Combined Craniofacial Approach Research Articles

Resection of Anaplastic Meningioma via Combined Craniofacial Approach

Introduction: Meningiomas are common and mostly benign intracranial tumors but may show a histological progression to malignancy. The mechanism of malignant transformation remains unclear. Malignant meningiomas usually bear a high recurrence rate and unfavorable prognosis; hence, multiple surgical resections are required for the treatmentCase Presentation: A 41-year-old woman with a prior history of craniotomy at another center six years ago with Meningioma Grade 1 presented to our institution with new neurological symptoms. The magnetic resonance image demonstrated a large frontal base mass that extended to the nasal cavity with diffuse contrast enhancement and extensive surrounding edema. A craniofacial approach combined with a bifrontal approach was performed in multistage tumor resection. The tumor and the infiltrated dura were radically removed. The histopathology demonstrated an Anaplastic Meningioma. The patient also underwent radiation therapy.Conclusion: Treatment of recurrent meningioma with anaplastic histology remains challenging because recurrence rates remain high with a poor prognosis.

S1-16 JOURNEY THROUGH REPAIR OF FRONTAL SKULL BASE ENCEPHALOCELES IN AFRICA

Introduction: The authors present the experiences of treating 10 consecutive cases of frontobasal encephaloceles in sub-saharan Africa on a floating hospital ship. To see the sustainability and feasibility of treating complex craniofacial anomolies through teamwork and mentoring of local expertise. Emphasis on telecommunications and telemedicine and radiology in the process is highlighted. Methods: 10 out of 12 encephaloceles presented were fronto-basal; male to female ratio was 7 to 3. All cases were operated by the same team of 3 surgeons - neuro, plastic and max-fac, along with an even more international team of anesthesiologist and OR personnel. Age varied from 3months to 19 yrs. Pre-operative planning was done with the help of CT with contrast and 3D recontruction to help the planning of repair and to see the associated brain anomalies. Results: All cases were operated successfully via a combined craniofacial and direct approach to repair the herniated brain and correct the cosmetic deformity with no mortality. The most common morbidity was CSF leaks ~ 70%, this was managed successfully with conservative methods which will be discussed in the presentation. we did not have established cases of post of meningitis or vranial wound infection. All patient were prophylactically given antibiotics during their hospital stay. Local wound breakdown and revision was required in two cases. Only one patient needed permanent VP shunt. There were no short to medium term neurological sequelae due to the intervention. Conclusion: It is feasible to treat complex frontal encephaloceles via a combined craniofacial approach in countries with very poor access to safe surgical care. The involvement of local expertise which included max-fac and neurosurgeon during the 4 consecutive field services helps to dissociate knowledge and skills. The model of care is one of the alternatives to manage difficult craniofacial anomalies and could be applied to other areas of complex conditions.

Single-Stage Combined Craniofacial Repair for Frontoethmoidal Meningoencephalocele.

Frontoethmoidal meningoencephalocele (FMEC) is a rare congenital anomaly characterized by herniation of brain tissue and meninges through a defect in the cranium and associated with facial dysmorphism. Treatment modalities include extra cranial, transcranial, or combined craniofacial approaches. The combined approach is considered the best treatment choice. Twelve patients with FMEC aging from 6 months to 4 years were treated by single-stage combined craniofacial approach between July 2011 and July 2015. They were followed up for evaluation of outcome and detection of complications. Seven patients (58.3%) were males and 5 patients (41.7%) were females. Eight patients (66.7%) were less than 2 years while 4 patients (33.3%) were between 2 and 4 years. The main presentations were external mass, telecanthus and hypertelorbitism, radiologically, frontobasal bone defect and herniated dural sac with brain tissue were detected in all patients. Excision of the mass with dural repair, craniofacial reconstruction, and medial canthopexy were done for all patients. Orbital translocation was done for 8 patients (75%), nasal reconstruction for 7 patients (58.3%), while dacryocystorhinostomy in 3 patients (25%). Venticuloperitoneal shunt was done before correction of FMEC in one patient (8.3%). The follow-up period ranged from 6 to 48 months with mean 29.2 months. The esthetic results were satisfactory in 9 patients (75%). Ugly facial scars were recorded in 3 patients (25%). Early surgical management for FMEC is advisable to avoid deleterious effects on facial growth. Meticulous perioperative care is important for successful surgery. The authors recommend combined craniofacial approach to achieve good outcome and decrease the incidence of complications.

