Open access peer-reviewed chapter
Abstract
The cavernous sinus is a very complex area, and surgical treatment requires detailed anatomical knowledge and familiarity with its relationship to surrounding structures. By exposing the lateral wall of the cavernous sinus with the extradural approach, it is possible to pass through the triangular corridor of the cavernous sinus and perform surgical treatment for diseases such as trigeminal schwannoma and meningioma inside and outside the cavernous sinus. In addition to the extradural infratemporal fossa approach, the extradural infratemporal fossa to the pterygoid fossa and the approach to the paranasal sinuses can be safely performed by inserting the endoscope into the bone corridor of the middle cranial fossa. Furthermore, in the last decade, transnasal endoscopic skull based approaches have further developed, facilitating surgical access to the cavernous sinus. The cavernous sinus is an unattachable site due to the complex structure of multiple nerves, veins, and internal carotid arteries, but if the anatomy of the cavernous sinus is known well we can treat this complex site. As for the choice of approach to the cavernous sinus, a better understanding of the anatomy surrounding the cavernous sinus will allow a rational choice between transcranial and transnasal approaches.
Keywords
- cavernous sinus
- middle fossa approach
- endoscopic approach
1. Introduction
This chapter shows the anatomically based bone removal to the original middle cranial fossa surgery method, which is difficult to reach using microscopy alone [1, 2]. The author advocates a safe method of reaching the middle cranial fossa surgery by rationally approaching the cavernous sinus, pterygopalatine fossa, paranasal sinuses from the cranial side, pharynx, and medial jugular foramen from the microanatomical viewpoint [3, 4, 5].
In addition, the anatomical relationship with the paranasal sinuses and Eustachian tubes will further enhance the anatomical understanding of transnasal endoscopic surgery. Safe bone removal is paramount in skull base surgery. In this article, it is possible to approach the petrous bone, clivus, sphenoid sinus, maxillary sinus, and ethmoidal sinuses from the infratemporal fossa. Furthermore, understanding the layered structure of the cavernous sinuses will allow for a rational choice of approach to the surgical target and method of tumor removal [6, 7, 8].
The various approaches to skull base surgery have a history of significant development through collaboration with pyramidal bone surgery in otolaryngology. As a result, the deepest region, the skull base, can now be safely reached using the pyramidal bone route to the depths of the skull base. Furthermore, since around 2000, neuroendoscopes have been introduced, and transnasal endoscopic surgery has been advocated for the approach through the sphenoid sinus to the sella turcica tumor, the clivus, and the pyramidal bone area [2, 9, 10, 11, 12, 13]. In addition, the transcranial approach to reaching surgery has made it possible to use endoscopes to observe deeper regions, expanding the variation of surgery to areas that could not previously be observed with microsurgery. However, despite advances in surgical methods that allow access to the skull base without craniotomy, one of the advantages of nasal endoscopic surgery, it has gradually become clear that endoscopic surgery still has its disadvantages.
Although the surgical wound is not visible in transnasal endoscopic surgery, damage to the mucosa of the nasal cavity can be significant. Because the structures within the nasal cavity have been destroyed, the nasal environment may deteriorate, resulting in nasal contamination, olfactory disturbances, and other symptoms [14].
The most problematic complication is CSF leakage. As safe and reliable methods have been established, the most rational method is selected for each disease based on the direction of tumor extension, site of origin, and surrounding anatomy, craniotomy, endoscopic surgery, and combined approaches of open and endoscopic surgery can be performed safely in response to clinical variations [15, 16, 17, 18].
In addition to the conventional middle cranial fossa craniotomy, we have further expanded the range of surgical approaches to the cavernous sinus around the trigeminal nerve by removing bone within a safe range, and by introducing an endoscope, we have expanded the scope of surgical approaches to the cavernous sinus, the inferior cranial nerve, the sinus cavity, and the pterygopalatine fossa. Furthermore, the nasal endoscope was used to approach the cavernous sinus from the pterygopalatine fossa (PPF), and the possibility of treatment from both sides was examined, and the advantages and disadvantages of this approach are discussed.
