Transpalatal Approach Research Articles

Transoral approaches to the clivus and nasopharynx

This article presents the surgical anatomy of the clivus, nasopharynx, and craniocervical junction as it relates to the transoral approach to the midline basicranium. Particular attention is given to the indications, limitations, and complications of this procedure. The transpalatal approach is discussed in detail. Finally, the transmandibular approach is also briefly discussed.

A transpalatal approach (Palate Split) to the Parapharyngeal space

This is a case of a 20 years young boy with a large parapharyngeal pleomorphic adenoma excised via transpalatal approach. The incision was taken about 0.5cm away from the edges of the tumor it provided good, surgical access to the whole length of upper parapharyngeal space and allowed complete tumor excision.

Transnasal mucosal flap rotation technique for repair of posterior choanal atresia.

To describe improved surgical treatment for posterior choanal atresia (PCA) by creating mucosal flaps with the aid of operating microscope, CO(2) laser, self-retaining nasal retractor, and stenting with a flat polytetrafluoroethylene (Teflon) keel. Retrospective study of 19 patients with PCA, their ages ranging from 6 days to 4 years 4 months at the time of first repair, representing a total of 32 PCA repairs. Four patients had unilateral PCA, and one did not return for follow-up and could not be located. A transnasal microscopic approach uses a myringotomy knife or CO(2) laser to create an anterior mucosal flap; the CO(2) laser is also used to remove any bone plate and to create the posterior flap. The flaps then are rotated into position and are kept separated by a flat Teflon keel instead of a traditional round stent to avoid pressure necrosis. When a stable epithelialized opening (2 x 2 to 3 x 4 mm) is created, it is enlarged by subsequent staged transnasal CO(2) laser submucosal scar excisions with preservation of the overlying mucosa. This creates rotation or sliding flaps to speed healing and prevents circumferential scar contraction. Eighteen patients were re-examined after periods of 3 months to more than 5 years from when their first epithelialized orifice was created with nasal endoscopy to measure the final orifice size. All 18 patients had clinically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 x 5 mm and a range of 2 x 2 to 4 x 10 mm. This "same day surgery" technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less surgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple dilation technique.

Transnasal mucosal flap rotation technique for repair of posterior choanal atresia

Purpose: To describe improved surgical treatment for posterior choanal atresia (PCA) by creating mucosal flaps with the aid of operating microscope, CO 2 laser, self-retaining nasal retractor, and stenting with a flat polytetrafluoroethylene (Teflon) keel. Materials and Methods: Retrospective study of 19 patients with PCA, their ages ranging from 6 days to 4 years 4 months at the time of first repair, representing a total of 32 PCA repairs. Four patients had unilateral PCA, and one did not return for follow-up and could not be located. A transnasal microscopic approach uses a myringotomy knife or CO 2 laser to create an anterior mucosal flap; the CO 2 laser is also used to remove any bone plate and to create the posterior flap. The flaps then are rotated into position and are kept separated by a flat Teflon keel instead of a traditional round stent to avoid pressure necrosis. When a stable epithelialized opening (2 × 2 to 3 × 4 mm) is created, it is enlarged by subsequent staged transnasal CO 2 laser submucosal scar excisions with preservation of the overlying mucosa. This creates rotation or sliding flaps to speed healing and prevents circumferential scar contraction. Results: Eighteen patients were re-examined after periods of 3 months to more than 5 years from when their first epithelialized orifice was created with nasal endoscopy to measure the final orifice size. All 18 patients had clinically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 × 5 mm and a range of 2 × 2 to 4 × 10 mm. This “same day surgery” technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less surgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple dilation technique. (Otolaryngol Head Neck Surg 2001;124:674-82.)

Incidence of pharyngeal hypophysis in neonates a histologic study.

The presence of adenohypophysial tissue in the nasopharynx is no longer disputed. This study was performed in 50 neonatal cadavers subjected to medical autopsy within 6 hours of death. The aim was to study the incidence of extrasellar pituitary tissue in the nasopharynx and its various histologic cell types. The transpalatal approach was used to obtain the specimens. The specimens were stained with hematoxylin and eosin and periodic acid-Schiff-orange G for selective demonstration of adenohypophysial cells. Histopathologic evaluation led to the detection of pituitary tissue in 16% of the examined specimens. Selective staining demonstrated a 6% positive incidence of adenohypophysial cells. The pharyngeal hypophysis exists in 2 forms: a typical adenohypophysial collection of cells and an atypical subepithelial cluster. The incidence of hypophysial tissue was higher in the older neonates, perhaps because of hormonal stimulation of the caudal remnant of Rathke's pouch.