Extracranial/intracranial vascular bypass and craniofacial resection: New hope for patients with locally advanced recurrent nasopharyngeal carcinoma.

The purpose of this study was to investigate the oncologic outcome and quality of life after surgical treatment of locally advanced (rT3-rT4) recurrent nasopharyngeal carcinoma (NPC) using the staged extracranial/intracranial vascular bypass and combined craniofacial approach. We conducted a prospective study. Between 1998 and 2013, 28 patients with rT3 to rT4 tumors were treated with the proposed surgical protocol. Clear resection margin was achieved in 46.4%. The median follow-up was 42.6 months. The rate of local recurrence was 17.8%. The 5-year overall survival was 52%. There was no change in the mean global health system score after the extensive surgery, although the physical functioning scores deteriorated significantly. The most common symptoms experienced by patients were speech and swallowing problems. The proposed surgical treatment for locally advanced recurrent NPC was associated with satisfactory local tumor control and survival. Quality of life after surgery was reasonable, although multidisciplinary training was required to maximize the postoperative speech and swallowing function. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1404-E1412, 2016.

The pattern of craniofacial encephalocel in Bethel Teaching General Hospital, Addis Ababa, Ethiopia

Craniofacial encephaloceles are commonly seen birth defects. The incidence is 1 in every 100, 000 live births. Six patients with craniofacial encephaloceles are treated by a combined craniofacial approach. The corrective measure allows reduction of the herniated encephalocele and correction of the craniofacial deformity in the same operation procedure. All cases admitted from May 2013 until June 13, 2014 to Bethel Teaching General Hospital were identified, and data were collected retrospectively, including demographics, clinical events, MRI and or CT scan findings, surgical techniques, complications and outcomes were analyzed using SPSS.

Reconstruction of anterior skull base defects using frontalis muscle galea aponeurotica skull pedicle flaps

Objective The aim of our study was to reconstruct soft and hard tissue perforating defects of the anterior skull base in a 1-stage surgical procedure with a combined craniofacial approach.

Recurrence and surgical salvage of sinonasal squamous cell carcinoma

To analyze the significant clinicopathologic factors related to tumor recurrence in patients with sinonasal squamous cell carcinomas (SCC) and to evaluate the effectiveness and plausibility of surgical salvage in the recurrent cases. The clinicopatholgic data of 107 patients with primary sinonasal SCC treated from 1996 to 2007 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were used to define the risk factors related to tumor recurrence. Salvage surgery with was selectively carried out in the recurrent sinonasal SCC using different surgical approaches, including lateral rhinotomy midfacial degloving or combined craniofacial approach. Immediate reconstruction of major surgical defects were performed with latissimus dorsi flap, pectoralis major myocutanneous flap, temperalis fasciomuscular flap, free rectus abdominis flap and free radial forearm flap. All patients were routinely follwed up and 5-year survival were calculated using directly calculating method and Kaplan-Meier's method. The 5-year survival rate of 107 cases was 52.3% (56/107). Local recurrence was the most common pattern of tumor relapse. Forty-four of the 107 cases had recurrence. Logistic regression analysis showed the T stag was the most important impacting factor for tumor recurrence (OR = 0.258, P = 0.001). Of 44 cases with recurrence, 33 cases underwent salvage surgery and the 5-year survival rate after salvage surgery was 29.1%. T stag is the most important impacting factor for tumor recurrence. Salvage surgery with immediate reconstruction of major surgical defects should be carried out in the selective cases of recurrent sinonasal SCC.

Combined craniofacial approach for the removal of a large trigeminal schwannoma invading the infratemporal fossa

Trigeminal schwannomas are rare tumours accounting for 0.07-0.36% of all intracranial tumours and 0.8-8% of intracranial schwannomas. Symptoms and signs of these lesions depend on the site of the tumour, which may compress the nerve of origin or adjacent nerves. We describe a case of a 69-year-old woman with a history of progressively worsening hypoesthesia involving the third division of the trigeminal nerve. A tumour of 5-cm diameter was revealed within the right cranial middle fossa, extending to the lateral wall of the cavernous sinus, the infratemporal fossa and the posterior wall of the maxillary sinus. A combined craniofacial approach was undertaken. A right extended subtemporal craniotomy was performed. The intracranial component of the tumour, originating from the third division of the trigeminal nerve and compressing the cavernous sinus, was removed in total. We proceeded with a Weber-Ferguson approach through which the extracranial component of the tumour was also totally resected. The postoperative computed tomography of the head has shown complete tumour removal. The histopathologic examination revealed a cellular neurinoma. Postoperatively, the patient expressed a transitory palsy of the oculomotor nerve, which resolved within a few weeks. The patient remains free of recurrence with mild hypoesthesia of the third trigeminal branch 5 years after treatment. Surgery of trigeminal schwannomas may be a very challenging task. Various surgical approaches for trigeminal schwannomas excision have been described. With this combined approach, the tumour was freed from the surrounding tissues and was easily and totally removed.