2. Anatomical structures
2.1 Inferior orbital fissure (IOF)
The IOF is defined as a space between the lateral wall and floor of the orbit. The IOF runs in a direction from the maxillary strut posteriorly to the zygomatic bone anteriorly. The zygomatic nerve (ZyN) of the maxillary nerve, infraorbital nerve (ION), orbital ganglionic branch of PPG, infraorbital artery, and inferior division of ophthalmic vein pass through the IOF [19].
2.2 Muller’s muscle (MM)
Muller’s muscle, an embryological remnant of the retractor bulbi in mammals, can be identified over the IOF and it blends with the periosteum. Muller’s muscle forms a bridge over the IOF, separating the orbital content from the PPF [19].
2.3 Zygomatic nerve (ZyN)
The zygomatic nerve (ZyN) is the first branch of the maxillary nerve that divides off after emerging from the FR to enter the PPF. The ZyN can be found about 5 mm distal from the anterior point of the maxillary strut. Coursing superiorly, it enters the orbit laterally through the IOF. It divides two branches distally, the zygomaticotemporal nerve, which is parasympathetic branch and connected lacrimal nerve, and the zygomaticofacial nerve, which is a sensory branch carried from the skin of the zygomatic area [20].
2.4 Pterygoid fossa
Under the temporalis muscle, the superior head of the lateral pterygoid muscle (LPM) lies on and attaches to the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone, while the lower head attaches to the lateral surface of the lateral pterygoid plate (LPP). The origin of the Medial pterygoid muscle (MPM) can be seen between the LPP and medial pterygoid plate (MPP). Under the MPP, the wall of epipharynx can be found. The third segment of the internal maxillary artery is located in the pterygoid fossa. The maxillary artery branches into the descending palatine artery, the infraorbital artery, the artery of the pterygoid canal, the artery of the FR, and the sphenopalatine artery [21].
2.5 Vidian nerve
The VN arises from the junction of the greater petrosal nerve and the deep petrosal nerve within the vidian canal, after which it merges with the PPG. Between V2 and V3, the VN lies, on average, 8.0 ± 1,2 mm below V2 and parallel to V2. The bony windows superior and inferior to the VN (between the VN and V2 and between the VN and the superior wall of the pharynx) are the corridor to the posterior SphS [5].
2.6 Sphenoid sinus
The sphenoid sinus is well known as a part of para-sinus which is close to the skull base. It can be used for the transnasal, transsphenoidal approach. However, it can be accessed from the transcranial approach. The posterior part of the SphS can be opened above and below the VN. After exposing and opening the vidian canal, the VN can be followed to the PPG anteriorly. The sphenopalatine artery supplies the SphS mucosa, except for the area of the planum sphenoidal, which is supplied by the posterior ethmoidal artery.
2.7 Maxillary sinus
The posterior wall of the MaxS can be opened below the pterygopalatine fossa through the V2-V3 vidian corridor, between V2 and the palatine nerve. Muller’s muscle can be incised along with V2 and the fat around the PPG in the PPF removed. Under V2, the PPG can be translocated medially and inferiorly, thus exposing the upper part of the posterior wall of the MaxS, below the orbit.
3. Extended approaches to the paracavernous sinus
Ophthalmo-maxillary nerve corridor (V1-V2 corridor)
Maxillary-mandibular corridor (V2-V3 corridor)
Extended anterior petrosal approach (petrous rhomboid corridor)
4. Basic exposure of the middle fossa for anterior infratemporal fossa approach
A frontotemporal craniotomy is performed first, with the temporal muscle reflected posteroinferiorly to provide maximal exposure of the anterior temporal base. The pterion and the lesser and greater sphenoid wings are then drilled. The foramen spinosum (FS) and middle meningeal artery (MMA) are identified in the infratemporal fossa extradurally, and the MMA is coagulated and cut. Then, the dura propria is elevated from SOF side or V3 side. The elevation of the dura-propria is performed and exposing SOF, V2, and V3. The lateral wall of the SOF is exposed, and the lateral orbital wall is removed anteriorly exposing the periorbita.
