eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Skull Base, Infratemporal Fossa Approach

Author: Ricardo L Carrau, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, Department of Neurological Surgery, Department of Oral and Maxillofacial Surgery, University of Pittsburgh School of Medicine; Professor of Oral and Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine
Coauthor(s): Amin B Kassam, MD, Professor and Chairman, Department of Neurological Surgery, University of Pittsburgh School of Medicine; Director, Minimally Invasive Endoneurosurgery Center, University of Pittsburgh Medical Center; Carl H Snyderman, MD, Professor, Departments of Otolaryngology and Neurological Surgery, University of Pittsburgh Medical Center; Amol M Bhatki, MD,, Attending Physician, Department Of Otolaryngology–Head and Neck Surgery, Specialty Chief, Division of Endoscopic Skull Base Surgery, Baylor University Medical Center
Contributor Information and Disclosures

Updated: Jul 8, 2009

Introduction

History of the Procedure

In 1961, Fairbanks-Barbosa was the first to report an infratemporal fossa (ITF) approach, indicated for advanced tumors of the maxillary sinus.1 Transtemporal approaches described by Fisch, preauricular approaches described by Schramm and Sekhar, and transmaxillary approaches described by Terz, Janecka, and Cocke validated the efficacy of and indications for this technique, and provided the framework for other modifications.2,3,4 Recently, transnasal endoscopic and endoscopic-assisted approaches have been added to the armamentarium of skull base surgeons.


Coronal view MRI depicting a V3 neurilemoma.

Coronal view MRI depicting a V3 neurilemoma.

Coronal view MRI depicting a V3 neurilemoma.

Coronal view MRI depicting a V3 neurilemoma.

Problem

Any of the structures contained within or surrounding the ITF may be the origin of a tumor. Although rare, the ITF may also be affected by metastasis. Evaluation of patients with ITF tumors requires the identification of their nature, origin, and extent. These factors, as well as the biologic behavior of the tumor, the patient's needs and demands, comorbidities, and the training and experience of the surgeon influence the selection of the surgical approach. A multidisciplinary team is critical to ensure an adequate diagnosis, staging, tumor extirpation, and reconstruction of consequent cosmetic and functional deficits.

Presentation

Patients with ITF tumors can present with various symptoms depending on the structures affected. Mass effects, eustachian tube dysfunction, trismus, and cranial neuropathies are common. Physical examination is inadequate to evaluate the ITF; therefore, imaging is the keystone of the clinical evaluation.

Indications

An infratemporal fossa approach is a complex procedure that involves significant time, effort, and cost; therefore, under most circumstances, one must consider the procedure only as part of a curative therapeutic plan. Endoscopic approaches are more appropriate than conventional approaches if the goal is palliation. However, in select patients, a transnasal endoscopic approach may be used as the sole approach, yielding a complete resection that is equivalent to that of a conventional approach. Note that the indications for an endoscopic approach are in a state of rapid flux. Technology, new instrumentation, and experience drive the design and advancement of these and other minimally invasive techniques. Thus, some of these factors determine the selection of a conventional versus an endoscopic approach.

An ITF approach may provide the access required for the resection of a tumor, or it may be adjunctive to other approaches, such as transcranial-subtemporal, Le Fort I, transmaxillary, or anterior subfrontal approaches. Infrequently (ie, when fine-needle aspiration biopsy [FNAB], true-cut biopsies, and other means have failed to obtain an adequate sample), an ITF approach is used to obtain an adequate biopsy. In these cases, the endonasal endoscopic approach is preferable to conventional approaches.

Indications for a preauricular approach include tumors that originate in the ITF and intracranial tumors that originate at the anterior aspect of the temporal bone or greater wing of the sphenoid bone and that extend into the ITF. A preauricular approach may also be combined with other approaches to expose tumors that extend posteriorly or anteriorly. However, the preauricular approach provides inadequate exposure for the resection of tumors that invade the tympanic bone and does not provide adequate access to the intratemporal facial nerve or jugular bulb.

The postauricular approach is designed to expose and resect lesions that involve the temporal bone and that extend into the ITF.

The transfacial approach is best used to resect sinonasal tumors that require maxillectomy and that invade the ITF, the masticator space, or the pterygomaxillary fossa and for tumors of the nasopharynx extending into the ITF. However, the authors reserve its use for cancers of the antrum that extend into the ITF.

