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1.
A A Pract ; 15(8): e01502, 2021 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-34403375

RESUMO

Adenotonsillectomies are one of the most common otolaryngologic surgeries performed to alleviate obstructive sleep-disordered breathing and apnea in children. The pain management following adenotonsillectomy continues to be a challenge for both pediatric anesthesiologists and otolaryngologists due to the mortality that stems from the use of opioid pain medications in children who have an increased baseline risk airway obstruction and apnea that is exacerbated by any exposure to opioids. We present a case utilizing bilateral suprazygomatic maxillary nerve (SZMN) blocks or, more accurately, suprazygomatic infratemporal-pterygopalatine fossa injections to achieve opioid-free perioperative analgesia for pediatric adenotonsillectomy with nasal turbinate reduction.


Assuntos
Analgésicos Opioides , Tonsilectomia , Analgésicos Opioides/uso terapêutico , Criança , Humanos , Dor Pós-Operatória/tratamento farmacológico , Fossa Pterigopalatina , Conchas Nasais
2.
Acta Neurochir (Wien) ; 163(8): 2165-2175, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33914166

RESUMO

OBJECTIVE: To demonstrate the utility and limitations of the extradural endoscopic-assisted anterior temporal fossa approach to the pterygopalatine fossa (PPF), infratemporal fossa (ITF), paranasal sinuses (PS), parapharyngeal region (PPR), nasal cavities (NC), epipharynx (EP), and clivus. METHODS: A frontotemporal orbitozygomatic craniotomy is performed. The dura is elevated from the cavernous sinus (CS). The anterior temporal fossa floor is drilled. Foramen rotundum and ovale are opened. The PPF is exposed and the lateral margin of inferior orbital fissure (IOF) is removed. The anterolateral triangle (ALT) is drilled and the vidian nerve (VN) is exposed. Drilling between the maxillary nerve (V2) and the VN provides access to the sphenoid sinus (SphS). The medial pterygoid plate is drilled exposing the EP. The maxillary sinus (MaxS) is opened anterior to the PPF. V2 is transposed laterally to enlarge the anteriomedial triangle (AMT). The orbital muscle of Muller is removed as well as the medial margin of the IOF, which opens the SphS. Anteriorly, the posterior ethmoid air cells are opened. Morphometric measurements evaluating the size of the ALT were done and the PS, NC, EP were explored with the endoscope. RESULTS: The ALT and AMT triangle provides a wide exposure of the PPF, ITF, PPR. In addition, those triangles represent a deep entry point to explore the PS, NC, and EP. CONCLUSION: The ALT and AMT are useful corridors to access to the SphS, MaxS, PS, NC, and EP via a transcranial approach. The use of the endoscope through this corridor widely extend the extradural anterior temporal fossa approach which may be considered as a valuable alternative to the extended endoscopic endonasal approach for selected skull base lesions extending both intracranial and into the PS, NC and EP.


Assuntos
Cavidade Nasal , Seios Paranasais , Cadáver , Humanos , Neuroendoscopia , Seios Paranasais/cirurgia , Fossa Pterigopalatina/anatomia & histologia , Fossa Pterigopalatina/cirurgia , Osso Esfenoide/anatomia & histologia
3.
World Neurosurg ; 150: 171, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33838335

