststimulation., Conclusions: PPG activation via electroacupuncture elicited a short-term increase in ChT and ChVI in the ipsilateral eye compared to sham stimulation, with ChT increases trailing those of ChVI but displaying greater persistence., Translational Relevance: Electrical stimulation of the PPG can produce a short-term increase in ipsilateral ChT and ChVI.

Introduction: Trigeminal autonomic cephalalgia (TAC) is a type of one-sided cerebral painful headache, with attacks regularly accompanied by autonomic responses, such as tearing, runny nose, panic, nausea and vomiting on the affected side. Currently, the most common treatment strategies are drugs, nerve grafts and surgery. Clinical understanding of TACs is limited. Here, we report the case of thermocoagulation treatment of the pterygopalatine ganglion in an uncommon TAC under local anesthesia. Case Presentation: A rare case of TAC was treated with computed tomography (CT)-guided thermocoagulation within the pterygopalatine ganglion. Pain and autonomic signs were relieved immediately after surgery, with the patent retaining only slight numbness on the left side of the face. This numbness completely resolved at 6 months of follow-up and there was no recurrence. Discussion: Trigeminal autonomic cephalalgia seriously affects the patient's quality of life, but clinical understanding is limited. In the case reported here, we performed CT-guided thermocoagulation of the pterygopalatine ganglion at 90 °C for 180 s for treatment of a trigeminal autonomic headache. To our knowledge, this is the first report of using thermocoagulation at 90 °C to treat the pterygopalatine ganglion. We found that this strategy results in fewer side effects and is a more cost-effective treatment for such patients than other options. Conclusion: Computed tomography-guided thermocoagulation of the pterygopalatine ganglion at 90 °C for 180 s for treatment of trigeminal autonomic headache is a safe and economical treatment option. [ABSTRACT FROM AUTHOR]

Background: Both the endoscopic transnasal Denker's and prelacrimal approaches provide surgical access to the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). Objectives: This study compares the potential maximum exposure of the PPF and ITF and quantifies the difference in surgical freedom via endoscopic Denker's and prelacrimal approaches. Methods: Six cadaveric specimens (12 sides) were dissected using a prelacrimal approach on one side and an endoscopic Denker's approach on the contralateral side. The contents of the PPF and ITF were sequentially exposed. Surgical freedom for each corridor was subsequently calculated. Results: This study confirms that both the prelacrimal and Denker's approaches provide adequate exposure of the PPF and ITF. The maximum exposure boundaries were similar for both approaches, including the middle cranial fossa superiorly, floor of the maxillary sinus inferiorly, zygomatic arch and temporomandibular joint laterally, and post-styloid space posteriorly. However, the data revealed a statistically significant difference (p < 0.05) regarding the surgical freedom of the prelacrimal (388.17 ± 32.86 mm2) and the endoscopic Denker's approaches (906.35 ± 38.38 mm2). Conclusion: When compared with an endoscopic Denker's approach, a prelacrimal approach seems to achieve a similar extent of exposure (ie, visualization) of the PPF and ITF. Nonetheless, the endoscopic Denker's approach offers superior surgical freedom ; thus, it is preferred for the management of complex lesions which requires increased instrument maneuverability with a 3- or 4-handed technique. [ABSTRACT FROM AUTHOR]

Objectives Large-scale procedural safety data on pterygopalatine fossa nerve blocks (PPFBs) performed via a suprazygomatic, ultrasound-guided approach are lacking, leading to hesitancy surrounding this technique. The aim of this study was to characterize the safety of PPFB. Methods This retrospective chart review examined the records of adults who received an ultrasound-guided PPFB between January 1, 2016, and August 30, 2020, at the University of Florida. Indications included surgical procedures and nonsurgical pain. Clinical data describing PPFB were extracted from medical records. Descriptive statistics were calculated for all variables, and quantitative variables were analyzed with the paired t test to detect differences between before and after the procedure. Results A total of 833 distinct PPFBs were performed on 411 subjects (59% female, mean age 48.5 years). Minor oozing from the injection site was the only reported side effect, in a single subject. Although systolic blood pressure, heart rate, and oxygen saturation were significantly different before and after the procedure (132.3 vs 136.4 mm Hg, P  < 0.0001; 78.2 vs 80.8, P  = 0.0003; and 97.8% vs 96.3%, P  < 0.0001; respectively), mean arterial pressure and diastolic blood pressure were not significantly different (96.2 vs 97.1 mm Hg, P  = 0.1545, and 78.2 vs 77.4 mm Hg, P  = 0.1314, respectively). Similar results were found within subgroups, including subgroups by sex, race, and indication for PPFB. Discussion We have not identified clinically significant adverse effects from PPFB performed with an ultrasound-guided suprazygomatic approach in a large cohort in the hospital setting. PPFBs are a safe and well-tolerated pain management strategy; however, prospective multicenter studies are needed. [ABSTRACT FROM AUTHOR]

We report a case of Immunoglobulin G4 (IgG4) related disease involving the pterygoplataine fossa. A 83-year-old male presented with left ocular pain and visual disturbance. CT showed an isodense soft tissue lesion in the left pterygopalatine fossa with bony sclerotic changes and erosion. MRI revealed an infiltrative soft tissue mass in the left pterygopalatine fossa as a T2 slightly low signal intensity and heterogeneous enhancement. The patient underwent left ethmoidectomy, and biopsy of the mass was conducted. The histopathological diagnosis was IgG4-related disease. In this case, it was difficult to differentiate invasive aspergillosis, which is common in immunocompromised patients, considering the patient’s clinical history of diabetes mellitus. This report describes the imaging findings of IgG4-related disease mimicking invasive sinusitis such as invasive aspergillosis.

