Anterior Fossa Research Articles

In vivo analysis of endocanalicular light pipe transillumination in endoscopic dacryocystorhinostomy: Anatomic considerations and cautions for the transitioning

ABSTRACT Purpose Localization of the lacrimal sac is a critical step during endoscopic dacryocystorhinostomy (endo-DCR). A “light pipe” can be used to transilluminate the lacrimal sac endonasally. We hypothesized that this may misguide the surgeon learning endo-DCR to create an osteotomy mostly posterior to the maxillary line if only the bone overlying the transillumination was to be removed, as the thinner lacrimal bone will transmit light more readily than the thicker maxillary bone of the frontal process of the maxilla that forms the anterior lacrimal sac fossa. Methods The charts of 32 patients with primary acquired nasolacrimal duct obstruction in whom a lighted system was used during endo-DCR at Massachusetts Eye and Ear from April 2015 through October 2016 were reviewed. Patients with prior history of lacrimal surgery or trauma directly to the lacrimal sac fossa were excluded. Location of the maximal point of transillumination in relation to the maxillary line was observed and noted intraoperatively. Results Of a total of 39 endo-DCR surgeries performed, the intraoperative transillumination point was entirely posterior to the maxillary line in 32 instances (82%). Conclusions Use of an endocanalicular light pipe preferentially illuminates posterior to the maxillary line endonasally. The anterior lacrimal sac fossa (maxillary line and anterior as visualized endonasally) is rarely transilluminated, likely due to thicker bone in that region. Surgeons learning how to perform endo-DCR using a light pipe should be aware of this phenomenon.

The Transorbital Pericranial Flap

The objective of the present study was to describe and evaluate the feasibility, mobility, and surface area provided by the simple and extended transorbital pericranial flap (TOPF). Furthermore, we compared this novel technique with the current practice of pericranial flap harvesting and insetting techniques. We also studied the adequacy of the TOPF in the reconstruction of postoperative anterior cranial fossa (ACF) defects. The TOPF was performed bilaterally in 5 alcohol-preserved, latex-injected human cadaveric specimens. The TOPF was harvested in 2 stages: the orbitonasal stage and the cranial stage. For the orbitonasal stage, a transorbital superior eyelid approach was used. We have described 2 harvesting techniques for creating 2 distinct TOPF types (simple and extended) according to the main vascular pedicle. The superficial flap areas offered by the simple and extended TOPF and the traditional bicoronal pericranial flap were calculated and compared. The distances from the supratrochlear and supraorbital arteries to specified anatomical landmarks were also measured. Additionally, the ACF defect area of relevant surgical cases performed using endoscopic transcribriform approaches were measured on immediate postoperative computed tomography head scans using radiological imaging software. The harvest of both the simple and the extended TOPFs was efficient. As expected, the areas offered by simple and extended TOPFs were smaller than that offered by the traditional bicoronal flap. However, the surface area offered by either the simple or extended TOPF provides sufficient coverage for most ACF defects. A high spatial distribution was observed between the vascular pedicles and their respective foramen or notch. The TOPF represents a novel harvesting, tunneling, and insetting technique that offers a large, versatile, pedicled flap for coverage of most standard ACF defects after endoscopic surgery.

The Incidence Rate of Cranii Base Fracture in Dr. Kariadi Hospital Semarang Period 2019

Introduction: Head injury is a major cause of death, especially in young adults and a major cause of disability. The incidence of head injuries is increasing due to the increasing use of motorized vehicles. As many as 4% of cases of head fracture occur in the base of the cranii.
 Method: This research used a descriptive observational method. The data used is secondary data taken from medical records. In this study, we wanted to know the incidence of cranii base fracture cases due to head trauma in patients treated at Dr. Kariadi period 2019.
 Result: From 29 samples of medical records obtained, 48.3% had mild head trauma, 27.6% had moderate head trauma, and 24.1% had severe head trauma. Symptoms of patients with the most clinical symptoms of cranii base fracture were raccoon eyes 51.7%, with the most fracture locations in the anterior fossa as much as 51.7%.
 Conclusion: The incidence of cranii fracture due to head trauma at RSUP Dr. Kariadi in 2019 was found mostly over 40 years old and most of them were men. The type of injury is a minor head injury, with the largest location in the anterior fossa, and the most common clinical sign found in patients with cranii fracture is raccoon eyes.