鼻中隔後端に有茎性に発生した腺癌例

We report here a rare case of low-grade adenocarcinoma at the posterior edge of nasal septum. A 22-year-old male was referred to our hospital with nasal obstruction. Local findings, CT scan, and MR images revealed a tumor 1cm diameter at the posterior edge of nasal septum. The tumor was completely excised by transpalatal approach under general anesthesia on June 19, 1998. A histopathological examinaton confirmed low-grade adenocarcinoma. He has been free from recurrence of the tumor for two years and half after surgery.

The transfacial approaches to midline skull base lesions: A classification scheme

A variety of transfacial surgical approaches to midline skull base lesions can be organized in a simple classification scheme of six techniques or levels. Three intracranial approaches use a subfrontal trajectory and variable amounts of transfacial exposure through the nasal and orbital bones. Surgical exposure increases with the amount of bone removed with the facial fragment: supraorbial bar (level 1), supraorbitonasal bar (level II), and orbitonasal bar (level III). Three extracranial approaches use a more inferior trajectory and variable amounts of transfacial exposure through the maxilla. The transnasomaxillary approach (level IV) requires a Le Fort II osteotomy with splitting of the maxillary fragment. The transmaxillary approach (level V) requires a Le Fort l osteotomy with splitting of the palate. The transpalatal approach (level VI) requires circumferential osteotomy and removal of the hard palate. These versatile transfacial approaches, used alone or in combination, have a distinct role in the armamentarium of the skull base surgeon who develops individualized treatment strategies for curative resection of midline skull base lesions.

The transpalatal approach for juvenile nasopharyngeal angiofibroma

The transpalatal approach to the nasopharynx is well suited for juvenile nasopharyngeal angiofibroma limited to the nasopharynx, with minimal extension to the sinuses or pterygopalatine fossa. It offers excellent exposure to this region, with minimal morbidity and excellent cosmetic results. This article will describe the indications for the transpalatal approach, as well as the surgical technique and possible complications.

Medial maxillectomy via midfacial degloving approach

Medial maxillectomy with or without ethmoidectomy has become the standard surgical procedure for management of inverted papilloma. The classic description of medial maxillectomy includes the lateral rhinotomy type of incision. However, the midfacial degloving approach is gaining popularity. The main advantage of the midfacial degloving approach over procedures such as Denker's, Caldwell-Luc, lateral rhinotomy, and transpalatal approach, is the combination of wide exposure, avoidance of facial skin incisions and scars, the ability to perform bilateral surgery, and avoidance of palatal dysfunction.

A quick and simple method of preparing a palatal stent

A simple, quick, and inexpensive method of preparing a palatal splint or stent is presented. It is very useful after any palatal surgery including the transpalatal approach, palate resection, and repair of the fistula.

Transcranial approach for transsphenoidal encephalocele: report of two cases

BACKGROUND Whereas the transcranial approach has been regarded as the therapy of choice for transethmoidal encephalocele, its feasibility for transsphenoidal encephalocele has remained controversial, particularly in neonates and infants. CASE REPORT Two cases of transsphenoidal encephalocele operated transcranially are presented. In the first case, this 6-year-old boy underwent a transpalatal operation with repair of a cleft palate in another hospital before admission. Reoperation via the transcranial route was carried out because of postoperative recurrent meningitis. With partial resection of the anterior wall, the encephalocele could be separated from the underlying tissue, and the interspace was filled with the pericranial flap. He made an uneventful recovery and has been well for the past 3 years. The second was a 3-month-old baby with a large encephalocele filling the nasopharyngeal space. As the cleft palate was absent, the transcranial approach was employed. In this case, the herniated tissue was excised at the lowest level possible. Postoperatively, panhypopituitarism became manifest. Re-evaluation of the preoperative magnetic resonance imaging (MRI) disclosed a small mass far below the dorsum sellae, which turned out to be an anomalous pituitary gland on histologic examination. CONCLUSIONS The transcranial approach is considered a valid alternative for the therapy of transsphenoidal encephalocele, particularly when the transpalatal approach is unfeasible. While the anterior wall of the herniated sac may be safely resected, the posterior wall should under no circumstances be sacrificed. The preoperative MRI is essential, as it may provide valuable information as to the location of vital structures within the herniated tissue.

