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PTERYGOPALATINE FOSSA &
ITS APPROACHES
DR.ASHWIN MENON
PTERYGOPALATINE FOSSA
• A small space between the posterior surface of the
Maxilla and the Pterygoid process of the Spheno...
BOUNDARIES
• It can be considered as a pyramidal space:
• ANTERIOR: posterior surface of maxilla below floor
of orbit
• PO...
ANTERIOR
WALL
POST WALL
OF MAXILLA
INFERIOR ORBITAL
FISSURE
ORBIT TRANSMITS INFRAORB
VESSELS,NERVES, ASC BR
OF PtP GANG
PO...
CONTENTS
MAXILLARY NERVE
3RD PART OF MAXILLARY ARTERY
PTERYGOPALATINE GANGLION
NERVE OF PTERYGOID CANAL
Fat (Bichat’s)
TRIGEMINAL NERVE
BRANCHES
BRANCHES
MAXILLARY NERVE
•ORIGIN- From a semilunar ganglion in Meckel’s cave
as 2nd part of trigeminal nerve.
•Sensory nerve.
IN MID
CRANIAL
FOSSA
MENINGEAL BRANCH DURA
IN
PTERYGO
PALATIN
E FOSSA
ZYGOMATIC BRANCH ENTERS ORBIT THROUGH INFRA ORBITAL ...
PTERYGOPALATINE GANGLION
• The pterygopalatine ganglion (ganglion
pterygopalatinum, meckel's ganglion, nasal
ganglion, sph...
PTERYGO PALATINE GANGLION
(HAY FEVER GANGLION)
PARASYMPATHETIC
(SECRETOMOTOR)
SUPERIOR SALIVATORY AND LACRIMAL NUCLEAS (PO...
BRANCHES
ASCENDING DESCENDING POSTERIOR MEDIAL
ORBITAL BRANCHES
(secreato motor to
lacrimal and
ethmoidal air cells)
GREAT...
NERVE OF PTERYGOID CANAL
(VIDIAN NERVE)
• The nerve of the pterygoid canal (Vidian nerve) is
formed by the junction of the...
• Parasympathetic preganglionic fibers from the facial
nerve (contained within the greater petrosal nerve)
which synapse i...
VIDIAN CANAL
• It is through this canal the vidian nerve passes. This is a
short bony tunnel seen close to the floor of sp...
ARTERY OF THE PTERYGOID CANAL
• The artery of the pterygoid canal (Vidian artery) is an
artery that can arise from the int...
MAXILLARY ARTERY
• The main arterial supply to the infratemporal fossa
• Largest terminal branch of the external carotid a...
• Divided into three parts by lateral pterygoid muscle
• BRANCHES:-
1ST PART 2ND PART 3RD PART
IN FRONT OF STYLOMAND
LIGAM...
THIRD PART OF MAXILLARY ARTERY
• Enters pterygopalatine fossa through
Pterygomaxillary fissure.
GREATER PALATINE AND LESSE...
IMAGING
IMAGING
Contrast-enhanced axial CT scan shows pterygopalatine
fossa (arrows) between posterior wall of maxillary sinus and
anterio...
CLINICAL SIGNIFICANCE
• REFERRED OTALGIA:
Mandibular nerve also innervates a portion of ear (by
Auriculo-Temporal branch) ...
• HAY FEVER GANGLION:
In allergic states, congestion of the nasal
glands, lacrimal glands and palatine glands
result in ru...
NERVE BLOCKS
• INFERIOR ALVEOLAR NERVE
• MAXILLARY NERVE
• MANDIBULAR NERVE
INFERIOR ALVEOLAR NERVE BLOCK
• By inserting the needle, lateral to pterygomandibular
raphae, about 6-10mm above the occlu...
MAXILLARY NERVE BLOCK
• By inserting the needle, through the mandibular notch
(gingivo buccal sulcus opp to 2nd molar) and...