RESUMO

The pterygopalatine fossa (PPF) is an inverted, pyramid-shaped space immediately behind the posterior wall of the maxillary sinus, and lesions arising here include juvenile angiofibromas, schwannomas, and, in exceptionally rare cases, malignant peripheral nerve sheath tumors.1,2 Surgical access to the PPF is challenging and has been historically achieved via an open transmaxillary approach associated with facial scaring/deformity as well as potential injury to facial and infraorbital nerve branches.3 We present the case of a 67-year-old woman with facial numbness secondary to a presumed trigeminal schwannoma in the right PPF on magnetic resonance imaging. This surgical video highlights the key stages in performing an endoscopic endonasal excision of a PPF tumor. We start with a wide medial maxillary antrostomy, mobilization of the inferior turbinate, ethmoidectomy, and sphenoidotomy. The posterior wall of the maxillary sinus is then lifted off the anterior aspect of the tumor. The soft tissue attachment medial to the tumor containing the sphenopalatine artery is then cauterized and divided. This is followed by circumferential blunt dissection of the tumor until it is sufficiently mobile to remove in a piecemeal fashion. The PPF is then examined for any residual tumor and any bleeding from the maxillary artery within the fat pad. Hemostasis and reattachment of the inferior turbinate into the lateral nasal wall is demonstrated. The patient did not have any new deficits postoperatively, but histology indicated a malignant peripheral nerve sheath tumor and she underwent postoperative proton beam therapy. Postoperative surveillance magnetic resonance imaging at 14 months showed no tumor recurrence. The patient consented to the procedure in a standard fashion (Video 1).


Assuntos
Neuroendoscopia/métodos , Neurofibrossarcoma/cirurgia , Fossa Pterigopalatina/cirurgia , Idoso , Feminino , Humanos , Seio Maxilar/cirurgia , Fossa Pterigopalatina/patologia , Resultado do Tratamento
4.
Head Neck ; 43(6): 1964-1970, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33764626

RESUMO

Robotic transmaxillary skull base surgery has been described using multiport systems. This cadaveric study investigates the feasibility of transmaxillary skull base surgery using a next-generation robot. An extended Caldwell-Luc antrostomy, measuring 3.3 cm by 4.0 cm, was performed in 15 min using a Kerrison rongeur and the robotic endoscope. A single-port, robotic system (da Vinci Sp®, Intuitive Surgical, Inc, Sunnyvale, CA, USA) was then deployed throught the extended Caldwell-Luc approach and provided sufficient reach, visualization, and maneuverability to work within the pterygopalatine fossa (PPF) and the infratemporal fossa (ITF) using three surgical instruments. The ITF dissection was easiest with two instruments using the third instrument to retract the muscles of mastication. This study demonstrates the feasibility of single-port robotic transmaxillary approaches to the lateral ITF. Using a single-port robotic system, the operating surgeon can for the first time work in the PPF and ITF using two functional arms for tumor dissection and a third to retract.


Assuntos
Fossa Infratemporal , Procedimentos Cirúrgicos Robóticos , Robótica , Cadáver , Humanos , Fossa Pterigopalatina
5.
J Craniofac Surg ; 32(2): 716-718, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33705017

RESUMO

ABSTRACT: Recent advances in endoscopic intranasal technology have allowed for a safe approach to the pterygopalatine fossa lesion. However, we consider that there is still scope of improvement to approach a broader area with better operability and minimal invasiveness. A 51-year-old man underwent endoscopic endonasal surgery due to the recurrence of chordoma at the left pterygopalatine fossa. To access the lower and lateral part of the pterygopalatine fossa, we performed endoscopic endonasal transmaxillary removal via an inferior turbinate incision. During surgery, a wide operative field and good operability could be secured by inserting an endoscope from the right nostril through a window of the nasal septum. Subtotal removal of the tumor was achieved without any complication during the surgery. Endoscopic endonasal transinfraturbinate approach with nasoseptal window was effective in the removal of the pterygopalatine fossa tumor because it is less invasive and provides a good surgical view with better operability.


