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Official Publication of Orofacial Chronicle , India

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ORIGINAL RESEARCH
Endoscopic Anatomy Variation of the Medial
Pterygopalatine Fossa structures and it's surgical
applications

Georgy Polev, MD
1
, Vladimir Averbukh, PHD
2
Russian Federal State Scientific-Research ENT Center

ABSTRACT:
Objectives: Describe the endoscopic anatomy variability of the medial
Pterygopalatine Fossa (PPF) structures during cadaveric dissection, and analyze
the relationship of the neurovascular structures in this region.
Methods: 20 non-injected fresh cadaveric specimens were dissected bilaterally
via the endonasal endoscopic approach. 40 medial PPF regions are described. The
distances between the vidian canal (VC) and palatovaginal canal (PVC) orifices are
measured and the mean length of the PVC is estimated. Also we measured the
distances between VC orifice and foramen rotundum (FR) to estimate the risk of
maxillary nerve lesion during the transnasal vidian neurectomy.
Results: The mean distance between PVC and VC orifices equaled 2.6 mm and
the mean length of the PVC was 6.4 mm. The mean length of the palatine bone
sphenoid process is 7.2 mm, which is always approximately equal to the distance
between the GPB and the PVC cranial orifice. The mean distance between the VC
orifice and FR is 4.6 mm.
Conclusions: Based upon this study, modified "retrograde" approach to the VC
orifice from the choanal arch behind the middle turbinate tail via the palatine bone

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sphenoid process along the PVC is proposed. The peculiarity of this approach is
the preservation of the PPF contents and sphenopalatine neurovascular bundle,
which are moved aside laterally during the dissection. Further investigation is
needed to establish the feasibility of this approach in vivo.
KEY WORDS: Endoscopy, medial pterygopalatine fossa , sphenopalatine
fossa
Cite this Article: Georgy P., Vladimir A. : Endoscopic Anatomy Variation of the Medial
Pterygopalatine Fossa structures and it's surgical applications, Journal of Head & Neck physicians
and surgeons Vol 2 Issue 1 2014 Pg 42-47

INTRODUCTION:
Golding-Wood was first to introduce the concept of vidian neurectomy as a
method of treatment of chronic rhinitis
1
. Vidian nerve provides the
parasympathetic innervation of nasal mucosa, thus transection of this nerve leads
to reduction of mucus production and oedema of the nasal mucosa
2,3
. It is shown
that vidian neurectomy leads to significant histologic changes in nasal mucosa,
such as mast cells depletion
4
, reduction of stromal oedema and reduction of
mucosal gland acini content
5
. One of possible vidian neurectomy complications is
the V2 neuralgia due to thermal damage to the maxillary nerve during vidian nerve
stamp cautery. This is explained by the close proximity between vidian canal
orifice and foramen rotundum, which is also individually variable
6
. There are
different approaches to the vidian nerve described in literature: transantral
7
,
transnasal
2
, transpalatal
8
and transsphenoidal
9
, transsphenoidal being the most
novel and less traumatic, but not always possible due to anatomical circumstances.
The disadvantage of the transnasal approach is the need to face the sphenopalatine
artery branches, which could lead to postoperative bleeding.
MATERIALS AND METHODS:
20 non-injected fresh cadaveric specimens were dissected bilaterally via the
endonasal endoscopic approach. 40 medial PPF regions are described. The
distances between the vidian canal (VC) and palatovaginal canal (PVC) orifices are
measured and the mean length of the PVC is estimated. Also we measured the

44

distances between VC orifice and foramen rotundum (FR) to estimate the risk of
maxillary nerve lesion during the transnasal vidian neurectomy.
RESULTS:
The mean distance between vidian canal (VC) and palatovaginal canal (PVC) was
3 mm (mean deviation 1 mm) (Fig. 3). To estimate the length of the palatovaginal
canal the bone of the palatine bone sphenoid process was removed. Mean length of
the PVC was 6,4 mm (standard deviation 1,4 mm). The distance between VC and
foramen rotundum varied from 1,4 to 7,6 mm, the mean distance was 4,6 mm (Fig.
1, 2).

Figure 1. Relationship of the median pterygopalatine fossa structures. MT middle turbinate, SS sphenoid sinus,
MA maxillary artery, VC vidian canal orifice, FR foramen rotundum, V2 second division of the trigeminal
nerve (maxillary nerve). Black arrow points the probe in the greater palatine canal. Red arrow indicates the distance
between vidian canal orifice and foramen rotundum.

