Anterior Craniofacial Resection Research Articles

Craniofacial malignant tumors, their extensions, and surgical strategy for their treatment

Purpose: To identify extension routes of craniofacial malignancies and formulate a surgical treatment plan based thereupon. Material and Methods: We retrospectively reviewed the medical records of 253 patients with craniofacial malignancies who underwent surgical treatment at the Romodanov Neurosurgery Institute from 2002 through 2022. Of the 253 patients, 112 had a primary tumor, and 141, a secondary tumor. Preoperative Karnofsky performance scores ranged from 50 to 70 points. Patients underwent neurological and ophthalmological status assessment, as per routine protocols. Results: Epithelial malignancies were the most common (53.7%), whereas anaplastic meningioma and embryonal malignancies were rather uncommon (1.2% and 0.4%, respectively) craniofacial malignancies. The presence of certain clinical symptoms was associated primarily with tumor origin and extension. A high rate of general brain and rhinological symptoms in our study sample was caused by a high percentage of intracranial and paranasal sinus tumors. Craniofacial malignancies most commonly originate from the midline (particularly, anterior midline skull base). Ethmoidal labyrinth was the most common site of origin (45.0%), followed by a sphenoid sinus (12.2%), pterygopalatine and infratemporal fossae (9.9%), whereas the cavernous sinus and olfactory fossa were the least common sites of origin (0.4% and 1.2%, respectively). Craniofacial tumors extended most commonly intracranially (transdurally, epidurally, via adhesion to the dura mater, and/or cavernous sinus growth) or intraorbitally. Anterior craniofacial resection (bifrontal craniotomy with combined with either lateral rhinotomy or supraorbital advancement; or a subcranial approach) was the most common surgical treatment. Postoperative cerebrospinal fluid rhinorrhea and infectious complications (meningitis and meningoencephalitis) were the most frequent complications. The overall postoperative mortality rate was 2.0%. Conclusion: First, compared to the transcranial and facial approaches, the craniofacial resection is advantageous in terms of the radicality of tumor excision. Second, the subcranial approach is preferable to the bifrontal approach in the presence of marked extracranial tumor component, whereas the transbasal Derome approach is effective in the presence of marked extracranial and/or intracranial tumor components. Finally, both the orbitozygomatic and infratemporal approaches allow for the radicality of excision of lateral skull base malignancies, but the latter approach is associated with a lower rate of complications.

Reconstructive Outcomes of Multilayered Closure of Large Skull Base Dural Defects Following Open Anterior Craniofacial Resection.

Introduction Standardized reconstruction protocols for large open anterior skull base defects with dural resection are not well described. Here we report the outcomes and technique of a multilayered reconstructive algorithm utilizing local tissue, dural graft matrix, and microvascular free tissue transfer (MVFTT) for reconstruction of these deformities. Design This study is a retrospective review. Results Eleven patients (82% males) met inclusion criteria, with five (45%) having concurrent orbital exenteration and eight (73%) requiring maxillectomy. All patients required dural resection with or without intracranial tumor resection, with the average dural defect being 36.0 ± 25.9 cm 2 . Dural graft matrices and pericranial flaps were used for primary reconstruction of the dural defects, which were then reinforced with free fascia or muscle overlay by means of MVFTT. Eight (73%) patients underwent anterolateral thigh MVFTT, with the radial forearm, fibula, and vastus lateralis comprising the remainder. Average total surgical time of tumor resection and reconstruction was 14.9 ± 3.8 hours, with median length of hospitalization being 10 days (IQR: 9.5, 14). Continuous cerebrospinal fluid drainage through a lumber drain was utilized in 10 (91%) patients perioperatively, with an average length of indwelling drain of 5 days. Postoperative complications occurred in two (18%) patients who developed asymptomatic pneumocephalus that resolved with high-flow oxygen therapy. Conclusion A standardized multilayered closure technique of dural graft matrix, pericranial flap, and MVFTT overlay in the reconstruction of large open anterior craniofacial dural defects can assist the reconstructive team in approaching these complex deformities and may help prevent postoperative complications.

Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction.