MANDIBULAR NERVE BLOCK
• By inserting the needle – 4cm deep through
Mandibular notch and sliding the needle posteriorly
al...
JUVENILE NASOPHARYNGEAL
ANGIOFIBROMA
• Spread of a tumor along the axis of Pterygomaxillary
fissure with the expansion of ...
APPROACHES TO PTERYGOPALATINE FOSSA
• TRANS ANTRAL APPROACH
• TRANS NASAL APPROACH
• TRANS PALATALAPPROACH
TRANS ANTRAL APPROACH
• Golding Wood -1961(Classic)
• Vidian neurectomy
• Maxillary artery ligation
• Nomura -1974 (sub pe...
VIDIAN NEURECTOMY
Indications:-
• Severe intractable vasomotor rhinitis
• Crocodile tears
• Senile nasal drip
• Severe rec...
• Elliptical
Posterior antral
window is made
with chisel cuts
after removing
mucosa
• A Zeiss
microscope with
300 mm lens ...
• Exposing
maxillary
artery, cleaning
and application
of occluding
clips and
division.
•Artery is
displaced
downwards seek
for maxillary
nerve and trace
upto foramen
rotundum.
• Identify and
follow
spenopalatine
bundle medial to
maxillary nerve
and trace it upto
medial butress.
Identify and
follow
spenopalatine
bundle medial to
maxillary nerve
and trace it upto
medial butress
where
shenopalatine
ar...
• Shenopalatine
bundle traced
further
medially to find
the ganglion
where it
diverges to
descending
palatine and
nasal bra...
• Shenopalatine
ganglion is found
8mm medial and
inferior to foramen
rotundum.
• A hook is slipped
over divergence of
Shen...
The mouth of
canal is then
coagulated with
diathermy.
• Surgery is completed with haemostasis
Post op complications
1. Absence of lacrimation
2. Facial analgesia
3. Ophthalmopl...
Maxillary artery ligation
• Indications:-
1. Acute massive epistaxis
2. Recurrent massive epistaxis
3. Herditary telengect...
TRANS NASAL APPROACH
• Endoscopic
• Minnis and Morrison -1971(Trans septal)
• Patel and Gaikward -1975 (Direct)
Endoscopic Transsphenoidal Approach
• After general anesthesia is administered,
the patient is placed in the semi-Fowler
p...
• The head of the middle turbinate is delicately
dislocated laterally to further widen the virtual
space between the middl...
• Once the sphenoid cavity is reached,
coagulation of the area around the sphenoid
ostium is performed. This serves to avo...
• Once the anterior sphenoidotomy is
completed, A 70° endoscope is used to identify
the vidian canal, usually at the sphen...
Intraoperative endoscopic views of
the transsphenoidal approach.
The vidian canal can be visualized
at the floor of the sp...
• The fragment of the nerve is removed
whenever possible and is sent for
pathologic examination. At the end of the
procedu...
TRANSNASALAPPROACH
• The patient is prepared, and the sphenoid
ostium is identified as in the
transsphenoidal approach. Sp...
• The vidian canal can usually be identified
between its exit from the sphenoid bone
and its entrance into the
pterygopala...
TRANS PALATALAPPROACH
• Done under GA
• Boyle – Davis mouth gag
• Curving incision 1 cm anterior to the
posterior margin o...
Maxillary nerve block
• Maxillary nerve may be blocked in PPF by
anaesthetic infiltration to greater palatine
canal
• Also...
• Two intra oral approaches
i. High tuberosity approach and
ii. Greater palatine canal approach
 High tuberosity approach...
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
Pterygopalatine fossa and approaches by Dr.Ashwin Menon
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Pterygopalatine fossa and approaches by Dr.Ashwin Menon

  1. 1. PTERYGOPALATINE FOSSA & ITS APPROACHES DR.ASHWIN MENON
  2. 2. PTERYGOPALATINE FOSSA • A small space between the posterior surface of the Maxilla and the Pterygoid process of the Sphenoid bone.