Assuntos
Recidiva Local de Neoplasia , Fossa Pterigopalatina , Endoscopia , Humanos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal/cirurgia , Nariz , Fossa Pterigopalatina/cirurgia
6.
Medicine (Baltimore) ; 100(8): e24916, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33663127

RESUMO

INTRODUCTION: Primary yolk sac tumor (YST) is an infrequently-diagnosed malignant extragonadal germ cell tumors. It is likely to recur locally and may present with widespread metastases once diagnosed. Primary YST of the head is uncommon but can cause severe complications, such as loss of vision once the tumor mass invades the optic nerve. PATIENT CONCERNS: A 20-month-old boy presented to the general clinic of the local children's hospital with a complaint of swelling of left face for 1 year and proptosis of the left eye for over 2 weeks as stated by his parents. Initially, he did have some vision, as he could walk by himself, but a special ophthalmologic examination was not performed. DIAGNOSES: Cranial computed tomography and magnetic resonance imaging revealed a large tumor accompanied by peripheral bone destruction in the left pterygopalatine fossa that extended to sphenoid, ethmoid, left maxillary sinuses, left nasoethmoid, and left orbit. The optic nerve was invaded on both sides. Chest and abdominal imaging were normal. A primary diagnosis of Langerhans cell hyperplasia was made. However, blood tests on the second day of hospitalization revealed significantly elevated serum alpha-fetoprotein levels. On the third day, the boy lost his eyesight, with loss of pupillary and no light sensation during flashlight stimulation on both sides. INTERVENTIONS: Nasal endoscopy was performed on the fourth day, the vast majority of soft tissue mass was resected for biopsy. Histopathological examination revealed features of endodermal sinus tumor. A final diagnosis of primary YST of pterygopalatine fossa was made. Because the mass could not be resected completely, he received combined chemotherapy with bleomycin, etoposide, and carboplatin for 6 cycles over six months. OUTCOMES: The patient recovered with significant tumor shrinkage and without secondary metastasis after 18 months but left permanently blind. CONCLUSION: The worst complication of loss of vision after Primary YST of pterygopalatine fossa alerts us that close physical examination during the initial investigation should be performed, which is especially important in young children who cannot express complaints well. Early detection and treatment with surgical resection and chemotherapy may contribute to satisfactory outcomes and avoidance of visual impairment.


Assuntos
Tumor do Seio Endodérmico/diagnóstico , Tumor do Seio Endodérmico/patologia , Fossa Pterigopalatina/patologia , Neoplasias Cranianas/diagnóstico , Neoplasias Cranianas/patologia , Antibióticos Antineoplásicos/administração & dosagem , Bleomicina/administração & dosagem , Cegueira/etiologia , Carboplatina/administração & dosagem , Quimioterapia Adjuvante , Diagnóstico Tardio , Tumor do Seio Endodérmico/complicações , Tumor do Seio Endodérmico/terapia , Humanos , Lactente , Imageamento por Ressonância Magnética , Masculino , Neoplasias Cranianas/complicações , Neoplasias Cranianas/terapia , Tomografia Computadorizada por Raios X
7.
J Craniofac Surg ; 32(5): e510-e513, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33534320

RESUMO

ABSTRACT: A 13-year-old Japanese boy with a 6-month history of bilateral nasal obstruction and a 3-week history of recurrent epistaxis from the right nose was admitted to our department. Nasal endoscopy revealed a reddish, smooth-walled tumor occupying the right nasal cavity. Computed tomography scan revealed a 3.5 × 4.5 × 7.0-cm heterogeneously enhancing mass involving the right nasal cavity and extending posteriorly to the nasopharynx, and laterally to the pterygopalatine fossa and the medial part of the infratemporal fossa. We diagnosed as juvenile nasopharyngeal angiofibroma with Radkowski classification stage IIC. The internal maxillary and ascending pharyngeal arteries were embolized with polyvinyl alcohol followed by Embosphere using a conventional Seldinger technique. En bloc resection was performed with an endoscopic ipsilateral endonasal and sublabial Caldwell-Luc transmaxillary approach under general anesthesia. As of 3 years postoperatively, no recurrence has been found. We report a child case of juvenile nasopharyngeal angiofibroma successfully treated with less invasive surgery with preoperative embolization.