The Incidence Rate of Cranii Base Fracture in Dr. Kariadi Hospital Semarang Period 2019

Introduction: Head injury is a major cause of death, especially in young adults and a major cause of disability. The incidence of head injuries is increasing due to the increasing use of motorized vehicles. As many as 4% of cases of head fracture occur in the base of the cranii.
 Method: This research used a descriptive observational method. The data used is secondary data taken from medical records. In this study, we wanted to know the incidence of cranii base fracture cases due to head trauma in patients treated at Dr. Kariadi period 2019.
 Result: From 29 samples of medical records obtained, 48.3% had mild head trauma, 27.6% had moderate head trauma, and 24.1% had severe head trauma. Symptoms of patients with the most clinical symptoms of cranii base fracture were raccoon eyes 51.7%, with the most fracture locations in the anterior fossa as much as 51.7%.
 Conclusion: The incidence of cranii fracture due to head trauma at RSUP Dr. Kariadi in 2019 was found mostly over 40 years old and most of them were men. The type of injury is a minor head injury, with the largest location in the anterior fossa, and the most common clinical sign found in patients with cranii fracture is raccoon eyes.

Variation and Covariation of Size and Shape of the Sphenoidal Sinus in H. sapiens

No consensus about the function or evolutionary forces that influence variation of paranasal sinuses among humans has been established. By establishing the covariance of sinus shape with surrounding morphology, researchers may better develop hypotheses about the potential for independent evolution in the sinuses. The sphenoidal sinuses are rarely studied, despite being centrally located within the basicranium, at the intersection of the three cranial fossae and adjacent to the synchondroses, the location of cranial base angulation. The angulation of the cranial base and its relative orientation with the face is a distinctive, derived trait in Homo sapiens and is important to our understanding of the evolution of our species, yet there are aspects of that anatomy (the sphenoidal sinuses) that have not yet been investigated for their variation and influence in this highly integrated region. Previous research has shown that cranial base angulation is correlated with sphenoidal sinus size variation. Yet, the covariance of size, shape, and orientation of the cranial fossae have not been explored, though these likely have a developmental and evolutionary relationship with the sphenoidal sinus. Here we analyze the covariance of size and shape in the sphenoid sinus with metrics of the cranial base captured using geometric morphometric techniques. Computed tomography (CT) scans of 45 adult human crania were digitally segmented for analysis. Cranial fossa shape was captured with landmarks, while sinus volume was measured from manual segmentation of CT images. Regression analyses were performed between the landmark data and the sinus volume data to assess their covariation. Using a separate sample, we will analyze the three-dimensional shape of the sphenoidal sinus (i.e., the volumetric apportionment) using spherical harmonic coefficients, and compare its variance to variation in the shape of the cranial fossae and anterior cranial base using Two Block Partial Least Squares (TB-PLS) analyses. Previous findings support the existence of a relationship between basicranial angulation and sinus volumetric variation, but not the lateral expansion or shape of the posterior brain. These findings suggest that the sphenoidal sinus may be influenced by the shape and relative position of anterior fossa. These relationships likely represent the influence of the soft tissue anatomy (including the brain, pituitary gland, and the internal epithelial tissues) on the dimensions of the sphenoid, and thus the trajectory of its pneumatization. We expect the morphology of the sinus to demonstrate similar relationships. These findings on the pattern of covariation inform the directions of future research on the evolution and development of the sphenoidal sinuses and basicranium.

Extradural anterior temporal fossa approach to the paranasal sinuses, nasal cavities through the anterolateral and anteromedial triangles: Combined microscopic and endoscopic strategy.