Introduction As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results. Objective The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap. Design Retrospective chart review of patients treated by the University of California - San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months. Setting This study was conducted at Academic tertiary referral center. Participants A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

Anterior Craniofacial Resection for Squamous Cell Carcinoma Ethmoid Sinus Involving Anterior Skull Base

Abstract Sinonasal squamous cell carcinoma (SCC) is a rare form of head-and-neck malignancy, with an incidence of 3%, while SCC of the ethmoid sinus is even more infrequent with relatively few cases cited in the literature. Management of anterior skull base tumors is complex due to the anatomic detail of the region and the variety of tumors that occur in this area. Currently, the “gold standard” for surgery is the anterior craniofacial resection. A 61-year-old man with a locally advanced SCC of the ethmoid sinus involving orbit with intracranial extradural extension was surgically treated performing anterior craniofacial resection followed by adjuvant intensity-modulated radiation therapy to the tumor bed. Currently, the “gold standard” for ethmoid carcinoma with intracranial extension is the anterior craniofacial approach. It allows wide exposure of the complex anatomical structures at the base of the skull permitting monobloc tumor resection. A multidisplinary team approach involving an otolaryngologist, neurosurgeon, plastic surgeon, pathologist, and radiologist is required for effective management of these tumors.

Olfactory Neuroblastoma.

Olfactory neuroblastoma is a rare tumor. Nasal endoscopy typically identifies a soft mass arising from the olfactory cleft. Computer tomography and magnetic resonance imaging are mandatory for staging (in association with 18F-fluorodeoxyglucose positron emission tomography) in high-grade and/or high-stage tumors. Biopsy must be representative to confirm a diagnosis and for grading purposes. Two complementary classifications are described: one (Kadish) based on clinical-radiological analysis, and the other (Hyams) on histological criteria. Based on Hyams grading, studies have pointed out that grades III-IV entail significantly different behavior and prognosis. A multimodal approach, which may combine surgery, chemotherapy, and radiotherapy, is essential to manage these tumors. Treatment schedules which include surgery seem to be superior to others. Surgery classically consisted of anterior craniofacial resection to obtain good exposure. However, the role of transnasal endoscopic surgery has expanded because of its association with fewer complications, shorter hospital stays, and comparable oncologic results to the open surgical techniques. Unilateral endoscopic craniectomy can be performed for limited lesions to avoid definitive anosmia. Treatment that includes radio- and chemotherapy is recommended for advanced and high-grade tumors. The role of neoadjuvant chemotherapy in advanced-stage lesions is emerging. The main prognostic factors associated with poor patient outcome are Hyams grade III-IV, Kadish C-D, and positive surgical margins. Lifelong follow up is recommended.

Olfactory neuroblastoma: 14-year experience at an Australian tertiary centre and the role for longer-term surveillance.

Olfactory neuroblastoma is a rare sinonasal malignancy, with poorly defined treatment protocols. Management at a tertiary centre was retrospectively evaluated to inform future treatment and follow up. Cases treated with curative intent (2000-2014) were included. Data were collected, and overall and disease-free survival rates were calculated. Eleven cases were identified, with a median follow up of 87 months. One patient was Kadish stage A, one was stage B, eight were stage C and one was stage D. The latter patient underwent chemoradiotherapy alone. The remaining patients proceeded to: endoscopic-assisted wide local excision (n = 2), anterior craniofacial resection (n = 4) or endoscopic craniofacial resection (n = 4). No patients had primary nodal disease or elective neck treatment. One patient had neoadjuvant chemoradiation. Six patients had post-operative radiotherapy; three received adjuvant chemotherapy. Two patients had late cervical node failure, and proceeded to neck dissection and post-operative radiotherapy. Two patients had late local recurrence. Ten-year overall and disease-free survival rates were 68.2 and 46.7 per cent, respectively. Longer-term follow up is supported given the incidence of late regional and local recurrence. Prophylactic treatment of cervical nodes in locally advanced disease is an area for further investigation.

Endoscopic Endonasal Management of Olfactory Neuroblastoma: A Retrospective Analysis of 10 Patients with Quality-of-Life Measures

Anterior craniofacial resection has served as the traditional surgical treatment of olfactory neuroblastoma (ON). With the development of extended endonasal approaches, the opportunity exists for using minimal access techniques for management of select tumors. This study assesses the impact of endoscopic resection on ON and patient outcomes and quality of life. A retrospective review identified 10 patients with ON (3 women, 7 men; mean age 49.1 years) who underwent endoscopic resection during the period 2010-2013. Modified Kadish staging divided the cohort into 3 stage B patients (30%), 5 stage C patients (50%), and 2 stage D patients (20%). Outcome measures included extent of resection, complications, recurrence, and preoperative and postoperative Sino-Nasal Outcome Test-20 scores. Gross total resection was achieved in all patients, with negative margins in 9 patients. One patient had negative frozen section pathology but was noted to have a positive posterior dural margin on final pathology. There was a 20% complication rate (pneumocephalus, ethmoid meningoencephalocele). Neoadjuvant chemotherapy and radiation were performed in 2 patients (Kadish stage C and D). Adjuvant chemotherapy and radiation were performed in 5 patients (4 Kadish stage C and 1 stage D). Postoperative radiation alone was administered in 3 patients (Kadish stage B). Analysis of postoperative Sino-Nasal Outcome Test-20 scores demonstrated no significant change relative to preoperative Sino-Nasal Outcome Test-20 scores. At the most recent follow-up examination, there was no evidence of recurrent disease in patients who underwent endoscopic resection. One patient (Kadish stage D) died during the follow-up period. Mean follow-up duration was 21.1 months. This series adds to the growing body of literature that suggests equivalent or improved outcomes of purely endonasal resection for select patients. Given the advanced Kadish stage of most of our patients, longer follow-up is required to determine the full applicability of purely endoscopic approaches to the treatment of ON.

