BACKGROUND: The infratemporal fossa (ITF) is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Due to its difficult approach, surgical intervention at the ITF has remained a heavy burden to surgeons. The aim of this article is to review basic skull base approaches and ITF structures and to avoid severe complications based on the accurate surgical knowledge. METHODS: A search of the recent literature using MEDLINE (PubMed), Embase, Cochrane Library, and other online tools was executed using the following keyword combinations: infratemporal fossa, subtemporal fossa, transzygomatic approach, orbitozygomatic approach, transmaxillary approach, facial translocation approach, midface degloving, zygomatico-transmandibular approach, and lateral skull base. Aside from our Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial, there have been very few randomized controlled trials. The search data for this review are summarized based on the authors’ diverse clinical experiences. RESULTS: We divided our results based on representative skull base approaches and the anatomy of the ITF. Basic approaches to the ITF include endoscopic endonasal, transzygomatic, orbitozygomatic, zygomatico-transmandibular, transmaxillary, facial translocation, and the midfacial degloving approach. The borders and inner structures of the ITF (with basic lateral skull base dissection schemes) are summarized, and the modified zygomatico-transmandibular approach (ZTMA) is described in detail. CONCLUSIONS: An anatomical basic knowledge would be required for the appropriate management of the ITF pathology for diverse specialized doctors, including maxillofacial, plastic, and vascular surgeons. The ITF approach, in conjunction with the application of microsurgical techniques and improved perioperative care, has permitted significant advances and successful curative outcomes for patients having malignancy in ITF.
Humans ; Pathology ; Perioperative Care ; Plastics ; Skull Base ; Sphenoid Bone ; Surgeons ; Zygoma

OBJECTIVE: To review endonasal endoscopic surgeries aided by Fusion image guided system, and to explore the application value of Fusion image guided system in endonasal endoscopic surgeries. METHOD: Retrospective research. Sixty cases of endonasal endoscopic surgeries aided by Fusion image guided system were analysed including chronic rhinosinusitis with polyp (n = 10), fungus sinusitis (n = 5), endoscopic optic nerve decompression (n = 16), inverted papilloma of the paranasal sinus (n = 9), ossifying fibroma of sphenoid bone (n = 1), malignance of the paranasal sinus (n = 9), cerebrospinal fluid leak (n = 5), hemangioma of orbital apex (n = 2) and orbital reconstruction (n = 3). RESULT: Sixty cases of endonasal endoscopic surgeries completed successfully without any complications. Fusion image guided system can help to identify the ostium of paranasal sinus, lamina papyracea and skull base. Fused CT-CTA images, or fused MR-MRA images can help to localize the optic nerve or internal carotid arteiy . Fused CT-MR images can help to detect the range of the tumor. It spent (7.13 ± 1.358) minutes for image guided system to do preoperative preparation and the surgical navigation accuracy reached less than 1mm after proficient. There was no device localization problem because of block or head set loosed. CONCLUSION Fusion image guided system make endonasal endoscopic surgery to be a true microinvasive and exact surgery. It spends less preoperative preparation time, has high surgical navigation accuracy, improves the surgical safety and reduces the surgical complications.
Cerebrospinal Fluid Leak ; surgery ; Endoscopy ; instrumentation ; Fibroma, Ossifying ; surgery ; Humans ; Nasal Surgical Procedures ; methods ; Neurosurgical Procedures ; Nose ; pathology ; Papilloma, Inverted ; surgery ; Paranasal Sinuses ; pathology ; Retrospective Studies ; Sinusitis ; surgery ; Sphenoid Bone ; pathology ; Surgery, Computer-Assisted ; methods

Plasmacytoma is a monoclonal neoplastic proliferation of plasma cells derived from bone marrow. Plasmacytoma of the skull base is very rare. Recently, the authors experienced a case of a 50-year-old woman with a tumor like lesion originating from the right sphenoid bone. The patient presented with a 3-month history of right facial pain and paresthesia. She had been diagnosed and treated with multiple myeloma for more than 5 years, although she was in complete remission until recently. Imaging studies including contrast CT scan and MRI, showed a huge, enhanced and irregular shaped lesion in the sphenoid bone along with skull base destruction and intracranial invasion. The patient underwent transnasal endoscopic biopsy under local anesthesia. The pathology was consistent with a plasma cell tumor and it was confirmed as a solitary plasmacytoma of the bone of the skull base. We report this rare case along with a literature review.
Anesthesia, Local ; Biopsy ; Bone Marrow ; Cheek* ; Facial Pain ; Female ; Humans ; Magnetic Resonance Imaging ; Middle Aged ; Multiple Myeloma* ; Paresthesia* ; Pathology ; Plasma Cells ; Plasmacytoma* ; Skull Base* ; Sphenoid Bone ; Tomography, X-Ray Computed

