Pterygopalatine Fossa Research Articles

Comparison between Ultrasonographic-Guided Temporal and Coronoid Approaches for Trigeminal Nerve Block in Dogs: A Cadaveric Study.

The trigeminal nerve is responsible for innervating the periorbita. Ultrasound-guided trigeminal block is employed in humans for trigeminal neuralgia or periorbital surgery. There are no studies evaluating this block in dogs. This study aims to evaluate and compare two approaches (coronoid and temporal) of the trigeminal nerve block. We hypothesised superior staining with the coronoid approach. Thirteen dog heads were used. After a preliminary anatomical study, two ultrasound-guided injections per head (right and left, coronoid and temporal approach, randomly assigned), with an injectate volume of 0.15 mL cm-1 of cranial length, were performed (iodinated contrast and tissue dye mixture). The ultrasound probe was placed over the temporal region, visualising the pterygopalatine fossa. For the temporal approach, the needle was advanced from the medial aspect of the temporal region in a dorsoventral direction. For the coronoid approach, it was advanced ventral to the zygomatic arch in a lateromedial direction. CT scans and dissections were conducted to assess and compare the position of the needle, the spread of the injectate, and nerve staining. No significant differences were found. Both approaches demonstrated the effective interfascial distribution of the injectate, with some minimal intracranial spread. Although the coronoid approach did not yield superior staining as hypothesised, it presents a viable alternative to the temporal approach. Studies in live animals are warranted to evaluate clinical efficacy and safety.

Angioleiomyoma of the Pterygopalatine Fossa: A Case Report.

Angioleiomyoma (ALM) is a benign neoplasm marked by the presence of blood vessels and smooth muscle cells, commonly located within the subcutaneous or deep dermal layers. Its manifestation in the pterygopalatine fossa is infrequent, thereby posing difficulties in its diagnosis and distinction from other benign tumors within the same anatomical site. In the present case study, an ALM originating in the right pterygopalatine fossa of a 44-year-old female patient was investigated. The patient underwent surgical intervention for the vascular smooth muscle tumor, and there has been no recurrence noted during the postoperative monitoring period.

Endoscopic approach to a Radkowski IIB juvenile angiofibroma

The origin of juvenile angiofibroma is usually around the region of the maxillary artery, and the surgical ma­nage­ment of large tumors can be challenging. Traditional ap­proaches to advanced tumors involved open transfacial or transcranial microscope-assisted surgery. Advances in en­do­na­sal endoscopic techniques have made endonasal en­do­sco­pic approaches to the pterygopalatine fossa and in­fra­tem­po­ral possible. Endoscopes allow for greater mag­ni­fi­ca­tion and visualization of complex anatomy, and endoscopic approaches allow the surgeon to avoid ma­ni­pu­la­tion of the osseous midfacial structures that may result in cra­nio­fa­cial abnormalities in this adolescent population.

Advantages and caveats of endoscopic to the infratemporal fossa as isolated and combined techniques.

Identify the benefits and caveats of combining minimal access approaches to the infratemporal fossa (ITF), such as the endoscopic transnasal, endoscopic transorbital, endoscopic transoral, and endoscopic sublabial transmaxillary approaches to address extensive lesions not amenable to a single approach. The study provides anatomical metrics including area of exposure and degree of surgical freedom. Five human cadaveric specimens (10 sides) were dissected to expose and methodically analyze the anatomical intricacies of the ITF using the following minimal access approaches: endoscopic transnasal transpterygoid (EETA), endoscopic sublabial transmaxillary, endoscopic transorbital via infraorbital foramen, and endoscopic transoral techniques. Area of exposure at the pterygopalatine fossa and surgical freedom at the ITF were obtained for each approach. The endoscopic sublabial transmaxillary sinus and the combined approach afford a significantly greater exposure than an isolated EETA. The difference in exposure (mean) between the endoscopic sublabial transmaxillary and EETA was 1.62 ± 0.85 cm2 (p < 0.001), and the difference between the combined approach and EETA was 4.25 ± 0.85 cm2 (p < 0.001). Combining minimal access endoscopic approaches to the ITF can provide significantly greater exposure than an isolated EETA; thus, providing enhanced access to address lesions with extensive involvement of the ITF, especially those with superolateral and inferolateral extensions. In addition, some approaches may have an adjunctive role to the resection, such as the endoscopic transoral approach offering the potential for early control of the internal maxillary artery and its branches, some of which may be supplying the tumor in the ITF; or the endoscopic transorbital approach yielding a direct line of sight to the superior ITF and middle cranial fossa. NA.