4.1 V1-V2 corridor
sphenoid sinus, maxillary sinus, pterygopalatine fossa (Figures 1 and 2) [8].
Figure 1.
Schematic images of V1-V2 corridor. A. the V1 and V2 are exposed after removing the bone of the anterior inferior temporal fossa. The PPF, which is included V2 and pterygopalatine ganglion, can be translocated posteriorly. The incision line is shown on the schema. B. after removing the maxillary strut, the sphenoid, ethmoid, and maxillary sinus are opened between the maxillary orbit and pterygopalatine fossa. EthS; ethmoid sinus, FO; foramen ovale, FR; foramen rotundum, ICA; internal carotid artery, ION; inferior orbital nerve, GG: Gasserian ganglion, MaxS; maxillary sinus, PPF: Pterygopalatine fossa, SOF; superior orbital fissure, SPA; sphenopalatine nerve, SphS: Sphenoid sinus, SupAN; superior alveolar nerve, V1; ophthalmic nerve, V2: Maxillary nerve, ZyN; zygomatic nerve.
Figure 2.
Stepwise dissections of the anteromedial middle fossa triangle. A. after frontotemporal craniotomy, the middle fossa is exposed with elevation of the dura propria from the cavernous sinus lateral wall. The trigeminal nerve, trochlear nerve, and oculomotor nerve are exposed. B. the lateral orbital wall and orbital roof are removed, and the foramen rotundum is unroofed toward the pterygopalatine fossa. The periorbita and pterygopalatine fossa are exposed. C. an incision is made between the pterygopalatine fossa and orbit. D. the pterygopalatine fossa is translocated posteriorly and the zygomatic nerve is bridged between the pterygopalatine fossa and orbit. E. the bone around the maxillary strut is drilled to get access into the sphenoid sinus. The posterior wall of the maxillary sinus is opened between the maxillary and ophthalmic nerves. F. the maxillary, ethmoid, and sphenoid sinus can be opened through the maxillary and ophthalmic nerves. EthS; ethmoid sinus, FO; foramen ovale, FR; foramen rotundum, ICA; internal carotid artery, ION; inferior orbital nerve, GG: Gasserian ganglion, MaxS; maxillary sinus, PPF: Pterygopalatine fossa, SOF; superior orbital fissure, SPA; sphenopalatine nerve, SphS: Sphenoid sinus, V1; ophthalmic nerve, V2: Maxillary nerve, ZyN; zygomatic nerve.
The gap between the ophthalmic and maxillary nerve is used to reach the sphenoid, maxillary, or ethmoid sinuses. This approach is useful when the tumor extends from the periorbital to the infraorbital and further into the middle fossa, with extension into the SphS, MaxS, and PPF. The relationship of the periorbital area to the sinus trigeminal nerve should be known when increasing the tumor removal rate of benign tumors or when performing extensive resection of malignant tumors. Maxillary nerve is exposed along the nerve up to the MaxS. Delete the lateral orbital wall and leading to the middle cranium, the MaxS is covered by the fatty tissue of the PPF. The pterygopalatine ganglion is hidden in the fat tissue within this PPF and the connection between V2 and the vidian nerve can be seen. Initially, the ZyN branches off from the maxillary nerve and heads in the direction of the zygomatic arch. This ZyN is then transected, allowing the PPF to be detached from the orbit. The PPF will be able to deploy V2 backward along with PPG and palatine nerve and vidian nerve.
