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Otolaryngology online
Dr T Balasubramanian
Lateral: Bounded by Zygoma, the ramus of mandible, parotid gland and masseter
muscle
Medial: Bounded by superior constrictor muscle, Pharyngobasilar
fascia, Pterygoid plates
Anterior: The body of the maxilla lies anteriorly
Superior: Greater wing of sphenoid
Posterior: Auricular tubercle of the temporal bone, glenoid fossa and styloid
process
The floor of the infratemporal fossa is closed by the medial pterygoid muscle.
The infratemporal fossa communicates superiorly with middle cranial fossa by the
neurovascular formaina like carotid canal, jugular foramen, foramen spinosum,
foramen ovale and foramen lacerum. Medially the infratemporal fossa
communicates with pterygopalatine fossa through the pterygomaxillary
fissure. The pterygomaxillary fissure is contiguous with that of the infraorbital
fissure. The roof of the infratemporal fossa is open to the temporal fossa lateral
to the greater wing of sphenoid, deep to the zygomatic arch.
Benign tumors involving the infratemporal fossa always respect these boundaries
2. Temporalis muscle: This muscle occupies a wedge shaped space just lateral to
the lateral pterygoid muscle.
3. Pterygoid venous plexus: There is rich plexus of veins seen in this space. It lies
admixed with fatty tissue seen in the infratemporal fossa. These plexus could
cause troublesome bleeding during total maxillectomy surgery.
4. Infratemporal pad of fat: Lies between the temporalis muscle and the
infratemporal surface of maxilla. The pad of fat helps in outlining the posterior
antral tumor spread in CT scans. This infratemporal pad of fat continues with the
cheek pad of fat passing between the posterior wall of maxilla and the zygoma. A
mass present behind the maxilla always betrays itself by displacing this pad of fat
and causing a puffy swelling of cheek (i.e. angiofibroma).
5. Buccal lymph node: Within this infratemporal pad of fat lies the buccal lymph
node. This node links the infratemporal lymphatics to the facial lymphatics. This
node should never be left behind during surgical resection of infratemporal fossa
for malignant tumors as it could commonly cause local recurrence.
6. Mandibular nerve penetrates the roof of the infratemporal fossa through the
foramen ovale. It also gives rise to inferior alveolar and lingual nerve branches.
Tumors involving infratemporal fossa present with a variety of symptoms
depending on the structure involved. It could be a mass effect, eustachean tube
dysfunction, cranial neuropathies, trismus etc. The corner stone of diagnosis of
tumors of this area is imaging which includes a CT scan and MRI.
Pterygopalatine fossa:
This space lies between the posterior wall of the maxilla and the anterior face of
the pterygoid process. This is a small but very important distribution center for
the nasal cavity and the middle 1/3 of the face. Sensory, secretomotor, and
vasoregulatory nerves pass through this niche on their way from the middle
cranial fossa to the face, teeth, palate, turbinates, sinuses, lacrimal glands and
nasopharynx. Entrance to the pterygopalatine fossa from the infratemporal fossa
is through the pterygomaxillary fissure.
Cancers in the pterygopalatine fossa has ready access to the middle cranial
fossa via the foramen rotundum. The lesion here could also reach the orbital
apex through the infraorbital fissure, which is nothing but the open roof of the
pterygopalatine fossa. Lateral spread of tumors from this space could involve the
infratemporal fossa. Nasopharynx could be involved by medial infiltration of the
tumor via the sphenopalatine foramen. Hence involvement of the
pterygopalatine fossa is really ominous in patients with paranasal sinus
neoplasia.
3. Decreased lacrimation
7. Internal maxillary artery and its branches lies on the superficial or deep surface
of the lateral pterygoid muscle.
2. Petrous apex and its approaches.
3. Spaces of posterior mesotympanum.
4. Cavernous sinus.
Introduction:
Petrous apex is the medial portion of petrous bone that lies between the inner ear
and clivus. Since this is a difficult region anatomically various approaches have
been designed over the ears to access this area.