The importance of the palatine bone for endoscopic endonasal skull base surgery.

Endoscopic endonasal skull base surgery is increasingly prevalent, with its scope expanding from pathogens in the midline region to those in the paramedian region. Maximizing anterior sphenoidectomy is important for the median approach, and lateralizing the pterygopalatine fossa is crucial for the paramedian approach. Maximizing the surgical corridor in the nasal cavity and minimizing damage to neurovascular structures are vital for establishing a surgical field with minimal bleeding, ensuring safe, precise, and gentle procedures. However, the relationship between the maxillofacial and skull base bones in endoscopic endonasal skull base surgery is difficult to understand because these bones are intricately articulated, making it challenging to visualize each bone's outline. Understanding important bones and their related neurovascular structures is essential for all skull base surgeons to maximize the surgical corridor and minimize iatrogenic injury to neurovascular structures. This study aimed to elucidate the role of the palatine bone from a microsurgical anatomical perspective. Three dry skulls were used to demonstrate the structure of the palatine bone and its relationship with surrounding bones. A formalin-perfused cadaveric head was dissected to show the related neurovascular structures. The arteries and veins of the cadaveric heads were injected with red- and blue-colored silicon. Dissection was performed using a surgical microscope and endoscope. In addition, the utilization of the palatine bone as a landmark to identify neurovascular structures, which aids in creating a wider surgical field with less bleeding, was shown in two representative cases. The palatine bone consists of unique complex structures, including the sphenoidal process, ethmoidal crest, pterygopalatine canal, and sphenopalatine notch, which are closely related to the sphenopalatine artery, maxillary nerve, and its branches. The ethmoidal crest of the palatine bone is a well-known structure that is useful for identifying the sphenopalatine foramen, controlling the sphenopalatine artery and nerve, and safely opening the pterygopalatine fossa. The sphenoidal process of the palatine bone is a valuable landmark for identifying the palatovaginal artery, which is a landmark used to safely and efficiently expose the vidian canal. The sphenoidal process is easily cracked with an osteotome and removed to expose the palatovaginal artery, which runs along the pharyngeal groove, just medial to the vidian canal. By opening the pterygopalatine canal (also known as the greater palatine canal), further lateralization of the periosteum-covered pterygopalatine fossa contents can be achieved. Overall, the sphenoidal process and ethmoidal crest can be used as important landmarks to maximize the surgical corridor and minimize unnecessary injury to neurovascular structures.

Radiofrequency regulation of the sphenopalatine ganglion in managing herpes zoster ophthalmicus neuralgia: A case series.

Trigeminal herpes zoster, which comprises 10% to 20% of cases of herpes zoster, often leads to severe pain in the ophthalmic branches. Current treatments, including drug therapy and minimally invasive interventions, have limitations; accordingly, there is a need to explore alternative approaches. This study aimed to evaluate the efficacy and safety of computerized tomography (CT)-guided pulsed radiofrequency of the sphenopalatine ganglion in patients with intractable trigeminal herpetic pain. Three patients with intractable trigeminal ophthalmic zoster neuralgia were studied. All patients complained of bursts of headache, which occurred at least 10 times a day, usually in the periorbital and frontal regions. Conventional treatments, including oral medications and radiofrequency therapy targeting the trigeminal-semilunar ganglion and supraorbital nerve, could not sufficiently provide relief. Two patients were diagnosed with herpes zoster in the ocular branch of the trigeminal nerve with conjunctivitis, while one patient was diagnosed with postherpetic neuralgia in the ocular branch of the trigeminal nerve. This study employed a novel approach that involved CT-guided radiofrequency regulation of the pterygopalatine fossa sphenopalatine ganglion. In all three patients, pain relief was achieved within 1 to 3 days after treatment. During the follow-up, one patient had pain recurrence; however, its severity was ≈ 40% lower than the pretreatment pain severity. The second patient had sustained and effective pain relief. However, the pain of the third patient worsened again after 2 months. The average follow-up duration was 3 months. None of the enrolled patients showed treatment-related adverse reactions or complications. Our findings indicated that CT-guided radiofrequency regulation of the pterygopalatine fossa sphenopalatine ganglion was a safe and effective intervention for pain in patients with trigeminal ophthalmic zoster neuralgia, suggesting that it may be a therapeutic option if other treatments fail.