To demonstrate the utility and limitations of the extradural endoscopic-assisted anterior temporal fossa approach to the pterygopalatine fossa (PPF), infratemporal fossa (ITF), paranasal sinuses (PS), parapharyngeal region (PPR), nasal cavities (NC), epipharynx (EP), and clivus. A frontotemporal orbitozygomatic craniotomy is performed. The dura is elevated from the cavernous sinus (CS). The anterior temporal fossa floor is drilled. Foramen rotundum and ovale are opened. The PPF is exposed andthe lateral margin of inferior orbital fissure (IOF) is removed. The anterolateral triangle (ALT) is drilled and the vidian nerve (VN) is exposed. Drilling between the maxillary nerve (V2) and theVN provides access to the sphenoid sinus (SphS). The medial pterygoid plate is drilled exposing the EP. The maxillary sinus (MaxS) is opened anterior to the PPF. V2 is transposed laterally to enlarge the anteriomedial triangle (AMT). The orbital muscle of Muller is removed as well as the medial margin of theIOF, which opens the SphS. Anteriorly, the posterior ethmoid air cells are opened. Morphometric measurements evaluating the size of the ALT were done and the PS, NC, EP were explored with the endoscope. The ALT and AMT triangle provides a wide exposure of the PPF, ITF, PPR. In addition, those triangles represent a deep entry point to explore the PS, NC, and EP. The ALT and AMT are useful corridors to access to the SphS, MaxS, PS, NC, and EP via a transcranial approach. The use of the endoscope through this corridor widely extend the extradural anterior temporal fossa approach which may be considered as a valuable alternative to the extended endoscopic endonasal approach for selected skull base lesions extending both intracranial and into the PS, NCand EP.

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base.

SUMMARYThe transorbital approaches are a group of surgical procedures performed passing through the orbital spaces and aimed to reach deeper areas. This kind of surgery has been proved to be safe and effective in the management of selected lesions of the anterior, middle and infratemporal fossa. The aim of the present study is to perform a review of the literature, in order to draw the reader’s attention on the main features of this kind of surgery, focusing on the anatomical background and the surgical setting; we will also summary the current indications and contraindications to this approach and find out the related complications and the possible alternatives. Even if we consider the transorbital approach as a promising route to the skull base, we underline that there is no better approach over another and the choice must always consider several elements. Furthermore, as for every skull base procedure, a multidisciplinary management is strongly advisable.

Metopic triangle osteotomy in trigonocephaly Piezosurgery: a technical variant to control metopic emissary veins.

Premature fusion of the metopic suture results in trigonocephaly with variable degrees of anterior cranial fossa dysmorphia and craniofacial deformity. Different surgical corrective techniques that aim to reshape the forehead and enlarge the cranial volume have been described. Typical variations of the standard fronto-orbitary advancement carry the risk of relevant blood loss during frontal osteotomy, where paired emissary metopic veins are disrupted. The authors present a technical variant that preserves a bony triangle over the glabella to optimize control of these veins, which represent the major source of bleeding, and applies Piezosurgery to perform the osteotomies to minimize bone substance loss.The video can be found here: https://vimeo.com/511536423.

Three-Dimensional Evaluation Of The Temporomandibular Joint After Using Facemask Appliance; A Clinical Prospective Study.

Aim of the study This study was conducted to evaluate the three dimensional changes in the TMJ after the maxillary protraction using face mask therapy. Material and Methods Eighteen growing patients (ages ranged from 8-11 years) were included in the current study. All patients manifested features of skeletal class III due to maxillary deficiency. A Petit-type facemask was used for all patients and was attached intraorally to a fixed labiolingual appliance through extraoral elastics . A cone-beam CT scan had been applied for each patient before the start of the treatment and after 10 months. The three-dimensional (3D) temporomandibular joint measurements included: 1) anterior fossa line inclination, 2) posterior fossa line inclination, 3) anterior joint space, 4)posterior joint space,5) medial joint space, and 6) superior joint space. Results Regarding Anterior Joint space : measurements after using a facemask appliance were significantly higher than before (as P<0.05) ,while regarding Posterior and superior Joint spaces : measurements after using a facemask appliance were significantly lower than before (as P<0.05) Conclusion Facemask therapy for maxillary protraction in management of skeletal class III produced: 1- Decrease in both posterior and superior joint spaces ,while increase in the anterior joint spaces. 2- Bone remodeling in the glenoid fossa causes upward and backward displacement of the condyle.