Assuntos
Angiofibroma , Neoplasias Nasofaríngeas , Adolescente , Angiofibroma/diagnóstico por imagem , Angiofibroma/cirurgia , Criança , Endoscopia , Humanos , Masculino , Neoplasias Nasofaríngeas/diagnóstico por imagem , Neoplasias Nasofaríngeas/cirurgia , Recidiva Local de Neoplasia , Fossa Pterigopalatina/diagnóstico por imagem , Fossa Pterigopalatina/cirurgia
8.
Artigo em Chinês | MEDLINE | ID: mdl-33472300

RESUMO

Objective: To evaluate the application of combination use of endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically in skull base tumor with intra and extra-cranial involvement. Methods: A total of 7 patients (4 males and 3 females, aging from 27 to 65 years old, with a medium age of 48) undergone complicated skull base surgeries via endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically from May 2016 to January 2018 were reviewed respectively. The patients included 2 cases of recurrent invasive pituitary adenoma, 3 cases of basal skull meningiomas, 1 case of clivus chondrosarcoma, and 1 case of recurrent nasopharyngeal carcinoma. The lesion extensively infiltrated nasal cavity, extending to the paranasal sinus, bilateral cavernous sinus, sellar region, suprasellar, superior clivus, temporal lobe, pterygopalatine fossa, infratemporal fossa and important intracranial vessels. All the 7 patients were treated under general anesthesia by endoscopic endonasal approach combined with frontotemporal orbitozygomatic approach under the microscope. Total excision rate, intraoperative and postoperative complications and postoperative curative effect were observed. All of them were followed up for 6 to 12 months. The Glasgow Outcome Scale (GOS) was used to evaluate the prognosis. Result: Total tumor removal was performed in 5 cases, subtotal removel in 2 cases. There was no complication during the operation. Postoperative severe complications occurred in 2 cases, including 1 case of cerebrospinal fluid rhinorrhea and intracranial infection, which was cured by lumbar cistern drainage and intrathecal injection; 1 case occurred oculomotor nerve paralysis, which recovered during follow-up. Postoperative complications occurred in 1 case of trochlear nerve dysfunction, 2 cases of facial numbness, and 1 case of tinnitus. During follow-up, all patients recovered to varying degrees. There was no bleeding and death after the operation. No tumor recurred during the follow-up period. All patients were recovered well with GOS grade Ⅳ-Ⅴ. Conclusions: Endoscopic transnasal approach combined with microscopic frontotemporal orbitozygomatic approach can remove tumors in one stage, reduce surgical complications and improve surgical effect. It has good application prospects and is suitable for excising complex intracranial and extracranial communicating tumors of widely involving sellar, clivus and petrous apex area.


Assuntos
Neoplasias Meníngeas , Meningioma , Neoplasias da Base do Crânio , Adulto , Idoso , Endoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fossa Pterigopalatina , Estudos Retrospectivos , Base do Crânio/cirurgia , Neoplasias da Base do Crânio/cirurgia
9.
Neurocrit Care ; 35(1): 241-248, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33403584

RESUMO

BACKGROUND: Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal. METHODS: This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement. RESULTS: Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6-11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min. CONCLUSIONS: PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.


Assuntos
Hemorragia Subaracnóidea , Adulto , Analgésicos , Cefaleia , Humanos , Recém-Nascido , Masculino , Entorpecentes , Fossa Pterigopalatina , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/terapia
10.
Acta Neurochir (Wien) ; 163(2): 415-421, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32886225

RESUMO

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.


