Pterygopalatine Fossa Approach [Neurosurgery Wiki]

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====== Pterygopalatine Fossa Approach ======

The [[pterygopalatine fossa]] (PPF) is a small but complex anatomical space located posterior to the [[maxillary sinus]] and anterior to the [[pterygoid process]]. It acts as a neurovascular crossroads and is increasingly accessed via **[[endoscopic endonasal transpterygoid approach]]es** in neurosurgery and [[skull base surgery]].

===== Indications =====

**[[Endonasal]] [[access]] to the PPF** is indicated in the following scenarios:

  * Tumors involving:
    * PPF (schwannomas, carcinomas)
    * [[Infratemporal fossa]]
    * [[Lateral sphenoid sinus]]
    * [[Parasellar region]] (Knosp III–IV adenomas)
  * Management of vascular lesions:
    * Juvenile nasopharyngeal angiofibroma
    * Arteriovenous malformations
    * Severe posterior epistaxis
  * Neuralgia management:
    * [[Vidian nerve neuralgia]]
    * [[Sluder’s syndrome]]
  * Rare cases:
    * Abscess drainage (deep face spaces)

===== Surgical Corridor =====

The **endonasal transpterygoid approach** involves the following steps:

  - Medial maxillectomy (partial or complete)
  - Identification and resection of the posterior wall of the maxillary sinus
  - Removal of pterygoid process (partial)
  - Exposure of PPF and its contents

===== Key Anatomical Landmarks =====

  * **Maxillary nerve (V2)** — passes through the foramen rotundum
  * **Infraorbital nerve** — lateral to infraorbital artery
  * **Greater palatine nerve** — medial to the descending palatine artery
  * **Vidian nerve** — runs through the pterygoid canal
  * **Pterygopalatine ganglion** — located anterior to the vidian nerve, medial to V2
  * **Sphenopalatine artery** — a key vessel supplying the nasal cavity

===== Measurements (Cadaveric Study Reference) =====

Recent anatomical data from a cadaveric study (Akdemir Aktaş et al., 2025):

  * Maxillary nerve: ~15.93 ± 6.19 mm (length), 3.96 ± 0.69 mm (diameter)
  * Infraorbital nerve: ~24.4 ± 4.38 mm / 3.00 ± 0.71 mm
  * Greater palatine nerve: ~13.15 ± 4.25 mm / 2.70 ± 0.39 mm
  * Vidian nerve: ~16.78 ± 1.18 mm / 2.15 ± 0.51 mm
  * Pterygopalatine ganglion: ~4.59 mm wide / 5.18 mm tall

→ These metrics are useful for **navigation**, **instrument reach**, and **avoiding complications**.

===== Complications to Avoid =====

  * Injury to the internal maxillary artery or its branches → bleeding
  * Neuropathic pain syndromes due to nerve damage
  * Cerebrospinal fluid leak if extended laterally toward the skull base
  * Diplopia from injury to branches of the abducens nerve (in more extended routes)

===== References =====

  - Akdemir Aktaş H, et al. *Endoscopic endonasal approach to the nerves of the pterygopalatine fossa: a detailed cadaveric anatomical study*. Surg Radiol Anat. 2025; 47(1):122. doi:10.1007/s00276-025-03637-5.

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**TIP:** Consider neuronavigation, especially in tumors with lateral or superior extension, and preoperative CTA if vascular involvement is suspected.