Osteocutaneous radial forearm free flap for anterior cranial base reconstruction: Technical note

The reconstruction of anterior skull base defects after carcinologic surgery is challenging. Large defects can require the use of autologous free tissue transfer. Currently, most reconstructions use soft-tissue flaps. We describe the use of an osteocutaneous radial forearm free flap to reconstruct a large defect secondary to a malignant paraganglioma extending into the anterior cranial fossa and both orbits. The surgical resection required endonasal and transcranial approaches. We reconstructed the defect with a free osteocutaneous radial forearm flap. We laid the bone flap across the defect, resting on the orbital roof on each side, and sutured the soft component to the edge of the dura. The pedicle was funnelled from the craniotomy to a prepared cervicotomy and the micro-anastomoses were performed onto the facial artery and two satellite veins. Potential indications and major drawbacks of this technique are briefly discussed. Osteocutaneous radial forearm free flaps can be a valuable reconstructive option for patients with a large defect of the anterior skull base, needing both rigid support and a watertight closure.

Gross Total Resection of a Recurrent in-and-around Cavernous Sinus Meningioma through a Combined Transcavernous Anterior and Middle Infratemporal Fossa Approach with Extracranial-Intracranial Bypass.

Objectives  The study aims to describe surgical management of an invasive cavernous sinus meningioma with a combination of several skull base approaches and bypass surgery. Design  This study is an operative video. Results  Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. Cerebral bypass surgery is an essential adjunct in the armamentarium of skull base surgery when vessel reconstruction is required. In this paper, we describe our experience of successful treatment of an invasive recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 46-year-old woman presented with a 2-year history of gradually worsening left-sided exophthalmos and visual impairment. The patient had previously undergone two craniotomies for resection of the left-sided spheno-orbital meningioma. Pathological diagnosis was chordoid meningioma, which is classified as an intermediate-grade meningioma. The second surgery had been performed for a rapid tumor regrowth 6 months after the first surgery. The patient lost her left-side vision after the second surgery. Aggressive tumor regrowth was confirmed with extension into the left orbit, infratemporal fossa, and cavernous sinus with engulfment of the carotid artery. A balloon occlusion test revealed intolerance of the left internal carotid artery occlusion. Considering the patient's age, tumor behavior, and intolerance of the carotid artery of the lesion side, we scheduled gross total resection of the tumor with vessel reconstruction. Conclusion  Although cerebral bypass surgery is a technically challenging procedure, it plays an important role in the surgical management of the complex vessel-engulfing tumor. The link to the video can be found at https://youtu.be/GCmpxK3hW18 .

Surgical Outcome of Trigeminal Schwannomas.

Simple SummaryTrigeminal schwannomas are the most common among non-vestibular schwannomas. Treatment of trigeminal schwannomas may be challenging due to critical anatomical relations and involvement of different aspects of the skull base. Advances in microsurgery have led to improved outcomes over the last decades, whereas in contrast, some advocate stereotactic radiotherapy as an effective therapy, controlling the tumor volume with few complications. In this manuscript, we present outcome and adverse events in a contemporary cohort of trigeminal schwannomas and discuss surgical advantages and disadvantages of different performed classic skull-base approaches. (1) Background: As resection of trigeminal schwannomas is challenging, due to anatomical involvement of the anterior, middle and posterior fossa, the appropriate approach is important. We report our experience with surgical resection of trigeminal schwannomas by simple and classic skull-base approaches. (2) Methods: We performed a retrospective single-center study including patients who underwent surgery for trigeminal schwannoma tumors between June 2007 and May 2020, concentrating on surgical technique, extent of resection, postoperative outcome and complications. (3) Results: We included 13 patients (median age 57.5 with range of 36-83 years, 53.8% (7/13) female. The most common preoperative clinical presentations were facial pain in six (46.2%), hypoacusis in four (30.8%), trigeminal nerve hypesthesia in 11 (V1 46.2% (6/13), V2 (61.5% (8/13), V3 46.2% (6/13)) and headache in three (23.1%) patients. In three cases, the tumor was resected in a two-stage technique. The intradural subtemporal approach was performed in six cases, the extradural technique in two cases, the retrosigmoid approach in five cases, a Kawase approach in two cases and the transnasal endoscopic approach in one case. The gross total resection rate was 76.9% (10/13) and the median follow-up time 24.0 (0–136) months. Three (23.1%) patients developed postoperative anesthesia in at least one branch of the trigeminal nerve. Trigeminal motor function was preserved in 11 (84.6%) patients. Ten of the 11 patients (76.9%) who reported decreased gustation, cerebellar ataxia, visual impairment, or headache improved postoperatively. Two (15.4%) patients exhibited minimal facial palsy (House and Brackmann II–III), which resolved during the follow-up. The total adverse event rate requiring surgical intervention during follow-up was 7.7%. Surgery-related mortality was 0%. (4) Conclusions: Trigeminal schwannomas are rare benign lesions with intra- and extracranial extension. Considering the low operative morbidity and satisfying functional outcome, gross total resection of trigeminal schwannomas is achievable by classic, but also individually tailored approaches. More invasive or combined techniques were not needed with meticulous surgical planning.

