Subcranial Approach 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.

Local Approaches for the Reconstruction of Frontal and Naso-Orbito-Ethmoidal (NOE) Fractures: Presentation of a Clinical Case and Literature Review

Naso-orbito-ethmoidal (NOE) fractures are considered a challenge in reconstruction, due to the anatomical structures involved, such as the medial canthal ligament and the lacrimal apparatus [1], which leads to a complex functional and aesthetic compromise. For surgical access to the area, the use of the coronal, Lynch-Howarth, glabellar “open sky”, “gull wings” and a combination of the last two are described. However, the severity of the trauma and mainly the neurological compromise of the patient will dictate the choice of the approach that allows functional and comprehensive repair of the affected region. In cases where there is no neurological compromise and it is not necessary to carry out a subcranial approach, the use of local approaches is justified, providing adequate visibility and direct access to the fractured region, allowing an adequate reduction and placement of fixing material. A clinical case of anterior frontal sinus wall fracture and NOE fracture are presented, performing the combination of the gull-wing and open-sky approach, described as butterfly wings, achieving adequate visibility and reconstruction.

Subcranial Approach for Management of Secondary Frontal Bone Deformity.

Secondary correction for aesthetic purposes can be more challenging as the fractured segments may be united in abnormal positions and would require osteotomy procedures before mobilizing the segments for reconstruction. Such maneuvers require adequate exposure and visibility. The subcranial approach is an effective alternate to classical approaches, which required frontal lobe retraction. Subcranial approach is a viable alternative to posttraumatic deformity of frontal bone.

Microsurgical Excision of Olfactory Groove Meningiomas, Comparative Studies of Different Surgical Approaches

Introduction: To review the surgical approaches, techniques, outcomes and recurrence rates in a series of 11 olfactory groove meningioma (OGM) patients operated from January 2010 to April 2019. Methods: Eleven patients underwent craniotomy and micro-neurosurgical removal of olfactory groove meningioma. Tumor diameter varied from 5 to 8.5 cm among 11 cases, 2 cases underwent Transglabellar/ Subcranial approach, 3 cases by bifrontal approach, 1 case unifrontal approach, 2 extended endonasal and 3 cases fronto-lateral approach. Result: Total removal was possible in all cases except 2 cases. Histopathology revealed typical meningioma (WHO grade 1). There was 1 operative mortality and no permanent focal neurological deficit except anosmia. 3 patients developed CSF leak and two cases meningitis which were resolved by lumber drain and antibiotic therapy. Conclusion: Extended endonasal approach or transglabellar/ subcranial approach were sufficient for gross total removal of OGM which is associated with bony hyperostosis, paranasal extension and optic canal. Bang. J Neurosurgery 2020; 10(1): 9-19

Subcranial surgery of nasal CSF leak, endoscopic capabilities

Introduction: The problem of choosing surgical approach in the treatment of CSF leak is the subject of discussion depending of the location and the size of the bone defect of the skull base. Materials and methods: 37 patients with nasal CSF leak were treated. In 17 cases, nasal CSF leak was caused by meningo(encephalo)cele. Spontaneous nasal cerebrospinal fluid occurred in 14 cases. In 3 cases, nasal CSF leak was the result of traumatic brain injury (in one case, the cause of nasal CSF leak was post-traumatic meningoencephalocele of the frontal sinus); in the other 3 cases there was postoperative wound nasal cerebrospinal fluid. Results and discussion: Groups of patients were formed depending on the use of vascularized or moved (free) flaps: 1). Multilayer plastics of bone defects of the anterior and middle cranial fossae using displaced (free) flaps. 2). Multilayer plastic of bone defects of the anterior and middle cranial fossa using a nasoseptal flap or middle nasal concha on the leg. In all cases (100%) nasal CSF leak was eliminated. External lumbar drainage was performed in 6 patients and only in cases where the plastic of the bone defect was performed by displaced free flaps. Conclusions: 1). The use of endoscopic endonasal techniques is a minimally invasive method to close skull base bone defects (including large – more than 20 mm) in the area of the anterior and middle cranial fossae. 2). Subcranial approaches are expedient, effective and technically more convenient for nasal CSF leak defects of the frontal sinus and defects in the anterior cells of the etmoid bone.3). Vascularized flaps is expedient for plastic at middle (11-20 mm) and big (more than 20 mm) bone defects of skull base.

