Endoscopic Anatomy Variation of the Medial Pterygopalatine Fossa structures and it's surgical applications

8/12/2019 Endoscopic Anatomy Variation of the Medial Pterygopalatine Fossa structures and it's surgical applications

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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

ORIGINAL RESEARCH

Endoscopic Anatomy Variation of the Medial

Pterygopalatine Fossa structures and it's surgical

applications

Georgy Polev, MD1, Vladimir Averbukh, PHD

2

Russian Federal State Scientific-Research ENT Center

ABSTRACT:

Objectives: Describe the endoscopic anatomy variability of the medial

Pterygopalatine Fossa (PPF) structures during cadaveric dissection, and analyze

the relationship of the neurovascular structures in this region.

Methods: 20 non-injected fresh cadaveric specimens were dissected bilaterally

via the endonasal endoscopic approach. 40 medial PPF regions are described. The

distances between the vidian canal (VC) and palatovaginal canal (PVC) orifices are

measured and the mean length of the PVC is estimated. Also we measured the

distances between VC orifice and foramen rotundum (FR) to estimate the risk of

maxillary nerve lesion during the transnasal vidian neurectomy.

Results: The mean distance between PVC and VC orifices equaled 2.6 mm and

the mean length of the PVC was 6.4 mm. The mean length of the palatine bonesphenoid process is 7.2 mm, which is always approximately equal to the distance

between the GPB and the PVC cranial orifice. The mean distance between the VC

orifice and FR is 4.6 mm.

Conclusions: Based upon this study, modified "retrograde" approach to the VC

orifice from the choanal arch behind the middle turbinate tail via the palatine bone


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sphenoid process along the PVC is proposed. The peculiarity of this approach is

the preservation of the PPF contents and sphenopalatine neurovascular bundle,

which are moved aside laterally during the dissection. Further investigation is

needed to establish the feasibility of this approach in vivo.

KEY WORDS: Endoscopy, medial pterygopalatine fossa , sphenopalatine

fossa

Cite this Article: Georgy P., Vladimir A. : Endoscopic Anatomy Variation of the Medial

Pterygopalatine Fossa structures and it's surgical applications, Journal of Head & Neck physicians

and surgeons Vol 2 Issue 1 2014 Pg 42-47

INTRODUCTION:

Golding-Wood was first to introduce the concept of vidian neurectomy as a

method of treatment of chronic rhinitis1. Vidian nerve provides the

parasympathetic innervation of nasal mucosa, thus transection of this nerve leads

to reduction of mucus production and oedema of the nasal mucosa2,3

. It is shown

that vidian neurectomy leads to significant histologic changes in nasal mucosa,

such as mast cells depletion4, reduction of stromal oedema and reduction of

mucosal gland acini content5

. One of possible vidian neurectomy complications is

the V2 neuralgia due to thermal damage to the maxillary nerve during vidian nerve

stamp cautery. This is explained by the close proximity between vidian canal

orifice and foramen rotundum, which is also individually variable6

. There are

different approaches to the vidian nerve described in literature: transantral7,

transnasal2 , transpalatal

8and transsphenoidal

9, transsphenoidal being the most

novel and less traumatic, but not always possible due to anatomical circumstances.

The disadvantage of the transnasal approach is the need to face the sphenopalatine

artery branches, which could lead to postoperative bleeding.

MATERIALS AND METHODS:

20 non-injected fresh cadaveric specimens were dissected bilaterally via the

endonasal endoscopic approach. 40 medial PPF regions are described. The

distances between the vidian canal (VC) and palatovaginal canal (PVC) orifices are

measured and the mean length of the PVC is estimated. Also we measured the


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distances between VC orifice and foramen rotundum (FR) to estimate the risk of

maxillary nerve lesion during the transnasal vidian neurectomy.