A large area can be developed between V1-V2. In addition, a small bony ridge at the corner of V1-V2, the Maxillary strut, can be removed just below and anterior to the sphenoid sinus. The infraorbital nerve can be traced peripherally to enter the maxillary sinus. A sphenopalatine artery runs between the sphenoid sinus and the maxillary sinus, and the exit of the sphenopalatine foramen is visible. This approach is useful for the removal of tumors extending from the anterior middle fossa to the orbital wall, along the trigeminal nerve, or into the maxillary sinus.
4.2 V2-V3 vidian corridor
-sphenoid sinus, maxillary sinus, pterygoid - pharyngeal area, condyle- [6].
Vidian corridor to the para-sinus (Figure 3).
Figure 3.
Schema of the V2-V3 corridor. A. the sphenoid sinus is opened through the vidian corridor. The vidian nerve runs between the V2 and V3, parallel with V2. The sphenoid sinus is opened medially to the vidian nerve. B. the maxillary sinus and sphenoid sinus are opened in the infratemporal fossa with translocation of the fat tissue of the pterygopalatine fossa. The maxillary and sphenoid sinus are opened through the V2-V3 vidian corridor with a lateral corridor of the V2. The blue arrows show the direction of the sinus. C, D, E. the root of pterygoid is drilled and the vidian nerve is exposed completely. The sphenoid sinus can be opened medial to the vidian nerve. Between the vidian nerve and V2, a small corridor can be opened and used to access corridor to the sphenoid sinus. The vidian corridor can be enlarged with retraction of V2 and vidian nerve. EP; epipharynx, EthS; ethmoid sinus, FO; foramen ovale, FR; foramen rotundum, ICA; internal carotid artery, ION; inferior orbital nerve, GG: Gasserian ganglion, MaxS; maxillary sinus, MM; Muller muscle, PPF: Pterygopalatine fossa, SOF; superior orbital fissure, SPA; sphenopalatine nerve, SphS: Sphenoid sinus, V1; ophthalmic nerve, V2: Maxillary nerve, ZyN; zygomatic nerve.
The lateral wall of the SOF is exposed, and the lateral orbital wall is removed anteriorly exposing the periorbita. The temporal fossa floor lateral and anterior to FO and FR is drilled until the periosteum of the exocranial surface of the bone is reached. The FR is unroofed, and the pterygopalatine fossa is exposed as well as the fascia of the temporalis muscle and lateral pterygoid muscle (LPM). Further elevation of the periosteum of the exocranial surface of the temporal fossa floor can reveal the lateral aspect of the pterygoid process.
Drilling of the antero-superior aspect of the infratemporal fossa, between the LPM and temporal dura mater and lateral orbital wall was done in order to gain additional working space in the pterygoid fossa.
Limits of the pterygoid drilling required are the epipharynx inferiorly, the clivus posteroinferiorly, the posterior wall of the MaxS anteriorly, and the posterior part of the lateral wall of the SphS medially.
Access to the SphS is gained through the V2-V3 vidian corridor, which is in the depth of the FLT and limited superiorly by V2, posteriorly by V3, inferiorly by the superior wall of the pharynx, and anteriorly by the pterygopalatine ganglion (PPG). Following the VN anteriorly, the PPG is identified in the PPF along with the sphenopalatine artery (SPA), which is a branch of the internal maxillary artery (IMA). In some cases, lateral pneumatization of the SphS is extensive and the VN is dehiscent in the SphS. Below V2, the PPF can be opened, and the fat of the PPF removed. This exposes the PPG, SPA, and the posterior wall of the MaxS, which is located between the PPG and the inferior wall of the orbit. Anterior to the PPG and below the orbit, the MaxS can be accessed through this V2-V3 vidian corridor below V2.
The posterior wall of the MaxS is thin and can be opened easily, granting access to a large space to insert the endoscope. At this point, endoscopic assistance is required to provide additional illumination and widen the exposure of the SphS and MaxS.