Discussion: Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton

Discussion: Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton

Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton

An intracranial approach to the craniomaxillofacial skeleton can be effective for correcting complex craniofacial dystoses such as frontofacial hypoplasia, hypertelorism, and orbital dystopia. However, the significant morbidity resulting from the high complication rates has limited intracranial use. Given the need for intracranial approaches for certain clinical indications, the present study reevaluated intracranial frontofacial procedures to determine their safety and outcomes. A retrospective review was performed of all frontofacial procedures completed between 2007 and 2017 at a single institution. Patients who had undergone monobloc distraction alone or with facial bipartition, facial bipartition alone, or box osteotomy were included in the intracranial cohort. Those who had undergone Le Fort III distraction, advancement, or a combination with Le Fort I were included in the subcranial cohort. The recorded data included demographics, previous craniofacial surgery, and operative events. The complications rates were compared between the 2 cohorts. The present study included 65 patients-35 subcranial and 30 intracranial. The rates of previous craniomaxillofacial (P=.193) and intracranial (P=.340) surgery were equivalent between the 2 cohorts. Of the 30 intracranial and 35 subcranial patients, 26.7% and 34.3% experienced complications (P=.218). The intracranial patients experienced more dural tears (53.3 vs 5.7%; P<.0001); however, no significant differences were observed in cerebrospinal fluid leakage. Reintubations (n=3; 4.5%) occurred exclusively in the subcranial group. No significant differences in the major and minor complication rates were observed between the 2 cohorts. Intracranial and subcranial frontofacial procedures are associated with an equal riskof major and minor complications. Given the lack of an increase in risk, intracranial frontofacial procedures should be considered for the management of complex craniofacial dystoses.

Anterior Median Skull Base Reconstruction Using a Vascularized Free Flap: Rationale, Patient Selection and Outcome.

Objectives To present our method of median anterior skull base (ASB) reconstruction using a subcranial approach with a free flap in cases of naso-fronto-orbital (NFO) bony segment failure and in patients at high risk for future failure of the bony frontal segment. Design This study presents as a retrospective case series. Setting Tertiary university-affiliated medical center. Participants Adult and pediatric patients who underwent median ASB resection via the subcranial approach with a free flap reconstruction were participated in this study. Main Outcome Measures Pathologic outcome and postoperative quality of life (QoL) as assessed by a validated Hebrew version of the "Anterior Skull Base Quality-of-Life Questionnaire." Results The departmental database yielded 13 suitable patients aged between 15 and 70 years. The main indication ( n = 7) for ASB surgery was osteoradionecrosis (ORN) of the NFO bony segment which was first detected at an average of 3.6 years (range: 2-32 years) postradiation therapy. High-risk patients for future ORN of the NFO segment ( n = 3) were primarily reconstructed using a vascularized free flap. Nine patients had malignant disease, and four of them were alive without evidence of disease during the follow-up period (average, 48 months). Their QoL was comparable to that of patients who had undergone subcranial ASB resection without free flap reconstruction. Conclusions The ASB median free flap method of reconstruction is a safe and reliable in cases of large complex median ASB defects without orbital resection or maxillectomy. This approach is suitable for patients who had undergone previous surgery, radiotherapy and/or those who present with osteoradionecrosis, as well as for patients with high risk of NFO segment ORN.

Subcranial craniotomy in surgical management of advanced oral cavity malignancies: a technical note

Craniofacial resection is the technique of choice for tumors of the oral cavity or paranasal sinus extending close to the skull base of middle cranial fossa. Here we would like to describe a new technique of approaching these tumors through the facial incision itself. All patients treated with this technique at our institute were included in this retrospectively analyzed case series. The pathological clearance margins, complications and outcomes were studied. A total of nine patients underwent resection of tumor with the subcranial approach. There were seven males and two female patients. Mean age was 50.66 years (22–72 years). The diagnosis was squamous cell carcinoma in five patients, adenoid cystic carcinoma in three patients and alveolar soft part sarcoma in one patient. A lip split incision and mandibulotomy/mandibulectomy was done in seven patients; a Weber–Fergusson incision was used in one patient and details were not available in one other patient. Reconstruction was done with anterolateral thigh flaps with or without titanium mesh for all the patients. One patient developed thalamic infarct and was managed conservatively. None of the other patients had complications related to the craniotomy. The infratemporal fossa margin was close/involved in two patients (22.22%). Eight patients received adjuvant therapy without delay. One patient, who had received radiation previously, did not receive adjuvant radiation. This technique aims to reduce morbidity without compromising on the oncological outcomes for tumors extending short of or up to the skull base.