Management of Delayed Osteoradionecrosis after Craniofacial Resection

Introduction: We report a case of delayed frontal bone and frontal lobe radionecrosis with secondary infection treated with surgical debridement and microvascular reconstruction 4 years after anterior craniofacial resection and postoperative radiotherapy.

Combined Anterior Craniofacial Resection for Locally Advanced Ethmoid Carcinomas

Carcinoma of the ethmoid sinus is very rare, and treatment for locally advanced tumors remains as a formidable challenge to the clinician. We reviewed cases of ethmoid carcinoma in which anterior craniofacial resection had been undertaken and evaluated the safety and validity of the operative methods. We retrospectively reviewed 13 patients with ethmoid carcinoma who underwent combined anterior craniofacial resection. We evaluated the surgical procedures, complications, outcomes, local recurrence, and the survival rate. Coronal incision and anterior craniotomy were performed in all cases. Four out of 13 cases underwent ipsilateral orbital exenteration due to involvement of the orbital contents. There were no potentially fatal complications, except for two cases of epidural abscesses which were successfully cured. Positive surgical margins were observed in 6 patients, and they received postoperative radiotherapy and/or chemotherapy. Local recurrences occurred in 4 cases, and 3 died at 9, 11, and 49 months after the surgery. Distant metastasis was not observed during the observation period. The overall 5-year survival rate was 75.2% (Kaplan-Meier method). These tumors were safely removed without severe complications and postoperative mortality. Combined anterior craniofacial resection is an effective and safe option for treatment of locally advanced ethmoid carcinomas after various preoperative treatments.

The clinical evaluation of the effectiveness of anterior craniofacial resection for the treatmentof disseminated tumours and pseudotumour lesions in the nasal cavity, the paranasal sinuses, and the orbit

The objective of the present work was to evaluate the outcomes of anterior craniofacial resection (ACFR) in the patients presenting with disseminated tumours and pseudotumour lesions in the nasal cavity, the paranasal sinuses, and the orbit based on the results of dynamic clinical observations. A total of 24 patients with tumours and tumour-like lesions of these anatomical structures were involved in the study including 14 ones having benign neoplasms, 2 patients with pseudotumour lesion, and 8 patients having malignant tumours. In all the cases, the pathological processes in the form of destruction and infiltration encompassed the anterior portion of the base of the skull (mostly lamina cribrosae) and spread directly into the anterior cranial fossa. It was shown that ACRF ensured the radical elimination of the pathological process and the enhancement of the five-year survival rate in all the patients with benign tumours and pseudotumour lesions and in half of the patients presenting with disseminated malignant neoplasms.

Surgical Management of Olfactory Neuroblastoma: Outcomes and Patterns of Failure

Objectives: (1) Analyze survival, complications, and impact of transnasal endoscopic cranial base surgery. (2) Describe time course and patterns of local, regional, and distant failure patients with olfactory neuroblastoma (ONB) of the nasal cavity, ethmoid sinus, and/or anterior skull base. Methods: Review of prospectively collected clinical data of patients treated by a single head and neck surgeon at 2 academic medical centers over 16 years. Results: Thirty-seven patients were diagnosed with ONB confirmed by immunohistochemistry between 1996 to 2010, and 31 are available for review. There were 10 women and 21 men with a mean age of 50.9 years. Patients were treated with primary resection and no additional therapy (4), radiation therapy (24), or chemotherapy enhanced radiation therapy (3). Primary resections included open medial maxillectomy without craniotomy (n = 2), endoscopic anterior craniofacial resection (CFR) (n = 9), and open CFR (n = 20). Mean and median overall survivals were 95.95 and 80.62 months, respectively (range, 6.53 to 242 months). Operative complications were only observed in patients undergoing open CFR. Recurrences were either limited to the neck (3/11), the neck and a distant site (3/11), or distant sites alone (5/11). Time interval to the development of recurrence ranged from 3 to 186 months, and only patients with isolated recurrences could be salvaged. Intradural tumor extension correlated with recurrence but not necessarily early death. Conclusions: Margin negative resection of ONB should remain the goal of primary treatment. Long-term follow-up is necessary to identify patients with isolated recurrences who would benefit from aggressive salvage therapy.