This portion of the temporal bone is pyramidal in shape wedged in the skull base
between the sphenoid and occipital bones. It is directed medially, forwards and
slightly upwards.
It has an apex, base, three surfaces and three angles.
Base: This portion of the petrous bone is fused with the internal surfaces of the
mastoid and squamous portion of the temporal bone.
Apex: This is rough and uneven and is placed in the interval between the greater
wing of sphenoid and occipital bone. It has the internal orifice of the carotid canal.
It forms the postero lateral boundary of the foramen lacerum.
Anterior surface:
The anterior surface forms the posterior portion of the middle cranial fossa in the
skull base. It continues with the inner surface of the squamous portion of temporal
bone with which it is united by the petro squamous suture line. This suture line is
distinct even in the later phases of life. This surface is marked by the depressions
and convolutions of the brain.
Eagleton’s approach:
This is the superior approach to the petrous apex that involves removal of the
tegmen to the base of the zygoma together with removal of part of the squamous
temporal bone. The dura of the middle cranial fossa can now be elevated to expose
the petrous apex.
Thornvaldt’s operation:
This approach is also along the supra labyrinthine tracts. As the dissection
proceeds it merges with that of Eagleton’s approach.
Almoor’s approach:
This is an inferior approach to the petrous apex through a space bounded by the
cochlea, the carotid artery and the tegmen tympani.
Ramadier’s operation:
This approach is slightly anterior to that of Almoor’s operation that pursues the
peritubal cells to the petrous apex that exists between the cochlea and the carotid
artery.
Frenckner’s operation:
This approach to the petrous apex is through the arch of the superior semicircular
canal. The blood supply to the arch arises from within this arch and some
labyrinthine loss is almost inevitable with this approach. It has to be combined
with an inferior approach.
There are 4 sinuses in the posterior mesotympanum. They can be visualized only
after removing a portion of the annulus and tilting the head of the patient. Two of
them are located above the pyramidal eminence (Suprapyramidal) while the other
two lie below the pyramid (infrapyramidal).
Supra pyramidal recess:
Facial recess - Is defined as an aerated extension posterior superior
portion of the middle ear cavity medial to the tympanic annulus and
lateral to the fallopian canal.
Boundaries:
Medial – Facial nerve
Lateral – Tympanic annulus
Superior – Incus buttress (near the short process of incus)
Running through the wall between these two structures with varying
degrees of obliquity is the chorda tympani nerve. Chorda tympani nerve
always run medial to the tympanic membrane.
Drilling in this area between the facial nerve and annulus in the angle
formed by the chorda tympani nerve leads into the middle ear cavity.
This surgical approach to the middle ear cavity is known as facial recess
approach.
Sinus tympani -
Sinus tympani and facial recess are the two important spaces of posterior
mesotympanum. These spaces are important in deciding the spread of posterior
mesotympanic cholesteatoma. This space was first described by Meckel in 1820.
Sinus tympani:
This is the posterior mesotympanic space of middle ear cavity. Its boundaries
include:
Medially – Annulus of tympanic membrane
Superior – Ponticulus
Inferior – Subiculum
This area is very difficult to visualize as it lies under the pyramidal eminence.
Cholesteatoma is commonly known to be left behind in this area leading to a
recurrence of the disease.
4. Cavernous sinus.
This is a collection of thin walled venous sinuses lying lateral to the sella
turcica. The sinus is shaped like a boat with its narrow keel located at the superior
orbital fissure and its broader bow (posterior wall) located lateral to the dorsum
sellae above the petrous apex. This sinus has four walls (a roof, lateral, medial
and posterior walls). The roof is formed by the dura lining the lower margin of
anterior clinoid process. It receives blood from the ophthalmic vein through the
superior orbital fissure, and superficial cortical veins. It is connected to the basilar
plexus of veins posteriorly. Vital structures pass through this vascular space. They
include:
a. Internal carotid artery
b. Cranial nerves III, IV, V1, V2 and VI pass through this space.