Assuntos
Procedimentos Neurocirúrgicos , Espaço Parafaríngeo/anatomia & histologia , Espaço Parafaríngeo/cirurgia , Fossa Pterigopalatina/anatomia & histologia , Fossa Pterigopalatina/cirurgia , Cadáver , Dissecação , Endoscopia/métodos , Humanos , Seio Maxilar/anatomia & histologia , Seio Maxilar/cirurgia , Neuroanatomia , Osso Esfenoide/anatomia & histologia , Osso Esfenoide/cirurgia
11.
Ann Otol Rhinol Laryngol ; 130(1): 98-103, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32578449

RESUMO

BACKGROUND: Reconstruction of full thickness nasal defects usually requires different donor sites for the external skin envelope, structural elements, and internal nasal lining. In this paper we present a novel single site method for dual inner lining and skeleton repair for full thickness nasal defects with a composite nasoseptal flap and extended pedicle dissection. METHODS: A 72-year-old male presented with a T4b melanoma involving the nasal dorsum and left upper lateral cartilage. Following full thickness resection, reconstruction was performed with a nasoseptal flap (NSF) with attached septal cartilage and vomer in conjunction with a paramedian forehead flap. Extended pedicle dissection into the pterygopalatine fossa allowed the NSF to fully cover the defect. RESULTS: The nasal defect was fully corrected. There was no evidence of flap compromise or nasal valve stenosis at 1 month, 2 month, and 1 year follow-up visits. CONCLUSIONS: We present here the first successful application of a composite cartilage-osseous-mucosal NSF for multilayered nasal reconstruction. In appropriate patients, this technique may obviate the need for flaps or grafts from extranasal sources, limiting donor site morbidity.


Assuntos
Cartilagens Nasais/transplante , Mucosa Nasal/transplante , Neoplasias Nasais/cirurgia , Retalhos Cirúrgicos , Vômer/transplante , Idoso , Testa/cirurgia , Humanos , Masculino , Melanoma/cirurgia , Fossa Pterigopalatina/cirurgia
12.
Reg Anesth Pain Med ; 46(3): 276-279, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33323391

RESUMO

There is renewed interest in the central role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and the pathophysiology of different primary and secondary headache disorders. There are diverse neural structures (parasympathetic, sympathetic and trigeminal sensory) that convene into the SPG which is located within the pterygopalatine fossa (PPF). This makes the PPF an attractive target to neuromodulatory interventions of these different neural structures. Some experts advocate for the nasal application of local anesthetics as an effective route for SPG block with the belief that the local anesthetic can freely access the PPF. It is time to challenge this historical concept from the early 1900s. In this daring discourse, I will review anatomical studies, CT and MRI reports to debunk this old myth. Will provide anatomical evidence to explain that all these assumptions are untrue and the local anesthetic has to magically 'travel' a distance of 4-12 mm of adipose and connective tissue to reach the SPG in sufficient concentration and volume to effectively induce SPG blockade. Future research should focus on assessing a clinical biomarker to confirm SPG blockade. It could be regional cerebral blood flow or lacrimal gland secretion.


Assuntos
Bloqueio do Gânglio Esfenopalatino , Anestesia Local , Anestésicos Locais , Humanos , Lidocaína , Fossa Pterigopalatina
13.
Oper Neurosurg (Hagerstown) ; 20(3): E227-E228, 2021 02 16.
Artigo em Inglês | MEDLINE | ID: mdl-33372963

RESUMO

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular benign tumor that originates in the sphenopalatine foramen and often spreads to adjacent compartments.1 Microsurgical resection with preoperative embolization remains the treatment of choice.2 We present a case of a large JNA involving multiple compartments. The patient is a 20-yr-old male who presented with long-term right nasal congestion. The MRI demonstrated a large enhancing mass that extended from the right nasal cavity and nasopharynx into the right pterygopalatine fossa (PPF), infratemporal fossa (ITF), and parapharyngeal space. Preoperative angiogram for embolization showed a highly vascular tumor with blood supply mainly from the internal maxillary artery and about 10% from a persistent mandibular branch of the internal carotid artery. Based on the UPMC JNA staging system, this tumor was a stage IV.2 A combined anterior transmaxillary (Caldwell-Luc) with an endoscopic endonasal transpterygoid approach was performed. The addition of the anterior transmaxillary approach increases the surgical freedom for traditional bipolar devices and improves the view and trajectory to more lateral structures like the PPF and ITF.3 Gross total resection was achieved without complications. The patient was discharged home with a partial V2 numbness (right superior gum) that improved with time. The endoscopic endonasal approach is a safe and effective technique even for large JNA. A multidisciplinary team consisting of an interventional radiologist, a skull base neurosurgeon, and an otorhinolaryngologist with expertise in endoscopic surgery may play a role for optimal surgical results. The patient consented for the procedure and for the video production.