Relationship between the posterior septal artery and the upper edge of the choana.

The pedicled nasoseptal flap has been a key element in advancing the endoscopic transnasal approach (ETA) for the treatment of skull base lesions from the anterior cranial fossa to the occipitocervical junction. To preserve vascular supply, an anatomical knowledge of the location of the posterior septal artery (PSA) is essential. The objective of this work is to establish the relationship between PSA and the superior edge of the choana to define a safety margin during the opening of the sphenoidal rostrum preserving PSA. One hundred and eighty angiotomographies of the brain were assessed. The sphenopalatine artery (SPA) was evaluated in the pterygopalatine fossa and PSA at its entrance into the nasal cavity and on the sphenoidal rostrum. PSA was found in all 3 tomographic planes (axial, coronal and sagittal) in 100 patients (200 PSAs). Thirty-five were male and 65 were females. Average age was 62years with a range of 19-90years. Total average distance between PSA and the superior edge of the choana was 8.5mm with a range of 2.5-18 (12.45 90th percentile). Although the distance between the choanal edge and PSA is 8.5mm on average, due to its variability, a distance of at least 12.45mm for the opening of the sphenoidal sinus in the ETA approach should be considered as a safety margin.

Craniometric Measurements and Surgical Outcomes in Trigonocephaly Patients Who Underwent Surgical Treatment.

ObjectiveThe aim of this study was to discuss the results of craniometric measurements and surgical treatments in patients operated for isolated trigonocephaly (TC) in light of the current literature.MethodsA total of 18 cases who underwent surgery for isolated TC were included in the study. Age, gender, family history, follow-up time, complications, duration of surgery, surgical blood loss, and amount of blood replacement in these patients were recorded. Craniometric measurements such as metopic angle (MA), cephalic index (CI), interparietal distance (IPD), intercoronal distance (ICD), and their ratio to each other were evaluated according to pre-and postoperative parameters. Photographs of the patients were taken before and after the operation. The Whitaker classification and Kampf "aesthetic outcome staging" were used in the evaluations.ResultsThe mean MA values after the operation increased to reach above 147 degrees in all cases. The average CI did not change. ICD measurement averages increased significantly. The average IPD/ICD ratio decreased due to the increase in ICD and the enlargement of the anterior fossa after the operation. According to the Whitaker classification and Kampf “aesthetic outcome staging” scale, 17 of our cases were at stage I, rated as perfect, and one was at stage II, rated as good.ConclusionSurgery performed at the appropriate time for TC yields cosmetically satisfactory results. Since potential neurological and cognitive morbidities occur mostly in school-age patients, long-term follow-up of the cases is required. Performing craniometric measurements enables patients to be evaluated with objective and measurable numerical data.

Cephalocranial Disproportionate Fossa Volume and Normal Skull Base Angle in Pfeiffer Syndrome.

