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Middle infratemporal fossa less invasive approach for radical resection of parapharyngeal tumors: surgical microanatomy and clinical application

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Surgery of the infratemporal fossa (ITF) and parapharyngeal area presents a formidable challenge to the surgeon due to its anatomical complexity and limited access. Conventional surgical approaches to these regions were often too invasive and necessitate sacrifice of normal function and anatomy. To describe a less invasive transcranial extradural approach to ITF parapharyngeal lesions and to determine its advantages, 17 patients with ITF parapharyngeal neoplasms who underwent tumor resection via this approach were enrolled in the study. All lesions located in the ITF precarotid parapharyngeal space were resected through a small operative corridor between the trigeminal nerve third branch (V3) and the temporomandibular joint (TMJ). Surgical outcomes and postoperative complications were evaluated. Pathological diagnosis included schwannoma in eight cases, paraganglioma in two cases, gangliocytoma in two cases, carcinosarcoma in one case, giant cell tumor in one case, pleomorphic adenoma in one case, chondroblastoma in one case, and juvenile angiofibroma in one case. Gross total resection was achieved in 12 cases, near-total and subtotal resection were in 3 and 2 cases, respectively. The most common postoperative complication was dysphagia. Surgical exposure can be customized from minimal (drilling of retrotrigeminal area) to maximal (full skeletonization of V3, removal of all structures lying lateral to the petrous segment of internal carotid artery) according to tumor size and location. Since the space between the V3 and TMJ is the main corridor of this approach, the key maneuver is the anterior translocation of V3 to obtain an acceptable surgical field.

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Auriculotemporal nerve


Petrous (horizontal) segment of internal carotid artery


Vertical segment of internal carotid artery


Chorda tympani


Deep temporal nerve


Gasserian ganglion


Eustachian tube


Greater petrosal nerve


Gross total resection


Inferior alveolar nerve


Internal carotid artery


Infratemporal fossa


Infratemporal fossa approach


Cranial nerve IX (glossopharyngeal nerve)


Lingual nerve


Lateral pterygoid muscle


Maxillary artery


Middle meningeal artery


Medial pterygoid muscle


Near-total resection


Root of zygoma


Styloid diaphragm


Stylopharyngeus muscle


Temporal muscle


Temporomandibular joint


Tensor tympani muscle


Tensor veli palatini muscle


Trigeminal nerve second branch


Trigeminal nerve third branch


Zygomatic arch


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The authors wish to thank to Lori Radcliffe for providing the follow-up studies and examinations.

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The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Correspondence to Yoichi Nonaka.

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Mauricio Coelho Neto, Curitiba, Brazil

Nonaka Y et al. described with details the anatomy and the approaches to the infratemporal fossa used for parapharyngeal lesions resections. We have been using such approach by several reasons: it is less invasive in terms of cosmetic results if compared with paralateral or middle facial splits; when we deal with big tumors, the tumor itself opens the space for a safer dissection of the infratemporal space and its components; and the dissection of the trigeminal branches is done before dealing with the tumor at the middle fossa, which makes it easier to keep their functionality. In order to avoid catastrophic damage of the carotid artery we are using neuronavigation as a routine. For this purpose, current preoperative imaging protocols and registration with anatomical landmarks are mandatory to obtain the right accuracy of the method. We encourage neurosurgeons and skull base teams to use this paper as reference in future cases.

Thomas Santarius, Cambridge, UK

Nonaka et al. have analyzed Dr Fukushima’s cases and presented their experience with surgical management of tumors in the infratemporal fossa and parapharyngeal space, focusing of those accessed via the middle infratemporal approach (ITFA). These are relatively rare cases and here presented experience is a valuable resource for anyone who operates in this region.

The 17 cases approached via the middle IFTA are set against the background of 64 cases located in the infratemporal fossa/parapharyngeal space, giving the reader a flavor of the optimal indication for the use of this approach.

Surgical anatomy and technique have been described in detail and these have been beautifully illustrated with schematic drawings and photographs of cadaveric dissections. In addition, scans and intraoperative photographs of representative cases were also included.

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Nonaka, Y., Fukushima, T., Watanabe, K. et al. Middle infratemporal fossa less invasive approach for radical resection of parapharyngeal tumors: surgical microanatomy and clinical application. Neurosurg Rev 39, 87–97 (2016).

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