The techniques for endoscopic approaches to the ITF are in rapid evolution, spearheaded by the emergence of technology geared to this type of surgery. Indications for these approaches are likewise in a state of flux, parallel to these advancements. At present, the transnasal endoscopic approaches are mostly used for benign tumors of the sinuses, nose, and throat (ie, juvenile angiofibroma), tumors that arise at the infratemporal fossa (eg, trigeminal neurilemoma) or skull base (ie, meningiomas). This approach is also indicated for select malignancies, such nasopharyngeal carcinomas that persist or recur after chemoradiation and do not involve the internal carotid artery (ICA), or as palliative debulking of cancers of the sinuses, nose, and throat, such as adenoid cystic carcinoma.

Relevant Anatomy

The infratemporal fossa (ITF) is a potential space bounded superiorly by the temporal bone and the greater wing of the sphenoid bone; medially by the superior constrictor muscle, the pharyngobasilar fascia, and the pterygoid plates; laterally by the zygoma, mandible, parotid gland, and masseter muscle; anteriorly, by the pterygoid muscles; and posteriorly by the articular tubercle of the temporal bone, glenoid fossa, and styloid process. By this definition, the ITF comprises the contents of both the parapharyngeal space (ie, internal carotid artery [ICA], internal jugular vein [IJV], cranial nerves [CN] IV to XII) and the masticator space (ie, V3, internal maxillary artery [IMA], pterygoid venous plexus, pterygoid muscles).

The ITF communicates with the middle cranial fossa via the neurovascular foramina (ie, carotid canal, jugular foramen, foramen spinosum, foramen ovale, foramen lacerum). Medially, the ITF communicates with the pterygopalatine fossa via the pterygomaxillary fissure, which is contiguous with the inferior orbital fissure and, thus, the orbit.

Benign tumors usually respect these boundaries and expand the ITF in the direction of its soft-tissue planes, or they follow preexisting pathways (eg, foramen ovale, pterygomaxillary fissure). Conversely, malignant tumors can infiltrate and destroy all structures within the ITF and adjacent spaces.

The presence of neurovascular structures within the ITF (eg, ICA) or adjacent to it (eg, CN VII) limits the exposure of any particular surgical approach to the ITF. Thus, surgical approaches are designed not only to remove the tumor but also to preserve and identify these neurovascular entities.

Contraindications

Patients in whom an ITF approach or dissection are contraindicated include those with lymphoreticular tumors, which are best treated with radiation and/or chemotherapy; patients who are poor surgical candidates due to pulmonary, cardiac, renal, or other significant co-morbidities; and patients with disseminated disease. The main limiting factor in choosing an ITF approach is extension of the tumor and its relationship to neurovascular structures.

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References

References

  1. Barbosa JF. Surgery of extensive cancer of paranasal sinuses. Presentation of a new technique. Arch Otolaryngol. Feb 1961;73:129-38. [Medline].

  2. Sekhar LN, Schramm VL Jr, Jones NF. Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg. Oct 1987;67(4):488-99. [Medline].

  3. Janecka IP, Sen CN, Sekhar LN, Arriaga M. Facial translocation: a new approach to the cranial base. Otolaryngol Head Neck Surg. Sep 1990;103(3):413-9. [Medline].

  4. Cocke EW Jr, Robertson JH, Robertson JT, Crook JP Jr. The extended maxillotomy and subtotal maxillectomy for excision of skull base tumors. Arch Otolaryngol Head Neck Surg. Jan 1990;116(1):92-104. [Medline].

  5. Catalano PJ, Biller HF. Extended osteoplastic maxillotomy. A versatile new procedure for wide access to the central skull base and infratemporal fossa. Arch Otolaryngol Head Neck Surg. Apr 1993;119(4):394-400. [Medline].

  6. Fisch U. The infratemporal fossa approach for the lateral skull base. In: The Otolaryngologic Clinics of North America. Philadelphia, Pa: WB Saunders Co; 1984:513-552.

  7. Terz JJ, Young HF, Lawrence W Jr. Combined craniofacial resection for locally advanced carcinoma of the head and neck II. Carcinoma of the paranasal sinuses. Am J Surg. Nov 1980;140(5):618-24. [Medline].

  8. Biller HF, Shugar JM, Krespi YP. A new technique for wide-field exposure of the base of the skull. Arch Otolaryngol. Nov 1981;107(11):698-702. [Medline].