Pfeiffer syndrome is a rare syndromic craniosynostosis disorder, with a wide range of clinical manifestations. This study aims to investigate the structural abnormalities of cranial fossa and skull base development in Pfeiffer patients, to provide an anatomic basis for surgical interventions. Thirty preoperative CT scans of Pfeiffer syndrome patients were compared to 35 normal controls. Subgroup comparisons, related to differing suture synostosis, were performed. Overall, the volume of anterior and middle cranial fossae in Pfeiffer patients were increased by 31% (P < 0.001) and 19% (P = 0.004), versus controls. Volume of the posterior fossa in Pfeiffer patients was reduced by 14% (P = 0.026). When only associated with bicoronal synostosis, Pfeiffer syndrome patients developed enlarged anterior (68%, P = 0.001) and middle (40%, P = 0.031) fossae. However, sagittal synostosis cases only developed an enlarged anterior fossa (47%, P < 0.001). The patients with solely bilateral squamosal synostosis, developed simultaneous reduced anterior, middle and posterior cranial fossae volume (all P ≤ 0.002). The overall skull base angulation, measured on both intracranial and subcranial surfaces, grew normally. Enlarged anterior cranial fossae in Pfeiffer syndrome children is evident, except for the squamosal synostosis cases which developed reduced volume in all fossae. Volume of the middle cranial fossa is influenced by associated cranial vault suture synostosis, specifically, sagittal synostosis cases develop normal middle fossa volume, while the bicoronal cases develop increased middle fossa volume. Posterior cranial fossa development is restricted by shortened posterior cranial base length. Surgical intervention in Pfeiffer syndrome patients optimally should be indexed to different suture synostosis.

Concurrent Inverted Papilloma and Squamous Cell Carcinoma with Intradural Extension Presenting with Frontal Lobe Syndrome

AbstractInverted papilloma is an uncommon tumor mostly arising from the lateral wall of the nasal cavity and displays a benign but locally aggressive behavior. Intracranial extension is an extremely rare presentation of inverted papilloma. Extension occurs either as a benign lesion or due to malignant transformation. We report a case of concurrent inverted papilloma and squamous cell carcinoma presenting with epistaxis and recent-onset altered behavior and memory impairment. After literature review of similar cases having inverted papilloma with intracranial extension, we could identify a total of 12 cases, most of which were recurrences of a primary inverted papilloma that were resected before extension into the cranial cavity. Most cases were of extradural extension, and intradural spread resulted in poor prognosis on follow-up. Concurrent inverted papilloma and squamous cell carcinoma extending into the anterior cranial fossa and frontal lobe is a very rare clinical entity and can present as frontal lobe syndrome.

Frailty as a Predictor of Postoperative Complications Following Skull Base Surgery.

Frailty has emerged as a powerful risk stratification tool across surgical specialties; however, an analysis of the impact of frailty on outcomes following skull base surgery has not been published. The aim of this study was to assess the validity of the 5-factor modified frailty index (mFI-5) as a predictor of perioperative morbidity and mortality in patients undergoing skull base surgery. A mFI-5 score was calculated for patients undergoing skull base surgeries using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2018. Multivariate logistic regression analysis was used to evaluate the association of increasing frailty with complications in the 30-day postoperative period, with a subanalysis by operative location. A total of 17,912 patients who underwent skull base procedures were identified, with 45.5% of patients having a frailty score of one or greater; 44.9% were male and the mean age was 52.0 (±16.1 SD) years. Multivariable regression analysis revealed frailty to be an independent predictor of overall complications (odds ratio [OR]: 1.325, P < .001), life-threatening complications (OR: 1.428, P < .001), and mortality (OR: 1.453, P < .001). Higher frailty also correlated with increased length of stay. When procedures were stratified by operative location, frailty correlated significantly with overall complications for middle, posterior, and multiple-fossae operations but not the anterior fossa. Frailty demonstrates a significant and stepwise association with life-threatening postoperative morbidity, mortality, and length of stay following skull base surgeries. mFI-5 is an objective and easily calculable measure of preoperative risk, which may facilitate perioperative planning and counseling regarding outcomes prior to surgery. 3 Laryngoscope, 131:1977-1984, 2021.

