A graduated endoscopic multi-angle approach for access to the infratemporal fossa: A cadaveric study

Introduction: The infratemporal fossa (ITF) has historically been one of the more difficult regions of the head and neck to access surgically. Available open approaches are complex, associated with high morbidity, and do not always afford optimal visualization. Endoscopic access to the ITF provides an improvement in visualization for management of many sinonasal and lateral skull base lesions involving this region. The purpose of this study is to evaluate a graduated multi-angle approach for endoscopic access to this area using a cadaveric model. Methods: Endoscopic dissection was performed on a total of 10 sides of 5 fresh cadaveric heads. Four different approaches to the ITF were studied: ipsilateral endonasal, contralateral endonasal via septotomy, Caldwell-Luc anterior maxillary antrostomy, and Gillies transtemporal. High quality endoscopic pictures and high definition videos of each technique were obtained in order to document the differences in access achieved with each approach. Results: The combination of the four different endoscopic techniques allowed complete access to all areas of the ITF. The contralateral septotomy approach resulted in excellent far lateral access, the Caldwell-Luc improved anteroposterior access, and the Gillies incision allowed postero-superior visualization and instrumentation. Conclusions: Endoscopic access to the ITF can be accomplished by each of the four methods described. A multi-angle, graduated approach can provide surgeons the ability to customize surgical access depending on the location of a specific lesion within the ITF.