OtolaryngologyHead and Neck Surgery (2009) 140, 861-865

ORIGINAL RESEARCHSKULL BASE SURGERY

Endoscopic transnasal study of the infratemporal

fossa: A new orientation
Islam R. Herzallah, MD, Ross Germani, MD, and Roy R. Casiano, MD,
Zagazig, Egypt; and Miami, FL
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
ABSTRACT
INTRODUCTION: The medial portion of the infratemporal
fossa (ITF) is not infrequently involved in sinonasal and skull base
pathologies. However, endoscopic view of the ITF remains unclear
with lack of studies addressing this region from the endoscopic
perspective.
METHODS: Using an extended endoscopic approach, the pterygopalatine and infratemporal fossae were dissected in 10 sides of
five adult cadaver heads. A plane of dissection along the pterygoid
base and the infratemporal surface of the greater sphenoid wing
was developed. High-quality images were produced by coupling
the video camera to a digital recording system.
RESULTS: The foramen rotundum, ovale, and spinosum were
accessed and new landmarks were described from the endoscopic
point of view. The sphenomandibularis muscle was also highlighted. Maxillary and mandibular nerves and middle meningeal
artery were all identified. Columellar measurements to the foramen
rotundum and ovale ranged from 6.1 to 8.0 cm for the former and
7.0 to 9.1 cm for the latter, with a mean of 6.75 cm and 7.78 cm
respectively.
CONCLUSION: The current study provides a novel endoscopic
orientation to the medial ITF. Such knowledge should provide an
anatomical basis for experienced surgeons to endoscopically address this region with more safety and efficacy.
2009 American Academy of OtolaryngologyHead and Neck
Surgery Foundation. All rights reserved.

he infratemporal fossa (ITF) is a deeply seated region

beneath the skull base. Management of lesions arising
in or extending to the ITF often requires invasive surgical
procedures, a source of cosmetic and functional complications.1-6 A better understanding of the endoscopic anatomy
of the ITF may lead to alternative, less invasive approaches
to pathology in this region.
Anatomically, the superior border of the ITF is composed of the greater wing of the sphenoid featuring the
foramen ovale and spinosum (Fig 1), and the temporal
fossa, which contains the temporalis muscle. Medially, the
ITF is bounded by the lateral pterygoid plate and commu-

nicates with the pterygopalatine fossa (PPF) via the pterygomaxillary fissure. The ITF is limited laterally by the
mandibular ramus, extends anteriorly to the posterior wall
of the maxillary sinus, and opens inferiorly into the parapharyngeal space.7
The ITF approaches are categorized as lateral (transzygomatic and lateral infratemporal), inferior (transmandibular and transcervical), or anterior (transfacial, transmaxillary, transoral, and transpalatal).8 In general, transfacial
approaches are indicated for sinonasal or nasopharyngeal
tumors invading the ITF.
Concordant with the evolution of minimally invasive
surgery in this era, many attempts have been made to enodoscopically address different pathologies extending to the
ITF. Transnasal excision of advanced juvenile nasopharyngeal angiofibromas (JNA) is the leading example in recent
literature.9-11 A handful of case reports have also described
transnasal endoscopic access to the ITF in managing the
rare maxillary nerve schwannomas, solitary fibrous tumors,
and mucoceles.11-13 Additionally, for a small subset of infratemporal masses such as lymphomas and rhabdomyosarcomas, biopsy results before a definitive procedure should
prove useful in guiding management.
Despite rapid progress in the number of minimally invasive approaches being performed endoscopically, the ITF
anatomy as described from the endoscopic view remained
unclear, with the literature lacking studies that fully addressed this region from the unique endoscopic perspective.
The aim of this work was to provide a new endoscopic orientation to the medial portion of the ITF and to describe the
anatomical details and measurement variations of some key
ITF landmarks, from the transnasal endoscopic approach.

MATERIALS AND METHODS

Ten sides in five adult cadaver heads were dissected endoscopically in a position simulating that in the operating room to
achieve as much real surgical information as possible. Transnasal dissection was performed using 4 18-cm rod-lens

Received September 5, 2008; revised November 10, 2008; accepted February 12, 2009.

