Downloaded from http://journals.lww.com/jcraniofacialsurgery by BhDMf5ePHKbH4TTImqenVH0e3gbzxI4tsIrYo12X3Y0xveYZavDEDS6x9ovuSOTe on 01/31/2019 Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Intraoral Endoscopic Ligation of Maxillary Artery in the Infratemporal Fossa Georgiy A. Polev, MD, PhD,  Ricardo L. Carrau, MD, PhD, y Denis A. Golbin, MD, PhD, z Klementina S. Avdeeva, MD,  Nickolai S. Grachev, MD, PhD,  Igor N. Vorozhtsov, MD,  Nikolay V. Lasunin, MD, PhD, z Vasily A. Cherekaev, MD, PhD, z and Juan Eugenio Salas Galicia, MD, PhD § Abstract: Ligation of the sphenopalatine and posterior nasal arteries is indicated for posterior epistaxis as initial treatment or when conservative measures fail. In some patients, a transnasal approach or its alternative transantral approach are not possible due to tumor filling the nasal corridor, pterygopalatine fossa, or maxillary sinus. Aim of this study was to evaluate feasibility of endoscopically assisted transoral approach for the ligation of the maxillary artery (MA). Six fresh cadaver specimens (12 sides), previously prepared with intravascular injections of colored latex, were dissected. A combined transnasal and transoral approach exposed the MA from the deep belly of the temporalis muscle laterally to its terminal branches medially. Anatomical relationships of the MA with the deep belly of the temporalis muscle and the lower head of the lateral pterygoid muscle, and feasibility of access to the MA via a transoral approach were assessed. In all specimens, the MA was found at the point where horizontal fibers of the lower head of the lateral pterygoid muscle cross the vertical fibers of the deep belly of the temporalis muscle. In 5 specimens, the artery ran anteriorly and laterally to lower head of the lateral pterygoid muscle, and in 1 specimen, it ran posteriorly and medially to this muscle, diving between its fibers. The modified endoscopically assisted transoral approach is feasible to ligate the MA. It can be used for proximal vascular control in cases when transnasal and transantral approaches are not viable. Key Words: Endoscopic endonasal approach, infratemporal fossa, maxillary artery, severe epistaxis, transoral approach (J Craniofac Surg 2019;30: 137–140) S urgical treatment of epistaxis often ensues as initial treatment in severe cases or when conservative measures fail. Endoscopic dissection and cautery or clipping of the sphenopalatine artery (SPA) and posterior nasal artery for posterior epistaxis is associated with a high success rate and minor morbidity. 1–4 However, there are circumstances where the transnasal endoscopic approach to the distal branches of maxillary artery (MA) is not feasible, for exam- ple, tumor filling the nasal cavity. Lateral approaches have been previously described, including the transantral and the transoral with dissection of the artery between the ramus of the mandible and temporalis muscle. 5,6 Similar to the transnasal approach, the trans- antral approach may also be hindered by tumor in the pterygopa- latine fossa (PPF) or maxillary sinus. Developed in the pre- endoscopic era, these approaches may carry significant morbidity, mainly in the form of facial numbness and trismus due to the manipulation of the pterygoid muscles. 6 This study introduces the modified transoral endoscopic- assisted (‘‘around-the-maxilla’’) approach for MA ligation at a point that is medial to the deep belly of temporalis muscle (DBTM). Furthermore, this study aims to evaluate the viability and safety of transoral approach and to highlight critical anatomical landmarks based on a series of cadaveric dissections. A case presentation of a patient who required urgent transoral endoscopic MA ligation as an alternative procedure to embolization illustrates the utility of the approach. METHODS The anatomic study was performed in 6 fresh cadaver specimens (12 sides), previously prepared with intravascular injection of colored latex. All dissections were performed using a 4 mm 308 rigid rod- lens endoscope and full-HD video camera (all manufactured by Karl Storz GmbH & Co KG, Tuttlingen, Germany) using basic set of instruments for sinus and skull base surgery. All photo and video recordings were performed using digital HD video recorder. Each cadaveric dissection followed the same consecutive steps. First, the transnasal corridor step was expanded to include a medial maxillectomy, PPF, and infratemporal fossa (ITF) dissection, exposing the MA, its terminal branches, and the buccal nerve. Then, the transoral corridor was opened. An intraoral vertical vestibular incision was carried starting just inferior to maxillary tuberosity. A subperiosteal dissection with the endoscopic assis- tance exposed the anterolateral maxillary sinus wall back to the level of posterior wall. At this level the buccal fat herniated into the wound and was removed with careful preservation of its supplying vessels (in most specimens, branches of the anterior deep temporal artery and posterior superior alveolar artery were found at this From the  Department of Oncology and Pediatric Surgery, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncol- ogy and Immunology, Moscow, Russia; y Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH; z Department of Skull Base and Craniofacial Surgery, Laboratory for Neuroanatomy and Biorepository, NN Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia; and § Department of Otolaryngology - Head and Neck Surgery, Endo- scopic Sinus Surgery and Skull Base Surgery, Autonomous University of Veracruz, Xalapa, Mexico. Received July 3, 2018. Accepted for publication July 24, 2018. Address correspondence and reprint requests to Georgiy A. Polev, MD, PhD, Department of Oncology and Pediatric Surgery, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela str, 1, Moscow 117997, Russia; E-mail: drpolev@gmail.com The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofa- cialsurgery.com). Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004981 ORIGINAL ARTICLE The Journal of Craniofacial Surgery  Volume 30, Number 1, January 2019 137