Transoral Finger-Retraction for Endonasal Endoscopic Resection of Masseteric and Buccal Space Lesions

Lesions involving the masseteric and buccal spaces have traditionally required transoral or transcervical approaches. Herein, the authors describe the successful endonasal endoscopic resection of a juvenile nasopharyngeal angiofibroma (JNA) with significant extension into the masseteric and buccal spaces facilitated by transoral finger retraction. Juvenile nasopharyngeal angiofibromas are hypervascular tumors originating in the pterygopalatine fossa (PPF) with complex relationships to skull base and orbital structures. Endoscopic approaches have allowed for resection of JNAs with excellent visualization and without traditional transfacial approaches, decreasing morbidity and reducing incidence of facial deformity with similar outcomes as open approaches. While the endonasal endoscopic approach to the masseteric and buccal spaces is unconventional, encapsulated tumors in these regions can be delivered into the nasal cavity through the maxilla and PPF with the use of transoral finger-retraction. The authors present a case of a 10-year-old male referred to their tertiary care center with left-sided epistaxis, nasal obstruction, and facial swelling. Imaging demonstrated a vascular lesion in the PPF involving the left nasal cavity and paranasal sinuses, with extension into left middle cranial fossa, infratemporal fossa, orbit, and deep spaces of the neck including the masticator, masseteric, and buccal spaces. The patient underwent preoperative embolization and endoscopic endonasal surgical resection with transoral finger-retraction without complication. Transoral finger-retraction represents a supplemental technique that allows for encapsulated lesions involving the masseteric and buccal spaces to be delivered into the nasal cavity for endoscopic resection in a safe and effective fashion, preventing the need for transfacial incisions. Address correspondence and reprint requests to David A. Gudis, MD, FACS, Assistant Professor of Rhinology, Skull Base Surgery, Pediatric Otolaryngology, Department of Otolaryngology – Head and Neck Surgery, New York Presbyterian Hospital, Morgan Stanley Children's Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032; E-mail: Dag62@cumc.columbia.edu Received 18 April, 2018 Accepted 3 July, 2018 Presented at the American Rhinologic Society for the Combined Otolaryngology Sections Meeting, San Diego, CA, 2017. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

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