BackgroundMini-implant-assisted rapid palatal expansion (MARPE) appliances have been developed with the aim to enhance the orthopedic effect induced by rapid maxillary expansion (RME). Maxillary Skeletal Expander (MSE) is a particular type of MARPE appliance characterized by the presence of four mini-implants positioned in the posterior part of the palate with bi-cortical engagement. The aim of the present study is to evaluate the MSE effects on the midpalatal and pterygopalatine sutures in late adolescents, using high-resolution CBCT. Specific aims are to define the magnitude and sagittal parallelism of midpalatal suture opening, to measure the extent of transverse asymmetry of split, and to illustrate the possibility of splitting the pterygopalatine suture.MethodsFifteen subjects (mean age of 17.2 years; range, 13.9-26.2 years) were treated with MSE. Pre- and post-treatment CBCT exams were taken and superimposed. A novel methodology based on three new reference planes was utilized to analyze the sutural changes. Parameters were compared from pre- to post-treatment and between genders non-parametrically using the Wilcoxon sign rank test. For the frequency of openings in the lower part of the pterygopalatine suture, the Fisher's exact test was used.ResultsRegarding the magnitude of midpalatal suture opening, the split at anterior nasal spine (ANS) and at posterior nasal spine (PNS) was 4.8 and 4.3 mm, respectively. The amount of split at PNS was 90% of that at ANS, showing that the opening of the midpalatal suture was almost perfectly parallel antero-posteriorly. On average, one half of the anterior nasal spine (ANS) moved more than the contralateral one by 1.1 mm. Openings between the lateral and medial plates of the pterygoid process were detectable in 53% of the sutures (P

Purpose: Rhinocerebral mucormycosis is a rapidly progressive angioinvasive fungal infection commonly seen in diabetics. In the COVID-19 pandemic we have witnessed a sudden surge in these cases. We aimed to evaluate the disease presentation, patterns of spread, and any association with the COVID-19 virus. Methods: This prospective study was conducted on mucormycosis patients operated between March and July 2021. The diagnosis was confirmed either on KOH staining, fungal culture or histopathological examination. Results: Thirty one cases (21 males, 10 females) with a mean age of 53.3 years were included, of which 9 (29.1%) were COVID positive on presentation, 17 (54.8%) were post-COVID, while 5 (16.1%) had radiological evidence of COVID sequelae. Most common symptoms were cheek numbness (87.1%), headache (83.9%), visual disturbances (77.4%), and palate involvement (58.1%). Blackening of turbinates was uncommon (22.6%). Ethmoid sinus was involved in all patients. Pterygopalatine fossa involvement was present in 77.4%, and was accurately diagnosed on contrast enhanced MRI scan. There were 8 (25.8%) deaths, while the remaining are discharged or under treatment. Conclusion: An increase in the incidence of mucormycosis in the COVID-19 pandemic is probably due to a compromise in host immunity along with a synergistic effect in thrombotic microangiopathy. Spread of infection to the soft tissues of the infratemporal fossa, orbit or palate occur via neurovascular structures rather than by bone erosion. The pterygopalatine fossa is involved in most individuals. [ABSTRACT FROM AUTHOR]

Background and Objectives: The maxillary sinus hypoplasia (MSH) is an occasional variation of the maxilla, occurring either unilaterally or bilaterally. Previous studies dealing with MSH have not detailed the consequent anatomical changes of the maxilla and adjacent fossae. Materials and Methods: A 58-year-old female case was scanned in Cone Beam Computed Tomography and found to have asymmetrical bilateral MSH, who was then further evaluated anatomically. Results: The maxillary sinuses were hypoplastic and had mild mucosal thickenings. The orbital floors were curved. The uncinate process and the ethmoidal infundibulum were laterally displaced beneath the orbit floor. On each side, the lateral nasal wall protruded within the respective maxillary bone to reach above the vestibular cortical plate of the alveolar process. This expansion of the lateral nasal walls was limited to the premolar and first molar regions. The inferior turbinates were laterally curved. The perpendicular palatine plate was building a postero-lateral nasal wall in front of the pterygopalatine fossa. Conclusions: The classification systems of MSH should be detailed to indicate whether the normal uncinate process is medial or inferior to the orbit. The lateral expansion of the lateral nasal wall in MSH is limited to the anterior part of that wall. The laterally expanded nasal fossa could reach anterior to the pterygopalatine fossa in MSH. Seemingly, CBCT is a better tool than CT to evaluate the detailed anatomy of the modified anatomical structures in MSH; as such, it could be of help in a surgical approach. [ABSTRACT FROM AUTHOR]

Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; the maxilla, anteriorly; the medial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone, medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.