Surgical anatomy of the pterygopalatine fossa*

By ROBERT T. WENTGES (Nijmegen)

THE pterygopalatine fossa is an area, centrally located in the head, which

serves as a distribution centre for the vessels and nerves of the middle third
of the face. In this small area, which can be approached with relative ease,
many important structures are crammed together; hence its surgical
importance. It has been called, somewhat facetiously, 'the Piccadilly Circus
of the face'. An impression of the surgical anatomy of this region will be
given.
The name pterygopalatine fossa (in the older literature: sphenopalatine
fossa) is derived from the fact that the bony confines of the fossa are mainly
formed by the medial plate of the pterygoid process of the sphenoid bone
(Fig. i) and by the vertical plate of the palatine bone (Fig. 2). It will be
3 4 5

FIG. 1.
The sphenoid bone, anterior view: I. orbital surface; 2. maxillary surface; 3. sphenoidal
crest and rostrum; 4. ostium of the sphenoidal sinus; 5. foramen rotundum; 6. bony ridge
between foramen rotundum and vidian canal; 7. mouth of the vidian canal; 8. lateral plate
of the pterygoid process; 9. medial plate of the pterygoid process.

noted that the vertical plate of the palatine bone ends superiorly in two
processes: the orbital process anteriorly; and the sphenoidal process post-
eriorly. These two processes articulate with the body of the sphenoid, thus
forming the sphenopalatine foramen, through which the major nasal vessels
and nerves enter the nasal cavity. The posterior wall of the antrum forms
the anterior wall of the pterygopalatine fossa; whereas its posterior wall is
formed by the medial plate of the pterygoid process and the greater wing of
*Read at the Section of Laryngology meeting, Royal Society of Medicine, 1 February,
'974-
35
 R. T. Wentges
the sphenoid bone. In particular, attention should be paid to the relation-
ship between the foramen rotundum and the mouth of the vidian (or
pterygoid) canal; between the two is a massive bony ridge, which is of great
surgical importance (Fig. i).

FIG. 2.
The palatine bone, posterior view: i. horizontal part; 2. perpendicular part; 3. orbital
process; 4. sphenoidal process.

In a lateral direction the pterygopalatine fossa opens into the infra-

temporal fossa via the pterygomaxillary fissure, which has the shape of a
scythe and is continuous with the inferior orbital fissure (Fig. 3). In an

FIG. 3.
Right pterygopalatine fossa with maxillary nerve. The zygoma, part of the sphenoid and the
lateral orbital wall have been removed: 1. maxillary nerve; 2. infraorbital nerve; 3. posterior
wall of the antrum; 4. greater palatine foramen; 5. greater palatine canal; 6. the foramen
of Juvara*; 7. sphenopalatine foramen.
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 Surgical anatomy of the pterygopalatine fossa
inferior direction the fossa is funnel-shaped (Fig. 4), since the posterior wall
of the antrum and the pterygoid process of the sphenoid bone approach
each other, thus forming the greater palatine canal. This canal ends in the
hard palate as the greater palatine foramen (Fig. 5). The relationships of

FIG. 4.
Right pterygopalatine fossa and greater palatine canal. Probes have been introduced into
some foramina. (After Juvara): i. foramen rotundum; 2. bony ridge between foramen
rotundum and vidian canal; 3. sphenopalatine foramen; 4. vidian canal; 5. the foramen of
Juvara*; 6. posterior wall of the antrum; 7. lesser palatine canal; 8. greater palatine canal.

FIG. 5.
The bony palate: 1. incisive foramen; 2. greater palatine foramen.

the different bony components of the pterygopalatine fossa are well-

illustrated in Figures 6 and 7. Both represent horizontal cuts through the
fossa, the first one at the level of the vidian canal and the sphenopalatine
*This foramen has first been described by E. Juvara in his thesis (1895). It is not men-
tioned in most English textbooks.

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 FIG. 6.
Horizontal cut through the pterygopalatine fossa, at the level of the sphenopalatine foramen:
i. posterior wall of the antrum; 2. pterygomaxillary fissure; 3. foramen rotundum; 4. foramen
ovale; 5. pterygoid process; 6. sphenoidal process of palatine bone; 7. orbital process of
palatine bone; 8. vidian canal; 9. sphenopalatine foramen.

FIG. 7.
Horizontal cut through the pterygopalatine fossa, at the level of its junction with the
greater palatine canal: 1. pterygopalatine fossa; 2. pterygoid process; 3. palatine bone;
4. posterior wall of the antrum.
 Surgical anatomy of the pterygopalatine fossa
foramen, the second one slightly lower, approximately at the point where
the pterygopalatine fossa changes into the greater palatine canal.
The main openings through which the pterygopalatine fossa communi-
cates with the surrounding structures are: the foramen rotundum, through
which the maxillary nerve enters from the middle fossa; the vidian or
pterygoid canal; the sphenopalatine foramen with the nasal cavity; the
inferior orbital fissure with the orbit; and the greater palatine canal with
the oral cavity. Some other connecting foramina and canals, of less import-
ance, will only be mentioned in the Table I.