0194-5998/$36.00 2009 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2009.02.020

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OtolaryngologyHead and Neck Surgery, Vol 140, No 6, June 2009

A 30-degree endoscope was consistently used for further
dissection. The orbital process that forms the anterior
boundary of the sphenopalatine foramen was taken off, with
drilling sometimes helpful to remove this thick bone. The
posterior wall of the maxillary sinus was then removed with
a curette in medial-to-lateral direction, and the anterior
periosteum of the PPF was then opened. Generally, the
maxillary nerve (V2) lies at a higher level than the internal
maxillary artery (IMA) in the lateral portion of the PPF.
This interrelationship of the neurovascular structures has
been further detailed in our previous study14 and should
allow safer dissection into the PPF. The fat filling the PPF
was then dissected and different IMA branches were identified and transected as necessary. The pterygoid process
that forms the posterior wall of PPF was identified. Three
foramina open into the back wall of the PPF. These are the
pharyngeal canal most medially, the vidian canal immediately lateral to this in the base of the pterygoid process, and
the foramen rotundum superolateral to vidian canal (Fig 2).
The V2 passes through the foramen rotudum, crossing the
upper part of the PPF towards the infraorbital canal. As the
V2 lies high up in the PPF, dissection was maintained just
below its level to avoid inadvertent injury. However, care is
taken that, with dissection of the fat in the PPF, the V2 tends
to droop below the level foramen rotundum as it moves
anterolaterally towards the inferior orbital fissure to continue as the infraorbital nerve.14

Figure 1 Inferior view of the skull base. BPP, base of pterygoid

process; GWS, infratemporal surface of the greater wing of sphenoid; FO, foramen ovale; FS, foramen spinosum; FL, foramen
lacerum; CC, carotid canal; JF, jugular foramen; FM, foramen
magnum.

endoscopes (Karl Storz and Co., Tuttlingen, Germany) with 0-,

30-, and 70-degree lenses. The endoscope was connected to a
light source through a fiberoptic cable and to a video camera
coupled to a 21-inch monitor. High-quality digital files were
produced utilizing a video camera connected to a digital recording system ((DV-Cam, JVC, Victor Company of Japan,
Ltd., Tokyo, Japan). Digital pictures were reproduced by coupling the DV-Cam to a computer video capture system. Institutional Review Board approval was not necessary as the study
involves de-identified cadaveric specimens, and thus is not
considered human subject research.
To accomplish an adequate access to the ITF, an endoscopic transnasal transantral transpterygoid approach was
used. The approach was started by performing partial middle turbinectomy, removing the inferior half of the middle
turbinate and preserving its olfactory mucosa. A wide middle meatal antrostomy and anterior and posterior ethmoidectomies were also classically performed.
A vertical incision was performed in the posterior part of
the middle meatus just behind the posterior fontanelle. A
mucosal flap was elevated to expose the thick orbital process of the vertical plate of the palatine bone and its ethmoid
crest. The sphenopalatine foramen and the sphenopalatine
artery were then identified and carefully dissected.

Figure 2 Diagrammatic anterior view of the sphenoid bone

including its pterygoid process and greater wing (GWS). The base
of the pterygoid process (BPP) forms the posterior boundary of the
pterygopalatine fossa. Three foramina open into the back wall of
the fossa. These are the pharyngeal canal (PC) most medially, the
vidian canal (VC) immediately lateral to this in the base of the
pterygoid process, and the foramen rotundum (FR) superolateral to
VC. The dashed arrow represents the course of endoscopic dissection on the pterygoid base and then along the infratemporal surface
of the GWS towards the foramen ovale. The yellow and red arrows
on the right side depict the course of the maxillary nerve (V2) and
the tortuous internal maxillary artery (IMA) in the pterygopalatine
fossa. Modified with permission from Daniels DL, Mark LP,
Ulmer JL, Mafee MF, McDaniel J, Shah NC, Erickson S, Sether
LA, Jaradeh SS. Osseous anatomy of the pterygopalatine fossa.
AJNR Am J Neuroradiol. 1998 Sep;19(8):1423-32. The American
Society of Neuroradiology.

Herzallah et al

Endoscopic transnasal study of the infratemporal . . .

The inferior and superior heads of the lateral pterygoid

muscle attach to the lateral surface of the pterygoid base and
the infratemporal surface of the greater sphenoid wing,
respectively. Thus, further dissection was performed along
these bones by separating the lateral pterygoid muscle heads
from their bony attachments.
More access to the ITF was accomplished by continued
lateral dissection of the posterior wall of the maxillary sinus.
The deep belly of the temporalis muscle was then identified
and dissected lateral to the foramen rotundum and lateral
pterygoid muscle.
In order to appropriately plan the dissection in the medial
ITF, a Fisch B approach was implemented on one cadaver
head. Endoscopic transnasal dissection was also performed
and the structures revealed from both approaches were correlated. This allowed better understanding of the anatomy in
the other endoscopically dissected sides.

