Infratemporal Fossa Extension Research Articles

301P - Oncological outcome following 3 Drug NACT for Bucco-Alveolar carcinoma with Supra-notch ITF extension

BackgroundBucco-alveolar carcinoma is a clinical entity prevalent in Asia. These cancers have early involvement of Infra-temporal fossa (ITF) and subsequent poor oncological outcomes. Locally advanced Bucco-alveolar complex carcinoma (T4b) with supra-notch (supra-sigmoid) ITF extension is oncological challenge with poor outcome. We analysed oncological outcome in patients managed with 3-drug Neo-adjuvant chemotherapy (NACT) followed with surgical compartmental resection and adjuvant chemoradiation. Methods33 cases of T4b Bucco-alveolar complex carcinoma with supra-notch ITF extension included from June 2009 to January 2017. Patients received 3-Drug NACT (3-day regimen: IV Cisplatin 75 mg/m2 or IV Carboplatin 70 mg/m2 + IV Docetaxel 75 mg/m2 + IV 5-FU 1000 mg/m2) for 2-3 cycles every 21 days. Response assessed with clinical examination, improvement in symptoms (improved mouth opening etc.) and Response Evaluation Criteria In Solid Tumors (RECIST) criterion. Patients showing good response on NACT underwent Compartmental surgical resection with complete ITF clearance followed by adjuvant chemoradiotherapy (5-6 cycles weekly Inj. Cisplatin with 60Gy/30# RT). Data analyzed using STATA 13 and Kaplan Meir graphs for survival rates. Results31 patients (93.9%) showed response on NACT and underwent Surgery, with 2 patients showing disease progression after 1st cycle of NACT were treated non-surgically with palliative intent. Clinical response according to RECIST criterion & subjective clinical improvement > 50% was noted in 18 cases while < 50% in 13 cases. 22 of 31 patients were disease free with 7 loco-regional recurrences. There were no recurrences in ITF. Overall survival and disease-free survival rate was 81.8% and 70.9% respectively at mean follow-up of 30 months. Conclusions3-drug NACT followed by surgical resection in cases showing response to NACT with adjuvant chemoradiation provides a realm of hope for these borderline resectable T4b supra-notch cases. NACT provides an opportunity to attain better microscopically negative resection margins and helps in proper bio-selection of cancers according to their radio-chemosensitivity and response leading to better oncological outcomes. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Osteossarcoma crâniofacial: um enfoque imagenológico

Objetivo: relatar um caso de osteossarcoma craniofacial e revisar a literatura sobre os achados de imagem. Relato de Caso: as informações foram obtidas por revisão de prontuário. A paciente do sexo feminino, 25 anos, com parestesia e dor em hemiface direita. Os exames de imagem evidenciaram extenso tumor comprometendo seio maxilar, palato, arcada dentária e cavidade nasal e extensão à fossa infratemporal. Discussão: a maioria dos osteossarcomas craniofaciais são lesões líticas com sinais de agressividade em radiografias. A tomografia é excelente para detectar lesões ósseas e calcificações. A ressonância magnética (RM) mostrou baixo sinal nas ponderações em T1 e alto sinal em T2, com realce heterogêneo pelo meio de contraste. A tomografia computadorizada (TC) é excelente para detectar calcificações e lesões ósseas. A ressonância magnética (RM) é excelente para caracterizar a extensão da lesão. Conclusão: os achados imaginológicos trazem importantes informações para avaliação pré-operatória e monitoramento de recidivas.

Adipofascial anterolateral thigh flaps for reconstruction of maxillary defects with infratemporal fossa extension

Adipofascial anterolateral thigh flaps for reconstruction of maxillary defects with infratemporal fossa extension