The diagnosis of death by drowning is one of the hardest challenges in forensic pathology. Circumstantial factors and physical evidence such as autopsy findings are both important in drowning. However, drowning findings are not specific and no laboratory tests can specifically detect drowning. It has been suggested that fluid in the paranasal sinuses, especially the sphenoid sinuses, is a sign of drowning, in conjunction with other autopsy findings. This study aimed to determine the frequency of detection of fluid in the sphenoid sinuses in cases of death by drowning. From 2003 to 2012, 54 autopsied cases of drowning were selected and reviewed in the Department of Forensic Medicine, Kyungpook National University School of Medicine, Daegu. The most common autopsy findings were foaming at the mouth and nostrils (13%), frothy fluid in the airways (28%), pulmonary edema with overexpansion of lungs (87%), drowning liquid in the stomach and duodenum (52%) and hemorrhages in the petromastoid part of the temporal bone (93%). Fluid in the sphenoid sinuses was detected in 45/54 cases (83%). The plankton test was positive in 33/54 cases (87%), however, in 26 of these cases, plankton was found only in the lung tissue. In conclusion, detection of fluid in the sphenoid sinuses could be a diagnostic sign for death by drowning. The sphenoid sinuses are easily accessible on autopsy, so it is highly recommended to look for fluid in the sphenoid sinuses when performing an autopsy on bodies recovered from water.
Autopsy ; Cause of Death ; Drowning ; Duodenum ; Forensic Medicine ; Forensic Pathology ; Hemorrhage ; Humans ; Lung ; Mouth ; Paranasal Sinuses ; Plankton ; Pulmonary Edema ; Sphenoid Sinus ; Stomach ; Temporal Bone

OBJECTIVETo study the clinical value of the whole-course endoscopic extended transsphenoidal approach assisted by neuronavigation in surgical resection of complex sphenoclival lesions.

METHODSImage reconstruction and registration were performed for 15 patients with complex sphenoclival lesions using the neuronavigation system, and the bilateral nasal extended transsphenoidal approach was adopted to remove the lesions with a whole-course endoscopic procedure.

RESULTSPostoperative pathological examination reported pituitary adenomas in 7 cases, chordomas in 5 cases, and cavernous angiomas in 3 cases. Total removal of the lesions was achieved in 10 cases, subtotal removal in 4 cases, and partial removal in 1 case. Transient polyuria occurred in 3 cases and 2 patients experienced temporary cerebrospinal rhinorrhea. No death occurred in these cases after the operation. During the follow-up ranging from 3 to 26 months, only 2 patients with partial lesion removal showed recurrence and received subsequent radiotherapy.

CONCLUSIONThe combination of whole-course endoscopic technique and neuronavigation can help improve the surgical outcomes and reduce complications of complex sphenoclival lesion removal via the extended transsphenoidal approach.

Adult ; Aged ; Chordoma ; surgery ; Female ; Humans ; Male ; Middle Aged ; Neuroendoscopy ; Neuronavigation ; Pituitary Neoplasms ; surgery ; Skull Base Neoplasms ; surgery ; Sphenoid Bone ; pathology ; surgery

Bone Cysts ; diagnosis ; Bone Cysts, Aneurysmal ; diagnosis ; Humans ; Male ; Middle Aged ; Sphenoid Bone ; pathology

A 69-year old man presented to us with decreased vision in his right eye and a relative afferent pupillary defect. Under the presumption that he was suffering from retrobulbar optic neuritis or ischemic optic neuropathy, visual field tests were performed, revealing the presence of a junctional scotoma. Imaging studies revealed tumorous lesions extending from the sphenoid sinus at the right superior orbital fissure, with erosion of the right medial orbital wall and optic canal. Right optic nerve decompression was performed via an endoscopic sphenoidectomy, and histopathologic examination confirmed the presence of aspergillosis. The patient did not receive any postoperative antifungal treatment; however, his vision improved to 20 / 40, and his visual field developed a left congruous superior quadrantanopsia 18 months postoperatively. A junctional scotoma can be caused by aspergillosis, demonstrating the importance of examining the asymptomatic eye when a patient is experiencing a loss of vision in one eye. Furthermore, damage to the distal optic nerve adjacent to the proximal optic chiasm can induce unusual congruous superior quadrantanopsia.
Aged ; Antifungal Agents/therapeutic use ; Aspergillosis/*complications/diagnosis ; Decompression, Surgical/methods ; Diagnosis, Differential ; Endoscopy/methods ; Eye Infections, Fungal/*complications/diagnosis/therapy ; Follow-Up Studies ; Hemianopsia/*complications/diagnosis/therapy ; Humans ; Magnetic Resonance Imaging ; Male ; Optic Nerve/pathology ; Scotoma/diagnosis/*etiology/therapy ; Sphenoid Bone/surgery ; Visual Acuity ; Visual Fields

BACKGROUNDSurgery of pituitary adenomas invading cavernous sinus has always been thought as a challenge due to the complex anatomical structures and high risk of complications. The purpose of this study was to evaluate endoscopic transsphenoidal approach to pituitary adenomas invading cavernous sinus.

