Preauricular Approach Research Articles

Skull Base Approach to Carotid Artery Lesions: Technique, Indications, and Outcomes

Operative approaches to lesions of the carotid artery at the skull base are challenging and place multiple cranial nerves at risk. Herein, we describe a preauricular approach utilizing anterior dislocation of the temporomandibular joint with microscopic drill-out of the medial glenoid and Eustachian tube to identify and skeletonize the carotid artery in the foramen lacerum. The facial nerve remains undissected during this approach. Nine of 10 patients presented with aneurysm, six spontaneous and three following blunt trauma, and one patient presented with carotid artery rupture after penetrating trauma. Three of the patients presented with cranial nerve (CN) deficits that persisted. One patient was unevaluable preoperatively due to trauma but awoke with multiple CN deficits. Only one of nine evaluable patients suffered a new long-term CN deficit (XI). One patient had persistent temporomandibular joint dysfunction. All patients had long-term patency of the graft or anastamosis and no new neurologic symptoms were reported with a mean follow-up of 55 months. Open approaches to the carotid artery at the skull base are feasible and with careful anatomic dissection can be performed with minimal morbidity in most cases. We present full details and images of the operative approach.

Analysis of two different surgical approaches for fractures of the mandibular condyle

Fractures of the condyle account for one third of all the mandibular fractures. Different surgical approaches to the condyle described hitherto testify to the advantages and disadvantages of the different surgical techniques used for approaching the condyle in such cases of fractures. We have described and compared two of such surgical techniques in this study. The aim of this study is to compare the outcome of dealing with condylar fractures by two different surgical techniques: the mini retromandibular approach, and the preauricular approach. A prospective study of 31 patients who had suffered with mandibular condylar fractures was carried out. Of these, 26 patients had unilateral condylar fractures, and 5 patients had a bilateral fracture. Further, 19 of these patients were treated by the mini retromandibular approach and 12 by the preauricular approach. The treated patients were followed up and evaluated for a minimum period of 1 year and assessed for parameters such as the maximum mouth opening, lateral movement on the fractured side, mandibular movements such as protrusion, dental occlusion, scar formation, facial nerve weakness, salivary fistula formation and time taken for the completion of the surgical procedure. t- test was used for statistical analysis of the data obtained in the study. Dental occlusion was restored in all the cases, and good anatomical reduction was achieved. The mean operating time was higher 63.53 (mean) ± 18.12 minutes standard deviation (SD) in the preauricular approach compared to 45.22 (mean) ± 18.86 minutes SD in the mini retromandibular approach. Scar formation was satisfactory in almost all the cases.

Trans-tragal incision for improved exposure of diacapitular and condylar neck fractures

The authors present a modification of the preauricular approach that improves the exposure of the condyle whilst reducing diacapitular and condylar neck fractures. The incision is a combination of the hockey-stick and endaural incisions. Its inferior part runs within the ear on the posterior face of the tragus; the tragal cartilage is transected together with the retrotragal skin and included in the anterior skin flap. Between May 2009 and December 2010, 16 patients with diacapitular or condylar neck fractures were treated with this approach. All patients showed good occlusion postoperatively and satisfactory aesthetic results. No infection or cartilage necrosis was observed in this series. This approach improves the exposure of the condylar head during the reduction of diacapitular and condylar neck fractures, ensuring easier internal fixation and good cosmetic results.

The post-auricular approach for gap arthroplasty – A clinical investigation

Objective of this prospective study was to evaluate and compare posterior auricular approach for surgery of temporomandibular joint ankylosis with preauricular approach. These evaluations were done on the basis of certain parameters like incidences of facial nerve injury, time taken to expose ankylotic mass, haemorrhage and quality of exposure of joint and surrounding structures. This study was conducted among 15 patients of temporomandibular joint ankylosis. A total number of 30 joints were operated. These joints were divided in two groups i.e. Group A – preauricular group, Group B – postauricular group. Fifteen joints were operated in each group. Age of patients was in range of 4–65years. All the patients were operated under general anesthesia. Preoperative, intraoperative and postoperative evaluations were done according to parameters. Patients were recalled up to 3months for observations. Results have shown that in postauricular group incidences of facial nerve injury was significantly less, more time was taken to expose the ankylotic mass, incidences of haemorrhage was more and exposure of structures anterior to joint was difficult. Whereas preauricular approach is less time consuming, incidence of facial nerve damage is higher, exposure of structures anterior to joint is good and intraoperative incidences of haemorrhage is less.