Allergic Fungal Sinusitis Infratemporal Fossa Involvement: Saudi Experience

Objectives: Allergic fungal rhinosinusitis (AFRS) is well known to expand and to extend to the surrounding structures like the orbit and the brain; however, it has not been reported to extend to the infratemporal fossa (ITF). Because of the difficulty of accessing the ITF, we report our experience over 5 years. Methods: One hundred one patients with AFRS were operated upon by the author between 2008 and 2013. Results: All of these patients had preoperative computed tomography scans (CTs), and all but 2 had postoperative CT of the paranasal sinus. Twelve had expansion or extension of the disease into the ITF: 8 males and 4 females, their ages ranged from 10 to 34 years with mean of 20.4 years. Four of them were children below 15 years of age. Three patients had bilateral disease and 9 had unilateral sinus involvement. Seven cases had expansion of the posterior wall of the maxillary sinus into the ITF, which was unilateral and mil; however, extension from the sphenoid sinus was more extensive in most of the cases; bilateral in 2 and unilateral in the others. Conclusions: ITF extension from the sphenoid sinus is more extensive than from the maxillary sinus. In a pediatric population, because of the incomplete fusion of the suture line, the disease expanded and eroded into the ITF. In adults, the opticocarotid recess is the weakest area and the disease can expand through it into the ITF. Posterior wall of maxillary sinus expansion into the ITF is mild in all cases, and all the ITF extensions were cured endoscopically.

Versatility of adipofascial anterolateral thigh flap for reconstruction of maxillary defects with infratemporal fossa extension.

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm(2) (range, 120-180 cm(2)). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.

Surgery for juvenile nasopharyngeal angiofibroma with lateral extension to the infratemporal fossa

The study aimed to assess the usefulness of skull base surgery for large juvenile nasopharyngeal angiofibroma (JNA) with lateral extension to the infratemporal fossa. Eleven cases were enrolled for this study, and the mean age was 17.7 years old (range: 8-32). Six out of 11 cases underwent surgery as an initial treatment, and the other five underwent secondary surgery after initial surgery or radiotherapy in other institutions. The range of extension of tumor, feeding arteries, surgical approach, and treatment outcome were estimated. All tumors originated from the sphenopalatine foramen. Based on the imaging study, there was extension to the cavernous sinus observed in eight cases, as well as to the middle cranial fossa (8), orbit (4), and anterior cranial fossa (1). These tumors were diagnosed as Andrews' Stage IVa (3) and IVb (8). However, infiltration into the cavernous sinus was observed in one case only during surgery. Ten tumors were separated carefully from the cavernous sinus or dura and were accurately diagnosed as Stage IIIb. In all cases, the main arterial feeders of the JNAs were branches of the external carotid artery, which were embolized prior to surgery. However, 10 cases were also fed by branches of the internal carotid artery (branches of the ophthalmic artery), in which these arteries could not be embolized. Coronal skin incision (1) and a facial dismasking flap (9) were used, and in one case, wide lateral skin incision with temporary incision of the facial nerve was applied. The orbito-zygomatic approach and its modification was applied to all the cases. Fronto-lateral craniotomy was applied in four cases and lateral craniotomy in seven cases. Total resection was achieved in 10 cases and subtotal resection in one case. No mortality was noted in this series. Temporal trismus was observed in all cases which subsided gradually. Cheek numbness and facial palsy were observed in three and two cases, respectively. Coupled with craniotomy, tumor removal was successfully carried out in 11 patients with JNAs, which showed large lateral extension. Our surgical strategy is a safe and effective approach for the removal of JNAs with infratemporal fossa extension.

Endoscopic assisted sublabial and buccolabial incision approach for juvenile nasopharyngeal angiofibroma with extensive infratemporal fossa extension

ObjectiveThe aim of this study is to evaluate endoscopic assisted sublabial and buccolabial incision approach as treatment option for Juvenile nasopharyngeal angiofibroma (JNA) with extensive infratemporal fossa (ITF) extension. MethodsSeven patients diagnosed as JNA with extensive ITF extension and underwent surgery at our department between 2006 and 2010 were retrospectively reviewed. All patients underwent diagnostic arteriography followed by embolization preoperatively and intratumor injection with N-butyl cyanoacrylate (NBCA). Endoscopic assisted sublabial and buccolabial incision approach was used to remove the tumors. ResultsComplete resections of the tumors were achieved in all patients. Mean blood loss was 700ml. The follow-up period ranged from 9 to 20 months, with a mean of 14.3 months. One patient had a recurrent tumor six months after operation. ConclusionsEndoscopic assisted sublabial and buccolabial incision is an optional approach to remove JNA with extensive ITF extension.

Pictorial essay: Orbital tuberculosis

Tuberculosis of the orbit is rare, even in places where tuberculosis is endemic. The disease may involve soft tissue, the lacrimal gland, or the periosteum or bones of the orbital wall. Intracranial extension, in the form of extradural abscess, and infratemporal fossa extension has been described. This pictorial essay illustrates the imaging findings of nine histopathologically confirmed cases of orbital tuberculosis. All these patients responded to antituberculous treatment.