4.3 Combined V2-V3 corridor and anterior petrosal approach with endoscopic assistance
-Clivus, condyle, dorsal cavernous sinus, medial aspect of the jugular foramen- [7] (Figure 4).
Figure 4.
Schematic representation of the infratemporal fossa, with opening of the vidian corridor and petrous rhomboid. A. the blue arrow shows the direction of access to the upper-mid and lower clivus through the vidian corridor. The green arrow shows the trajectory to the petrous apex and inferior cavernous sinus through the petrous rhomboid. The purple arrow shows the posterior view to the medial jugular foramen and hypoglossal canal through the petrous rhomboid. The light green arrow shows the direction to the clivus. B. the cadaveric view of the middle fossa. The blue arrow shows the direction of access to the upper-mid and lower clivus through the vidian corridor. The purple arrow shows the posterior view of the medial jugular foramen and hypoglossal canal through the petrous rhomboid. The light green arrow shows the direction to the clivus.
The posterior border of the temporal muscle was incised and detached from the temporal bone. The temporal muscle is retracted anteriorly and exposed to the posterior point of the root of zygoma. The temporal craniotomy was performed and access to the middle fossa extradullary.
Initially, the MMA is traced to confirm the foramen spinosum (FS), and the dura mater is thoroughly dissected anteriorly and posteriorly. The arcuate eminence (AE) is identified posteriorly, the GSPN is peeled off posteriorly to expose the pyramidal bone.
The middle meningeal artery (MMA) is coagulated and cut 1 mm out of the FS. The foramen rotundum (FR) is identified anteriorly, where the dura mater enters the bone. An incision is made in the dura above the foramen ovale (FO), and one thin layer of dura (osteal dura) is elevated to lift the dura propria and expose the lateral wall of the cavernous sinus [22, 23, 24, 25, 26].
After performing the anterior petrosal approach with post meatal drilling, the petrous rhomboid bounded by the GSPN, superior semicircular canal, petrous ridge, and the posterior border of the mandibular verve, gives a working space to the middle and posterior fossa.
The facial, cochlear, and vestibular nerves have a distance from the dura mater of the internal auditory canal (IAC) from this side. Thus, the dura mater can open if they are not compressed and drained by the tumor.
Then, an anterior petrosectomy with extended petrous bone removal toward the petrous apex and ventral cavernous sinus wall through the petrous rhomboid. The bone around the internal auditory canal (IAC) can be removed completely. Usually, the IPS is a landmark of the inferior limit of the anterior petrosal approach.
When the tumor extends to the clivus and/or condyle, the tumor makes a tumor corridor around the petrous and clivus bone. After crossing the IPS, the clivus cancellous bone can be drilled and arrive at the medial aspect of the jugular bulb. A partial clivectomy could be performed by removing bone around the JF.
4.3.1 Anterior view from the petrous rhomboid corridor
The petrous rhomboid area provides a large bone corridor to the petrous and clivus lesion. The endoscopic assistance offers a deep exposure of the middle to lower clivus, epipharyngeal space, and bilateral condylar regions (Figure 5). Advancing the petrous rhomboid corridor toward the petrosal apex allows us to drill the bone beneath the Gasserian ganglion. The IPS can be seen where it joins the cavernous sinus. And the ICA is seen rising from the neck just below the GSPN and joining the cavernous sinus. Laterally and anteriorly, the posterior wall of the retropharyngeal mucosa is seen behind the ICA. Care must be taken during exposing the essential structure around the cavernous sinus. Continuing to follow the bony corridor and proceeding with the removal of bone from the clivus, it reaches the mid-clivus until lower clivus. At this time, when the petrous rhomboid and V2-V3 corridor are combined, the posterior aspect of the sphenoid sinus can be reached. Posteroinferiorly, at the level of the mid and lower clivus, it follows to posterior wall of epipharynx. The ability of the V2-V3corridor to provide light assistance and an enlarged working space allows for extra resection of the pterygoid or sphenoid sinus tumor.