Automatic pterygopalatine fossa segmentation and localisation based on DenseASPP.

Allergic rhinitis constitutes a widespread health concern, with traditional treatments often proving to be painful and ineffective. Acupuncture targeting the pterygopalatine fossa proves effective but is complicated due to the intricate nearby anatomy. To enhance the safety and precision in targeting the pterygopalatine fossa, we introduce a deep learning-based model to refine the segmentation of the pterygopalatine fossa. Our model expands the U-Net framework with DenseASPP and integrates an attention mechanism for enhanced precision in the localisation and segmentation of the pterygopalatine fossa. The model achieves Dice Similarity Coefficient of 93.89% and 95% Hausdorff Distance of 2.53mm with significant precision. Remarkably, it only uses 1.98M parameters. Our deep learning approach yields significant advancements in localising and segmenting the pterygopalatine fossa, providing a reliable basis for guiding pterygopalatine fossa-assisted punctures.

Risk factors and clinical presentation of rhino-orbital mucormycosis: Lesson learnt during Covid pandemic.

To analyze the potential predisposing factors and clinical presentation of mucormycosis in patients with COVID-19. Medical records of 141 patients with COVID-19-associated mucormycosis (CAM) treated at a tertiary care center in Bihar were reviewed. The predisposing factors, clinical features, and imaging findings of mucormycosis were analyzed. The median age was 48 years (IQR, 43-60). A total of 58 patients developed concurrent CAM and 83 post-CAM. The median interval between COVID-19 and onset of CAM symptoms was 15 days (IQR, 9-16). A total of 80 patients received at-home treatment for COVID-19, and 73 had mild-to-moderate disease. While 61 patients received in-hospital treatment, 57 had severe disease. At presentation, 131 patients had hyperglycemia: 64 type 2 diabetes mellitus (DM) and 67 new-onset DM. The history of glucocorticoid use for COVID-19 was present in 125 patients; 47% were administered at home without monitoring plasma glucose. The common presenting features were toothache, periocular or facial pain, and edema. Rhino-orbital mucormycosis was the most common. Imaging revealed rhinosinusitis in all patients, including pansinusitis (68%), pterygopalatine fossa involvement (21%), cavernous sinus thrombosis (38%), brain abscess (8%), and infarct (4%). All patients received intravenous liposomal amphotericin B, and surgical debridement was performed in 113. COVID-19 patients with hyperglycemia are at risk of developing CAM, irrespective of the severity. Timely recognition of symptoms and prompt initiation of therapy by primary healthcare physicians are imperative for enhancing outcomes. Additionally, glucocorticoid overuse should be avoided, and close monitoring for hyperglycemia development is warranted.

Schwannoma of the pterygopalatine fossa: Transfacial approach and maxillary swing technique

The pterygopalatine fossa is a complex anatomic space related to the skull base. Primary and secondary tumors can be located in this area. The approach to this space can be challenging due to its anatomy and neurovascular relations. The aim of this paper is to describe systematically the maxillary swing technique used in the resection of a V2 Schwannoma located in the right pterygopalatine fossa. With this report we want to highlight that this classic approach should we considered in the management of Deep facial spaces when endoscopic approach cannot be performed.

A rare case of extra-parotid pleomorphic adenoma

A 56-year-old male patient presented to the Department of Otolaryngology with a gradually enlarging soft palatal mass on the right side over several months. Clinical examination revealed a non-ulcerated, dome-shaped, palatal swelling on the soft palate. The mass, measuring approximately 2x2 cm, was smooth, uninodular, firm, non-tender, and non-fluctuant, without involvement of adjacent teeth. No overlying ulceration or discoloration was observed. Computed tomography scan indicated a well-circumscribed solid lesion (2.3 x 1.9 x 1.7 cm) with no evidence of infiltration into surrounding soft-tissue structures, the pterygopalatine fossa, or palatine nerve foramina (Figure 1, arrow). The lesion was successfully resected through a transoral approach, easily dissected from surrounding tissue, and sparing the overlying mucosa (Figure 2). Pathological analysis confirmed a diagnosis of pleomorphic adenoma. The patient recovered well, and subsequent follow-up in the outpatient department revealed no signs of recurrent tumor.