Correction of Rabbit Model With Mandibular Ramus Shortening by Distraction Osteogenesis at Condylar Neck

The rabbit model has been established to mimic the effect of temporomandibular joint (TMJ) arthroplasty of ankylosis, and distraction at the level of the condylar neck is used to elongate the ascending ramus. The histomorphologic changes of TMJ and distraction gap were investigated. The unilateral condyles and articular discs were extirpated, and the experimental mandibular rami were shortened by 5 mm. An embedded distracter was used to restore the height of the mandibular ramus by unilateral condylar neck distraction (0.8 mm daily for 7 days). A total of 12 adult white rabbits were used, 8 in the experimental group and 4 in the control group. Of the 8 rabbits in the experimental group, 4 each were killed at 4 and 8 weeks after completion of distraction. The TMJ and distracted calluses were harvested and processed for radiographic and histologic examination. An open bite was seen in all rabbits postoperatively that had diminished at the end of distraction. The newly formed condyles radiologically showed remodeling, flattening, and sclerosis. The bony transport disc had gradually remodeled to a new condyle that was similar to the original condyle in appearance and structure. The surface of the transport disc was covered with a fibrous tissue. Moreover, the bony regeneration was perfect in the distraction gap. These results suggest that distraction osteogenesis at the condylar neck using the traditional preauricular approach of TMJ surgery, without the additional incision, can be performed concurrently with arthroplasty of TMJ ankylosis at the same region.

Surgical Complications of Mandibular Condylar Fractures

The purpose of this study was to retrospectively evaluate the complications of 58 patients who underwent surgery for mandibular condylar process fractures. Data were collected from patients during a 10-year period (1999-2009). The data recorded included demographic data, etiology, diagnosis, type of condylar fracture, surgical approaches, and postoperative complications. A total of 58 underwent surgery for reduction of the condylar fractures. There were 22 patients with bilateral condyle fractures and 36 patients with unilateral condyle fractures, accounting for 65 surgeries. In 8 fractures, a preauricular approach was performed to access the fractures condyle, whereas the retromandibular approach was performed in 57 fractures. There were 2 temporary facial palsies, 1 permanent facial palsy, and 1 sialocele. There were no cases of hypertrophic scar, Frey syndrome, or salivary fistula. In conclusion, permanent deformities after surgical complications were unusual, and the results are acceptably safe.

Resection of cavernous sinus tumor with subtomperal preauricular extradural approach: clinical experience and analysis of 60 cases

Objective To review our experience of microsurgery for 60 cavernous sinus tumors from 2002 to 2009.The clinical features,surgical techniques and outcome of cavernous sinus tumor in 60 cases were investigated retrospectively.Methods The patients included 23 hemangiomas,18 shwannomas,9 dermoid cysts,4 meningiomas,3 chordomas,3 pituitary adenomas.All the tumors were removed with subtomperal preauricular extradural approach.Results The tumors were removed satisfactorily.The shwannomas were totally removed.The hemangiomas were totally removed in 18,near- totally removed in 5 cases.Nine dermoid cysts were removed totally.For the 4 meningiomas,3 were removed completely,neartotally removed in 1 cases.The 3 Chordomas were resected near- totally and achieved a completely removal with combined approach.Conclusion The subtomperal preauricular extradural approach is a rational choice.It can reveal the cranial nerve branches and artery at an early stage so that cranial nerves Ⅲ ～Ⅵand internal carotid artery can be preserved during operation.The tumor exposure is ideal and brain traction and contusion are slightly.The adjunctive radiotherapy is demanded for residual tumors adhering to nerves and arteries severely. Key words: Cavernous sinus tumor ; Extradural approach ; Microneurosurgery ;

