| Objective: To provide anatomical guidance for the operation of skull base communicating tumors through the maxillary swing approach, and combined with clinical application, explore its feasibility.Methods: (1) Anatomical study: 10 well-preserved cadaveric wet adult heads fixed with formalin, and inject red and blue latex into two carotids arteries and vertebral artery and internal jugular vein respectively. Simulating surgical method of the maxillary swing approach to excise tumor in skull base, dissect pterygopalatine fossa,infratemporal fossa, ethmoid-sphenoid areas, and expose pterygoid process, maxillary artery, infraorbital nerve, maxillary nerve, mandibular nerve, pterygoid canal, foramen rotundum, foramen ovale , foramina lacerum, foramen spinosum. Observe and shoot important blood vessels, nerves and their relationship with the fissures around. Mark the important bone at skull base, measure the distance of holes in skull base and undertake statistical analysis whose result will be marked with average±. Finally skull base is to be removed to expose middle cranial fossa, carvernous sinus and clival region, observing and shooting the microanatomical relationship of important structures such as veins and nerves. (2) Clinical application: to excise tumor in skull base using maxillary swing approach in 6 cases, 4 of which being male and 2 female, aging 38-55 years old, averaging 45.2 years old, and the course of disease being from 4 months ~ 2.5 years. Postoperative pathology: two cases of schwannoma at infratemporal fossa and middle skull base, one case of schwannoma at nasal cavity and middle cranial base, two cases of meningioma at infratemporal fossa and middle cranial fossa , and one case of chordomasat at cavernous sinus and clival region.Results: 1, Anatomy: (1) The pterygopalatine fossa took the shape of an inverted cone, with small space to accommodate the maxillary nerve, pterygopalatine ganglion, pterygopalatine at maxillary artery. Pterygopalatine ganglion is composed of pterygoid canal nerve which runs backward and pterygopalatine which runs to the outside and palate large and small nerve, all of which form subtriangular pattern. Maxillary artery after entering the pterygopalatine fossa, sprouts upper oalveolar artery, infraorbital artery, descending palatine artery, pterygoid canal artery, sphenopalatine artery. (2) The infratemporal fossa mainly ccommodates pterygoideus, pterygoid venous plexus, mandibular nerve and its branches, and second segment of internal maxillary artery. This muscular parenchyma in this area is complicated and rich with venous plexus. The main branches of Internal maxillary artery in the infratemporal fossa are arteria temporalis profunda, masseteric artery, buccal artery, pterygoideus branch. Mandibular nerve,after going through foramen ovale ,was divided into front and after part. The front part mainly sprouts the deep temporal nerve, masseteric nerve, and buccal nerve, and the after part, auriculotemporal nerves, tongue nerve, and inferior alveolar nerve. (3) Inferior lamina of sphenoid bone is composed of the interior and exterior lateral plate with integration at the rear end. Pterygoid canal lies at at the bottom of the interior lateral plate, foramen rotundum lies about 5 mm outside of its top. Foramen ovale lies at the bottom of the outside of exterior lateral plate, and the opening of foramen spinosum is about 3 mm outside the back of foramen ovale. And foramina lacerum is located near roof of nasopharynx at the bottom of the back of the interior lateral plate (4) Both sides of the root of pterygoid process correspond roughly to the cavernous sinus on both sides. The removal of the root of pterygoid process can expose the inferior cavernous sinus. Maxillary nerve is an important anatomical mark into the cavernous sinus, and from the observation of the skull base, the cavernous sinus is located on the medial top of maxillary nerve, and the temporal subdural lies at lateral outside of maxillary nerve. (5) Being anatomized along the middle turbinate to the root, sphenoid opening and piriform bone can be seen, and into the sphenoid sinus cavity the saddle can be seen of at the end of the central uplift,and lateral optic nerve - internal carotid artery recess at its outside. Opening the saddle can enter the pituitary fossa at the end, and clival bone is located below the saddle. After removal clival bone , can enter anterior pon cistern, vertebrobasilar artery and its branches could be observed. The middle cranial fossa, petroclival region can be revealed after the grinding of the skull base bone mill at the connection between hole and foramen ovale.2, clinical: (1) This approach can provided excellent exposure to all the tumors, and tumors are totally removed. There are no operative death and serious complications. (2) The patients can get out of bed to do activities the following day, and incision scar is not obvious after three months.Conclusions: (1) The maxillary swing approach can fully expose anterior, middle and lateral skull base to provide adequate space for the skull base surgery; (2) Middle turbinate, pterygoid pross, maxillary nerve, round hole, foramen ovale, optic - carotid artery maxillary recess are the important anatomical landmarks of maxillary swing approach; familiarity with these important anatomical landmarks and their adjacent tissues is an important security assurance to maxillary swing approach to remove skull base tumors; (3) It is feasible to remove communicating tumors in the skull base via the maxillary swing approach, because it can reduce the damage to brain, vascular injury significantly, and because of its fewer postoperative complications and rapid recovery;... |
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