Mucinous cysts of the pterygoid sinus are usually characterized by headache and loss of vision as the main symptoms. The diagnosis is based mainly on CT examinations. Nasal endoscopic surgery usually requires cyst opening. Because of the long history of mucus cysts in the pterygoid sinus, the surrounding bone has been compressed and resorbed. Opening the anterior wall of the pterygoid sinus through the olfactory fissure and enlarging the stoma to form a long-term stable drainage opening in the anterior wall of the pterygoid sinus is sufficient. As the septal fossa is narrower, part of the posterior end of the middle and superior turbinate needs to be removed to make the drainage channel spacious. With a longer history of extensive mucus cysts in the pterygoid sinus, there will be a greater extent of resorption and destruction of the surrounding bone, and the cyst may expand by extrusion into the skull. When opening the cyst and releasing the cystic fluid, care should be taken not to make the cystic fluid flow out too fast to avoid brain herniation. Since the bone between the optic nerve and the internal carotid artery and the cyst wall can be absorbed, the lateral wall of the pterygoid sinus should not be operated easily after the cyst fluid is aspirated to avoid damage to the optic nerve and the internal carotid artery. In order that the stoma of the pterygoid sinus cyst will not be narrowed and occluded again, the posterior end of the nasal septum and the posterior septal air chamber can be partially removed. Zhang Liqiang, Department of Otolaryngology, Qilu Hospital, Shandong University
Chronic pterygoid sinusitis, especially fungal pterygoid sinusitis, is another common type of pterygoid sinus lesion. A single inflammation of the pterygoid sinus is usually treated by opening the pterygoid sinus through the natural opening of the pterygoid sinus by the olfactory fissure approach. Fungal pterygoid sinusitis is more difficult to open due to a longer history and thickening of the pterygoid sinus wall. In this case, the anterior wall of the pterygoid sinus can be positioned with careful reading of the CT film, and the anterior wall of the pterygoid sinus can be opened directly with a thin flat chisel, and then the pterygoid sinus stoma can be enlarged with biting forceps or grinding drills. Note that when enlarging the pterygoid sinus stoma downward, small arterial bleeding may be encountered, and electrocoagulation is appropriate to prevent postoperative bleeding. In cases with better pneumatization of the pterygoid sinus, some of the air spaces may extend to the root of the pterygoid process, forming the lateral crypt of the pterygoid sinus. When fungal pterygoid sinusitis occurs in this type of pterygoid sinus, the opening of the pterygoid sinus needs to be enlarged downward, and a larger branch of the pterygopalatine artery can be encountered at this time, which needs to be cut by electrocoagulation and then enlarged with a pterygoid sinus ostomy. For fungal masses adhering to the lateral wall of the pterygoid sinus, the pterygoid sinus can be flushed with an elbow aspirator. Try not to operate hard on the lateral wall of the pterygoid sinus to avoid contusion of the forming optic nerve. Sometimes fungal pterygoid sinusitis occurs after surgery with repeated narrowing and atresia of the pterygoid sinus stoma, which is considered to be caused by heavy damage to the surrounding mucosa, exposed bone, and the formation of a circular stenosis at the stoma. In order to prevent the narrowing of the sinus opening, a longitudinal incision of about 1 cm is made on each side of the lower edge of the sinus opening before biting off the anterior wall of the pterygoid sinus, and the mucoperiosteum below the sinus opening is separated to make a mucoperiosteal flap with the tip in the anterior lower wall of the pterygoid sinus. After biting off the bone below the opening of the anterior wall of the pterygoid sinus, the mucoperiosteal flap was turned into the sinus to cover the bone margin. At the same time, the posterior septal airspace is partially excised to enlarge the surrounding space. When performing the opening of the pterygoid sinus via the septal sinus, care needs to be taken not to mistake the suprasellar septum for the pterygoid sinus. Usually the pterygoid sinus is always located at the lowermost part of the septal sinus. If this cannot be clearly determined, the pterygoid sinus can be opened at the superior border of the posterior nasal aperture and then compared with the septum above.
Pituitary tumor surgery should begin with obtaining a more spacious surgical view. Applying a pterygoid sinus biting forceps, the opening of the pterygoid sinus is enlarged downward to the base of the pterygoid sinus; laterally to the septal septal fossa (taking care not to damage the optic nerve and internal carotid artery); and inwardly to the pterygoid spout. If necessary, the pterygoid can be removed. Usually do not expand upward to avoid damage to the horizontal plate of the sieve. The pterygoid sinus septum can be visualized by removing a portion of the pear bone about 1 cm posterior to the nasal septum with a cutting suction device or stripper backbite forceps. This facilitates the exposure of the pterygoid sinus cavity, increases the space for surgical operation, and allows full play of the assistant, who can use instruments to attract or pull from one side of the nostril, solving to some extent the difficulty that the operator cannot operate with both hands at the same time. The purpose of the pterygoid sinus opening is to provide access to the internal carotid artery and the lateral aspect of the optic nerve rongeur below the pituitary fossa with instruments, and to achieve this purpose the anterior wall of the pterygoid sinus needs to be lowered with a cutting suction. Electrocoagulation of the posterior branch of the pterygopalatine artery is required to stop the bleeding during the downward widening of the pterygoid sinus opening. A similar pterygoid sinus opening is performed in the contralateral nasal cavity, followed by removal of the pterygoid septum to expose the pituitary fossa. The base of the pterygoid saddle and the anterior wall of the pterygoid saddle are identified, and if the anterior wall of the pituitary fossa is thick, it can be thinned with a grinding drill until it becomes soft. The bony wall of the anterior pituitary wall is fractured and removed with a pterygoid sinus bite forceps, and then the bone between the cavernous sinuses on both sides is removed to obtain a spacious view of the anterior pituitary wall. The dura mater is fully exposed. A fine needle is used to puncture for the presence of intercavernous sinuses, and if the bleeding from the needle hole is very aggressive at the time of puncture, careful consideration is given to whether to proceed with the procedure. A sickle-shaped knife is then used to make a “ten” shaped incision in the meninges. After the meningeal incision, the tumor will slowly flow out from the dural incision under intracerebral pressure. The tumor should be removed first from the tumor adjacent to the saddle base, then from the tumor near the cavernous sinus on both sides, then from the tumor behind and above the saddle, and finally from the tumor in front and above the saddle. This can avoid the premature drop of the saddle diaphragm and obscure the operation field, and the decompression of the lower part of the saddle makes the upper part of the tumor, especially the part invading the supra-saddle, gradually drop down by the brain pressure. If the tumor extends more superiorly to the pterygoid saddle, a 30 degree endoscope can be used to view the suprasellar region and remove the tumor under direct vision. The use of an angled endoscope is the greatest advantage of endoscopic surgery, as it can remove tumors that cannot be seen with a conventional microscope under direct vision. In addition, since some tumor tissue may remain in the corner between the saddle diaphragm and the cavernous sinus, one operator can lift the saddle diaphragm to expose this corner while the other operator gently removes all remaining tumor tissue. If there is cerebrospinal fluid leakage and bleeding, the pterygoid saddle can be filled with muscle. The pterygoid sinus is filled with gelatin sponge. The middle turbinate is repositioned and the nasal cavity is filled with iodoform gauze.