Perilymph:
The perilymphatic space which contains perilymph is continuous between the
vestibular and cochlear divisions. The site of production of perilymph is
controversial. Some authors consider it to be ultra-filtrate of blood produced by
Drtbalu’s otolaryngology online Page 12
perilymphatic capillaries. Some others consider it to originate from CSF. Ionic
concentration of perilymph resembles extracellular fluid composition with high
sodium content and low potassium content. Electrical potential of perilymph
range between +5 - +7 mV.
3. Physiology of balance.
4. Physiology of swallowing.
The physiological act of swallowing is known as deglution. During this process
bolus / liquid is transferred from the buccal cavity into the stomach. This
process is a complex, integrated, continuous act which involves somatic and
visceral afferent and efferent nerves together with associated striated and
smooth muscles. For purposes of description the act of deglution has been
divided into three phases:
a. Oral phase
b. Pharyngeal phase
c. Oesophageal phase
The initiation of the first two phases of deglutition is under conscious control
involving the striated muscles which are controlled by a complex of stimulatory
and inhibitory signals from the brain stem. The third phase involves the smooth
muscles of oesophagus depending both on central co-ordination and local
intramural reflex arcs.
The major sphincteric mechanisms protecting the airways are the soft palate
guarding the pharyngeal isthmus and those guarding the laryngeal inlet. Airway
protection mechanisms are activated ahead of the passing bolus. Deglutition
Water
Inorganic constituents:
Sodium
Potassium
Chloride
Calcium
Phosphate
Bicarbonate
Thiocyanate
Iodine
Bromide
Fluoride
Copper
Magnesium
Organic constituents:
Mucoproteins
Serum proteins
Enzymes – amylase, lysozyme
Glycoproteins – Fucose, Neuraminic acid, mannose, galactose
Free sugars – glucose
Blood group substances
Lipids
Aminoacids
Urea
The pH of saliva is low when the glands are not actively secreting, but raises
with faster flow rates due to the outpouring of bicarbonate.
The calcium content of saliva is lowest in the parotid and highest in the
accessory salivary glands.
About a third of calcium content of saliva is bound to proteins in the form of
complexes of which amylase comprises a significant proportion.
Salivary secretion of iodine is due to active transport of iodide from the plasma
and is always higher than that of plasma concentration.
Thiocyanate when found in the saliva is of a higher concentration than in
plasma. This is more evident in smokers.
Salivary proteins:
The transfer of genetic material using non-viral systems preceded the developed
of viral- based vectors. Non-viral vectors, also called physical mechanisms of
gene transfer, can be traced back to the work of Avery, MacLeod, and
McCarthy, in 1944 which showed that genes were transferred by nucleic acids.
Several studies in the early 1960s reported changes in cellular phenotype
following exogenous DNA exposure. The first non-viral technique to gain wide
acceptance was calcium phosphate-mediated transfection. This system has
undergone little change since being well characterized in the early 1970s. It was
not until the advent of cationic liposomes in 1988 that non-viral vectors offered
an efficient means to transfer genes into cells.
Non-viral vector therapy can be divided into those that are limited to in vitro
applications and those that can be used for both in vitro and in vivo
applications.
Microinjection:
Microinjection delivers plasmid DNA directly into the cell's nucleus. Using the
light microscope, a glass pipette is guided into the nucleus and a small amount
of DNA or RNA injected. In doing so, both cytoplasmic and lysosomal
degradation of the injected material is avoided and efficient gene expression can
be expected from the surviving cells. Unfortunately, this technique is extremely
labor intensive and requires well isolated cells.