  3. 3. BOUNDARIES • It can be considered as a pyramidal space: • ANTERIOR: posterior surface of maxilla below floor of orbit • POSTERIOR: lateral pterygoid plate and a part of medial plate also • MEDIAL: perpendicular plate of palate • LATERAL: pterygomaxillary fissure • SUPERIOR: under surface of greater wing of sphenoid • INFERIOR: ABSENT (the post wall meets the ant wall and between them is greater palatine canal)
  4. 4. ANTERIOR WALL POST WALL OF MAXILLA INFERIOR ORBITAL FISSURE ORBIT TRANSMITS INFRAORB VESSELS,NERVES, ASC BR OF PtP GANG POSTERIOR WALL LATERAL AND MEDIAL PTERYGOID PLATES PTERYGOID CANAL MIDDLE CRANIAL FOSSA NEAR F.LACERUM TRANS VIDIAN NERVE AND VESSELS MEDIAL WALL PERP PLATE OF PALATE SPHENOPALATINE FORAMEN NASAL CAVITY SP ARTERY BR AND PtP GANG BRANCHES TO NP MUCOSA LATERAL WALL GAP BETWEEN THE PTERYGOID PLATES AND MAXILLA PTERYGOMAXILLA RY FISSURE INFRATEMPOR AL FOSSA TRANS MAX ARTERY SUPERIOR WALL GREATER WING OF SPHENOID F. ROTUNDUM MID CRANIAL FOSSA TRANSMITS MAXILLARY NERVE INFERIORLY ABSENT GREATER PALATINE AND LESSER PALATINE CANALS ORAL CAVITY ROOF GREATER PALATINE AND LESSER PALATINE NERVES AND VESSELS
  5. 5. CONTENTS MAXILLARY NERVE 3RD PART OF MAXILLARY ARTERY PTERYGOPALATINE GANGLION NERVE OF PTERYGOID CANAL Fat (Bichat’s)
  6. 6. TRIGEMINAL NERVE
  7. 7. BRANCHES
  8. 8. BRANCHES
  9. 9. MAXILLARY NERVE •ORIGIN- From a semilunar ganglion in Meckel’s cave as 2nd part of trigeminal nerve. •Sensory nerve.
  10. 10. IN MID CRANIAL FOSSA MENINGEAL BRANCH DURA IN PTERYGO PALATIN E FOSSA ZYGOMATIC BRANCH ENTERS ORBIT THROUGH INFRA ORBITAL FISSURE, THROUGH ZYGOMATICO ORBITAL FORAMEN AND SUPPLIES LACRIMAL GLAND AND ZYG-FACIAL AND ZYG-TEMP GANGLIONIC BRANCH PTERYGOPALATINE NERVES TO GANGLION POSTERIOR SUPERIOR ALVEOLAR NERVE ENERS POST SURFACE OF MAXILLA AND SUPPLY MOLARS IN ORBIT ANT SUP ALV NERVE (FROM INFRAORBITAL NERVE- A CONTINUATION OF MAXILLARY) MAIN TRUNK AFTER ENTERING ORBIT, GIVES THIS BRANCH FOR PREMOLARS, CANINE AND INCISORS MIDDLE SUPERIOR ALV NERVE SEEN AT TIMES IN FACE TERMINAL BRANCHES PALPABRAL, NASAL, LABIAL, LOWER EYELID, ANT NASAL APERTURE, ANT CHEEK
  11. 11. PTERYGOPALATINE GANGLION • The pterygopalatine ganglion (ganglion pterygopalatinum, meckel's ganglion, nasal ganglion, sphenopalatine ganglion) is a parasympathetic ganglion found in the pterygopalatine fossa. • It is one of four parasympathetic ganglia of the head and neck. (The others are submandibular gang., otic gang., and ciliary gang.).