RESULTS:

The mean distance between vidian canal (VC) and palatovaginal canal (PVC) was

3 mm (mean deviation 1 mm) (Fig. 3). To estimate the length of the palatovaginal

canal the bone of the palatine bone sphenoid process was removed. Mean length of

the PVC was 6,4 mm (standard deviation 1,4 mm). The distance between VC and

foramen rotundum varied from 1,4 to 7,6 mm, the mean distance was 4,6 mm (Fig.

1, 2).

Figure 1. Relationship of the median pterygopalatine fossa structures. MT middle turbinate, SS sphenoid sinus,

MA maxillary artery, VC vidian canal orifice, FR foramen rotundum, V2 second division of the trigeminal

nerve (maxillary nerve). Black arrow points the probe in the greater palatine canal. Red arrow indicates the distancebetween vidian canal orifice and foramen rotundum.

Figure 2. Relationship of the vidian nerve (V), maxillary nerve (V2), palatovaginal nerve (PVN) and sphenoid sinus

(SS). Cchoana. Blue arrow indicates the distance between vidian and maxillary nerves.

FR


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CONCLUSIONS:

Based upon this study, modified "retrograde" approach to the VC orifice from the

choanal arch behind the middle turbinate tail via the palatine bone sphenoid

process along the PVC is proposed. The peculiarity of this approach is thepreservation of the PPF contents and sphenopalatine neurovascular bundle, which

are moved aside laterally during the dissection. The additional advantage of

dissecting the vidian nerve from medial to lateral direction is the theoretically

lesser chance of damaging maxillary nerve, which leaves laterally also. Further

investigation is needed to establish the feasibility of this approach in vivo.

REFERENCES

1. Golding-Wood PH. Observations on petrosal and vidian neurectomy in chronicvasomotor rhinitis. J Laryngol Otol. 1961 Mar; 75(3):232-47

2. Kamel R, Saher S. Endoscopic transnasal Vidian neurectomy. Laryngoscope 1991; 101:316-318

3. Fernandes CM. Bilateral transnasal Vidian neurectomy in the management of chronicrhinitis. J Laryngol Otol 1988; 102:894-895

4. Konno A, Togawa K. Vidian nerve neurectomy for allergic rhinitis. ArchOtorhinolaryngol 1979; 225: 67-77

5. Robinson SR, Wormald PJ. Endoscopic vidian neurectomy. Am J Rhinol. 2006 Mar-Apr;20(2):197-202

6.

Li SL, Wang ZC, Xian JF. Study of variations in adult sphenoid sinus by multislice spiralcomputed tomography. 2010 Aug 17;90(31):2172-6

7. Rose KG, Ortmann R, Wustrow F, Seegers D. Vidian neurectomy: neuroanatomicalconsiderations and a report on a new surgical approach. Arch Otorhinolaryngol.

1979;224(3-4):157-68

8. Krajina Z. Critical review of Vidian neurectomy. Rhinology. 1989 Dec;27(4):271-69. Lee JC, Kao CH, Hsu CH, Lin YS. Endoscopic transsphenoidal vidian neurectomy. Eur

Arch Otorhinolaryngol. 2011 Jun;268(6):851-6.

10.Fortes FS, Sennes LU, Carrau RL et al. Endoscopic anatomy of the pterygopalatine fossaand the transpterygoid approach: development of a surgical instruction model.

Laryngoscope. 2008 Jan;118(1):44-9.11.Kassam AB, Vescan AD, Carrau RL et al. Expanded endonasal approach: vidian canal as

a landmark to the petrous internal carotid artery. J Neurosurg. 2008 Jan;108(1):177-83.

12.Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM, Paluzzi A, SnydermanCH, et al. Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a

landmark for dissection of the vidian nerve during endonasal transpterygoid approaches.

Laryngoscope. 2012 Jan;122(1):6-12.


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Acknowledgement-None

Source of Funding-Nil

Conflict of Interest-None Declared

Ethical Approval-Not Required

Correspondence Addresses :

Dr, Georgy Polev MD

119121, Moscow,

Pluschikha, 43/47, 53

E-mail: polev_gor @mail.ru

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Endoscopic Anatomy Variation of the Medial Pterygopalatine Fossa structures and it's surgical applications