Treatment of Intracapsular Condylar Fractures With Resorbable Pins

The surgical treatment of intracapsular condylar fractures (ICFs) of the mandible is complex. Type A and B fractures (classified by Neff et al1 and others), in particular, are difficult to treat. These fracture types are characterized by laterocranial to mediocaudal fracture lines with ventromedial dislocation of the fragments. The Axhausen2 and Bockenheimer3 retroauricular approaches or the Rasse4 and preauricular approach are usually performed. The complications associated with these surgical approaches include facial nerve injury, impaired circulation in the ear, bleeding, and scarring.

Prominent zygomatic complex reduction by C-type osteotomy

Objective To explore the operation of C-type osteotomy for reduction of prominent zygomatic complex. Methods Based on the severity and characteristics of prominent zygomaitc complex, Ctype osteotomy was designed for the malar complex reduction by using oral and minor pre-auricular approaches under general anaesthesia. Two paralleled osteotomic lines of C-type were marked from zygomatic alveola to the conjunction of lateral orbital margin and zygomatic arch through the inferio-lateral edge of orbit. The extension of zygomatic arch reduction was determined the width of two osteotomic lines. The bone which marked lines was removed by reciprocating saw and osteotome. The zygomatic arch root was osteotomiced by pre-auricular approaches. Then, the zygomatic complex could move freely towards superior-medial position. Finally, the zygoma was fixed with titanium mini-plates. Results 12 patients with prominent zygomatic complex had been successfully operated by C-type osteotomy from July 2006 to April 2009. Of them, six cases were symmetrical and six cases were unsymmetrical. Postoperative follow-up for 4-24 months, infection was not occurred, and the scar of pre-auricular incision was not obvious. All the patients obtained positive results. Conclusion C-type osteotomy for correction of prominent zygomtic complex through intra-oral and minor pre-auricular approach is an effective surgical method and gives superior results. It preserves the intactness of maxillary sinus, prevents facial slack, and is especially effective for patients with prominent zygomatic arch. Key words: C-shape osteotomy; Zygomtic; Prominent zygomtic complex; Correction

Synovial cyst of the temporomandibular joint: A case report and literature review

Synovial cysts are lesions that usually occur on the wrist, foot and knee. They are rarely involved in the region of the temporomandibular joint (TMJ), with only 10 cases reported from 1978 to 2007. The authors report a case of a synovial cyst of the TMJ in a 45-year-old woman. The patient presented with a right preauricular swelling, 1cm anterior to the tragus. A computed tomography (CT) scan showed a small oval hypodense mass of soft tissue in the right temporomandibular region with no relation to the condyle. Fine needle aspiration reported a synovial cyst of the TMJ. The patient was taken to the operating room and a preauricular approach extending to the temporal region was carried out resulting in surgical excision of the mass. The histological findings were consistent with the diagnosis of a synovial cyst. The long term clinical and radiological follow-up (after 18 months) showed no sign of recurrence. The authors suggest, in accordance with the literature, that a surgical approach should be the treatment of choice in the case of a synovial cyst of the TMJ.

The Perilobule Approach to Subcondylar Fractures

Several approaches to the management of subcondylar fractures have been used, including the submandibular approach, the preauricular approach, and the retromandibular approach. Although they provide excellent access to repair fractures of body, ramus, and condyle, we have found it difficult to manage subcondylar fractures using either of these approaches. We describe a novel approach for subcondylar fractures that provides direct access to the fracture site. A total of 17 consecutive patients underwent open reduction and internal fixation of their subcondylar fractures using this technique. The incision line is located just anterior and posterior to the ear lobe, and is comprised of lower part preauricular and upper retroauricular incisions. Intraoperatively, the method applied shortened the time necessary for and simplified the procedure of reduction and osteosynthesis. The postoperative course was uneventful in most patients. Radiologic follow-up revealed correct reduction and fixation in all the cases. There were no occlusal disturbances, no trismus, no lateral deviations of the mandible, and no nerve lesions. Our findings indicate that the short perilobe approach is an easy and safe technique for displaced subcondylar fractures.