Assuntos
Angiofibroma , Neoplasias Nasofaríngeas , Angiofibroma/diagnóstico por imagem , Angiofibroma/cirurgia , Humanos , Masculino , Cavidade Nasal , Neoplasias Nasofaríngeas/diagnóstico por imagem , Neoplasias Nasofaríngeas/cirurgia , Fossa Pterigopalatina , Base do Crânio
14.
Eur. j. anat ; 24(4): 263-267, jul. 2020. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-193957

RESUMO

The sphenopalatine ganglion occupies a special place in neuropathology and dental neuropathy, accompanied by such pronounced symptoms as "vegetative storm". The aim of the research was obtaining information on the external structure of the sphenopalatine ganglion, the morphometric characteristics of its neurons in norm and in experimental diabetes. The study was carried out on male Wistar rats weighing 260-300 g: with a stereoscopic biological microscope, using ophthalmic instruments, we removed almost the entire gland that was not accompanied by significant bleeding under general anesthesia. Peculiarities of the external structure of the sphenopalatine ganglion of the white rat were studied by macro-micro preparations under a binocular microscope at 50 objects pervaded with silver nitrate, according to Christen-sen


No disponible


Assuntos
Animais , Masculino , Ratos , Doenças Metabólicas/induzido quimicamente , Diabetes Mellitus Experimental/induzido quimicamente , Fossa Pterigopalatina/anatomia & histologia , Osso Esfenoide/anatomia & histologia , Ratos Wistar , Doenças Metabólicas/fisiopatologia , Modelos Animais , Fossa Pterigopalatina/metabolismo , Nitrato de Prata/efeitos adversos , Gânglio Geniculado/anatomia & histologia , Gânglio Geniculado/efeitos dos fármacos
15.
World Neurosurg ; 141: 251, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32454201

RESUMO

Trigeminal schwannomas are benign slow-growing tumors originating from the peripheral nerve sheath. They account for 0.1%-0.4% of all intracranial tumors and 1%-8% of all intracranial schwannomas.1-3 While most of these tumors develop in the trigeminal ganglion within the middle fossa, trigeminal schwannomas can develop anywhere along the course of the trigeminal nerve. As a result, they can be intradural, interdural, and extradural.4,5 Trigeminal schwannomas from the pterygopalatine fossa (PPF) are extremely rare and very difficult to remove because of limited access to this region and the rich neurovascular contents. Numerous traditional microsurgical approaches to the PPF have been described; however, they are more invasive with increased morbidity.6,7 Therefore, endoscopic endonasal surgery is a feasible solution. This technique allows good visualization of the region with decreased morbidity and a shorter recovery period. A previously healthy, 40-year-old woman presented with right facial pain for 3 weeks. On neurologic examination, the patient had hypoesthesia in the territory of the maxillary (V2) branch of the right trigeminal nerve. She had no other symptoms on physical examination. Cranial computed tomography and magnetic resonance imaging were performed and showed a high signal density mass in the right PPF that exhibited heterogeneous contrast enhancement. She was initially treated with low-dose carbamazepine; however, the dose could not be further increased because of drowsiness and dizziness. Given the size and location of the mass, an endoscopic endonasal approach was performed, and the tumor was successfully resected (Video 1). The postoperative course was uneventful, and the patient had significant improvement of her symptoms and was discharged with no new neurologic deficits. However, she continued to have hypoesthesia of the V2 segment of the trigeminal nerve.