Endoscopic Resection and Postoperative Brachytherapy in the Treatment of Sinonasal Melanoma

Sinonasal melanoma is a rare disease with limited data regarding its optimal treatment. It is an aggressive disease with up to 60% of patients developing local recurrence or distant metastases in the first 24 months after treatment. We report a case of sinonasal melanoma involving the skull base which was treated by endoscopic anterior craniofacial resection together with brachytherapy postoperatively. The patient has been followed up regularly and at 89 months there is no sign of local recurrence or distant metastases. The use of postoperative brachytherapy to achieve local control has not been reported in the management of sinonasal melanoma.

Delayed Complications after Anterior Craniofacial Resection of Malignant Skull Base Tumors

Objective To report complications occurring at least 6 months after completion of treatment for patients with anterior skull base malignancy undergoing anterior craniofacial resection (CFR). Design Retrospective review of medical records of all patients undergoing traditional CFR for treatment of anterior skull base malignancy from 2002 through 2011. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Thirty-one consecutive patients who had at least 18 months of follow-up for analysis were reviewed. All patients underwent traditional CFR. A total of 28 patients received postoperative proton beam radiation therapy. Eleven patients received adjuvant chemotherapy. Main Outcome Measures A delayed complication was any complication occurring at least 6 months after the completion of treatment. Results Seventeen patients had delayed complications. Orbital complications were the most common type (13 patients) followed by issues with wound healing (6 patients). The most common orbital complication was epiphora (7 patients). The most common wound complication was a nasocutaneous fistula (5 patients). Conclusions Patients with anterior skull malignancy can develop complications months to years after the completion of treatment. Therefore, it is important to continue to follow and report complications for several years when deciding on the optimal approach for treatment of these patients.

Surgery minimizing at median craniofacial tumors

Introduction. For surgery minimizing at median craniofacial tumors subcranial surgery is used, in particular endoscopic endonasal surgery or subcranial approach (via frontal sinus).Materials and methods. In 93 patients with malignant craniofacial tumors anterior craniofacial resections was performed: in 63 patients — bifrontal, in 30 — subcranial approach. Histological form and intracranial spread of the tumors was identical in both groups.Results. Total removal when applying subcranial and bifrontal approach differed slightly (respectively 63 and 68%). Indexes of cancer survival do not show significant differences depending on surgical approach (P>0.0500). Postoperative complications were observed more often after bifrontal approach — in 15% patients than after subcranial approach — in 8%. General condition improving was observed in both groups, but after subcranial approach it was significant.Conclusions. Effectiveness of the subcranial approach is similar to that of bifrontal one by surgery radicalism and indexes of overall survival in patients been operated because of malignant craniofacial tumors. At the same time, subcranial surgery of skull base malignant neoplasm is associated with lower frequency of postoperative complications (in our study, twice) and best patients’ state (according to Karnofsky scale).

Orbital Preservation in Patients with Esthesioneuroblastoma

Objectives Surgical resection in addition to adjuvant radiation with or without chemotherapy is the mainstay of treatment for esthesioneuroblastoma (ENB). However, management of patients with orbital involvement remains controversial. Historically, orbital exenteration has been advocated when there is evidence of periorbital invasion. Recently, the indications for orbital exenteration have become more selective and orbital preservation has been advocated. We report our experience with anterior craniofacial resection and orbital preservation in patients with ENB. Design Retrospective review of all patients diagnosed with esthesioneuroblastoma who underwent traditional open anterior craniofacial resection at the Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center from 1997 to 2008. Results Sixteen patients were identified with a mean follow-up of 76 months. All patients underwent anterior craniofacial resection via an open approach and adjuvant proton beam radiation. Six of the 16 patients had evidence of either periorbital or lacrimal sac involvement at the time of surgery. All of these patients underwent periorbital resection to negative histologic margins with preservation of the orbit. Conclusion In our study, patients with ENB and periorbital invasion-who were treated with anterior craniofacial resection and periorbital resection with orbital preservation-had no evidence of decreased survival. In all patients, negative histologic margins of the periorbital resection were achieved.