A Case of External Auditory Canal Cholesteatoma Involving the Zygomatic Arch Root

External auditory canal cholesteatoma involving the zygomatic arch root is rare. A 15-year-old youth with aural stenosis had a history of right temporomandibular joint trauma and right external auditory canal cholesteatoma surgery. Computed tomography (CT) showed soft tissue density from the attic to the root of the zygomatic arch. The lesion showed high signal intensity in diffusion-weighted magnetic resonance imaging (MRI) and the case was diagnosed as external auditory canal cholesteatoma, subsequently resected combining retro auricular and pre auricular approaches.

TMJ Ankylosis: Multidisciplinary Approach of Treatment for Dentofacial Enhancement—A Case Report

This report describes the multidisciplinary phasewise treatment of a 20-year-old female patient having unilateral right TMJ bony (true) ankylosis whose mouth opening was restricted to 2 mm and mandibular retrognathism; additionally, she was also suffering from speech problems, snoring, difficulty in breathing, and low level of self-esteem and self-confidence. Bilateral gap arthroplasty and temporalis myofascial graft interpositioning through preauricular approach were done in surgical phase followed by the aggressive jaw physiotherapy in postsurgical period. Oral prophylaxis and restorations were followed by the fixed orthodontic therapy to resolve bimaxillary protrusion. Advancement sliding genioplasty was performed to enhance the chin button. Speech therapy and psychological counseling were also performed from time to time to boost up the self-esteem and self-confidence. At the end of treatment, facial esthetics was improved considerably and patient got over the impact of disfigurement, impaired functions, and psychosocial stigma. Rationale to use the multidisciplinary team approach in treatment of such cases is discussed.

Modified Gap Arthroplasty and Myrhaug's Incision as a Treatment Option in Management of Temporomandibular Joint Ankylosis: A Study of 10 Cases

The purpose of this study was to evaluate effectiveness of modified gap arthroplasty procedure and modified Myrhaug's preauricular incision for treating bony temporomandibular joint (TMJ) ankylosis. A total of 10 cases were included in the study with Sawhney's type III and IV TMJ ankylosis. Study consisted of 6 males and 4 females. Three cases were treated for bilateral ankylosis and 7 were treated for unilateral ankylosis. All the patients were treated with modified gap arthroplasty and modified Myrhaug's incision was used. In this modification, osteotomy cuts were modified in such a way that coronoid process was also removed simultaneously along with the osteotomized ankylosed mass in one piece. All the patients were followed up for 5 years and none of them presented with recurrence. Two patients had transient paresis to zygomatic and temporal branch of facial nerve and none had permanent damage to the nerve. Seven patients had mouth opening more than 25 mm (p) when followed for 5 years. Anterior open bite was seen in 4 patients and deviation of the jaw on ipsilateral side was noted in 2 patients. Modified gap arthroplasty gave successful results in the follow-up period and eliminated the need of separate coronoidectomy. Use of modified Myrhaug's preauricular approach, provided excellent visibility particularly of the elongated coronoid process, minimized bleeding, prevented damage to the vital anatomical structures surrounding the joint and gave acceptable cosmetic results. The modified incision has been found to be reducing intra- and postoperative morbidity as well as provides excellent accessibility. The modified osteotomy technique eliminated the need for separate coronoidectomy thus significantly reducing the operating time.