Assuntos
Neoplasias dos Nervos Cranianos/cirurgia , Neurilemoma/cirurgia , Fossa Pterigopalatina/cirurgia , Nervo Trigêmeo/cirurgia , Adulto , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Neurilemoma/diagnóstico , Neuroendoscopia , Nariz/cirurgia , Fossa Pterigopalatina/diagnóstico por imagem
16.
Head Neck ; 42(9): 2745-2749, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32364647

RESUMO

Endoscopic transmaxillary approaches to remove juvenile nasopharyngeal angiofibromas (JNAs) have been described previously and are used for tumors that extend laterally in the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). There is no previous description of robotic-assisted JNA removal in the literature. The video will demonstrate the success of this technique. Robotic transmaxillary approaches to the lateral PPF and ITF are easily achieved through an extended Caldwell-Luc antrostomy. Total operative time was 519 minutes. Total robotic operative time was 283 minutes. The endoscopic approach provided no assistance in tumor dissection or removal. Robotic-assisted transmaxillary JNA removal allows the operating surgeon to control the endoscope and to operate free of collisions from the robotic console while having an active assistant surgeon at the patient bedside. A video demonstrating the technique is found on Head & Neck's web site.


Assuntos
Angiofibroma , Fossa Infratemporal , Neoplasias Nasofaríngeas , Procedimentos Cirúrgicos Robóticos , Angiofibroma/cirurgia , Endoscopia , Humanos , Neoplasias Nasofaríngeas/cirurgia , Fossa Pterigopalatina/cirurgia
17.
Pain Med ; 21(10): 2441-2446, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32232479

RESUMO

SETTING: Post-tonsillectomy pain in adults can be severe and is often poorly controlled. Pain can lead to decreased oral intake, bleeding, longer hospital stays, emergency department visits, dehydration, and weight loss. Due to persistent pain despite scheduled medications, other methods for pain control are needed. Local/regional anesthetic options have been previously studied in this population. Unfortunately, neither the injection of local anesthetics into the tonsillar fossa nor the postoperative topical application of local anesthetics to the tonsillar bed has demonstrated efficacy in large systematic reviews. PATIENTS: Here we report on the post-tonsillectomy pain experience of three patients who were treated with perioperative nerve blocks placed in the pterygopalatine fossa. This represents an as-yet unexplored option for post-tonsillectomy pain control. INTERVENTION: After induction of general anesthesia, before surgical incision, a 25-gauge spinal needle was advanced into the pterygopalatine fossa using a suprazygomatic, ultrasound-guided approach. Ropivacaine and dexamethasone were deposited into the pterygopalatine fossa. RESULTS: All three patients experienced excellent pain control for the duration of their recovery and required ≤10 mg of oxycodone over the two weeks after surgery. CONCLUSIONS: Our case series of three patients provides proof of concept that use of nerve blocks in the pterygopalatine fossa can be useful for the control of post-tonsillectomy pain. Further study is needed to confirm these initial results.


Assuntos
Tonsilectomia , Adulto , Anestésicos Locais , Humanos , Dor Pós-Operatória/tratamento farmacológico , Fossa Pterigopalatina , Ropivacaina , Nervo Trigêmeo
18.
J Craniofac Surg ; 31(5): 1334-1337, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32282482