Endoscopic Endonasal Transethmoidal Transcribriform Transfovea Ethmoidalis Approach to the Anterior Cranial Fossa and Skull Base

The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach. An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis. Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors. The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

Lesiones no malignas que implican a senos paranasales y fosa craneal anterior

Background and objectivesThe lesions that involve the paranasal sinuses and the anterior cranial base at the same time are not unusual. These diseases have different features. The aim of this study is to set out the particularities of the non-malignant lesions involving both zones. Material and methodsRetrospective study of 32 patients between 1986 and 2007 diagnosed with: non-malignant tumours (31.2 %), tumorlike lesions (3.1 %), fibrous-osseous lesions (12.5 %), congenital or acquired malformations (18.7 %) and infection disease (34.3 %). We analyse the diagnostic imaging, the treatment and pathogen mechanism. ResultsOnly 6 of 43 osteomas involved the paranasal sinuses and anterior cranial fossa (13.04 %): 3 cases have developed meningitis and 1 developed a pneumocephalus. 2 cases are meningiomas: 1 was asymptomatic and the other one caused destruction at subtotal frontal bone. 1 giant hemangioma associated with Klippel-Trenaunay syndrome is treated by combined craniofacial approach. The fibrous-osseous lesions were specifically fibrous dysplasia and affected the ethmoides. The encephalocele were predominating in the malformations group, 2 were diagnosed after repeated meningitis. 11 cases are included by infection: 10 cases caused osteomielitis and the eleventh is a patient with a mucormycosis. Surgery has been used in 84.3 % of the cases: frontal craniotomy 37 %, combined craniofacial approach 18.5 %, subfrontal approach 18.5 %, osteoplastic technique 18.5 %, lateronasal approach 3.7 %, endonasal microscopic resection 3.7 %. ConclusionsIn this study the diagnosis, extension and surgical management were supported in the imaging. A closed separation between the anterior cranial fossa ant the sinus is necessary after the resection. The reconstruction was performed using a pedicled pericranial flap and titanium mesh in most of the cases.

Non-malignant lesions involving the paranasal sinuses and anterior skull base

Background and objectivesLesions involving the paranasal sinuses and the anterior cranial base at the same time are not unusual. These diseases have different features. The aim of this study is to set out the particularities of the non-malignant lesions involving both zones. Material and methodsRetrospective study of 32 patients between 1986 and 2007 diagnosed with: non-malignant tumours (31.2%), tumour-like lesions (3.1%), fibrous-osseous lesions (12.5%), congenital or acquired malformations (18.7%), and infectious diseases (34.3%). We analyse the diagnostic imaging, the treatment, and the pathogen mechanism. ResultsOnly 6 of 43 osteomas involved the paranasal sinuses and anterior cranial fossa (13.04%): 3 cases have developed meningitis and 1 developed a pneumocephalus. Two cases are meningiomas: 1 was asymptomatic and the other one caused destruction of the subtotal frontal bone. A giant haemangioma associated with Klippel-Trenaunay syndrome is treated by combined craniofacial approach. The fibrous-osseous lesions were specifically fibrous dysplasia and affected the ethmoides. The encephalocele were predominating in the malformations group, 2 were diagnosed after repeated meningitis. Eleven cases are inclluded by infection: 10 cases caused osteomyelitis and the eleventh is a patient with a mucormycosis. Surgery has been used in 84.3% of the cases: frontal craniotomy 37%, combined craniofacial approach 18.5%, sub-frontal approach 18.5%, osteoplastic technique 18.5%, lateronasal approach 3.7%, endonasal microscopic resection 3.7%. ConclusionsIn this study the diagnosis, extension, and surgical management were supported in the imaging. A closed separation between the anterior cranial fossa and the sinus is necessary after the resection. The reconstruction was performed using a pedicled pericranial flap and titanium mesh in most of the cases.