  9. Bilsky MH, Bentz B, Vitaz T, Shah J, Kraus D. Craniofacial resection for cranial base malignancies involving the infratemporal fossa. Neurosurgery. Oct 2005;57(4 Suppl):339-47; discussion 339-47. [Medline].

  10. Carrau RL, Pou A, Eibling DE, Murry T, Ferguson BJ. Laryngeal framework surgery for the management of aspiration. Head Neck. Mar 1999;21(2):139-45. [Medline].

  11. Fortes FS, Carrau RL, Snyderman CH, et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope. Jun 2007;117(6):970-6. [Medline].

  12. Fortes FS, Sennes LU, Carrau RL, et al. Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: development of a surgical instruction model. Laryngoscope. Jan 2008;118(1):44-9. [Medline].

  13. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. Oct 2006;116(10):1882-6. [Medline].

  14. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. Jul 15 2005;19(1):E6. [Medline].

  15. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. Jul 2005;19(1):E6.

  16. Mansour OI, Carrau RL, Snyderman CH, Kassam AB. Preauricular infratemporal fossa surgical approach: modifications of the technique and surgical indications. Skull Base. Aug 2004;14(3):143-51; discussion 151. [Medline].

  17. Netterville JL, Jackson CG, Civantos F. Thyroplasty in the functional rehabilitation of neurotologic skull base surgery patients. Am J Otol. Sep 1993;14(5):460-4. [Medline].

  18. Nuss DW, Janecka IP, Sekhar LN, Sen CN. Craniofacial disassembly in the management of skull-base tumors. Otolaryngol Clin North Am. Dec 1991;24(6):1465-97. [Medline].

  19. Pou AM, Carrau RL, Eibling DE, Murry T. Laryngeal framework surgery for the management of aspiration in high vagal lesions. Am J Otolaryngol. Jan-Feb 1998;19(1):1-7. [Medline].

  20. Sekhar LN, Sen C, Snyderman CH. Anterior, anterolateral, and lateral approaches to extradural petroclival tumors. In: Sekhar LN, Janecka IP, eds. Surgery of Cranial Base Tumors. NY: Raven Press; 1993:157-223.

  21. Snyderman CH, Carrau RL, deVries EJ. Carotid artery resection: Update on preoperative evaluation. In: Johnson JT, Derkay CS, Mandell-Brown MK, Newman RK, eds. AAO-HNS Instructional Courses. 1993:341-346.

Further Reading

Keywords

infratemporal fossa approach, skull base, subtemporal approach, lateral skull base approach, ITF, eustachian tube dysfunction, trismus, cranial neuropathies, preauricular approach, postauricular approach, transfacial approach, angiography balloon occlusion with xenon computed tomography, ABOX-CT, Fisch approaches, anterior transfacial approach, facial translocation, transorbital approach, endoscopic approach, endoscopic endonasal approach, endoscopic trans-pterygoid approach

Contributor Information and Disclosures

Author

Ricardo L Carrau, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, Department of Neurological Surgery, Department of Oral and Maxillofacial Surgery, University of Pittsburgh School of Medicine; Professor of Oral and Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine
Ricardo L Carrau, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, North American Skull Base Society, Pennsylvania Medical Society, and Triological Society
Disclosure: Storz Endoscopy Inc Honoraria Speaking and teaching; Stryker Navigation Honoraria Speaking and teaching

Coauthor(s)

Amin B Kassam, MD, Professor and Chairman, Department of Neurological Surgery, University of Pittsburgh School of Medicine; Director, Minimally Invasive Endoneurosurgery Center, University of Pittsburgh Medical Center
Amin B Kassam, MD is a member of the following medical societies: American Association of Neurological Surgeons and Ontario Medical Association
Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Stryker Instruments Consulting fee Consulting; NICO Corporation Equity stake Board membership

Carl H Snyderman, MD, Professor, Departments of Otolaryngology and Neurological Surgery, University of Pittsburgh Medical Center
Carl H Snyderman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, North American Skull Base Society, Pennsylvania Medical Society, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Amol M Bhatki, MD,, Attending Physician, Department Of Otolaryngology–Head and Neck Surgery, Specialty Chief, Division of Endoscopic Skull Base Surgery, Baylor University Medical Center
Amol M Bhatki, MD, is a member of the following medical societies: Alpha Omega Alpha and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Douglas D Backous, MD, Director of Listen for Life Center, Department of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center
Douglas D Backous, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Association for Research in Otolaryngology, North American Skull Base Society, Society for Neuroscience, and Washington State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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