  12. 12. PTERYGO PALATINE GANGLION (HAY FEVER GANGLION) PARASYMPATHETIC (SECRETOMOTOR) SUPERIOR SALIVATORY AND LACRIMAL NUCLEAS (PONS) – FACIAL NERVE – IN MID EAR TRVELS THROUGH GREATER SUPERFICIAL PETROSAL NERVE – THROUGH A HIATUS ENTERS MID CRANIAL FOSSA – ENTERS F. LACERUM – JOINS WITH DEEP PETROSAL NERVE (SYMPATHETIC) – VIDIAN NERVE – PTERYGOID CANAL – PTERYGOPALATINE FOSSA, RELAYED BY PPt GANG – POST GANG FIBRES SUPPLY LACRIMAL, NASAL, PALATINE GLANDS SYMPATHETIC (VASOCONSTRICTOr) FROM T1 AND T2 SEGMENTS OF SPINAL CORD – SUPERIOR CERVICAL SYMPATHETIC GANGLION – PLEXUS AROUND INTERNAL CAROTID –DEEP PETROSAL NERVE AT THE LEVEL OF F.LACERUM – PASSES THROUGH THE GANG WITHOUT RELAYING – SUPPLIES THE SAME GLANDS SENSORY FROM GANGLIONIC BRANCHES OF MAXILLARY NERVE
  13. 13. BRANCHES ASCENDING DESCENDING POSTERIOR MEDIAL ORBITAL BRANCHES (secreato motor to lacrimal and ethmoidal air cells) GREATER PALATINE NERVE (supplies hard palate and gives off Postero inferior lateral nasal branches) PHARYNGEAL BRANCH (supplies pharyngeal mucosa around the eust. tube orifice) POSTERIO- SUPERIOR MEDIAL NASAL (antero-inf septum and floor of nose) LESSER PALATINE NERVE (supply soft palate and tonsils) NASOPALATINE NERVES (roof of the mouth) POSTERO-SUPERIOR LATERAL NASAL (upper lateral quadrant of nasal septum)
  14. 14. NERVE OF PTERYGOID CANAL (VIDIAN NERVE) • The nerve of the pterygoid canal (Vidian nerve) is formed by the junction of the great petrosal nerve and the deep petrosal nerve within the pterygoid canal containing the cartilaginous substance which fills the foramen lacerum. • It passes forward through the pterygoid canal with its corresponding artery (artery of the pterygoid canal) and is joined by a small ascending sphenoidal branch from the otic ganglion. It then enters the pterygopalatine fossa and joins the posterior angle of the pterygopalatine ganglion.
  15. 15. • Parasympathetic preganglionic fibers from the facial nerve (contained within the greater petrosal nerve) which synapse in pterygopalatine ganglion. • Sympathetic postganglionic fibers from the deep petrosal nerve which do not synapse in pterygopalatine ganglion. • The postganglionic parasympathetic fibers of the deep petrosal nerve, upon synapsing in the pterygopalatine ganglion, will distribute to the nose, palate, and lacrimal gland through various nerves leaving the pterygopalatine fossa.
  16. 16. VIDIAN CANAL • It is through this canal the vidian nerve passes. This is a short bony tunnel seen close to the floor of sphenoid sinus. This canal transmits the vidian nerve and vidian vessels from the foramen lacerum to the pterygopalatine fossa. • According to CT scan findings the vidian canal is classified into:  Type I: The vidian canal lies completely within the floor of sphenoid sinus  Type II: In this type the vidian canal partially protrudes into the floor of sphenoid sinus  Type III: Here the vidian canal is competely embedded in the body of sphenoid bone
  17. 17. ARTERY OF THE PTERYGOID CANAL • The artery of the pterygoid canal (Vidian artery) is an artery that can arise from the internal carotid (ICA) or external carotid (ECA), or serve as an anastomosis between these arteries. • It more commonly arises from the ECA. • The artery passes backward along the pterygoid canal with the corresponding nerve. It is distributed to the upper part of the pharynx and to the auditory tube, sending into the tympanic cavity a small branch which anastomoses with the other tympanic arteries.