Zones of Approach for Craniofacial Resection: Minimizing Facial Incisions for Resection of Anterior Cranial Base and Paranasal Sinus Tumors

Anterior cranial base tumors are surgically resected with combined craniofacial approaches that frequently involve disfiguring facial incisions and facial osteotomies. The authors outline three operative zones of the anterior cranial base and paranasal sinuses in which tumors can be resected with three standard surgical approaches that minimize transfacial incisions and extensive facial osteotomies. The zones were defined by performing dissections on 10 cadaveric heads and by evaluating radiographic images of patients with anterior cranial base tumors. The three approaches performed on each cadaver were transbasal, transmaxillary, and extended transsphenoidal. Three zones of approach were defined for accessing tumors of the anterior cranial base, nasal cavity, and paranasal sinuses. Zone 1 is exposed by the transbasal approach, which is limited anteriorly by the supraorbital rim, posteriorly by the optic chiasm and clivus, inferiorly by the palate, and laterally by the medial orbital walls. This approach allows access to the entire anterior cranial base, nasal cavity, and the majority of maxillary sinuses. The limitation imposed by the orbits results in a blind spot in the superolateral extent of the maxillary sinus. Zone 2 is exposed by a sublabial maxillotomy approach and accesses the entire maxillary sinus, including the superolateral blind spot and the ipsilateral anterior cavernous sinus. However, access to the anterior cranial base is limited. Zone 3 is exposed by the transsphenoidal approach. This approach accesses the midline structures but is limited by the lateral nasal walls and intracavernous carotid arteries. An extended transsphenoidal approach allows further exposure to the anterior cranial base, clivus, or cavernous sinuses. The use of the endoscope facilitates tumor resection in the nasal cavity and paranasal sinuses. The operative zones outlined offer minimally invasive craniofacial approaches to accessing lesions of the anterior cranial base and paranasal sinuses, obviating facial incisions and facial osteotomies. Case illustrations demonstrating the approach selection paradigm are presented.

Craniofacial resection of advanced juvenile nasopharyngeal angiofibroma.

To describe the results of a craniofacial approach to resection of stage IIIB juvenile nasopharyngeal angiofibroma, performed by an integrated skull base surgical team. A retrospective case-series review was conducted with postoperative follow-up ranging from 28 to 63 months. Operations were performed at a tertiary medical center. A referred sample of 5 male patients, ranging in age from 10 to 23 years (mean, 15 years). All patients underwent resection of nasopharyngeal angiofibromas with intracranial extension. The procedure involved an infratemporal fossa approach via zygomatic osteotomy and subtemporal craniectomy. Anterior exposure was gained through a standard facial translocation. Dissection of the cavernous carotid artery was required in 3 patients. Intraoperative and postoperative morbidity. The average operating time was 12 hours 47 minutes. Estimated blood loss ranged from 700 to 1750 mL (mean, 1120 mL), with 2 patients requiring intraoperative transfusion. Patients were hospitalized for a mean duration of 5.6 days. Long-term morbidity includes facial dysesthesia, nasal crusting, and malodorous nasal discharge. No patients sustained stroke, oculomotor dysfunction, vision loss, or auditory impairment. At most recent follow-up, which ranges from 28 to 63 months, tumor recurrence has been confirmed in 1 patient. A combined craniofacial approach is appropriate for juvenile nasopharyngeal angiofibroma that extends intracranially. Complete tumor removal with acceptable morbidity can be expected.

前頭蓋底に浸潤したし骨洞腺へん平上皮癌例

Adenosquamous carcinoma of the nasal cavity and paranasal sinuses is very rare. We report a 56-year-old man with adenosquamous carcinoma of the left ethmoid sinus extending to the anterior skull base. Chief complaints of the patient were left nasal obstruction and left epistaxis. CT scan and MRI revealed a tumor shadow in the left ethmoid sinus extending to the nasal cavity, the left maxillary sinus, and the anterior skull base. Concomitant chemoradiotherapy (CBDCA+radiation) was performed preoperatively. Using a combined craniof acial approach, the tumor was completely removed, including the anterior skull base. There has been no evidence of recurrence for two years and six months since the operation.

