gms | German Medical Science

Objective: Different microsurgical approaches to the pterygopalatine fossa are used. Most of these approaches require a visible skin incision. Endoscopic surgeries, especially with image guidance, demonstrate minimally invasive alternatives in this location. But lateral and anterior extensions may not be reached by the transnasal route alone; a combination with a transmaxillary route may be needed. On the basis of our experience, a trajectory is defined, separating the accessibility via the nostril and the maxillary sinus, respectively.

Method: 5 patients (age median 15y, range 10–58y) with neoplasms in and around the pterygopalatine fossa were treated, 2 juvenile angiofibromas, 1 rhabdomyosarcoma, 1 adenoidcystic carcinoma, and 1 synovial carcinoma. The approach was started with the transnasal route for resection of tumor in the pterygopalatine fossa. Tumor lateral to the lateral pterygoid process was approached via the maxillary sinus. Therefore, a small osteotomy of the anterior wall of the maxillary sinus was performed after a sublabial incision. A transnasal approach alone was sufficient in 3 cases, the combination with a transmaxillary route was added in 2 cases.

Results: Gross total resection was achieved in 3 cases, in 2 cases remnants were left behind around the extracranial part of the internal carotid artery. Progression free survival in all cases, median follow-up 29 months, range 2–43 months. In 2 cases, a bacterial infection of the cavity was treated antibiotically. No carotid bleeding, csf fistula, nor new neurologic deficit was encountered. In our hands, the limit in the axial plane was the trajectory from the ipsilateral nostril to the lateral pterygoid process. For the tumor extensions lateral to that line, a transmaxillary route was added. In our opinion, the use of neuronavigation with a CT angio is mandatory for the location of the carotid artery in the potentially hard tumor.

Conclusions: The pure endoscopic transnasal approach provided an excellent access medial to the line drown from the ipsilateral nostril to the lateral pterygoid plate. Tumor lateral to this line was accessible via a small osteotomy of the anterior wall of the maxillary sinus. This combined endoscopic approach may serve as a solid method for the resection of extended tumors of the anterior skull base.