Adenoid cystic carcinoma (ACC) is an uncommon malignant neoplasm that predominantly arises from major and minor salivary glands, accounting for about 1% of head and neck malignancies. ACCs originating from the pterygopalatine fossa (PPF) are extremely rare. In this case report, we present a 77-year-old male patient who experienced a two-year hemi-facial numbness and mild trismus, with intact nasal mucosa. He underwent Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) which revealed opacification of the left PPF with extension to the left infratemporal fossa and osteolytic areas of the sphenoid bone. Histopathology, following blind biopsies, revealed ACC of the PPF, which was subsequently treated with combined therapy (radiotherapy and chemotherapy). Due to their slow and progressive growth, as well as their tendency for perineural invasion, ACCs should always be considered in the differential diagnosis of painless swelling or nerve dysfunction. To our knowledge, this case is the fifth described in the English literature.

Medical students often struggle to appreciate the anatomy of the pterygopalatine fossa. This is due to the difficulty in understanding the spatial orientation through textbook diagrams, as well as its deeper location and smaller size in cadaveric specimens. Research has proven that three-dimensional visualization enhances the spatial understanding of anatomy. However, studies have not compared the effectiveness of two different instructional designs that cater to 3D visualization. We conducted a mixed methodology (quasi-experimental pre-test/post-test control design with additional qualitative components) study to compare the effectiveness of a physical model and a 3D image in small-group teaching. The students were divided into control and intervention groups based on their roll numbers. The control group utilized a series of 3D images delivered through Microsoft PowerPoint software on computers. The students in the intervention group used a physical model made of cardboard, with colored wires representing the neurovascular structures. We used 20 spatial anatomy-based multiple-choice questions (MCQs) to assess knowledge acquisition before and after the small group discussion. Additionally, we utilized a validated 10-item feedback questionnaire to evaluate participants\' perception of the teaching sessions. There was no significant difference in the knowledge gain and perception scores between the control and intervention groups. These findings suggest that a well-designed 3D image can provide an equivalent learning outcome and level of satisfaction compared to a physical model.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s40670-024-02063-3.

The pterygopalatine fossa and infratemporal fossa are often approached through an external incision because of their deep facial location, but this can present problems such as facial scarring and deformity. In schwannoma surgery, intraneural dissection is a useful surgical technique for achieving gross total resection while preserving the capsule, including the nerves. For appropriate enucleation and preservation of the functional nerve, it is indispensable to distinguish between the pseudocapsule and the tumor capsule. This case report presents a case of endonasal surgical intervention for an extracranial trigeminal schwannoma employing the tri-port approach and narrow-band imaging.

Introduction  The endoscopic endonasal transpterygoid approach (EETPA) with or without the addition of the endoscopic-assisted sublabial anterior transmaxillary approach (ESTA) has become increasingly utilized for lesions posterior to the pterygopalatine fossa (PPF), including infratemporal fossa (ITF), lateral recess of the sphenoid sinus, Meckel\'s cave, petrous apex, and parapharyngeal space. The main goal of this study is to develop an educational resource to learn the steps of the EETPA for trainees. Methods  EETPA and ESTA were performed in 12 specimens by neurosurgery trainees, under supervision from the senior authors. One EETPA and one ESTA were performed on each specimen on opposite sides. Dissections were supplemented with representative cases. Results  After a wide unilateral sphenoidotomy, ethmoidectomy, and partial medial maxillectomy, the anteromedial bone limits of the PPF were identified and drilled out. The pterygoid progress was modularly removed. By enlarging the opening of the posterior and lateral walls of the maxillary sinus through EETPA and ESTA, respectively, the neurovascular and muscular compartments of the PPF and ITF were better identified. The EETPA opens direct corridors to the PPF, medial ITF, middle cranial fossa, cavernous sinus, Meckel\'s cave, petrous apex, and internal carotid artery. If a more lateral exposure of the ITF is needed, the ESTA is an appropriate addition. Conclusion  Despite the steep learning curve of the EETPA, granular knowledge of its surgical anatomy and basic surgical steps are vital for those advancing their learning in complex endoscopic approaches to the ventral skull base when expanding the approach laterally in the coronal plane.