Osteoma of the Frontoethmoidal Sinuses

Frontoethmoidal involvement by benign tumors may lead to aesthetic and functional sequelae. The key for removal of such lesions is a proper planned craniofacial approach based on the preoperative evaluation. If total extirpation requires resection of part of the forehead or orbit, immediate reconstruction is mandatory. In recent years, craniofacial techniques and strategies have become popular. Among these are the use of split cranial bone, rotation of skull bones, the use of galeal-pericranial flaps, and the introduction of internal rigid fixation. We present a case of frontoethmoidal osteoma treated with a combined craniofacial approach. For the reconstruction, modern principles of craniofacial surgery have been applied.

Cephaloceles: classification, pathology, and management.

A cephalocele is defined as a herniation of cranial contents through a defect in the skull. Cephaloceles are classified according to their contents and location. We have reviewed a total of 112 patients with cephaloceles, 51 of whom had sincipital meningoencephaloceles (fronto-ethmoidal meningoencephaloceles). This group is distinctive in its demographic distribution, in the effect on growth of other facial structures, and in the combined craniofacial approach needed to treat them. This review is based on the sincipital encephaloceles with the other cephaloceles included for completeness. Despite many theories, the cause of congenital cephalocele is not known. Preoperative work-up includes 3-dimensional computed tomography scan of the facial skeleton, and surgical management is multidisciplinary in nature. The aim is to remove the lesion before the deformity has time to greatly distort facial growth, which appears to realign itself after surgery. The 50 patients who underwent surgery for fronto-ethmoidal encephalocele all survived with minimal complications.

Reconstruction of the Anterior Skull Base by Galeo-Periosteal Flap with calvarial Bone

The patient was a 23-year-old female with adenocarcinoma of nasal cavity. Previously she had resection of tumor by transal approach. But she visited our hospital because of recurrence of tumor. From findings of CT, MRI, and X-P examination performed prior to the reoperation of this time, it was confirmed that the tumor invaded the anterior skull base. The tumor was removed by combined craniofacial approach, and a defect of 3×1.5cm in size was formed in the anterior skull base. An axial galeo-p eriosteal flap, which was based on the superficial temporalartery, was applied for reconstruction of skull base. Moreover a part of the outer-table of calvarial bone attached with the flap was used for bone reconstruction of skull base. After that, from the nasal side, split-thickness skin graft was sutured to the inferior surface. Postoperative results was successul and she was discharged without complication after 6 weeks.It is considered that this surgical technigue i suseful for reconstruction of defecet in the anterior skull base.

Craniofacial Resection for Malignant Tumors of Ethmoid and Anterior Skull Base

A combined craniofacial approach is described for resection of tumors that involve the ethmoid sinuses and adjacent base of the skull in the frontal fossa. This operation provides a more thorough en bloc excision than by conventional methods with reasonable safety since both the neurosurgeon and the head and neck surgeon are guided by each other during the mobilization of the specimen, and adequate repair of dural defects can be accomplished. Reconstruction of the bony defect in the skull base is performed with a pedicled periosteal flap from the scalp and a skin graft.

Total Removal of Angiofibroma

<i>To the Editor</i>.—I recently read an article entitled "Intracranial and Extracranial Nasopharyngeal Angiofibroma" by Gill et al.¹The authors may be interested in knowing that total removal of angiofibroma with intracranial extension was first successfully done and described by Lt Col E. A. Krekorian, MC, USA (ear, nose, and throat), and Col L. G. Kempe (neurosurgery) using a combined craniofacial approach in 1969.²Since publication of the first article, Lt Col Krekorian has added two cases with similar findings. This added material was presented at the Midwestern Section of the Triologic at Minneapolis, Minn, in January 1976 and has been accepted for publication in the<i>Laryngoscope</i>. 1. Gill G, Rice DH, Ritter FN, et al: Intracranial and extracranial nasopharyngeal angiofibroma: A surgical approach.<i>Arch Otolaryngol</i>102:371-373, 1976. 2. Krekorian EA, Kempe LG: The combined otolaryngology-neurosurgery approach to extensive benign tumors.<i>Laryngoscope</i>79:2086-2103, 1969.

Combined craniofacial resection for malignant disease

A combined craniofacial approach has been employed in nineteen patients with tumors involving the base of the skull. Monoblock resection of the temporal bone, anterior fossa, or anterior and middle fossa can be achieved with acceptable mortality, even in cases of advanced cancer that recurs after radiation. Immediate reconstruction with a full thickness flap was routinely employed to provide improved cosmesis and to minimize the risk of intracranial infection.