Transorbital Endoscopic Approach to the Pterygopalatine Fossa: A Less Invasive Alternative to Traditional Access

Abstract

Purpose: The purpose of this article and accompanying video is to demonstrate a transorbital endoscopic approach for accessing the pterygopalatine fossa (PPF). This technique does not require a skin incision, avoids dissection of critical neurovascular structures, and utilizes a comparatively small osteotomy. The 2 cases presented in this article highlight the utility of a transorbital endoscopic approach for accessing an anatomic region that has traditionally required more invasive techniques to reach. Methods: Description of surgical technique with 2 illustrative clinical cases and accompanying surgical video. Results: Surgical technique: A trans-conjunctival approach is taken to the inferior orbital rim, and a subperiosteal dissection is propagated posteriorly. The bone of the posterior orbital floor is then deroofed, and the superior portion of the posterior wall of the maxillary sinus is removed, allowing access to the PPF for an incisional biopsy. Case 1: A 76-year-old male with a history of left cheek squamous cell carcinoma presented with progressive V2 paresthesia and an abnormally enhancing lesion in the left PPF on MRI. Case 2: A 58-year-old male with no significant medical history presented with left facial numbness (V1-V3), ptosis, an abduction deficit, and decreased hearing. Contrast-enhanced MRI demonstrated an abnormally enhanced lesion in the left PPF extending to Meckel’s cave. The transorbital approach described was used to successfully obtain a diagnostic biopsy in both cases. Conclusions: These cases highlight the utility of a transorbital endoscopic approach to the PPF as a less morbid alternative to traditional access. Patient selection is key to identifying appropriate cases.