A Facelift for a Two-Year-Old: Alternative Use of Facelift Approach, to Achieve Serial Excision of a Medium Sized Congenital Naevus, in a Two-Year-Old Patient

Historically, face-lifting consisted of elevating the skin, placing it under tension to reduce the wrinkles, resecting the skin needed to accomplish this, and then securing the resected edges. However, over time, facelift surgery evolved beyond the Dorland’s definition of “rhytidectomy” (excision of skin for the elimination of wrinkles [1]) and various different techniques and indications have been described.We report of the pre-auricular facelift approach, as described by Skoog [2] for alternative use: The excision of a giant cell tumour, utilizing this facelift technique to achieve serial excision from a two year old, male patient’s face. This has resulted in a satisfactory aesthetic outcome and scar alignment in favourable area as well as excision of a significant part of the lesion, and awaiting further serial excision for completion.

Skull Base Approach to Carotid Artery Lesions: Technique, Indications, and Outcomes

Operative approaches to lesions of the carotid artery at the skull base are challenging and place multiple cranial nerves at risk. Endovascular approaches have enhanced the accessibility of this area, but some lesions are not amenable to endovascular management. Herein we describe a preauricular approach utilizing anterior dislocation of the temporomandibular joint with microscopic drillout of the medial glenoid and eustachian tube to identify and skeletonize the carotid artery in the foramen lacerum. Reviewing our experience with a direct open approach to the distal carotid artery revealed 10 patients from our institution. Nine of the patients presented with aneurysm, six spontaneous and three following blunt trauma, and one patient presented with carotid artery rupture after penetrating trauma. Eight patients underwent reverse saphenous vein grafting and two had resection with primary reanastomosis. Two of the patients presented with cranial nerve (CN) X deficits, and these persisted following surgery. Three of the eight patients without CN deficits preoperatively experienced postoperative deficits. One patient also suffered a mild CVA but had no permanent sequelae. Thus overall 5 (50%) of the 10 patients suffered no neurologic deficits and 7 (70%) suffered no new neurologic deficits as a result of surgery. One patient had persistent temporomandibular joint dysfunction. All patients had long-term patency of the graft or anastomosis, and no new neurologic symptoms were reported with a mean follow-up of 55 months. Open approaches to the carotid artery at the skull base are feasible and with careful anatomic dissection can be carried out with minimal morbidity in most cases. We present full details and images of the operative approach.

Pseudogout of the temporomandibular joint: an uncommon cause of temporomandibular joint pain and swelling

Pseudogout, or calcium pyrophosphate deposition, is a rare cause of pain, swelling, and trismus of the temporomandibular joint (TMJ). Diagnosis and management of the lesion are discussed. A 58-year-old female had a 2-month history of progressive swelling of right TMJ associated with trismus and facial pain. Imaging of the TMJ revealed a mixed radiolucent and radiopaque lesion associated with the right TMJ joint space. Surgical excision was performed successfully via preauricular approach. Pathology was consistent with calcium pyrophosphate deposition of the TMJ, also known as pseudogout. Surgical excision successfully treated her symptoms as expected. She is now disease free without recurrence. Pseudogout is a rare cause of TMJ pain, swelling, and trismus that should be included in the differential of joint pain and dysfunction. It can be treated successfully with surgery.

Temporomandibular joint herniation into the external auditory canal

Herniation of the temporomandibular joint (TMJ) into the external auditory canal (EAC) is a very rare condition, and it mostly occurs in patients with bony wall defects in the anterior EAC. The purpose of this study was to evaluate the clinical and radiological findings and the treatment results of TMJ herniation into the EAC by reviewing a large sample of temporal bone computed tomography (CT) scans. A retrospective study. We reviewed 985 adult temporal bone CT scans and evaluated the presence of defects, the size and location of defects, and TMJ herniation. We enrolled 23 cases with anterior EAC wall defects. Twenty-three (2.3%) patients from the 985 temporal bone CT cases revealed an anterior wall defect involving the EAC. We identified the causes for the defects, such as canal cholesteatoma and trauma, in eight of the 23 cases. We observed 15 (1.5%) patients with patent foramen of Huschke. The mean defect size was 3.06 × 2.69 mm. Among the patients with these lesions, six had a TMJ herniation into the EAC. Four of the six cases were surgically reconstructed using a titanium mesh via a preauricular approach, whereas the remaining two cases were managed with endaural removal and skin graft. TMJ herniation into the EAC is very rare and may not occur even if an anterior wall defect of the EAC is present. Lesions can be successfully managed with surgical reconstruction of the TMJ via a preauricular approach, whereas small lesions can be managed using an endaural approach.