TABLE I.
Direction Foramen or Connection Artery Nerve
canal with:
Posterior Foramen Middle fossa Artery of the Maxillary nerve
rotundum foramen
rotundum
Vidian canal Middle fossa Vidian artery Vidian nerve
Palato vaginal Nasopharynx Descending Pharyngeal nerve
canal pharyngeal (Bock)
artery
Vomerovaginal Nasopharynx ? ?
canal
Medial Sphenopalatine Nasal cavity Sphenopalatine Pterygopalatine
foramen artery nerve
Foramen of Nasal cavity Lateral nasal Branches of greater
Juvara branch palatine nerve
Inferior Greater Hard palate Greater Greater
palatine descending palatine nerve
foramen palatine artery
Lesser palatine Soft palate Lesser palatine Lesser palatine
foramen artery nerve
Anterior Infraorbital Orbit, cheek Infraorbital Infraorbital
fissure artery nerve
Lateral Pterygomaxillary Upper jaw Superior posterior Superior posterior
fissure alveolar artery alveolar nerve
. Pterygomaxillary Orbit — Zygomatic nerve
fissure

The contents of the fossa can be divided into two distinct layers: an
anterior one, which contains all the vessels; and a posterior one, which
contains all the nerves (Fig. 9). This is of surgical importance: as long as
one remains in the vascular layer, there need be no fear of damaging any
nerves; on the other hand, if one wants to attack the nerves, the work will
be facilitated by clipping and dividing the vessels.
39
 R. T. Wentges
All the arteries are branches of the maxillary artery (Fig. 10), which, in
its turn is a branch of the external carotid artery; their course is generally
very tortuous and shows great variability.

FIG. a.
Schematic view of the contents of the pterygopalatine fossa. The descending pharyngeal
artery and the artery of the foramen rotundum are not shown: i. foramen rotundum and
maxillary nerve; 2. sphenopalatine artery and pterygopalatine nerve; 3. vidian artery and
nerve; 4. infraorbital artery; 5. maxillary artery; 6. superior posterior alveolar artery and
nerve; 7. descending palatine artery and nerve.

Apart from the sphenopalatine vein, which runs an oblique course in or

just under the anterior periosteum of the pterygopalatine fossa, no veins of
any importance are found; there is, however, a venous, pterygoid plexus
situated more laterally in the infratemporal fossa. The neural contents are
shown diagrammatically in Figure 11. The second division of the trigeminal
nerve, the maxillary nerve, enters the fossa via the foramen rotundum and
runs its course through the infraorbital canal, from where it innervates the
skin of the lower eyelid, the cheek, the upper lip and part of the nostril.
Branches of the maxillary nerve cross the pterygopalatine ganglion and run
towards the palate (greater and lesser palatine nerve), the nose (pterygo-
palatine nerve), the upper jaw (superior posterior alveolar branches) and
the orbit (zygomatic nerve). The autonomic supply of the nasal mucosa and
the lacrimal gland is provided by the vidian nerve (according to the official
nomenclature: nerve of the pterygoid canal). This nerve is formed by a
minimum of two components: sympathetic fibres, coming from the carotid
plexus as the deep petrosal nerve, and parasympathetic fibres, coming from
the geniculate ganglion as the greater petrosal nerve. The latter fibres form
synapses in the pterygopalatine ganglion. It is probable that autonomic
fibres accompany all the nerves of sensation emerging from the pterygo-
palatine fossa; there is reason to presume that there is a preponderance of
the parasympathetic system in the vidian nerve.
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 1 s t part 2nd part 3 d part
in
pterygopalatine
15
fossa

21

The maxillary artery and its branches (adapted from Hollinshead): I. external carotid
artery; 2. posterior auricular artery; 3. deep auricular artery; 4. anterior tympanic artery;
5. superficial temporal artery; 6. middle meningeal artery; 7. accessory meningeal branch;
8. inferior alveolar artery; 9. mylohyoid branch; 10. branch to lingual nerve; n and 13.
pterygoid branches; 12. masseteric artery; 14 and 15. deep temporal arteries; 16. buccal
artery; 17. infraorbital artery; 18. superior posterior alveolar artery; 19. descending
pharyngeal artery; 20. sphenopalatine artery; 21. greater and lesser palatine arteries;
22. vidian artery.

FIG. 11.
Schematic view of the pterygopalatine ganglion. The zygomatic nerve is not shown:
I. foramen rotundum and maxillary nerve; 2. pterygopalatine nerve; 3. vidian nerve;
4. infraorbital nerve; 5. superior posterior alveolar nerve; 6. greater and lesser palatine
nerves.
 R. T. Wentges
The remainder of the pterygopalatine fossa is filled with fatty tissue
which is continuous with the infratemporal fat pad through the pterygo-
maxillary fissure. Finally, the contents of the fossa are surrounded by a
rather dense periosteum.
The remainder of this paper will be dedicated to a short review of the
different surgical approaches to the pterygopalatine fossa that have been
described throughout the years.
The first operation on the pterygopalatine fossa was probably done by
J. M. Carnochan of New York in 1856. His patient was a general practi-
tioner of French extraction, Henry Rousset, who was suffering from tri-
geminal neuralgia. The operation was done under chloroform anaesthesia
with the patient sitting upright in a chair, supported by several assistants.
The incision used by Carnochan is seen in Figures 12 and 13; the antrum

FIGS. 12 and 13.

