Download - Infra temporal fossa anatomy
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Infratemporal fossa
Dr. Prathyusha PG ENT
Narayana Medical College
Nellore
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• Introduction
• Boundaries
• Contents
• Applied anatomy
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Introduction • The infratemporal fossa is a complex and irregularly
shaped space, located deep to the masseter muscle and the mandible.
• It acts as a conduit for many neurovascular structures that travel between the cranial cavity and other structures of the head.
• Tumors here present a surgical and diagnostic challenge because of the complex anatomy and occult nature of tumors harbored there.
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Boundaries • Anterior: the posterior surface of the maxilla
• Posterior: the styloid process, carotid sheath and deep part of the parotid gland.
• Medial: lateral pterygoid plate of sphenoid
• Lateral: the ramus and coronoid process of the mandible
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The roof: the infratemporal surface of the greater wing of the
sphenoid.
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The infratemporal fossa has NO anatomical floor, being continuous with tissue spaces in the neck.
The infratemporal fossa communicates with the temporal fossa deep to the zygomatic arch
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Contents 1. Lateral and medial pterygoid muscles.2. Infratemporal pad of fat 3. Buccal lymph node4. Mandibular nerve5. Chorda tympani nerve6. Maxillary artery7. Pterygoid plexus of veins8. Otic ganglion9. Sphenomandibular ligament
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Lateral pterygoid muscle• largest component of the infratemporal fossa.
• This muscle has two heads, upper and lower.
• The upper head is smaller and arises from the greater wing of sphenoid,
• while the larger lower head arises from the lateral aspect of lateral pterygoid plate.
• The fibers of both these heads pass backwards to be inserted into the neck of the mandible.
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action• to pull the head of the condyle out of
the mandibular fossa along the articular eminence to protrude the mandible.
• Both lateral pterygoid muscles acts in helping lower the mandible and open the jaw
• only muscle of mastication that assists in depressing the mandible (opening the jaw).
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Medial pterygoid muscle• This muscle is the deepest of the four muscles of
mastication.
• It consists of two heads.
• The bulk of the muscle arises as a deep head from the medial surface of the lateral pterygoid plate.
• Thus, the lateral pterygoid plate of the sphenoid bone gives rise to both pterygoid muscles
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• The smaller, superficial head of the medial pterygoid muscle originates from
• the maxillary tuberosity and
• the neighbouring part of the palatine bone
• the fibres pass downwards and backwards to insert into the roughened surface of the angle of the mandible on its medial aspect.
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action• The medial pterygoid muscle is an elevator of the
mandible.
• It assists in lateral and protrusive movements.
• The medial pterygoid muscle is synergistic to the masseter muscle.
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Medial pterygoid muscle
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2. Infratemporal pad of fat: • Lies between the temporalis muscle and the
infratemporal surface of maxilla.
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Applied anatomy• The pad of fat helps in outlining the posterior
antral tumor spread in CT scans.
• This infratemporal pad of fat continues with the cheek pad of fat passing between the posterior wall of maxilla and the zygoma.
• A mass present behind the maxilla always betrays itself by displacing this pad of fat and causing a puffy sweeling of the cheek (angiofibroma)
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• Fat appears as a halo around the tumor
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3. Buccal lymph node: • Within this infratemporal pad of fat lies the buccal
lymph node. • This node links the infratemporal lymphatics to the
facial lymphatics.
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• Lymphatic drainage of the infratemporal fossa region is into the submandibular and upper deep cervical group of nodes
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Applied anatomy• enlargement of the nodes in this region should
alert the clinician to the possibility of infection arising in the infratemporal fossa.
• This node should NEVER be left behind during surgical resection of infratemporal fossa for malignant tumors as it could commonly cause local recurrence.
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4. Mandibular nerve• penetrates the roof of the infratemporal fossa
through the foramen ovale.
• It gives rise to inferior alveolar and lingual nerve branches.