  18. 18. MAXILLARY ARTERY • The main arterial supply to the infratemporal fossa • Largest terminal branch of the external carotid artery • The maxillary artery arises just posterior to the neck of the mandible in the substance of the parotid gland and courses somewhat obliquely through the fossa to end in the pterygomaxillary fissure. • Through its course It usually lies lateral (superficially to the lateral pterygoid muscle, but it can sometimes lie on the deep side of the muscle.
  19. 19. • Divided into three parts by lateral pterygoid muscle • BRANCHES:- 1ST PART 2ND PART 3RD PART IN FRONT OF STYLOMAND LIGAMENT ALONG THE LOWER BORDER OF LAT PTERYGOID DEEP TO LATERAL PTERY MUSCLE UPTO PTERYGOMAXILLARY FISSURE ENTERS PTERYGOMAXILLAY FISSURE INTO PTERYGOPALATINE FOSSA 1ST PART 2ND PART 3RD PART Deep auricular Anterior tympanic Middle meningeal Accessory meningeal Inferior alveolar Deep temporal Masseteric Pterygoid Buccal Post . Superior alveolar Infra orbital Greater palatine Sphenopalatine Pharyngeal  Art.of pterygoid canal
  20. 20. THIRD PART OF MAXILLARY ARTERY • Enters pterygopalatine fossa through Pterygomaxillary fissure. GREATER PALATINE AND LESSER PALATINE ARTERIES THROUGH THE GP AND LP CANALS AND SUPPLIES HARD AND SOFT PALATE POSTERIOR SUPERIOR ALVEOLAR ARTERY MOLARS, PREMOLARS AND MAXILLARY SINUS SPHENOPALATINE ARTERY ENTERS NOSE THROUGH POSTERIOR PART OF SUPERIOR MEATUS, THROUGH SPHENOPALATINE FORAMEN DIVIDES INTO: POST LATERAL NASAL AND POST SEPTAL ARTERY OF PTERYGOID CANAL SUPPLIES THE ROOF OF THE PHARYNX PHARYNGEAL ARTERY SUPPLIES ROOF OF NASOPHARYNX INFRA ORBITAL ARTERY CONTINUATION OF THE MAX ARTERY, ENTERS ORBIT AND APPEARS IN FACE THROUGH INFRA ORBITAL FORAMEN ANTERIOR SUPERIOR ALVEOLAR (INFRA-ORBITAL BR) BEFORE EXITING THROUGH THE INFRA-ORBITAL FORAMEN
  21. 21. IMAGING
  22. 22. IMAGING
  23. 23. Contrast-enhanced axial CT scan shows pterygopalatine fossa (arrows) between posterior wall of maxillary sinus and anterior surface of pterygoid process of sphenoid bone. Fossa is seen as low density because of contained fat.
  24. 24. CLINICAL SIGNIFICANCE • REFERRED OTALGIA: Mandibular nerve also innervates a portion of ear (by Auriculo-Temporal branch) and hence pain in infected lower tooth (by Inferior alveolar branch) may be referred to ear • FORAMEN OVALE LESION: Paraesthesia of mandible, teeth and side of the face and paralysis of Masticatory muscles, hearing abberations and jaw jerk loss
  25. 25. • HAY FEVER GANGLION: In allergic states, congestion of the nasal glands, lacrimal glands and palatine glands result in running nose and lacrimation due to stimulation of Pterygopalatine ganglion. Hence it is called “Hay fever ganglion”
  26. 26. NERVE BLOCKS • INFERIOR ALVEOLAR NERVE • MAXILLARY NERVE • MANDIBULAR NERVE
  27. 27. INFERIOR ALVEOLAR NERVE BLOCK • By inserting the needle, lateral to pterygomandibular raphae, about 6-10mm above the occlusal table of mandibular teeth, then sliding posteriorly along the medial aspect of the ramus. • Approach area of injection from contralateral premolar region ,with other hand thumb retracting the buccal mucosa pressing on the coronoid process. • Vicinity of mandibular foramen can be reached. • Tongue and skin of chin are also anaesthetised due to Lingual and mental nerve blockade.