RESULTS
Using the aforementioned approach, endoscopic dissection
of the neurovascular structures in the PPF and the medial
portion of the ITF was performed. The vidian nerve, pterygopalatine ganglion, and maxillary nerve as well as the
maxillary artery and its branches were all identified (Fig 3).
Endoscopic dissection behind the lateral portion of the
posterior maxillary wall was performed as far as the deep

Figure 3 Endoscopic view after removal of the left posterior

and posterolateral maxillary wall. PC, posterior choana; VC, vidian canal; SS, sphenoid sinus; PPG, pterygopalatine ganglion; GPN,
greater palatine nerve; V2, maxillary nerve; ION, infraorbital nerve;
IMA, internal maxillary artery; PSAA, posterior superior alveolar
artery; IOA, infraorbital artery; LBr, lateral pterygoid branch of IMA;
TBr, branch of IMA to the deep belly of temporalis muscle (TM);
LPM, lateral pterygoid muscle with its two heads partially separated
from the lateral surface of the pterygoid base and the infratemporal
surface of the greater wing of sphenoid bone (GWS).

863

Figure 4 Diagrammatic views of the left lateral and medial

pterygoid muscles and the deep belly of the temporalis muscle.
LPM, lateral pterygoid muscles, with its upper and lower heads
(UH and LH, respectively); MPM, medial pterygoid muscle, with
its superficial and deep heads (SH and DH, respectively); GWS,
greater wing of sphenoid; MS, maxillary sinus; SUP TM, superficial part of the temporalis muscle; Deep TM, deep belly of the
temporalis muscle ( sphenomandibularis muscle). Modified from
Geers C, Nyssen-Behets C, Cosnard G, et al. The deep belly of the
temporalis muscle: an anatomical, histological and MRI study.
Surg Radiol Anat. 2005; 27:184-191. With permission of Springer
ScienceBusiness Media.

belly of the temporalis muscle, or the so-called sphenomandibularis muscle (Figs 3, 4). These vertically oriented fibers
generally restrict further lateral endoscopic dissection unless electrocautery is used.
On the other hand, we were able to develop a dissection
plane by endoscopic separation of the lower and upper
heads of the lateral pterygoid muscle from the lateral surface of the pterygoid base and the infratemporal surface of
the greater wing of the sphenoid bone, respectively. Endoscopic dissection, thus, proceeded posteriorly along the
skull base toward the foramen ovale, the latter transmitting
the mandibular division of the trigeminal nerve. Posterior to

Figure 5 Endoscopic view of the left medial infratemporal

fossa. (A) The upper and lower heads of the lateral pterygoid
muscle (LPM [UH] & LPM [LH], respectively) are dissected from
the infratemporal surface of the greater wing of the sphenoid
(GWS) and from the lateral surface of the base of pterygoid
process (BPP). FR, foramen rotundum; VC, vidian canal; IMA,
internal maxillary artery retracted inferolaterally. (B) Further dissection of the LPM allows identification of the mandibular nerve
(V3) as it emerges from the foramen ovale. The dashed black line
depicts an area of the lateral pterygoid base that could be drilled to
provide a wider access to the medial infratemporal fossa.

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OtolaryngologyHead and Neck Surgery, Vol 140, No 6, June 2009

the foramen ovale, the foramen spinosum was identified

with a bridge of bone between both foramina. The middle
meningeal artery was identified passing through the foramen spinosum posterolateral to the mandibular nerve. Lateral to this, the mandibular condyle, laying in its articular
fossa, received the insertion of the endoscopically dissected
lateral pterygoid muscle (Figs 5, 6). Columellar measurements to the foramen rotundum and foramen ovale ranged
from 6.1 to 8.0 cm for the former and 7.0 to 9.1 cm for the
latter, with a mean of 6.75 cm and 7.78 cm, respectively
(Table 1).