Role of stereotactic radiosurgery for recurrent skull base acinic cell carcinoma: illustrative case.

Acinic cell carcinomas (AcCCs), rare malignancies of the salivary glands, often recur and metastasize, particularly in the skull base. Conventional radical resection can be invasive for skull base AcCCs adjacent to cranial nerves and major vasculature, and the effectiveness of stereotactic radiosurgery (SRS) as an alternative is not well established. This case report details the application of SRS for recurrent skull base AcCCs. A 71-year-old male with a history of resection for a right mandibular AcCC 23 years earlier experienced tumor recurrence involving the right cavernous sinus and nasal cavity. He underwent endoscopic transnasal surgery followed by SRS targeting different tumor locations-the cavernous sinus to the pterygopalatine fossa, maxillary sinus, and clivus-each with a prescribed dose of 20 Gy to the 40% to 50% isodose line. After the first skull base metastasis, additional sessions of localized SRS after endoscopic surgery led to a 12-year survival without sequela. This is a report indicating that SRS for skull base AcCCs can achieve favorable local control, functional preservation, and long-term survival. SRS may be suitable for skull base AcCC given the lesion's tendency toward multiple local recurrences. Further investigation is needed to validate the treatment's efficacy.

Pathophysiological mechanisms, diagnosis and treatment of the fractures of the temporal bone styloid process

The styloid process is a needle-like osseous projection beneath the temporal bone, typically measuring 2.5-3 cm. Its fracture is uncommon and mostly occurs in elongated processes, often due to trauma, dental procedures, or sports. This paper presents an unusual case of a normallength styloid process fracture in a 24-year-old serviceman, resulting from a mine explosion. The patient complained of intense headaches, and pain during yawning, swallowing, and head rotation. Examination revealed pain in the left pterygopalatine fossa, and decreased pharyngeal reflex on the left, and a CT scan showed brain contusion, subarachnoid haemorrhage and a linear fracture in the normal-sized left styloid process, with no displacement. Treatment with anti-inflammatory drugs and muscle relaxants led to symptoms improvement, and no fragment dislocation was observed in a follow-up CT. This report contributes to understanding the diagnosis of normal-length styloid process fractures, contrasting with the more reported elongated ones.

Pediatric Pterygopalatine Fossa Schwannoma Presenting as Vision Loss: A Case Report and Literature Review.

Neurosynovial tumors, originating from Schwann cells within nerve sheaths, are benign entities, with 25% to 45% manifesting in the head and neck region. However, occurrences in the pterygopalatine fossa (PPF) are exceptionally rare, and only a handful of cases have been documented. In this report, we present the unique case of a 6-year-old child exhibiting a sizable soft tissue mass in the left PPF, extending into the inferior orbital fissure. The patient underwent successful intranasal endoscopic removal of PPF schwannoma utilizing the prelacrimal recess approach, with postoperative pathology confirming the diagnosis of schwannoma. Schwannomas within the PPF are particularly uncommon, and instances of such tumors in pediatric patients are even more exceptional. This case highlights the diagnostic and therapeutic challenges associated with PPF schwannomas in children, emphasizing the significance of a multidisciplinary approach for optimal management. In addition, a comprehensive literature review is presented to provide insights into the existing knowledge on this rare entity, further contributing to the understanding of pediatric PPF schwannomas.

SNOT-22 subdomain outcomes following treatment for sinonasal malignancy: A prospective, multicenter study.

Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22-item Sinonasal Outcomes Test (SNOT-22) has been shown to improve with treatment. This study aims to characterize SNOT-22 subdomain outcomes in SNM. Patients diagnosed with SNM were prospectively enrolled in a multi-center patient registry. SNOT-22 scores were collectedat the time of diagnosis and through the post-treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT-22 subdomains. Note that 234 patients were reviewed, with a mean follow-up of 22 months (3 months-64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p<0.05). Subanalysis of 40 patients with follow-up at all timepoints showed statistically significant improvement in rhinologic, extra-nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69-8.66])), extra-nasal (2.21 [0.22-4.17]) and ear/facial (5.53 [2.10-8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54-5.93]) and ear/facial (2.97 [0.32-5.65]) subdomains. Positive margins (5.74 [2.17-9.29]) and surgical approach-combined versus endoscopic (3.41 [0.78-6.05])-were associated with worse psychological outcomes.Adjuvant radiation (2.28 [0.18-4.40]) was associated with worse sleep outcomes. Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra-nasal, psychological, and sleep subdomains.