  28. 28. MAXILLARY NERVE BLOCK • By inserting the needle, through the mandibular notch (gingivo buccal sulcus opp to 2nd molar) and guiding it 45degrees superiorly and medially, along the pterygoid plate, until the pterygopalatine fossa is reached at a depth of 6-7 cm . • This can be confirmed by absence of bony resistence and adjusting the angle accordingly. • Foramen rotundum can be reached. • Useful in trigeminal neuralgia involving maxillary division.
  29. 29. MANDIBULAR NERVE BLOCK • By inserting the needle – 4cm deep through Mandibular notch and sliding the needle posteriorly along the lateral surface of the pterygoid plates. • Foramen ovale can be reached. • Useful in trigeminal neuralgia involving Mandibular division.
  30. 30. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA • Spread of a tumor along the axis of Pterygomaxillary fissure with the expansion of the walls. • Tumor in the sphenopalatine foramen can spread to pterygopalatine fossa and through the PtM fissure into the infratemporal fossa. • Most important sign in the imaging is the ‘bowing’ of posterior wall of Antrum. • They quickly spread to parapharyngeal and carotid space.
  31. 31. APPROACHES TO PTERYGOPALATINE FOSSA • TRANS ANTRAL APPROACH • TRANS NASAL APPROACH • TRANS PALATALAPPROACH
  32. 32. TRANS ANTRAL APPROACH • Golding Wood -1961(Classic) • Vidian neurectomy • Maxillary artery ligation • Nomura -1974 (sub periosteal)
  33. 33. VIDIAN NEURECTOMY Indications:- • Severe intractable vasomotor rhinitis • Crocodile tears • Senile nasal drip • Severe recurrent nasal polyposis General anaesthesia-hypotensive-60 mm/Hg Antrum opened (wider) as for Caldwell Luc procedure- preserve infra orbital nerve
  34. 34. • Elliptical Posterior antral window is made with chisel cuts after removing mucosa • A Zeiss microscope with 300 mm lens used to remove only bone
  35. 35. • Exposing maxillary artery, cleaning and application of occluding clips and division.
  36. 36. •Artery is displaced downwards seek for maxillary nerve and trace upto foramen rotundum.
  37. 37. • Identify and follow spenopalatine bundle medial to maxillary nerve and trace it upto medial butress.
  38. 38. Identify and follow spenopalatine bundle medial to maxillary nerve and trace it upto medial butress where shenopalatine artery lies anteriorly.
  39. 39. • Shenopalatine bundle traced further medially to find the ganglion where it diverges to descending palatine and nasal branches.
  40. 40. • Shenopalatine ganglion is found 8mm medial and inferior to foramen rotundum. • A hook is slipped over divergence of Shenopalatine bundle and sickle knife passed beneath it to cut VIDIAN NERVE emerging from pterygoid canal.
  41. 41. The mouth of canal is then coagulated with diathermy.
  42. 42. • Surgery is completed with haemostasis Post op complications 1. Absence of lacrimation 2. Facial analgesia 3. Ophthalmoplegia 4. Infection of antrum
  43. 43. Maxillary artery ligation • Indications:- 1. Acute massive epistaxis 2. Recurrent massive epistaxis 3. Herditary telengectiasis 4. Nasopharyngeal angiofibroma
  44. 44. TRANS NASAL APPROACH • Endoscopic • Minnis and Morrison -1971(Trans septal) • Patel and Gaikward -1975 (Direct)
  45. 45. Endoscopic Transsphenoidal Approach • After general anesthesia is administered, the patient is placed in the semi-Fowler position. • Cottonoids soaked with diluted epinephrine (1:100 000) and cocaine, 10% benzoylmethylecgonine),are positioned between the middle turbinate and the nasal septum to enlarge the space between them and to obtain decongestion of the nasal mucosa.