Anterior Skull Base Oncocytoma

Oncocytic neoplasms are tumors composed of oncocytes (ie, epithelial cells with a large cytoplasm that is rich in mitochondria). Most cases are benign and originate from the salivary glands. Although there have been a few reported cases of oncocytomas being found in the sinonasal tract, most if not all cases seem not to involve the anterior skull base. We report a rare case of oncocytoma involving the anterior skull base occurring in a 44-year-old male patient. Preoperative carotid angiography and selective embolization was performed. The patient underwent an expanded endoscopic endonasal anterior craniofacial resection, which allowed complete resection of the tumor, with a low morbidity. The pathological diagnosis was oncocytoma. At 36 months after the initial treatment, the patient is free of disease. Based on our literature search, this may be the first such reported case. A brief review of the available literature examining the known body of knowledge regarding these neoplasms is presented.

Sinonasal Adenocarcinoma: A Single Surgeon's Experience

Background: Malignant sinonasal neoplasms are rare, and most tumors are diagnosed at an advanced stage. Treatment is primarily surgical, whether through an anterior craniofacial resection or a minimally invasive endoscopic approach. Given the rarity of sinonasal adenocarcinoma, there are no established management guidelines. The aim of this study was to review a surgeon's experience with sinonasal adenocarcinoma.

Combined endoscopic and open approach to resection of the anterior skull base

Although en-bloc resection is the traditional teaching in oncological surgery, with recent technologic advancements and literature to support both safety and efficacy, there has been a growing acceptance of alternative techniques for the surgical management of paranasal sinus and anterior skull base malignancies. The endoscopic-assisted external approach affords many of the benefits of endoscopic resection while allowing for the management of lesions with marked intracranial extension that would otherwise require anterior craniofacial resection. Here we describe our endoscopic technique for resection of the anterior skull base and its role when combined with anterior craniotomy.

Prevertebral Corridor

Regional vascularized flaps, such as the pericranial and temporoparietal fascia flaps, are currently used for reconstruction of skull base defects after endoscopic endonasal surgery whenever local vascularized flaps, such as the nasoseptal flap, are not available. Two different transposition pathways, infratemporal transpterygoid and subfrontal, have been proposed for regional flaps. The objective of this study was to describe and assess the feasibility of the transposition of a vascularized pedicled flap from the occipital galeopericranium via the prevertebral space corridor into the nasopharynx. Ten heads were injected with colored silicone. An endoscopic endonasal anterior craniofacial resection and panclival approach were performed in each specimen. The occipital flap was harvested using a previously described technique. The prevertebral corridor, extending from the neck to the nasopharynx, was dissected superficial to the paraspinal muscles. Computed tomography-based image guidance was used to assess the relationship between the corridor and adjacent neurovascular structures. Length of the corridor and pedicle and area of the donor flap were measured. The flap was harvested and successfully transposed into the nasopharynx using the proposed corridor in all studied specimens (10 heads, 20 sides). All flaps provided complete coverage of the skull base defects. The average length of the pedicle was 70.5 (SD, 6.5) mm, and the average length and width of the flap were 99.9 (SD, 14.6) mm and 59.3 (SD, 10.9) mm, respectively. The average length of the prevertebral corridor was 49.7 (SD, 4.8) mm. The occipital flap has favorable anatomic characteristics for use in skull base reconstruction. Transposition of the flap via the prevertebral corridor is a suitable option for vascularized reconstruction of expanded endonasal skull base defects when other local or regional flaps are not available. Additional clinical studies are necessary to define its role in endoscopic endonasal surgery.

Anterior craniofacial resection for malignant paranasal tumors: A monoinstitutional experience of 366 cases

The purpose of this study was to evaluate the results of a mono-institutional series of patients treated with anterior craniofacial resection for malignant paranasal sinus tumors. We analyzed all patients with malignant paranasal sinus tumors treated with anterior craniofacial resection at our institution between 1987 and 2007. All tumors were classified according to both the American Joint Committee on Cancer (AJCC)-2002 and the Istituto Nazionale Tumori (INT) classifications. The sample included 366 patients. There was intraorbital spread in 108 cases. The skull base was eroded in 127 patients, with dura or brain involvement in 93 patients. The 10-year disease-specific survival was 53.1%. Histologic subtype, INT stage, surgical margins, and postsurgical radiotherapy were significant, independent predictors for both local relapse and disease-specific survival (DSS). The AJCC-2002 classification was not significant when tested in place of INT stage. Our data indicated that craniofacial resection and postsurgical radiotherapy remain the primary option for malignant tumors involving the anterior skull base.