Reposition of zygomatic complex fracture via subciliary incision combined with preauricular temporal approach

Objective To investigate the application of subciliary incision combined with preauricular temporal approach in the treatment of zygomatic complex fracture. Methods Fifty-three patients with zygomatic complex fracture including 41 males and 12 females were selected. Subciliary incision combined with preauricular temporal incision was employed to exp the site of fracture. After reduction of the fractures, rigid internal fixation was applied to fix the fractured bones. The facial profile, mouth opening, occlusion, view sight, movement of eye ball and local scar were evaluated postoperatively. Results The wounds of all the cases healed by first intension. All the cases had been recovered with normal face profile, mouth opening, occlusion, view-sight and eye ball movement. Facial nerve function of one case among the three cases with facial nerve trauma preoperatively was recovered totally after surgical treatment. And one case with suborbital nerve dysfunction preoperatively was not recovered. There was no case with the complications of entropion and ectropion, visible scar and temporal amyotrophia. Permanent trauma of temporal branch of facial nerve and supraorbital nerve was not observed after surgical therapy, but temporary facial nerve dysfunction occurred in 18 cases postoperative 1-3 months. Conclusion It is suggested that the approach of subciliary incision combined with preatrricular temporal incision could be employed to treat zygomatic complex fracture. Key words: Zygomatic complex; Fracture; Subciliary incision; Preauricular temporal approach

Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular Condyle Fracture of the Mandible

This article reports a modified preauricular approach for intracapsular condyle fracture (ICF) of the mandible and evaluates the stability of various internal fixation methods in the temporomandibular joint (TMJ) division of the Shanghai Ninth People's Hospital. One hundred fifty-one patients with 208 ICFs diagnosed by panoramic radiograph and computed tomographic (CT) scan received open treatment in the TMJ division from 1999 to 2008. Their charts were reviewed. Classification of the fracture was based on coronal CT scan. Forty-three patients also underwent magnetic resonance imaging before the operation to check displacement of the disc. A modified preauricular approach was used for all patients. Various internal fixation methods from wire, to screw, to plate were evaluated for stability. There were 110 ICFs of type A fracture, 60 of type B fracture, 9 of type C fracture, 25 of type M fracture, and 4 fractures without displacement. A modified preauricular approach was used for open treatment, which can better expose and protect the TMJ and superficial temporal vessels. Wire and plate is the commonly used stable fixation method for type A, B, and M fractures, which accounted for 56.7% (101/178). Small fracture fragments were removed with disc repositioning for all type C fractures (n = 9) and some type B (n = 9) and M fractures (n = 5). Three type M fracture and 3 nondisplaced ICFs were treated closed. Eighty-nine patients with 115 ICFs had postoperative CT scan, which showed anatomic and nearly anatomic fracture reduction rates of 95.6%. Thirty-five patients with 44 ICFs had long-term follow-ups from 3 months to 5 years. Among them, 63.2% (n = 12/19) pediatric ICFs had continuous condyle growth after open reduction and rigid fixation; 92% adults had ICFs that healed well (n = 23/25). Postoperative complications were facial nerve injury (n = 3), TMJ clicking (n = 1), and condyle resorption that required plate removal (n = 4). A modified preauricular approach provides better exposure and protection of the TMJ and superficial temporal vessels. Wire and plate provides stable fixation for type A and some type B and M fractures. Open reduction and rigid fixation produce good results for adult patients.