Figure 5.
An endoscopic image and schema and cadaveric dissection image of the anterior view from the anterior petrosal approach. A. an anterior view through the petrous rhomboid corridor after removing the petrous apex and upper clival bone. The ICA goes into the cavernous sinus. The superior and inferior petrosal sinus emerge from the cavernous sinus. B. Below the mandibular nerve (V3), a large cavity can be obtained after removing the petrous apex.
4.3.2 Endoscopic-assisted posterior view of the petrous rhomboid to the condyle, medial aspect of the jugular foramen
The IPS leads to finding the location of the medial aspect of the jugular bulb and jugular foramen. To visualize below the IAC, the endoscopic assisted visualization is necessary (Figure 6). The posterior view of the petrous rhomboid can provide exposure to the medial jugular complex up to the level of the hypoglossal canal (HGC). The location of the HGC indicates the same level of the condyle. The bone around the condyle is cancellous and can be easily drilled. When the posterior fossa dura is opened, the glossopharyngeal, vagal, and accessory nerves are seen. In the case of tumors originating from the bone, such as chordoma and chondrosarcoma, the tumor provides the surgical corridor by itself. The medial aspect of the jugular bulb is the deepest lesion because of the sigmoid sinus and jugular vein. This route is one of the choices of how to reach the medial jugular lesion.
Figure 6.
Posterior view through the petrous rhomboid. A, B. schematic drawing showing a posterior view onto the medial part of the jugular foramen through the petrous rhomboid. C. Endoscopic view, in a posterior trajectory, through the petrous rhomboid. The inferior petrosal sinus, which connects to the medial wall of the jugular bulb, is visualized below the cochlea. D. the horizontal segment of the ICA was skeletonized and followed posteriorly to the vertical segment of the ICA, close to the JB. E. the IPS was cut, exposing the medial wall of the jugular foramen. The jugular tubercle is located between the jugular foramen and hypoglossal canal. Under the hypoglossal canal, the condyle and foramen magnum can be accessed. The dura mater of the posterior fossa was opened. The cranial nerves VII, VIII, IX, X, XI, XII, and vertebral artery can be identified in the intradural space.
5. Clinical case
5.1 Case 1
A 58 year old female patient, who operated on 9 years ago for the cavernous sinus meningioma, had an MRI that revealed a recurrence tumor extending into the middle fossa, sphenoid sinus. A pterional approach was performed and exposure of the middle fossa was obtained. An anterior clinoidectomy was performed first. Wide drilling of the bone of the anterior middle fossa was done to remove as much of the tumoral bony infiltration and hyperostosis as possible. The fascia of the pterygoid muscles was exposed and the SOF, Muller muscle, V1 and V2 were skeletonized. A Maxillary strut was drilled and opened the sphenoid sinus between the V1 and V2 corridor. In addition, an incision was made on the posterior border of the Muller’s muscle with preserving the zygomatic nerve and transposed anteriorly in order to enlarge the anterior medial triangle. Tumor in the sphenoid sinus was removed under seeing of the endoscope visualization (Figure 7).
Figure 7.
Pre and post-operation MR images of the cavernous sinus meningioma and intraoperative images of the cavernous meningioma surgery. A, B. preoperative MR image show enhanced mass effect originates from the cavernous sinus extends into the sphenoid sinus. C, D. postoperative MR image shows the yellow arrow showing the removal of the tumor in the sphenoid sinus. E. Sphenoid sinus was opened between the V1 and V2. F. Incision was made between the Muller’s muscle and V2. G. the zygomatic temporal nerve was identified in the distal of the V2 and the window of the V1-V2 corridor was enlarged. H. Endoscopic view shows a tumor in the sphenoid sinus and removed with suction. I. Two instruments are inserted through the V1-V2 triangle. IOF; inferior orbital fissure, PPF; pterygopalatine fossa, MM; Muller’s muscle, SOF; superior orbital fissure, V1; ophthalmic nerve, V2; maxillary nerve.
