The Lateral Facial Approach to the Nasopharynx and Infratemporal Fossa

Abstract

Surgical access to the nasopharynx and infratemporal fossa is restricted by the bony structures that support and define these areas. Traditional surgical approaches to the nasopharynx for removal of benign neoplasms follow three directions: (1) the anterior route via the nasal cavity and the maxillary and, if necessary, the ethmoid sinuses; (2) the inferior route through the palate; and (3) the anterolateral retromaxillary pathway via the gingivobuccal sulcus into the pterygoid space. These approaches provide fair access, but limited visibility and little technical control of the neurovascular supply. For the small- to medium-sized tumor, the experienced surgeon is able to successfully manage the majority of cases using these approaches, singly or in combination. However, in patients with larger tumors—when recurrence is more common—approaches offering greater visualization have been developed, such as Panje's facial bifiap,1 Mann's transmaxillary,2 and Fisch's transtemporal.3 These provide better access and control at the cost of increased locoregional morbidity, long operating time, and considerable technical complexity. I have developed a simpler, more direct surgical approach that combines the exposure concepts of the head and neck surgeon with the microsurgical techniques of the otosurgeon. It has been applied to eight cases, with minimal morbidity and excellent results, and appears to be the procedure of choice for cases of angiofibroma with early intracranial extension. Subsequently, a similar approach, developed previously by Holliday,4 has been published in which access into the anterior temporal lobe, petrous apex, and clivus are gained. In this report, I describe and illustrate the anatomic and technical considerations of this approach and report a single case in which it was first applied.