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Surgical anatomy and nuances of the expanded transpterygoid approach to the pterygopalatine fossa and upper parapharyngeal space: a stepwise cadaveric dissection

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Abstract

Background

Superb knowledge of anatomy and techniques to remove the natural barriers preventing full access to the most lateral aspect of the skull base determines the ease of using the transpterygoid approach (ETPA) as the main gateway for all the coronal planes during endonasal surgeries.

Methods

Throughout stepwise image-guided cadaveric dissections, we describe the surgical anatomy and nuances of the ETPA to the pterygopalatine fossa (PPF) and upper parapharyngeal space (UPPS).

Conclusion

The ETPA represents a lateral extension of the midline corridor and provides a valuable route to access the PPF/UPPS. Major landmarks for this EEA are the infraorbital canal, sphenopalatine foramen, and vidian nerve. It comprises the removal of the palatine bone, posterior wall of the maxillary sinus, and PPF transposition to drill the pterygoid process.

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Abbreviations

EEA:

Expanded endoscopic endonasal approach

ETPA:

Expanded transpterygoid approach

e-ICG:

Indocyanine-green video angiography

ITF:

Infratemporal fossa

IMA:

Internal maxillary artery

JNA:

Juvenile angiofibroma

PPF:

Pterygopalatine fossa

SPA:

Sphenopalatine artery

PWMS:

The posterior wall of the maxillary sinus

UPPS:

Upper parapharyngeal space

VN:

Vidian nerve

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Acknowledgments

We thank Thaïs Cristina Rejane-Heim, MD (Department of Pediatric Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio, USA, and Department of Pediatric Endocrinology, Federal University of Santa Catarina, Florianópolis, SC, Brazil); Thiago Albonette-Felicio, MD (Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA); Leonardo Schmidt Bertazzo Silveira and Andrei Koerbel, MD (Department of Neurological Surgery, University of Joinville, SC, BR); Ahmed Gamal Sholkamy Diab, MD (Department of Otolaryngology-Head and Neck Surgery, Assiut University, Egypt); Mohammad Salah Mahmoud Mady (Department of Otolaryngology-Head and Neck Surgery, Ain Shams University, Egypt); and Ruichun Li, MD (Department of Neurological Surgery, the first affiliated hospital of Xi’an Jiaotong University, China) for their contribution to this project.

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Authors and Affiliations

  1. Department of Neurological Surgery, The Ohio State University Medical Center, N-1049 Doan Hall, 410 West 10th. Avenue, Columbus, OH, 43210, USA

    Giuliano Silveira-Bertazzo, Rafael Martinez-Perez, Ricardo L. Carrau & Daniel M. Prevedello

  2. Department of Neurosurgery, University of Joinville Region, and Neurological and Neurosurgical Clinic of Joinville, Joinville, SC, Brazil

    Giuliano Silveira-Bertazzo

  3. Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, Columbus, OH, USA

    Ricardo L. Carrau & Daniel M. Prevedello

Authors
  1. Giuliano Silveira-Bertazzo
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  2. Rafael Martinez-Perez
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  3. Ricardo L. Carrau
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  4. Daniel M. Prevedello
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Corresponding authors

Correspondence to Giuliano Silveira-Bertazzo or Daniel M. Prevedello.

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Conflict of interest

This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., Medtronic Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS-Martin and ACE MEdical. Ricardo L. Carrau is a consultant for Medtronic Corp.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Key points

• The ETPA provides an avenue in the-off midline corridor and a valuable route to access the PPF/UPPS.

• If there is no need for extensive drilling of the pterygoid process or PPF/ITF dissections, the VN can be preserved, while the PPF is gently lateralized (still covered by the periosteum) avoiding neurovascular injury.

• The CE of the palatine bone helps to identify the sphenopalatine foramen and control the SPA.

• The adoption of e-ICG can help locate the carotid artery.

• The vascularized nasoseptal flap should be raised from the contralateral side.

• Identification of the VN, ET, and tubal muscles with the full understanding of its surrounding anatomy helps to locate the various ICA segments and avoid catastrophic bleeding.

• The ION serves as a landmark to delineate the PPF/ITF-approach and to estimate the need for early exposures (i.e., Denker)

• Adoption of the endonasal-Doppler and CT-A/MRI-neuronavigation help to reduce vascular complications.

• Cranial nerves and extraocular EMG monitoring reduce postoperative comorbidities.

• Staying anterior to the ET and V3 would avoid parapharyngeal-ICA injury.

This article is part of the Topical Collection on Neurosurgical Anatomy

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Silveira-Bertazzo, G., Martinez-Perez, R., Carrau, R.L. et al. Surgical anatomy and nuances of the expanded transpterygoid approach to the pterygopalatine fossa and upper parapharyngeal space: a stepwise cadaveric dissection. Acta Neurochir 163, 415–421 (2021). https://doi.org/10.1007/s00701-020-04551-y

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