Surgery of the Infratemporal Fossa and Parapharyngeal Space

Infratemporal fossa (ITF) and parapharyngeal space (PPS) are areas located below the middle cranial fossa. ITF is found between the ascending ramus of the mandible, the pterygoid process and the maxillary tuberosity and the main anatomic structures included here are the mandibular branch of the trigeminal nerve, the middle meningeal artery and the maxillary artery. PPS is located behind the ITF and is lateral to the pharynx and ventral to the cervical spine and the main elements that are contained here are: the styloid process, the carotid artery, the jugular vein and the lower cranial nerves. Both are clinically silent areas and so, it is not rare that tumors located here, usually have reached huge dimensions at diagnosis. For that reasons in many cases, it becomes necessary to combine two or more approaches to get a wide and safe surgical exposure. In this chapter, we present the zygomatic-transmandibular approach as a very good option for the removal of tumors, particularly giants, located here. It is performed by two surgical teams and consists in the combination of a pterional orbito-zygomatic craniotomy plus a transfacial trans-mandibular route, by making a vertical cut in the ascending ramus of the mandible and rotating (as a hinge) the posterior part of this ramus. In this manner, the tumor is dissected from the middle cranial fossa (by neurosurgeons), for final tumor removal (by head and neck surgeons) from bellow. This approach allows a wide and safe surgical exposure, without affecting chewing or facial function.