Combined Approach of the Anterior Skull Base in Sinonasal Tumours

Malignancies of the nasal cavity and the paranasal sinuses are rare, counting for less than 3 % of the ENT-cancers. The insidious onset of these tumours with non-specific symptoms often leads to a delayed diagnostic. Advanced disease stage combined with the complex anatomy of the sinonasal cavities and anterior skull base encouraged surgeons to extend beyond the boundaries the classic surgical techniques. Surgical approaches to anterior skull base lesions can be divided into open approches: craniofacial, subcranial, endoscopic techniques or combined approaches when a craniotomy is associated with an endonasal endoscopic approach. The indication must take into consideration the oncologic principles, histopathology exam, extent of disease and surgeon skill and experience. Combined approach should be taken into consideration for patients with extended disease or significant intraorbital or intracranial extension. For certain tumours that require a craniotomy for the superior, superolateral, and anterior extensions of the disease and also a nasal and paranasal sinus tumor that could be removed endoscopically, an endoscopic-assisted approach can be considered.

The clinical behavior of sinonasal inverted papilloma with cellular dysplasia: case series and review of the literature

The prognosis and recurrence rate of inverted papilloma (IP) with concomitant cellular dysplasia are not well-delineated. Demographic, clinical and imaging data of all patients who were surgically treated for sinonasal inverted papilloma (SNIP) in our center between 1996 and 2013 were reviewed. Data regarding the coexistence of dysplastic changes or malignancy within the resected tissues were also retrieved. After the exclusion of malignant cases and patients who were lost for follow-up, 92 patients were included in the study. Five patients had coexisting cellular dysplasia (4.7%), four of them had severe dysplasia and one had mild-to-moderate dysplasia. All four cases with severe dysplasia recurred, three were primarily treated endoscopically and one by external approach. Only the case with mild to moderate dysplasia which had been treated by subcranial approach did not recur. Patients with dysplasia had significantly higher recurrence rate than patients without dysplasia (80 vs. 14%, p=0.019). This significant relation between histology and recurrence remained even after adjustment to tumor extent. The adjusted odd ratio of dysplasia (dysplasia vs. no dysplasia) is 9.7, p=0.043. SNIP with dysplasia should be treated aggressively and followed closely. The histopathologic investigation of SNIP specimens should always note the presence of dysplasia and its severity. Further investigation on the clinical behavior of SNIP with dysplasia is needed. Multicenter studies are warranted due to the rarity of dysplastic SNIP.

Subcranial craniofacial resection for advanced sinonasal malignant tumours involving the anterior skull base.

The subcranial approach is a modification of traditional craniofacial resection. It provides similar broad access to the anterior skull base, but with lower mortality and morbidity. It has been the surgical technique of choice at our institution since 2006 for treating advanced stage sinonasal tumours (American Joint Committee on Cancer stage III or above). This paper reports our experience and outcomes. Eighteen patients underwent subcranial craniofacial resection over a seven-year period, this being combined with a second adjunctive procedure in 89 per cent of cases. Forty per cent of patients required reconstruction of the primary defect. No peri-operative deaths occurred. One patient had a transient cerebrospinal fluid leak. The major complication rate was 33 per cent, of which 67 per cent were directly related to soft tissue reconstruction. Tumour recurrence rate was 17 per cent and the five-year disease-free survival estimate was 40 per cent. The subcranial approach is a safe and effective technique that may be used to successfully treat advanced sinonasal malignancies with anterior skull base extension.

Frontoethmoidal osteoma with orbital extension. A case report

Case reportA case is presented of a right frontoethmoidal osteoma with intraorbital invasion in a 43-year-old male, who was seen in the clinic with a proptosis, retro-orbital pain, peri-palpebral inflammation, and binocular diplopia due to muscular route limitation. Open surgery was performed using a subcranial approach, with removal of several fragments of osteoma. Histological analysis confirmed the diagnosis. DiscussionOsteomas are benign bone-forming tumours with slow growth. They are usually asymptomatic until mass effect complications occur in the brain or in the orbit, or locally, generating mucoceles due to sinus drainage obstruction.

Osteoma frontoetmoidal con extensión intraorbitaria. A propósito de un caso

Case reportA case is presented of a right frontoethmoidal osteoma with intraorbital invasion in a 43-year-old male, who was seen in the clinic with a proptosis, retro-orbital pain, peri-palpebral inflammation, and binocular diplopia due to muscular route limitation. Open surgery was performed using a subcranial approach, with removal of several fragments of osteoma. Histological analysis confirmed the diagnosis. DiscussionOsteomas are benign bone-forming tumours with slow growth. They are usually asymptomatic until mass effect complications occur in the brain or in the orbit, or locally, generating mucoceles due to sinus drainage obstruction.