Endoscopic Skull Base Surgery I: A New Animal Model for Pituitary Surgery

Endoscopy has emerged as a new means to perform minimally invasive surgery of the skull base. Specifically, endoscopic techniques and instruments can be used to safely and effectively approach and resect tumors of the pituitary gland in humans. No animal model currently exists to serve as a template upon which to refine and develop endoscopic surgical technique in this region of the anatomy. We operated on two purpose-bred Hampshire-Yorkshire-Duroc hybrid swine to demonstrate the application of endoscopy to pituitary surgery. Based upon similar anatomical relationships in humans and swine between the oropharynx, nasopharynx, and skull base, we used a transoral, transpalatal approach to access the vomer of the swine. Under endoscopic exposure, we resected the vomer, entered the sphenoid sinus, and then resected the sphenoid septum, sella turcica, and adenohypophysis. Clear visualization of the pituitary, hypophyseal stalk, cavernous sinuses, and carotid prominences was achieved and documented with digital photography. Benefits and limitations of the technique were noted. These results have pertinent implications both for the study of the surgical anatomy of the swine craniofacial skeleton, and for future development of endoscopic surgical manipulation of the skull base.

Analysis of 33 patients with nasopharyngeal carcinoma--surgical management for persistent tumor after radiation therapy

We report thirty-three patients treated for nasopharyngeal carcinoma (NPC) in our clinic from 1976 to 1997. They consisted of 24 males and 9 females, and their ages ranged from 17 to 76 years with an average of 56 years. Fourteen patients initially presented with ear symptoms due to tubal insufficiency, 11 with cervical lymphadenopathy, 6 with nasal symptoms and 4 with cranial nerve paralysis. The mean interval from the onset of their complaints to the time of difinite diagnosis of NPC was 5.8 months. Seventeen patients (51.5%) had primary sites with T3 or T4. Twenty-four (72.7%) had cervical lymphnode metastases. Thirty (90.9%) were classified as stage III or IV. Radiation therapy is a mainstay of treatment of NPC because of anatomic restrictions and a high degree of radiosensitivity. An average of total radiation dose was 63.9Gy for the primary site except in one patient (28Gy followed by surgery due to poor response to radiation). In two patients, high-dose intracavity radiation by remote afterloading system was performed. They have been free from disease since then for more than 3 years. Radiation therapy was combined with an administrations of 5-fluorouracil and vitamim A (FAR therapy), or a low-dose of cisplatin in 2 and 5 patients, respectively. Local recurrence was detected in none of these patients and this combined therapy seemed to be effective in controlling the primary lesion. The overall 5-year survival rate was 56.9% (Kaplan-Meier method), however, that of patients with stage IV was still poor; 33.2%. This emphasizes the importance of an early diagnosis of NPC. Twelve patients underwent surgical resection of the residual tumor at the primary site after radiotherapy. As a surgical approach to the nasopharynx, the transmandibular transpterygoid approach was employed in five patients. This procedure offers a wider exposure of the nasopharynx than either the transmaxillary or the transpalatal approaches. Although distant metastasis was detected in three of the five patients, none of them developed local recurrence. The 5-year survival rate in 12 patients with surgery was 65.6%, which was better than 49.2% in 21 patients without surgery. Neck dissection was performed on 14 patients after radiotherapy. None had cervical recurrence postoperatively. The surgical treatments are recommended for patients with postradiation residual primary tumor and/or cervical metastasis.

Transpalatal approach for the extracranial surgical repair of transsphenoidal cephaloceles in children.

The surgical treatment of transsphenoidal cephaloceles in children is controversial. Reduction and repair via a transcranial approach are associated with high postoperative rates of morbidity, mortality, and hypothalamic dysfunction. In this study, four patients, aged 3 to 35 months at surgery, underwent successful transpalatal repair of two encephaloceles and two meningoceles. Two patients presented with nasal obstruction in infancy, one presented with unexplained meningitis, and in one patient the lesion was found incidentally during evaluation for seizures. Two children had median cleft face syndrome, another had an associated Arnold-Chiari type I malformation, and the fourth had no other cranial abnormalities. All patients underwent preoperative evaluation including magnetic resonance (MR) imaging. Auditory, ophthalmological, genetic, endocrinological, or other evaluation was undertaken as indicated. Lesions were approached through the median raphe of the hard and soft palates. All cephaloceles were easily visualized and dissected after division of the nasal palatal mucosa. The dural sac and its contents were reduced by surface coagulation after division and dissection of the overlying mucosa. Once reduced, the bone defect was obliterated in three of four patients. The dura was not opened and anomalous neural elements were not resected. At follow-up evaluation, all patients demonstrated resolution of preoperative symptoms without evidence of infection or lasting morbidity. Follow-up MR imaging showed reduction in all cases. The authors conclude that this transpalatal approach is safe and reliable for the treatment of transsphenoidal cephaloceles in young children.

