Anterolateral corridor approach to the infratemporal fossa and central skull base in maxillectomy: rationale and technical aspects

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Abstract

We describe the technical aspects and report our clinical experience of a surgical approach to the infratemporal fossa that aims to reduce local recurrence after operations for cancer of the posterior maxilla. We tested the technique by operating on 3 cadavers and then used the approach in 16 patients who had posterolateral maxillectomy for disease that arose on the maxillary alveolus or junction of the hard and soft palate (maxillary group), and in 19 who had resection of the masticatory compartment and central skull base for advanced sinonasal cancer (sinonasal group). Early proximal ligation of the maxillary artery was achieved in all but one of the 35 patients. Access to the infratemporal fossa enabled division of the pterygoid muscles and pterygoid processes under direct vision in all cases. No patient in the maxillary group had local recurrence at median follow up of 36 months. Four patients (21%) in the sinonasal group had local recurrence at median follow up of 27 months. Secondary haemorrhage from the cavernous segment of the internal carotid artery resulted in the only perioperative death. The anterolateral corridor approach enables controlled resection of tumours that extend into the masticatory compartment.

Introduction

Local recurrence remains the most common manifestation of relapse after treatment for midfacial cancer.1, 2, 3, 4, 5, 6 In most patients it follows a predictable pattern, which can be explained by the relative inaccessibility of posterior and superior disease, and the proximity of vital structures,2, 6 and it is reflected in the T-staging for carcinoma of the maxillary sinus and ethmoid sinus.7

To maximise the likelihood of cure, operation is usually indicated for cancer of the midface,2, 6 and resection to uninvolved margins remains essential. The traditional technique for maxillectomy relies on posterior separation, which gives a poor view and inadequate vascular control, and for advanced and posteriorly-extending cancers of the maxilla it makes complete excision difficult.

We describe the technical aspects of an expanded field resection for cancer that involves the posterior maxilla, and report our experience.

Section snippets

Anatomical position of the maxillary artery in relation to the lateral pterygoid muscle

We examined 100 contrast-enhanced computed tomograms (CT) (slice width 0.9 mm, 200-300 mAs) from a consecutive series of patients with cancer of the head and neck, and noted the course of the maxillary artery with particular reference to the lateral pterygoid muscle. To measure the variance between observations, scans were read twice and the 2 readings were separated by 2 weeks.

Cadaveric investigation

We dissected 3 formalin-fixed cadaver heads (6 sides) using the anterolateral corridor approach. Maxillectomy was done

Evaluation of the anatomical relation of the maxillary artery to the lateral pterygoid muscle (on contrast CT)

We recorded 3 types of relation of the maxillary artery to the lateral pterygoid muscle: posteromedial, anterolateral, and posteromedial to anterolateral. In 20% of the patients there was asymmetry in the course of the maxillary artery. A total of 46 patients were female and 54 were male but its course did not differ significantly between sexes.

In 53 cases, the artery passed for most of its course on the right of the posteromedial aspect of the lateral pterygoid muscle, and it passed

Discussion

Local recurrence remains the most common sign that treatment for midfacial cancer has failed, irrespective of the type of disease and the treatment given.1, 2, 3, 4, 5, 6 We have previously reported that it often occurs in posterior and superior sites,4 specifically, the infratemporal fossa and orbital apex and, through the foramina at the base of the skull, in the cavernous sinus, Meckel's cave, and petrous apex. It has also been described by others,9, 10 and suggests an anatomical

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patient's permission

This project was approved by the Clinical Network. Written consent for inclusion of images has been granted by the patient concerned and is held in the medical illustration dataset.

References (12)

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