UNASSIGNED: In this paper, the goal of the authors is to present the anatomic nuances and their clinical experience with lesions of the pterygopalatine fossa and infratemporal fossa using an endoscopic transnasal prelacrimal recess transmaxillary approach (PLRMA).
UNASSIGNED: An endoscopic anatomical dissection of three fresh cadaveric heads was performed bilaterally to evaluate the feasibility of the PLRMA. Prior to dissection, stereotactic computed tomography scans were obtained for each head to obtain anatomical measurements. The area of exposure on the posterior wall of the maxillary sinus was determined using stereotaxis. The cases of six patients with schwannomas or epidermoid cysts who underwent the transnasal PLRMA were illustrated.
UNASSIGNED: The mean area of exposure on the posterior wall of the maxillary sinus was 9.55 cm2. Total resection was achieved in all six patients. The mean follow-up time was 16 months, and one patient complained of postoperative facial numbness, which resolved gradually. No cases of chronic sinusitis were reported.
UNASSIGNED: The endoscopic transnasal PLRMA provides efficient operative exposure to the pterygopalatine fossa and infratemporal fossa. Preserving the integrity of the mucosa on the nasal lateral wall is an advantage of this approach.

This study describes the clinical anatomical topography and relationship of the terminal branches of the maxillary artery to the bony wall of the maxillary sinus in the pterygopalatine fossa (PPF) to estimate the bleeding risk during surgical interventions. Using contrasted computer tomography records, (i) the route of the maxillary artery in the infratemporal fossa, (ii) the number of the arteries in the critical PPF surgery plane, (iii) the diameter of the largest artery in the area and (iv) its relation to the posterior wall of the maxillary sinus were examined. Furthermore, measurements were extended with (v) the minerality of the bony posterior wall of the maxillary sinus on bone-window images. For statistical analyses Student\'s t- and Fisher-test were applied. 50 patients (n = 50, 100 cases including both sides) were examined in this study. The maxillary artery reached the pterygomaxillary fissure on the lateral side of the lateral pterygoid muscle in 56% of the cases (n = 32), in 37% (n = 23) on its medial side and in 7% (n = 4) on both sides. The number of arteries at the level of the Vidian canal in the PPF varied between 1 and 4 with a median of 2. The diameter of the biggest branch was 1.2-4.7 mm, the median diameter was 1.90 mm. In 41% (n = 30) of the cases the biggest artery directly contacted the posterior wall of the maxillary sinus, and the mineral density of the posterior wall was decreased in 14.3% (n = 12) of all investigated cases. The present description and statistical analysis of the vasculature of the PPF optimizes operative planning-like clip size or the type and direction of the surgical approach-in this hidden and deep head/neck region.

Ballistic traumas among civilians are usually from low velocity, low calibre weapons such as soft air guns. The facial skeleton is an area of high aesthetic/functional value, and therefore, this is a showcase for technical description of a minimally invasive endoscopic approach for the removal of a bullet from the pterygopalatine fossae.

The pterygopalatine fossa (PPF) is a challenging space and pathological processes in this anatomical space are uncommon. This report presents a case of glomus tumor right PPF in a 65 years old female patient who underwent tumor removal by endoscopic transnasal-transmaxillary approach with preoperative selective embolization of the right internal maxillary artery.

Schwannomas of the sinonasal compartment are rare benign neoplasms of peripheral nerve sheath origin and constitute ~ 4% of all head and neck schwannomas. The presentation may simulate a range of benign and intermediate grade pathologies. Management involves surgical excision via open or endoscopic approach. To describe the clinico-epidemiological characteristics and surgical outcomes in sinonasal region schwannoma patients operated at our institute. The study is a descriptive case series of patients with sinonasal region schwannomas treated at our institution. A retrospective search of electronic database of the Department of ENT and Head and Neck Surgeries and Department of Pathology was conducted from January 2013 to January 2019. The various demographic and clinical details of the patients were extracted. A total of four patients operated for sinonasal region schwannoma were identified. The involved sites were nasal dorsum, nasal cavity, pterygopalatine fossa and infratemporal fossa. The mild, non-specific symptoms resulted in patients ignoring their symptoms for a while initially and presenting late. The nasal dorsum lesion was revealed as a surprise during open rhinoplasty for correction of nasal deformity. Complete excision was achieved in all the cases and no recurrence has been noticed during the follow up (varying from 6 months to 6 years) till date. The diverse clinical manifestations and approaches to the treatment of schwannomas in this specific region are discussed. The surgical excision is the standard of care in dealing with these neoplasms. This series highlights the rarity of this pathology in the sinonasal area, diagnostic surprises and the decision making to choose the correct surgical approach for complete excision. Once excised completely, recurrence is not expected.

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