Transantral approach to the pterygopalatine fossa, described by Carnochan (1858).

was opened and the infraorbital and maxillary nerve were followed towards
the foramen rotundum and excised together with the pterygopalatine (or,
as it was called at the time, Meckel's) ganglion. The postoperative course
was uneventful; after four days the usual 'healthy suppuration' appeared
and after two weeks the patient could leave the hospital 'in high spirits'.
Fourteen months after the operation Carnochan received a letter that the
patient was still free of pain. The approach, described by Carnochan (1858)
is still employed by most surgeons, except that nowadays a gingivolabial
incision is used. Seiffert (1929) used a transantral route in the first ligation
of the maxillary artery in epistaxis (Fig. 14) and Golding-Wood (1961)
developed Malcomson's (1959) idea of vidian neurectomy in describing a
transantral approach to this nerve.
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 Surgical anatomy of the pterygopalatine fossa
A lateral approach to the pterygopalatine fossa was first mentioned by
Segond in 1890 (Fig. 15) and later by Frazier (1921) and Braeucker (1932).
This method, however, has several disadvantages. In the first place an
external scar is produced, secondly the approach leads through a very
vascular area, thirdly the risk of damaging branches of the facial nerve is
always present and finally a poor view of the contents of the fossa is
obtained, since they lie in a coronal plane and are entered from a lateral
direction.

. , A. canalis Vidii
A. sphenopalatina
A. infraorbitalis
A. maxillaris intern a
- A. alveolaris sup. post.
'• A. palatina deacendens

FIG. 14.
Ligation of the maxillary artery. Original picture by Seiffert (1929).

A transpalatinal method of entering the pterygopalatine fossa was first

described by Averbukh et al. (1935) and later by Chandra (1969), who per-
formed several vidian neurectomies in this way. Disadvantages of this
approach are: a poor view of the contents of the fossa; a relatively long
convalescence; and the risk of palato-nasal fistulas (three in Chandra's
series of nineteen). A transnasal approach was described by Sluder (1913)
and a trans-septal one by Minnis and Morrison (1971). Both share the draw-
back of a poor view compared to the transantral route. In conclusion it can
be stated that the transantral approach seems to be the best way to enter
the pterygopalatine fossa. It leaves no external scar, it is well-known to
every otorhinolaryngologist, it has a low morbidity and it gives an excellent
view of the contents of the pterygopalatine fossa. The suitability of this
approach for any type of surgery in the fossa forms an added advantage.

43
 R. T. Wentges
Summary
The pterygopalatine fossa is the distribution centre for the main vessels
and nerves of the middle third of the face. Its surgical anatomy is discussed,
with particular emphasis on the relationship between the medial plate of
the pterygoid process of the sphenoid bone and the vertical plate of the
palatine bone; the position of the several foramina is reviewed also. It is
stressed that the vascular contents of the pterygopalatine fossa lie in a
coronal plane, anterior to the neural contents.

FIG. 15.
Lateral approach to the pterygopalatine fossa (Segond, 1890).

Finally, a short review is given of the different surgical approaches to

the pterygopalatine fossa. It is concluded that the transantral approach to
the fossa, as originally described by Carnochan (1858), still seems to be the
best way to gain access to this space.
BIBLIOGRAPHY
AVERBUKH, S. S., BREVDA, I. S., LUBOTSKY, D. N., and SEMENOVA, O. S. (1935)
Annals of Surgery, 101, 819-826.
BRAEUCKER, W. (1932) Langenbeck's Archiv fur Klinische Chirurgie, 167, 776-785.

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 Surgical anatomy of the pterygopalatine fossa
CARNOCHAN, J. M. (1858) American Journal of Medical Science, 1, 134-143.
CHANDRA, R. (1969) Archives of Otolaryngology, 89, 542-545.
FRAZIER, C. H. (1921) Annals of Surgery, 74, 328-330.
GOLDING-WOOD, P. H. (1961) Journal of Laryngology and Otology, 75, 232-247.
MALCOMSON, K. G. (1959) Journal of Laryngology and Otology, 73, 73-98.
MINNIS, N. L., and MORRISON, A. W. (1971) Journal of Laryngology and Otology, 85,
255-60.
SEGOND, P. (1890) Revue de Chirurgie, 10, 173-97.
SEIFFERT, A. (1929) Zeitschrift fur Hals Nasen Ohrenheilkunde, 22, 323-5.
SLUDER, G. (1913) Journal of the American Medical Association, 61, 1201-5.

Sin Radboud Ziekenhuis,

Ear, Nose and Throat Clinic,
Nijmegen,
Netherlands.

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