Incidence, Clinicopathological Profile and Location - Based Outcome of Intracranial Meningiomas: 10-Year Institutional Study with Review of Literature

Abstract Intracranial meningiomas are the most common extra-axial tumors, representing 15% of all brain tumors. Arising from the arachnoid cells, and common in middle-aged women, 90% meningiomas are benign. We conducted a 10-year study on 183 cases of intracranial meningiomas and observed a lower and decreasing trend; the mean age was 43.3 years but there was also a significant incidence in young females. Parasagittal/falx (29%), sphenoid ridge, convexity meningiomas and middle cranial fossa locations were more common. Histopathologically, meningothelial meningioma was the most common. Benign (WHO I) tumors were found in above 90%, atypical (WHO II) in 5% cases, and malignant (WHO III) in &lt; 4% patients. Most patients underwent Simpsons Grade I excision (35.6%) with dural reconstruction because of late presentations. Posterior fossa meningiomas were mostly benign, while intraventricular ones were mostly malignant with highest postoperation mortality. Mortality in operated patients was 9.8% but was highest in anterior fossa tumors (12.5%).

Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: Exploring the Potentialities of a Modified Lateral Retrocanthal Approach

Among the new perspectives to revolutionize skull base surgery, there are the transorbital neuroendoscopic (TONES) approaches to reach the anterior and middle cranial fossa (ACF and MCF). We conceived to explore the potentialities of a modified superiorly and medially extended lateral retrocanthal (LRC) approach. Six head specimens were dissected. Applying the established conic model and the key surgical landmark of sphenofrontal suture, we tested the feasibility of a modified LRC to reach ACF and MCF; computed tomography (CT) scans were performed before and after dissection to obtain a morphometric analysis of the surgical corridors using a polygonal surfaces model. Through our anatomical study, we were able to identify and explore 3 different surgical corridors to reach the ACF and MCF: the superomedial, the superolateral, and the inferolateral. The superomedial corridor appeared most suitable to reach the medial part of the ACF and the optic-carotid region, whereas through the superolateral and inferolateral corridors it was possible to reach and explore the lateral part of ACF and MCF. The mean volumes of the 3 surgical corridors calculated on post-dissection CT scans were: 12.72 ± 1.99, 5.69 ± 0.34, and 6.24 ± 0.47 cm3, respectively. The development of TONES approaches has not replaced the traditional open or endoscopic approach; nonetheless, identification of surgical corridors and the possibility to combine them represent a major breakthrough. Clinical studies are necessary to demonstrate their validity and test the effectiveness, safety, and reproducibility of TONES approaches in managing lesions harboring in the ACF and MCF.

Lateral frontal galeal-cutaneous flap for reconstruction after orbital exenteration for advanced periorbital skin cancer.

Background/aimOrbital exenteration (OE) is one of the most disfiguring procedures leading to significant deformity. Defect reconstruction is challenging, especially in elderly patients. Herein, experiences with orbital exenteration and primary reconstruction with lateral frontal galeal-cutaneous flap based on superficial temporal artery were reviewed.Materials and methodsData on patients treated for nonmelanoma skin cancer invading the orbit during a 10-year period were analyzed. The patient demographics, tumor features, reconstructive techniques used, complications, and survival were recorded with a median follow-up of 27.5 months.ResultsIncluded in the study were 26 patients in whom OE was performed, comprising 14 males and 12 females, with a mean age of 75.29 years (range: 61–87). The majority of the patients were treated for basal cell carcinoma with medial cantus as the primary site. All of the defects were closed using a lateral frontal galeal-cutaneous flap based on the superficial temporal artery, and in 2 patients, a temporalis muscle pedicle flap was used as an additional flap for reconstruction of the orbital roof in order to separate the brain from the empty orbit, and it was then covered with the same galeal-cutaneous flap. In 19 patients, the frontal area was closed primarily, and in 7 patients, skin graft was used for the secondary defect. There was no flap loss. Tumor-related death was registered in 3 patients (inoperable recurrent tumors) (11.5%), 7 died from complications that were unrelated to the tumors (2 were operated for recurrent orbital tumors), and 16 survived.ConclusionThe preferred method for reconstruction after OE at our university affiliated center is lateral frontal galeal-cutaneous flap based on the superficial temporal artery. Flap harvesting is simple, safe, and obtains enough tissue to cover the defects, even after extended exenteration. The complication rate is low. The simultaneous use of this flap with pedicle temporalis muscle flap is suggested only for reconstruction of the scull base after anterior cranial fossa resection.