RESUMO

The aim of this study was to provide volumetric data of the pterygopalatine fossa by semiautomatic segmentation based upon cone beam computed tomography.Cone beam computed tomography (CBCT) images of 100 patients were analyzed. By using the open source software "ITK-Snap," the volumetric measurements of 200 pterygopalatine fossae were performed. For statistical investigations paired t test, and independent Student t test were performed. Also, the Pearsons chi-square test was applied. P values P < 0.05 were considered significant.The mean volume was 578.376 mm for the right and 560.979 mm for the left side. The results indicated statistically significant differences according to the right and the left pterygopalatine fossa, regardless of gender (P < 0.05). The analysis of differences between males and females did not show any significant results (P > 0.05), although males present a slightly larger volume than females. According to the median age (59 years), younger patients presented smaller volumes, whereas older patients presented larger volumes. Nevertheless, no statistically significant differences according to age (χ = 3.520; P > 0.05) could be found.Clinical intervention with the application of local anesthetics into the complex and vulnerable anatomy of the pterygopalatine fossa makes a thorough knowledge about the volumetric capacity indispensable. Therefore, the semiautomatic segmentation of CBCT images provides a useful, available and validated tool. Our results show that a final injected anesthetic volume larger than 1 ml exceeds the pterygopalatine fossa capacity considerably and could cause complications. To prevent this, volumetric analysis of this region can provide further information and enables an individualized patients' treatment.


Assuntos
Fossa Pterigopalatina/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais , Distribuição de Qui-Quadrado , Tomografia Computadorizada de Feixe Cônico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fossa Pterigopalatina/cirurgia , Software , Adulto Jovem
19.
Oper Neurosurg (Hagerstown) ; 19(4): E396-E397, 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32348506

RESUMO

The infratemporal fossa (ITF) is bounded superiorly by the skull base, specifically the greater wing of the sphenoid, which contains foramen ovale. It is bordered posteriorly by the temporal bone, including the petrous portion of the carotid canal, anteriorly by the posterior wall of the maxillary sinus, laterally by the mandible, and medially by the pterygoid body and lateral pterygoid plate.1-3 In this video, we report a case of a rare, exclusively extradural, schwannoma originating from the third division of the trigeminal nerve with a widened foramen ovale at the skull base. The tumor filled the ITF and extended laterally just through the sigmoid notch of the mandible. The patient complained of left cheek and lower jaw numbness and intermittent left jaw spasms. The tumor was deemed appropriate for endoscopic resection. To access the ITF, left-sided endoscopic sinus surgery, a modified endoscopic Denker's approach,4 and posterior nasal septectomy were first performed. A nasoseptal flap was also harvested in case an intraoperative cerebrospinal fluid (CSF) leak required repair. Dissection was carried out through the posterior wall of the maxillary sinus and pterygopalatine fossa to reach the ITF. Tumor resection was achieved through a 2-surgeon, 4-handed approach in which appropriate traction and countertraction were carefully applied to tease the tumor away from the skull base and dehiscent carotid canal. No CSF leak or carotid injury occurred, and the posterior maxillary sinus wall defect was repaired with the nasoseptal flap. The patient did well postoperatively. The patient consented to the procedure in a standard fashion.


Assuntos
Neoplasias dos Nervos Cranianos , Fossa Infratemporal , Neurilemoma , Neoplasias dos Nervos Cranianos/diagnóstico por imagem , Neoplasias dos Nervos Cranianos/cirurgia , Humanos , Neurilemoma/diagnóstico por imagem , Neurilemoma/cirurgia , Fossa Pterigopalatina , Base do Crânio/diagnóstico por imagem , Base do Crânio/cirurgia
20.
Reg Anesth Pain Med ; 45(4): 301-305, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31924742

RESUMO

BACKGROUND AND OBJECTIVES: Blockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF. METHODS: The literature search was performed by searching the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009-March 2019 for keywords targeted toward "trigeminal nerve," "maxillary nerve," or "pterygopalatine fossa," "ultrasound," and "nerve block," using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study. RESULTS: There are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1-5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg. CONCLUSIONS: These studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored.


Assuntos
Anestesia por Condução/métodos , Nervo Maxilar/diagnóstico por imagem , Bloqueio Nervoso/métodos , Adulto , Cadáver , Humanos , Injeções , Estudos Prospectivos , Fossa Pterigopalatina , Nervo Trigêmeo , Ultrassonografia
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