Sino nasal undifferentiated carcinoma – A diagnostic conundrm

Sinonasal undifferentiated carcinoma (SNUC) is a rare and highly aggressive tumour frequently arising from the maxillary sinus and nasal cavity. Here we report a 34-year-old female patient who presented with a pale polypoidal mass which bleeds on touch involving the left nasal cavity and nasopharynx. Imaging showed a multilobulated lesion involving the left nasal cavity and left paranasal sinuses with extension into the left masticator space, pterygopalatine fossa and retropharyngeal space supplied by a branch of the left maxillary artery. It suggested a possibility of a benign vascular mass lesion. The mass was surgically removed via the maxillary swing approach. Immunohistochemical analysis showed epithelial origin (AE1/AE3+, EMA+) and no reactivity for neuroendocrine, melanocytic, hematolymphoid, or mesenchymal markers. A diagnosis of SNUC was reached and the patient was given concurrent radiotherapy and chemotherapy. The patient is disease free one year post surgery. To conclude, a vigilant correlation of clinical, microscopic, and immunohistochemical characteristics is essential for early diagnosis and optimal management of SNUC.

The imaging presentations of the fallopian canal cerebrospinal fluid leaking

Objective: To summarize the imaging presentations of the fallopian canal cerebrospinal fluid leaking (FCCFL). Methods: The high resolution CT (HRCT)and MRI materials of 4 patients (4 ears) with FCCFL confirmed by surgery between August 2016 to November 2023 were retrospectively analyzed. Among these, there were 2 males and 2 females, their ages ranged from 6 to 69 years. Results: All of the FCCFL were unilateral, including 2 on the left and 2 on the right.Clinically, the patients with FCCFL suffered from clear nasal fluid flow, ear tightness, and hearing loss. On CT, all of the affected ears were depicted markedly dilatation of the proximal portion of fallopian canal(FC), the labyrinthine segment and geniculate fossa were involved in 4 cases, and involvement of tympanic segment in 1 case at the same time. The geniculate fossa in the affected side were significantly enlarged, protruding upwards into the tympanic cavity, with one case simultaneously involving the cochlea. On MRI, the hyposignal on T1WI and hypersignal on T2WI or water sequence like cerebrospinal fluid (CSF) were shown in the enlargement FC, without diffusion restriction, and non-enhancing with administration Gadolinium contrast.CSF-like signal effusion was shown in all of the affected tympanum, of which, the CSF-like signal effusion was demonstrated in the area along the superficial petrosal nerve, the right pterygopalatine fossa and the parapharyngeal space. The adjacent intracranial meninges were presented thickening in 3 cases. Conclusion: The imaging appearances of FCCFL present some characteristics:on HRCT, the proximal portions of the affected FC depicts markedly enlargement,especially the geniculate fossa.While they present CSF-like signal, no diffusion restriction, and no enhancement administration, Gadolinium contrast on MRI, accompanying the CSF-like signal effusion in the affected tympanum.

Combined Endoscopic Transmaxillary Approach for Resection of an Extracranial V3 Schwannoma: 2-Dimensional Operative Video.

Tumours of the pterygopalatine (PPF) and infratemporal fossa (ITF) are rare tumours and are difficult to access. The lateral cervical approach is hampered by the mandibular angle and the vascular nervous elements.1 The classic endonasal endoscopic medial maxillectomy approach has been developed over the past 2 decades but does not allow good control of the most lateral and inferior part of the ITF.2 The surgical video presents a 68-year-old woman with trigeminal neuralgia. The radiologic workup showed a trigeminal V3 schwannoma (TS) into the PPF and ITF. This tumor grew during the follow-up despite fractionated radiosurgery. A 2-dimensional intraoperative video illustrates the gross total removal of the TS through a combined endoscopic endonasal and transgingival transmaxillary approach. The combination of these 2 approaches allows on the one hand, a better view of the lateral and inferior part of the maxillary sinus and ITF and on the other hand, a gain of handling in the operating field and security for our surgical procedure.3 The mini-Caldwell-Luc approach gives good aesthetic results without stomatological complication. Neuralgia disappeared after the surgery, and a gross total resection was achieved, and no recurrence was observed during the follow-up. This combined approach is a good alternative of medial extended maxillectomy, which presents a risk for the lacrimal duct risk and postoperative aesthetic deformity because of the removal of the medial and anterior wall of the maxillary sinus. The patient consented to the procedure and publication of her image.

Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes

Abstract Background Transpterygoid approaches to the skull base require dissection of the sphenopalatine artery, potentially compromising the option to harvest an ipsilateral nasoseptal flap (NSF) for reconstruction. In cases where other reconstructive options are limited, it may be necessary to utilize a NSF ipsilateral to the transpterygoid approach. Here, we describe the technique of NSF pedicle preservation with reconstruction outcomes. Methods This was a retrospective single-institution review of all expanded endonasal skull base cases utilizing a NSF ipsilateral to a transpterygoid approach. Reconstruction outcomes collected include intraoperative fluorescence with indocyanine green (ICG), postoperative magnetic resonance imaging (MRI) gadolinium enhancement, endoscopic assessment, and reconstruction-related complications. Results Twenty-one cases were included in this study (mean age 51.0 ± 20.6 years, 61.9% female). Indications for NSF ipsilateral to the transpterygoid approach included: bilateral transpterygoid approach (52.4%), revision reconstruction (23.8%), or significant septal deviation (19.0%). Twelve of 14 (85.7%) flaps demonstrated intraoperative perfusion with ICG, 15 of 15 (100%) enhanced on postoperative MRI, and 21 of 21 (100%) flaps had a healthy, viable appearance on postoperative endoscopy. There were no instances of flap necrosis or postoperative cerebrospinal fluid leaks. Technical keys to optimize mobilization of the pedicle include wide decompression of the sphenopalatine foramen and release of neurovascular tethering points of the pterygopalatine fossa. These steps allow for wide skull base exposure with preservation of the sphenopalatine artery. Conclusion With this technique, the transpterygoid approach can be performed in a manner that preserves the pedicle for an ipsilateral NSF and achieve an excellent reconstructive outcome.

Facial Palsy in Post COVID-19 Invasive Fungal Sinusitis.

This study aimed to study the various presentations of post COVID-19 invasive fungal sinusitis with 7th cranial nerve palsy and to correlate topodiagnostic tests and radiological findings to identify the site of lesion. A retrospective study was conducted at a tertiary care hospital where 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy presented to our institute. Detailed history, clinical examination, radiological imaging were done for all patients. A total of 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy were included in this study. The mean age of the patients was 44.8, with a male to female ratio of 4.5:1. Diabetes Mellitus was a major factor contributing to immunosuppression in our study with 9 patients who were known cases of diabetes mellitus and 2 newly diagnosed cases. On MRI, 10 patients had involvement of the Pterygopalatine fossa and 4 patients had involvement of the petrous apex. Post COVID-19 invasive fungal sinusitis can present with facial palsy, and diabetes mellitus is a major contributing factor to immunosuppression in these patients. The involvement of the petrous apex is a possible site of involvement, and MRI can aid in localizing the site of the lesion. Further studies are required to identify the exact mechanism of facial nerve palsy in invasive fungal sinusitis.

The Maxillary Artery Loops Dangerously Approaching the Mandible's Lingula and Inferior Orbital Fissure.

The maxillary artery (MA) leaves from the external carotid artery and further courses through the infratemporal fossa to reach the pterygopalatine fossa. It typically has an ascending course either on the lateral or on the medial side of the inferior bundle of the lateral pterygoid muscle. While studying retrospectively, the computed tomography angiogram of an adult male case with peculiar tortuosities of the MA was documented. The left MA described a large inferior sagittal loop applied on the mandible's ramus's inner cortical in the pterygomandibular space's upper part. That loop reached 1.66 cm inferior to the mandible's notch and 0.5 cm superior to the mandibular foramen and was applied on the mandible's lingula (spine of Spix). That MA continued to the pterygomaxillary suture, and a second superior coronal loop was found applied on the posterior wall of the maxillary sinus, reaching the inferior orbital fissure. It is therefore mandatory to take good care in the decortication of the mandibular ramus or during osteotomies of the ramus. When an inferior loop of the MA approaches the spine of Spix, bleeding when an inferior alveolar nerve block is performed seems hardly avoidable.