Microinjection delivers plasmid DNA directly into the cell's nucleus. Using the
light microscope, a glass pipette is guided into the nucleus and a small amount
of DNA or RNA injected. In doing so, both cytoplasmic and lysosomal
degradation of the injected material is avoided and efficient gene expression can
be expected from the surviving cells. Unfortunately, this technique is extremely
labor intensive and requires well isolated cells.
Electroporation:
Liposomes:
Cationic liposomes: are positively charged liposomes which interact with the
negatively charged DNA molecules to form a stable complex. Cationic
liposomes consist of a positively charged lipid and a co-lipid. Commonly used
co-lipids include dioleoyl phosphatidylethanolamine (DOPE) or dioleoyl
phosphatidylcholine (DOPC). Co-lipids, also called helper lipids, are in most
cases required for stabilization of liposome complex. A variety of positively
charged lipid formulations are commercially available and many other are under
development. One of the most frequently cited cationic lipids is lipofectin.
Lipofectin is a commercially available cationic lipid first reported by Phil
Felgner in 1987 to deliver genes to cells in culture.
All gene transfer vector systems rely heavily on plasmid DNA. Surprisingly,
transgene expression has been observed in rodent and primate muscle following
intramuscular injection of plasmid DNA. The simplicity of injecting plasmid
DNA into muscle with a syringe has greatly influenced many aspects of gene
therapy research. Tissues which exhibit transgene expression following plasmid
DNA injection include the thymus, skin, cardiac muscle, and skeletal muscle.
Of these tissues, long-term transgene expression was observed only in striated
muscle. Expression in mouse skeletal muscle has been observed for greater than
19 months following a single intramuscular injection. It has been assumed that
the plasmid DNA must have entered the nucleus in order for gene expression to
occur. Plasmid DNA does not undergo changes in its methylation pattern
suggesting that it has not replicated following its injection into muscle. Also, the
plasmid DNA does not integrate into the host genome following intramuscular
injection.
Definition:
General anesthetic is a drug which is capable of causing reversible loss of
consciousness.
Categories of general anesthetics:
1. Inhalational: This include gases and vapours which are used to induce
general anesthesia
2. Injections: This category includes drugs used parenterally to induce
general anesthesia. Injections can be used to induce anesthesia / maintain
it.
Inhalational agents:
These agents are either volatile liquids / gases and need special apparatus for
their administration. This apparatus enables mixing of oxygen along with the
anesthetic agent and ambient air and supplies it to the patient. Liquid anesthetic
agents can be vaporised in this machine using special vaporizers.
Commonly used volatiles include:
Desflurane
Isoflurane
Sevoflurane
Halothane
Enflurane
Methoxyflurane
1. Lipid theory
2. Protein (receptor) theory
3. Binding theory
V. PATHOLOGY (3 x 5 = 15)
1. Ameloblastoma - histopathology and subtypes.
This is the most common odontogenic neoplasm with a low malignant
potential.
Types of ameloblastoma:
1. Follicular type
2. Plexiform type
3. Granular cell type
4. Desmoplastic type
5. Vascular type
6. Acanthomatous type
7. Papilliferous – keratotic type
8. Dentinoid induction type
These tumours arise from:
a. Epithelial lining of dentigerous cyst
b. Remnants of dental lamina and enamel organ
c. Basal layer of oral mucosa
A majority of these tumors arise from mandible.
Etiopathogenesis:
1. Epstein - Barr virus: E.B. virus infections have been postulated to be the
etiological agent responsible for nasopharyngeal carcinoma. The presence of
raised antibody titers, and demonstration of viral genome in tumor cells are
ample proof.
- well differentiated
- moderately differentiated
- poorly differentiated
4. Nodular fasciitis.
1. The virus may remain dormant (latent stage) allowing the cell to perform
its normal functions
2. The virus may begin to proliferate and start to infect other cells
promoting viral transmission
Incubation period – This asymptomatic phase could last anywhere between 4-6
weeks.