Evaluation of extensions of sinonasal mass lesions by computerized tomography scan

Cross-sectional imaging has had a significant impact on the management of the sinonasal malignancy. Staging of these lesions has been closely monitored by dependence on computerized tomography (CT) scan and now in small proportion with MRI. The objective of the study was to evaluate the reliability of CT scan in assessing the extensions of the sinonasal mass lesions and their impact on tumor staging. All cases of sinonasal lesions were reviewed retrospectively from June 2001 to May 2006 (five years) at KMIO, Bangalore. Only those cases that had CT scan reports and Histopatholgy Examination (HPE) reports were included in the study. All the cases, which were subjected to radiotherapy prior to surgery, were excluded from the study. There were a total of 38 cases with slight male preponderance. Tumor staging was done according to the sixth edition of TNM classification of malignant tumors. Two observers evaluated all the cases (Blinded Study) and sensitivity, specificity, positive predictive value, negative predictive value and predictive accuracy were estimated. The relation between the CT scan findings and HPE reports was high. Though false positivity was noted more in the ethmoid sinuses, significant impact on tumor staging was noted with false positivity of the nasopharynx. Also, false positivity was noted with orbital wall/content extensions, resulting in unnecessary exenterations of the orbit. However, CT scan reliably predicted infratemporal fossa extension in the absence of trismus. False negativity was noted more often in soft palate, indicating the need of using MRI for delineation of tumor extension. Thus, we conclude that judicious use of CT scan in all cases and MRI in selected cases will translate into better tumor-free resections and improves survival.

Nasomaxillary Swing - A Novel Approach for Bilateral Angiofibroma

Abstract Juvenile nasopharyngeal angiofibroma (JNA) is a high-risk tumor of adolescent males. Choice of the approach should be based on the stage and site of the lesion. For complete removal of tumor, surgical exposure must be adequate. We here present a case of nasopharyngeal angiofibroma with intracranial and bilateral infratemporal fossa extension in which tumor was completely excised by nasomaxillary swing approach.

Endoscopic Approach to the Infratemporal Fossa for Treatment of Invasive Fungal Sinusitis

Invasive fungal sinusitis is a progressive disease that can often extend beyond the nasal cavities and paranasal sinuses into surrounding soft tissue and bone. Aggressive antifungal therapy and surgical debridement are the mainstays of management. The pterygopalatine fossa and infratemporal fossa are two regions that are commonly involved in patients with invasive fungal sinusitis. When fungal disease extends to the infratemporal fossa, surgical debridement can be challenging. Traditionally, open approaches have been used for the management of disease in these areas. Advances in endoscopic skull base surgery may allow for less invasive approaches for the management of disease in the infratemporal fossa. This article describes a transnasal endoscopic approach to the infratemporal fossa for debridement of invasive fungal sinusitis. Patients with invasive fungal sinusitis extending into the infratemporal fossa were treated with endoscopic debridement. Records of these patients were reviewed. Endoscopic debridement was performed in four patients with infratemporal fossa extension of invasive fungal sinusitis. Responsible organisms included Aspergillus, Mucor, and Candida. Adequate access and excellent visualization of the infratemporal fossa were obtained in all patients. The endoscopic anatomy and surgical technique are presented. Endoscopic approaches have been used to manage a variety of disease processes that extend beyond the confines of the paranasal sinuses. Invasive fungal sinusitis disease with extension into the infratemporal fossa can be safely debrided via a transnasal endoscopic technique. The approach provides excellent visualization with low morbidity.

Endoscopic assisted antral window approach for type III nasopharyngeal angiofibroma with infratemporal fossa extension

To assess the efficacy and safety of endoscopic assisted antral window approach in advanced nasopharyngeal angiofibroma with infratemporal fossa extension. Sixteen cases diagnosed as juvenile nasopharyngeal angiofibroma type III with infratemporal fossa extension were surgically managed using endoscopic assisted antral window approach (group A) and compared with another group of similar number that were managed using endoscopic assisted midfacial degloving (group B). Inclusion criteria were type III JNA with infratemporal fossa extension and a minimum follow-up of 2 years. Operative time, blood loss, adverse events and recurrences were recorded in all cases. The amount of blood lost in group A was significantly less than group B. The operative time of group A was significantly less than group B. No major complications were seen in both groups. Twenty-eight patients showed complete tumor clearance. Four recurrences were seen: two in group A and two in group B. Endoscopic assisted antral window approach provides a safe, reliable, effective and minimally invasive technique in management of type III JNA with infratemporal fossa extension. Preoperative embolization is a safe measure in the experienced hands that helps to reduce intraoperative blood loss and improves the quality of the surgical field.