METHODSThe clinical data of 22 patients who admitted to Xuanwu Hospital with pituitary adenomas invading cavernous sinus were analyzed retrospectively. All patients underwent endoscopic transsphenoidal surgery. To expose the surgical field sufficiently, the opening of sellar floor was exceeded the bone overlying the invaded cavernous sinus, and synthetic dura was used to repair and strengthen the sella floor for preventing the leak of cerebrospinal fluid.

RESULTSAmong 22 patients, total resection was achieved in 14, subtotal resection in 5, and partial resection in 3; no patient underwent insufficient resection. Visual symptoms improved in 7 of 9 patients. In one patient diplopia disappeared. Headache was relieved to various extents in all patients. No serious complications were found. Patient's hospital stay ranged from 7 to 20 days.

CONCLUSIONThese data suggest that the endoscopic transsphenoid approach is a safe, minimally invasive, and efficient surgical technique, which might be an important therapeutic strategy for the pituitary adenoms invading cavernous sinus.

Adenoma ; pathology ; surgery ; Adult ; Aged ; Cavernous Sinus ; pathology ; Endoscopy ; methods ; Female ; Humans ; Male ; Middle Aged ; Minimally Invasive Surgical Procedures ; Neoplasm Invasiveness ; Pituitary Neoplasms ; pathology ; surgery ; Sphenoid Bone ; surgery

Running through the infratemporal fossa is the lingual nerve (i.e. the third branch of the posterior trunk of the mandibular nerve). Due to its location, there are various anatomic structures that might entrap and potentially compress the lingual nerve. These anatomical sites of entrapment are: (a) the partially or completely ossified pterygospinous or pterygoalar ligaments; (b) the large lamina of the lateral plate of the pterygoid process; and (c) the medial fibers of the anterior region of the lateral pterygoid muscle. Due to the connection between these nerve and anatomic structures, a contraction of the lateral pterygoid muscle, for example, might cause a compression of the lingual nerve. Any variations in the course of the lingual nerve can be of clinical significance to surgeons and neurologists because of the significant complications that might occur. To name a few of such complications, lingual nerve entrapment can lead to: (a) numbness, hypoesthesia or even anesthesia of the tongue's mucous glands; (b) anesthesia and loss of taste in the anterior two-thirds of the tongue; (c) anesthesia of the lingual gums; and (d) pain related to speech articulation disorder. Dentists should, therefore, be alert to possible signs of neurovascular compression in regions where the lingual nerve is distributed.
Cranial Fossa, Middle ; Foramen Ovale ; pathology ; Humans ; Ligaments ; pathology ; Lingual Nerve ; pathology ; Nerve Compression Syndromes ; complications ; pathology ; Ossification, Heterotopic ; pathology ; Paresthesia ; etiology ; Pterygoid Muscles ; pathology ; Sphenoid Bone ; pathology ; Tongue ; innervation

OBJECTIVE: To investigate the diagnosis and treatment of fibrous dysplasia (FD) involving the skull base. METHOD: The clinical data of 15 patients with fibrous dysplasia involving the skull base was retrospective analysis. RESULT: All patients were underwent CT examinations. FD involved orbital roof in 15 patients, ethmoidal bone in 15 patients, middle and lower nasal turbinate in 8 patients, frontal bone in 8 patients, sphenoidal bone in 6 patients, and maxillary bone in a patient. Although the optic canal was affected in 4 patients, only one patient had impaired vision. All the patients were treated by craniofacial approach. One patient with impaired vision was performed decompression of optic canal and had improved in vision. The titanium mesh was use for construction of skull base defect. There were not complications, such as infection, cerebral hemorrhage, etc. CONCLUSION It should be underwent surgical treatment for fibrous dysplasia involving skull base which resulted in clinical manifestations. Whether prophylactic decompression of optic canal is performed or notr depends on the patients clinical and radiological information.
Adolescent ; Adult ; Female ; Fibrous Dysplasia of Bone ; pathology ; surgery ; Frontal Bone ; pathology ; Humans ; Male ; Maxilla ; pathology ; Orbit ; surgery ; Retrospective Studies ; Skull Base ; pathology ; Sphenoid Bone ; pathology ; Young Adult