Figure 2. Relationship of the vidian nerve (V), maxillary nerve (V2), palatovaginal nerve (PVN) and sphenoid sinus
(SS). C choana. Blue arrow indicates the distance between vidian and maxillary nerves.


FR

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Figure 3 demonstrates the relationship between vidian canal orifice (VC), palatovaginal canal distal orifice with
palatovaginal nerve (PVN) descending to the nasopharynx and palatine bone sphenoid process (PBSP), which is a
stable anatomical landmark to the former. White line borders the choanal arch.

Figure 4 demostrate the novel approach to the vidian canal from the choanal arch behind the middle turbinate tail
via the palatine bone sphenoid process. PBSP palatine bone sphenoid process, VN vidian nerve, C choana, MT
middle turbinate, SS sphenoid sinus, PVN palatovaginal nerve (pointed by white arrow).

DISCUSSION:
With the development of endoscopic sinus and skull base surgery there is a
growing interest to the variable anatomy of medial pterygopalatine fossa (PPF)
structures
10
. Vidian nerve has been shown as an important anatomical landmark in
skull base surgery
11
, especially in transpterygoid approach
12
. At the same time
newly described techniques of vidian neurectomy show the method being an
alternative and effective way to control such symptoms as rhinorrhea and nasal
congestion in patients with chronic rhinitis
2-5
. Thus further investigation of
anatomical variability of the medial PPF region along with the development of new
approaches to the vidian canal orifice is essential.

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CONCLUSIONS:
Based upon this study, modified "retrograde" approach to the VC orifice from the
choanal arch behind the middle turbinate tail via the palatine bone sphenoid
process along the PVC is proposed. The peculiarity of this approach is the
preservation of the PPF contents and sphenopalatine neurovascular bundle, which
are moved aside laterally during the dissection. The additional advantage of
dissecting the vidian nerve from medial to lateral direction is the theoretically
lesser chance of damaging maxillary nerve, which leaves laterally also. Further
investigation is needed to establish the feasibility of this approach in vivo.
REFERENCES
1. Golding-Wood PH. Observations on petrosal and vidian neurectomy in chronic
vasomotor rhinitis. J Laryngol Otol. 1961 Mar; 75(3):232-47
2. Kamel R, Saher S. Endoscopic transnasal Vidian neurectomy. Laryngoscope 1991; 101:
316-318
3. Fernandes CM. Bilateral transnasal Vidian neurectomy in the management of chronic
rhinitis. J Laryngol Otol 1988; 102:894-895
4. Konno A, Togawa K. Vidian nerve neurectomy for allergic rhinitis. Arch
Otorhinolaryngol 1979; 225: 67-77
5. Robinson SR, Wormald PJ. Endoscopic vidian neurectomy. Am J Rhinol. 2006 Mar-
Apr;20(2):197-202
6. Li SL, Wang ZC, Xian JF. Study of variations in adult sphenoid sinus by multislice spiral
computed tomography. 2010 Aug 17;90(31):2172-6
7. Rose KG, Ortmann R, Wustrow F, Seegers D. Vidian neurectomy: neuroanatomical
considerations and a report on a new surgical approach. Arch Otorhinolaryngol.
1979;224(3-4):157-68
8. Krajina Z. Critical review of Vidian neurectomy. Rhinology. 1989 Dec;27(4):271-6
9. Lee JC, Kao CH, Hsu CH, Lin YS. Endoscopic transsphenoidal vidian neurectomy. Eur
Arch Otorhinolaryngol. 2011 Jun;268(6):851-6.
10. Fortes FS, Sennes LU, Carrau RL et al. Endoscopic anatomy of the pterygopalatine fossa
and the transpterygoid approach: development of a surgical instruction model.
Laryngoscope. 2008 Jan;118(1):44-9.
11. Kassam AB, Vescan AD, Carrau RL et al. Expanded endonasal approach: vidian canal as
a landmark to the petrous internal carotid artery. J Neurosurg. 2008 Jan;108(1):177-83.
12. Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM, Paluzzi A, Snyderman
CH, et al. Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a
landmark for dissection of the vidian nerve during endonasal transpterygoid approaches.
Laryngoscope. 2012 Jan;122(1):6-12.

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Acknowledgement- None
Source of Funding- Nil
Conflict of Interest- None Declared
Ethical Approval- Not Required

Correspondence Addresses :

Dr, Georgy Polev MD
119121, Moscow,
Pluschikha, 43/47, 53
E-mail: polev_gor @mail.ru



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