若年性鼻咽腔血管線維腫の摘出術

This report describes three cases of juvenile nasopharyngeal angiofibroma and presents appropriate surgical management strategies. Case 1: 22-year-old male (stage III, Sessions' staging classification). Removal of the tumor by a transpalatal approach was attempted however the surgical procedure was not completed due to excessive bleeding. This patient subsequently received radiation a total dose of 40 Gy. Following radiation therapy, the tumor was reduced in size.Case 2: 10-year-old male (stage TEA). The tumor was removed in this patient by the transpalatal approach. After 10 months however, the tumor reappeared. Case 3: 18-year-old male (stage JIB).The tumor in this patient was removed by the transantral approach. The tumor in this case had not relapsed at five months after surgery.All three patients underwent preoperational selective arterial embolization. Surgical approaches and patient prognosis in eight cases, including the three described here, have been reported in the last 10 years. Using the transantral approach, a clearer view of the tumor and maxillary artery could be obtained than by the transpalatal approach. Therefore, the transantral approach was determined to be better than the transpalatal approach for surgical treatment of tumor which had grown into the pterygopalatine fossa. To choose the most appropriate surgical method for the management of juvenile nasopharyngeal angiofibroma however, it is necessary to first obtain a correct diagnosis based on CT findings and MR images.

Juvenile angiofibroma transpalatal approach for intracranial extensions.

Here we present transpalatal approach for removal of intracranial extensions of Juvenile Angiofibroma (JA) of nasopharynx. Modification of standard transpalatal approach, it is possible to remove extracranial as well as small intracranial tumour. Details of technique, advantages and limitations are presented.

上咽頭多形腺腫例

Pleomorphic adenoma in the epipharynx is rare. A 57-year-old female was referred to our department for treatment of a tumor in the epipharynx. Fiberscopic examination showed a roundshaped mass arising from the upper torus of the right eustachian tube. The tumor was removed surgically using the transpalatal approach with a Nd-YAG laser. The pathological examination revealed pleomorphic adenoma. Several months later, tumor recurrence was found and a second surgery was performed transnasally with an endoscope and a Nd-YAG laser. No signs of recurrence have been found after the second surgery.

Modified Transpalatal Approach로 제거한 早비공 폐쇄를 동반한 연구개 양성 혼합종 치험 1례

Modified Transpalatal Approach로 제거한 早비공 폐쇄를 동반한 연구개 양성 혼합종 치험 1례

The transoral transpalatal approach to the pituitary fossa.

Transpalatal trans-sphenoidal approaches to the sella turcica were described as early as 1900. Since the advent of effective trans-sphenoidal pituitary microsurgery in the 1960's, the sublabial transnasal approach became the most widely used. We reassessed the transoral transpalatal approach in 1978 and found the procedure to have distinct advantages over the transnasal operation. Between 1978 and 1992, 94 patients had transpalatal trans-sphenoidal explorations of the pituitary fossa at our institution. The detail of the operative technique, the results and the advantages are discussed.

Choanal Atresia and Congenital Pharyngeal Stenosis

From 1980 to 1992, 8 patients with choanal atresia were treated in our facility. The female to male ratio was 5:3. One patient, a girl, had unilateral osseous obstruction with membranous closure of the opposite naris while the other 7 had bilateral osseous obstruction. Seven of the 8 had other congenital anomalies, CHARGE association (2 cases), Apert's syndrome (1 case), meningocele and banded fingers (1 case), omphalocele (1 case), subdural hematoma (1 case), and nasal fistula (1 case). Of the 7 patients who underwent endonasal surgical repair, 3 (40%) experienced reclosure. The remaining one patient, whose obstruction was of the bilateral osseous type, was successfully operated on via a transpalatal approach. Surgical correction is particularly difficult in those with craniofacial abnormalities, e.g. Apert's syndrome and maxillary hypoplasia. We treated 5 congenital pharyneal stenosis cases (CPS). Our CPS cases were divided into Types 1, 2 and 3, the latter being a new type not previously reported on. We consider Type 3 to be the result of fetal tissue remnants. We performed uvula splitting surgery in 4 cases and obtained good results in 3.