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Buccal branch of mandibular nerve• Using the medial and lateral pterygoid muscles as
references
• the buccal branch of the mandibular nerve accompanying buccal artery
• The nerve and artery usually pass between the two heads of the lateral pterygoid muscle.
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Other branches• the lingual nerve
• inferior alveolar nerve
• These two nerves pass between the medial and lateral pterygoid muscles.
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Course of these nerves• Distally, the inferior alveolar nerve enters the
mandibular foramen.
• The lingual nerve lies superior to the inferior alveolar nerve and passes anteriorly to reach the tongue.
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• the inferior alveolar nerve, artery, and vein emerge from the mental foramen as
• the mental nerve,• mental artery, • And mental vein .
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Auriculo temporal nerve• the auriculotemporal nerve has two roots that
encircle the middle meningeal artery.
• It carries sensory fibers from the skin of the temporal region
• and postganglionic parasympathetic fibers from the otic ganglion to the parotid gland.
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5. Chorda tympani • chorda tympani nerve emerges from the
petrotympanic fissure
• passes anteriorly to join the lingual nerve
• This nerve carries special sensory taste fibers from the anterior two-thirds of the tongue and
• preganglionic parasympathetic fibers to the submandibular ganglion.
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Maxillary artery • it is divided into 3 parts in relation to lateral pterygoid
muscle
• First part : posterior to lateral pterygoid muscle
• Second part: within lateral pterygoid muscle
• Third part: anterior to lateral pterygoid muscle ( in pterygopalatine fossa through pterygomaxillary fissure)
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6. Pterygoid venous plexus
• venous plexus of considerable size,
• situated between the temporalis muscle and lateral pterygoid muscle,
• partly between the two pterygoid muscle
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Veins contributing for plexus• sphenopalatine• middle meningeal• deep temporal (anterior & posterior)• pterygoid• masseteric• buccinator• alveolar• some palatine veins (palatine vein which divides into the greater and
lesser palatine v.)• a branch which communicates with the ophthalmic vein through
the inferior orbital fissure• infraorbital vein
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• The pterygoid venous plexus communicates with the cavernous sinus via two routes.
• One route is via emissary veins passing through the foramen ovale, foramen spinosum.
• Another route is via the deep facial vein, which links the pterygoid venous plexus with the facial vein.
• The facial vein connects with the superior ophthalmic vein, which drains into the cavernous sinus.
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Applied anatomy• Due to its communication with the cavernous
sinus, infection of the superficial face may spread to the cavernous sinus, causing cavernous sinus thrombosis.
• These plexus could cause troublesome bleeding during total maxillectomy surgery.
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Cavernous sinus thrombosis
• Complications may include • edema of the eyelids,
conjunctivae of the eyes, • paralysis of cranial
nerves which course through the cavernous sinus.
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7. Otic ganglion• located inferiorly to the foramen ovale,
• medial to the mandibular nerve
• preganglionic fibres from inferior salivatory nucleus (associated with the glossopharyngeal nerve).
• Parasympathetic fibres travel within a branch of the glossopharyngeal nerve, the lesser petrosal nerve, to reach the otic ganglion.
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• Post ganglionic fibres along the auriculotemporal nerve (branch of the mandibular division of the trigeminal nerve).
• provide secretomotor innervation to the parotid gland.
• Sympathetic fibres from the superior cervical chain pass through the otic ganglion.
• They travel with the middle meningeal artery to innervate the parotid gland.
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7. Sphenomandibular ligament• a flat, thin band which is attached superiorly to the
spine of the sphenoid bone, and, becoming broader as it descends,• It is fixed to the lingula of the mandibular foramen. • it limits distension of the mandible in an inferior
direction. • It is slack when the TMJ is in closed position.• It is taut as the condyle of the mandible is in front
of the temporomandibular ligament.
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Communications • The infratemporal fossa communicates superiorly
with middle cranial fossa by the neurovascular formina like• carotid canal,• jugular foramen, • foramen spinosum,• foramen ovale • foramen lacerum.
