Note: Be careful with spelling and accentuation of the search words.
Pterygopalatine Fossa
Endoscopic removal of a schwannoma
 |
 |
| 1. Septal incision to work through the opposite nasal cavity. | 2. The presence of a concha bullosa narrows the working space. |
 |
 |
| 3. Middle meatus with a normal anatomy. | 4. Removing the lateral part of the concha bullosa. |
 |
 |
| 5. Cutting the uncinate process. | 6. The vertical part of the uncinate process. |
 |
 |
| 7. Removing the horizontal part of the uncinate process. | 8. Opening the antrostomy with a microdebrider. |
 |
 |
| 9. Posterior enlargement of the antrostomy. The antral bowing sign. | 10. Removing the bulla ethmoidalis. |
 |
 |
| 11. Reducing the size of the middle concha with a microdebrider. | 12. Elevating the mucosa to locate the sphenopalatine artery. The medial wall of the pterygopalatine fossa is thinned to an eggshell. |
 |
 |
| 13. Locating the sphenopalatine artery. | 14. Elevating the mucosa from the posterior wall of the antrum. |
 |
 |
| 15. Starting the removal of the bone covering the tumor at the area of the sphenopalatine foramen with a Hajek punch. | 16. The medial aspect of the tumor. A small vessel is seen inferiorly … |
 |
 |
| 17. … and is cauterized. | 18. Continuing to reveal the tumor by removing the posterior wall of the antrum |
 |
 |
| 19. Trying to identify the lateral borders of the tumor. | 20. Using a diamond burr to remove bone from the medial border. |
 |
 |
| 21. The medial aspect of the tumor. | 22. Cauterization of a vessel found at the region of the greater palatine canal. |
 |
 |
| 23. The lateral limits of the tumor. The fatty tissue of the fossa is seen. | 24. Dissection of the fibrous tissue connected to the tumor. |
 |
 |
| 25. Cauterization of the fibrous bands. | 26. Dissection along the upper limit of the tumor. |
 |
 |
| 27. Cauterization of a vessel running along the upper limit of the tumor. | 28. Identification of the mandibular branch of the trigeminal nerve. |
 |
 |
| 29. Cauterization of a fibrous band at the superior aspect of the tumor. | 30. Further dissection reveals blood vessels around the tumor. |
 |
 |
| 31. The vessels are cauterized. | 32. A large feeding vessel is identified during dissection. |
 |
 |
| 33. Haemostatic clips are placed and the vessel is cut. An inadvertent breach in the wall of the tumor is seen. | 34. Surrounding the tumor. The lower limit. |
 |
 |
| 35. Working with a second surgeon. The suction pushes the tumor inferiorly while the bipolar cauterizes the fibrous bands and blood vessels. | 36. A large vessel is seen crossing the branches of the mandibular nerve and initially cauterized. |
 |
 |
| 37. Haemostatic clips are placed on second thought. | 38. Continuing freeing the tumor from its vessels. |
 |
 |
| 39. The anterior wall of the sphenoid sinus is revealed. | 40. A final but strong attachment of the tumor to the greater palatine canal. A possible site of origin. |
 |
 |
| 41. Haemostatic clips are placed and the attachment is divided. | 42. The tumor free of its attachments ready to be removed. |
 |
|
|
43. The bed of the tumor. The anterior wall of the sphenoid sinus. |