5.2 Case 2
A 50-year-old male underwent an MRI at a medical health examination. The MRI detected a mass effect in the infratemporal fossa incidentally. The tumor was located in the cavernous sinus and the imaging was evocative of trigeminal schwannoma. The tumor resection was undertaken through a transcranial transcavernous sinus, extradural anterior infratemporal fossa approach. Frontotemporal approach was performed and elevated the frontal and temporal dura from the sphenoid bone. After identifying the superior orbital fissure and elevating the dura propria, the FR and FO were identified and exposed the V1, V2, V3 and the gasserian ganglion. However, the trigeminal nerve fibers lie on the surface of the tumor. In order not to damage the trigeminal nerve fibers, the maxillary strut was drilled and gained the working space to the tumor from the anterior aspect of the tumor. The pterygoid process, between V2 and V3, was thin and was easily drilled to allow wide exposure of the sphenoid sinus. The tumor extension into the SphS was better appreciated under endoscopic visualization. A more extensive resection was accomplished with this approach, although it remained subtotal. The posterior part tumor was removed through the petrous corridor. The pathology was concordant with a schwannoma, from the trigeminal nerve. After tumor resection, the window of the SphS was covered with a vascularized fascial flap harvested temporal muscle, supplemented by fibrin glue. The postoperative outcome was with slight facial sensation. (Figure 8A, B, C, D, E).
Figure 8.
A: T1 gadolinium enhanced MRI shows a high intensity lesion located in the pterygoid fossa, with an extension up to the sphenoid sinus. B: CT scan shows a mass lesion faces on the sphenoid sinus. C: Post-operative MRI T1 gadolinium image shows the tumor was removed. D; intraoperative microscopic view of the anterior infratemporal fossa view after resection of the tumor. The FLT and AMT were opened, and sphenoid sinus mucosa was seen inside of the sphenoid sinus, between V1-V2 and V2-V3. E; intraoperative endoscopic view below the V2 and the Gasserian ganglion. The tumor can be seen under endoscopic visualization. V1; ophthalmic nerve, V2; maxillary nerve, V3; mandibular nerve, Tu; tumor, SphS; sphenoid sinus, rt.VN; right vidian nerve.
Abbreviation
| IV | trochlear nerve |
| III | oculomotor nerve |
| AE | arcuate eminence |
| Cdy | condyle |
| CT | Computed tomography |
| CTA | computed tomography angiogram |
| CTV | computed tomography venous angiography |
| EP | epipharynx |
| FO | foramen ovale |
| FR | foramen rotundum |
| GG | gasserian ganglion |
| GdT1W | T1 with gadolinium contrast |
| GSPN | greater superficial petrosal nerve |
| HC | hypoglossal canal |
| IAC | Internal auditory canal |
| ICA | internal carotid |
| ION | inferior orbital nerve |
| IPS | inferior petrosal sinus |
| IJV | internal jugular vein |
| JB | jugular bulb |
| JF | Jugular foramen |
| JT | jugular tubercle |
| LPM | lateral pterygoid muscle |
| LPP | lateral pterygoid plate |
| MPP | medial pterygoid plate |
| MPM | medial pterygoid muscle |
| MM | Mullar’s muscle |
| MMA | middle meningeal artery |
| MF | middle fossa |
| MRI | magnetic resonance imaging |
| MS | maxillary strut |
| PPF | pterygopalatine fossa |
| PPG | pterygopalatine ganglion |
| PF | pterygopalatine foramen |
| SPA | sphenopalatine artery |
| PLL | petrolingual ligament |
| ShpS | sphenoid sinus |
| SOF | superior orbital fissure |
| SPS | superior petrosal sinus |
| V1 | ophthalmic nerve |
| V2 | maxillary nerve |
| V3 | mandibular nerve |
| VN | vidian nerve |
| ZyN | zygomatic nerve |
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