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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.