Combination antifungal therapy for invasive aspergillosis: can it replace high-risk surgery at the skull base?

Objective The increasing volume of literature on Aspergillus sinus infection is confusing because different authors stress different aspects of the disease. It is generally accepted that standard therapy consists of surgical debridement and medication with systemic amphotericin B. Patients who fail the standard therapy or those who cannot tolerate amphotericin B pose a dilemma. This study attempted to address the issues concerning combination therapy in invasive aspergillosis. Materials and methods We conducted a prospective randomized study on 6 apparently immunocompetent patients with invasive aspergillosis complicated by orbital and intracranial spread. All the patients were treated with a combination of amphotericin B (2.5 g) and itraconazole (6 months). They were monitored clinically and radiologically before, during, and after their combined antifungal therapy management. Results Among the 6 immunocompetent patients, orbital involvement was seen in 5, skull base erosion with intracranial extension was seen in 2, and infratemporal fossa extension was seen in 2. After completion of treatment with 1.5 g of amphotericin, the paranasal sinus part of the lesion disappeared. However, there was residual lesion in the intracranial part that completely disappeared only after treatment with 2.5 g of amphotericin and 6 months of itraconazole therapy. Conclusions Invasive aspergillosis has been increasingly reported among immunocompetent patients. No single surgical or medical maneuver, including orbital exenteration, guarantees cure. The combination of amphotericin B and itraconazole for skull base aspergillosis represents a real step forward in the treatment of invasive aspergillosis.

Gliosarcoma with infratemporal fossa extension

Gliosarcomas are bimorphic intraaxial tumors. Involvement of the skull base is highly unexpected. The authors present the case of a temporal lobe gliosarcoma with significant infratemporal fossa extension. This 55-year-old man presented with a 1-month history of severe progressive headache. Neurological examination was unremarkable except for bilateral papilledema. Magnetic resonance imaging revealed a 6-cm right temporal mass with extension into the infratemporal fossa. The patient underwent a right frontotemporal craniotomy together with drilling of the sphenoid ridge and middle fossa floor. The tumor consisted of intraaxial, intracranial as well as extradural, and extracranial components with extension to the posterolateral wall of the sphenoid sinus. It had a relatively well-circumscribed dissection plane. Gross-total resection was achieved, and the middle fossa floor was reconstructed using a rotated temporalis muscle flap. The postoperative course was uneventful except for hypesthesia in the distribution of the maxillary division of the right trigeminal nerve. The histopathological diagnosis was consistent with gliosarcoma. Radiotherapy and chemotherapy consisting of temozolomide were administered subsequently, and the patient was recurrence free 12 months after his initial diagnosis. In the presence of a mass lesion with both intraaxial and extracranial involvement, gliosarcoma should be considered among the differential diagnoses. Aggressive resection should be attempted, including the use of skull base surgical techniques to ensure an optimal outcome. The effect of skull base involvement to the overall treatment and outcome of patients with gliosarcomas would be difficult to determine given the rare occurrence of these lesions in such locations.

Experience with the resection of parapharyngeal cancers via the infratemporal fossa approach.

Between 1982 and 1984, a modified infratemporal fossa approach was used to resect cancers with extensive primary or secondary involvement of the infratemporal fossa and parapharynx in 10 patients. Nine patients exhibited persistent or recurrent disease of the upper aerodigestive tract and posterior cranial fossa following planned, curative-intent therapy; the remaining patient had a carcinoma ex-pleomorphic adenoma of the deep lobe of the parotid gland with a significant infratemporal fossa extension. Considered to have "unresectable" tumors, by traditional methods, 7 of the 10 patients underwent an en-bloc resection of their lesions with tumor-free margins. Tumor was present at the margins of the specimens in the other 3 patients. Two of the 10 patients died early in the postoperative period of medical complications. Another died 5 months postoperatively of a tumor-induced internal carotid artery rupture at the level of the foramen lacerum. A fourth patient died of his disease 6 months following his resection. One patient is alive, but has metastatic meningioma 2 years after surgery. The 5 remaining patients are without evidence of disease, with a mean follow up of 2 years. Indications for and refinements of the operative technique, particularly those related to the repair of such extensive ablative defects, are outlined on the basis of this early experience.