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• Medially the infratemporal fossa communicates with pterygopalatine fossa through the pterygomaxillary fissure.
• With orbit through infra orbital fissure
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• The pterygomaxillary fissure is contiguous with that of the infraorbital fissure.
• The roof of the infratemporal fossa is open to the temporal fossa lateral to the greater wing of sphenoid, deep to the zygomatic arch.
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Applied anatomy• Benign tumors involving the infratemporal fossa
always respect these boundaries
• They expand in the direction of soft tissue planes, or follow preexistant pathways and foramen described above.
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• Maxillofacial trauma , maxillary osteotomies, have the potential to disrupt the soft tissue contents of the infratemporal fossa
• These fractures frequently extend to involve the bones immediately adjacent to them
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• Infection of the infratemporal fossa is most
commonly associated with a pericoronitis of mandibular third molar tooth
• dental abscess of this tooth, or as a result of infection following tooth extraction
• Rarely, it may result from an infected needle used during an inferior alveolar nerve block.
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• Infection of the infratemporal region may be secondary due to spread from an adjacent infected tissue space.
• The main symptom is trismus (though a common symptom of parapharyngeal abscess)generally affecting the medial pterygoid muscle
• Externally there is usually little evidence of tissue
swelling.
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• Spread of infection from the infratemporal fossa region to involve the buccal space is characterised by the presence of a swelling of the cheek
• The swelling is bounded above by the zygomatic arch and below by the lower border of the mandible, both landmarks being palpable.
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• Infection from the infratemporal fossa may spread
• directly around the back of the maxillary tuberosity • into the orbit via the inferior orbital fissure.
• This may result in cavernous sinus thrombosis • Once in the orbit, further direct spread of infection
through the superior orbital fissure will gain entrance into the cranial cavity.
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• Spread from the infratemporal fossa via the pterygomaxillary fissure may also involve the pterygopalatine fossa,• which contains the maxillary nerve,• maxillary artery • pterygopalatine ganglion
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• From the pterygopalatine fossa a number of small canals lead into • nose, • pharynx • palate.
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Applied anatomy• Tumors of the infratemporal fossa can be described
as • primary,• secondary or metastatic. • Adenoid cystic carcinoma, adenocarcinoma, and
squamous cell carcinoma are common • nasopharyngeal fibroma frequently found in
benign lesions..
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• it is usually involved by tumors extending from areas such as• the paranasal sinuses,• middle cranial fossa,• nasopharynx,• parotid,• external auditory canal.
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• Primary tumors of the infratemporal fossa are seen less frequently and metastasis to this area is extremely rare.• Due to it’s concealed location, tumors often present
late.
• Clinical signs and symptoms are insidious and are frequently attributed to other structures or disease.
• In addition, surgical planning is confounded by the close proximity to intracranial structures, the orbit, sinuses, and the nasopharynx
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Take home message• Numerous structures in this deep irregular space expects us
to be anatomically oriented
• Potential communication to cavernous sinus, middle cranial fossa and orbit makes this area a potential high risk space
• Highly vascular area due to pterygoid plexus and maxillary artery warns surgeons to be alert to prevent bleeding
• Appearance of infections in other tissue spaces like orbit, pterygopalatine fossa, and in the maxillary antrum should prompt a primary site in infratemporal fossa
• Due to its concealed location tumours often present late
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Bibliography• Surgical Anatomy of the Infratemporal Fossa, John
D.Langdon, UK Barry K.B.Berkovitz MARTIN DUNITZ publications
2003
• Last’s Anatomy Regional and Applied. 12th edition 2011 Churchill Livingstone publications
• Grays Anatomy for Students, 2nd edition 2012 Churchill Livingstone publications
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![Page 87: Infra temporal fossa anatomy](https://reader033.vdocuments.mx/reader033/viewer/2022042605/58eb7db21a28abcb618b472d/html5/thumbnails/87.jpg)