  46. 46. • The head of the middle turbinate is delicately dislocated laterally to further widen the virtual space between the middle turbinate and the nasal septum. • After creation of adequate space between the middle turbinate and the nasal septum, the endoscope is angled upward along the roof of the choana until it reaches the sphenoid ostium, usually located approximately 1.5 cm above the roof of the choana.
  47. 47. • Once the sphenoid cavity is reached, coagulation of the area around the sphenoid ostium is performed. This serves to avoid arterial bleeding originating from septal branches of the sphenopalatine artery. • Ostium enlargement proceeds circumferentially by use of bone punches; care must be taken in the inferolateral direction, where the sphenopalatine artery or its major branches lie.
  48. 48. • Once the anterior sphenoidotomy is completed, A 70° endoscope is used to identify the vidian canal, usually at the sphenoid sinus floor, lateral to the natural ostium. Transection of the nerve is performed using an angle probe under direct vision.
  49. 49. Intraoperative endoscopic views of the transsphenoidal approach. The vidian canal can be visualized at the floor of the sphenoid sinus. A probe is used to transect the vidian canal. Successful transection of the vidian nerve is performed by direct vision.
  50. 50. • The fragment of the nerve is removed whenever possible and is sent for pathologic examination. At the end of the procedure, hemostasis is obtained, and the middle turbinate is gently restored in a medial direction. • Packing of the nasal cavity- bleeding from the nasal mucosa- usually removed on the second day. Most patients are discharged 2 days after surgery.
  51. 51. TRANSNASALAPPROACH • The patient is prepared, and the sphenoid ostium is identified as in the transsphenoidal approach. Sphenoidotomy is performed near the level of the sphenoid sinus floor. • Just enough space is offered for the entrance of a 4-mm endoscope. The mucoperiosteum is elevated off the anterior and inferior surfaces of the sphenoid
  52. 52. • The vidian canal can usually be identified between its exit from the sphenoid bone and its entrance into the pterygopalatinefossa, usually medial to the root of the middle turbinate. • The nerve is subsequently transected by a sickle knife or by an angle probe. The remainder of the procedure is performed as described for the transsphenoidal approach.
  53. 53. TRANS PALATALAPPROACH • Done under GA • Boyle – Davis mouth gag • Curving incision 1 cm anterior to the posterior margin of hard palate • 5mm bone removed • 300mm Zeiss microscope –visualise ET orifice • Incision over mucosa to expose medial pterygoid plate, -which is removed with burr • Pterygoid canal is 2-3 mm deep- cauterised
  54. 54. Maxillary nerve block • Maxillary nerve may be blocked in PPF by anaesthetic infiltration to greater palatine canal • Also a method of anaesthesia to posterior superior alveolar nerve • Indications: 1. Dento facial deformities 2. Maxillary sinus surgeries 3. Diagnostic or therapeutic in trigeminal neuralgia cases
  55. 55. • Two intra oral approaches i. High tuberosity approach and ii. Greater palatine canal approach  High tuberosity approach- direct needle posteriorly superior and medially along zygomatic and infraorbital surfaces of maxilla to enter the PPF • Depth of insertion is measuring distance from gingival crest of premolar to infra orbital rim on face  Greater palatine canal approach-7mm anterior to jn. Of hard and soft palate- a 25 g needle bent at 45 degree parallel to mid sagittal plane-in postero superior direction-gently rotate the needle as it falls into the canal
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A kaleidoscopic view into Pterygopalatine fossa and its approaches.

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