DISCUSSION
Endoscopic access to the ITF is not uncommonly required
when dealing with advanced or deeply located sinonasal
neoplasms. The endoscopic approach, whenever applicable,
does not only avoid the functional and cosmetic morbidity
of open surgical approaches, but should also provide a
magnified, multi-angled view, with good access to the neoplastic projections at various skull base foramina.
In 2001, Hartnick et al15 used the cadaveric model to
describe a new surgical endoscopic approach to the foramen
ovale via Gillies and lateral brow incisions. However, because many lesions extending to this area actually originate
in the sinonasal region or at the pterygopalatine fossa, the
value of such lateral endoscopic approach might be limited
to visualization of the ITF or performing a biopsy. In the
current study, we have explored this region in continuity
with the sinonasal endoscopic dissection, describing the key

Figure 6 Endoscopic view of the left infratemporal fossa posterolateral to the base of the pterygoid process (BPP). The labeled
structures have been confirmed by an open lateral approach. (A)
The lateral pterygoid muscle (LPM) is dissected of the lateral
surface of the BPP and of the infratemporal surface of the greater
wing of the sphenoid bone (GWS). The mandibular nerve (V3) and
the middle meningeal artery (MMA) are identified. BBP, base of
pterygoid process; FR, foramen rotundum; VC, vidian canal; MC,
mandibular condyle in its articular fossa. (B) A closer view showing the V3 emerging from the foramen ovale (FO). Posterolateral
to the FO is a bony bridge (BB) separating the latter from the
foramen spinosum (FS) that transmits the MMA. Of note also is
the bony spine (BS) at the posterolateral edge of the FS. MC,
mandibular condyle.

Table 1
Columellar measurements to the foramen rotundum
(FR) and foramen ovale (FO) as measured by the
endoscopic transnasal approach in five adult
cadaver heads
Columellar measurements (cm)
Right side

Left side

Head number

FR

FO

FR

FO

1
2
3
4
5
Mean distance

7
7.7
6.3
6.3
6.3
6.72

8.4
8.9
7.0
7.6
7.4
7.86

7
8
6.5
6.1
6.3
6.78

7.8
9.1
7.1
7.2
7.3
7.7

surgical landmarks from an anterior approach. In the surgical realm, this should allow more complete endoscopic
excision of advanced sinonasal lesions.
To the best of our knowledge, this is the first endoscopic
study to highlight the sphenomandibularis muscle. This
masticatory muscle, first described by Dunn et al in 1996,16
originates from the greater wing of the sphenoid bone and
inserts distally on the coronoid process of the mandible.
Further anatomical work by Geers and coworkers17 has
shown that the so-called sphenomandibularis muscle corresponds to the deep portion of the temporalis muscle, since
there is no epimysial septum between the two structures. In
agreement with the endoscopic orientation provided in our
results, the authors of the last anatomical study have described the medial limit of the temporalis muscle deep belly
to come close to the foramen rotundum and the maxillary
nerve, with a 4- to 7-mm-wide space containing adipose
tissue separating the two structures.17
In the present study, we have proposed a new dissection
plane along the bony attachments of the lateral pterygoid
muscle heads in order to access the superomedial portion of
the ITF beneath the foramen ovale. If the dissection is
attempted away from the base of the pterygoid process, both
the lateral pterygoid and the deep belly of the temporalis
muscle would be encountered, limiting the development of
a good surgical plane.
Finally, some key endoscopic landmarks are described in
this report. The foramen ovale and the bony bridge that
separates it from the foramen spinosum, as well as the spine
of the latter, were sequentially identified endoscopically.
These bony structures could serve as helpful endoscopic
landmarks if surgical dissection in this region is warranted.
In conclusion, the current work should present a new
endoscopic surgical orientation to the medial portion of the
ITF. In experience d hands, this would allow safer as well as
more effective management of lesions extending to, or arising at, such a surgically challenging area.

Herzallah et al

Endoscopic transnasal study of the infratemporal . . .

AUTHOR INFORMATION
From the Department of Otolaryngology, Faculty of Medicine, Zagazig
University, Egypt (Dr Herzallah); and the Department of Otolaryngology,
University of Miami, Miller School of Medicine, Miami, FL (Drs Germani
and Casiano).
Corresponding author: Islam R. Herzallah, MD, Department of Otolaryngology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
E-mail address: iherzallah@gmail.com.
Presented at the Annual Meeting of the American Academy of OtolaryngologyHead and Neck Surgery, Chicago, IL, September 21-24, 2008.

AUTHOR CONTRIBUTIONS
Islam R. Herzallah, review of previous studies, performing the dissection
work, and writing the manuscript; Ross Germani, assisting in the dissection work, reviewing the written manuscript; Roy R. Casiano, guiding the
study, providing dissection ideas based on the surgical experience, and
reviewing the work.

DISCLOSURES
Competing interests: Roy R. Casiano, consultant for Medtronic/Xomed
and Gyrus.
Sponsorships: None.

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