Following the canyon to reach and remove olfactory groove meningiomas.

Olfactory groove meningiomas (OGMs) represent approximately 10% of all intracranial meningiomas. They arise in the olfactory fossa, a variable depression delimited by the lateral lamella and perpendicular plate. The cribriform plate with the lateral lamella and ethmoidal and orbital roof could be viewed as a 'canyon' with the frontal sinus as the main entrance. Between January 2000 and December 2013, 32 consecutive patients underwent removal of OGMs through this 'canyon' at the Department of Neurosurgery of Brescia and Turin. Complete removal was achieved in all patients with this trans-frontal sinus subcranial approach (Simpson grade I; mean lesion volume, 46.6 cm3). Five patients (15.6%) experienced nasal CSF leakage, treated with external lumbar drain positioning for 4 days and resolved in all cases but one, which was re-operated. Two patients (6.2%) during the CSF leakage experienced meningitis at day 7 after surgery, both successfully treated by intravenous antibiotic therapy. After one month, one patient developed hydrocephalus, treated with a ventricular peritoneal shunt. In one patient, traction on the OGM caused bleeding of the callosomarginal artery, which was coagulated with superior frontal gyrus ischemia without neurological consequences. Glasgow Outcome Scale Score at 6 months was V in 29 patients, IV in one patient, and I in two patients. Advantages with this approach may include easy and early control of blood supply from its insertion in the skull base, minimal frontal lobe retraction, preservation of the frontal veins draining to the sagittal sinus, and a satisfactory aesthetic outcome.

The Subcranial/Transglabellar Approach to the Anterior Skull Base and Paranasal Sinuses: Our Experience with 39 Cases

Objective: To describe our experience with the subcranial approach developed by Raveh. Study Design: Retrospective case series of 39 consecutive patients managed surgically with this approach at our institution since 2007. Patients: The mean age was 38 years (range, 1-71 years), with a mean follow-up of 17 months. A standard bicoronal approach was used in all cases. Whenever the drainage pathway and posterior wall were intact, the frontal sinus was reconstructed. If the sinus was isolated from the intracranial cavity, but there were any doubts that it would be functional, obliteration was performed with bone dust, demineralized bone matrix, and/or pericranial flap. Otherwise, the sinus was cranialized. This approach was used in 19 trauma cases with craniofacial fractures, 8 patients with late sequelae of trauma, 7 tumors, 3 complicated sinusitises, 1 spontaneous CSF leak, and 1 congenital encephalocele. Results: None of the patients died. Short-term complications related to approach were: two postoperative CSF leaks (one was later diagnosed of intracranial hypertension) and one case of meningitis with full recovery. Permanent anosmia was common in trauma patients with complex fractures and patients with tumors invading the olfactory grooves. Conclusions: This approach gives wide access to the anterior cranial base and clival-sphenoid region for the treatment of a variety of pathologies. Also, it allows an adequate water and airtight reconstruction with minimal brain retraction.

Subcranial craniotomy approach for frontobasal fracture correction

ObjectiveFrontobasilar fracture types and the outcome of patients after management with the subcranial approach technique were evaluated. Material and methodsA retrospective analysis of 48 patients (45 males, mean age 38,5 years; range 16–82 years) who had a subcranial approach for frontal base fracture correction between April 1996 and April 2011 at a tertiary care academic hospital in Turku, Finland. ResultsSixteen (33%) patients had fractures including all frontobasilar fracture types (Type I-IV) i.e. fractures that involved frontal sinuses, orbital roofs, ethmoidal region, cribriform plate and sphenoidal region. Twenty-seven (56%) patients were considered to have had brain damage at presentation. Forty percent of patients were suffering from synchronous trauma. Peroperatively, 31 (65%) patients had exposure or defect of the dura due to bone dehiscence but only two patients suffered from cerebrospinal fluid (CSF) fistula following surgery. CSF fistulae were covered by pericranium in most of the cases (68%). There was no postoperative meningitis. Thirty-eight percent of the patients needed further operation with a subcranial craniotomy following primary reconstruction. At the last follow-up visit 35% were suffering from permanent neurological problems following brain injury. ConclusionsSubcranial approach seemed successful in the management of all frontobasilar fractures in this series with reasonably low complication rate. Therefore, we would recommend it as the technique of choice in multiple and even in the most complicated frontal base fractures.

A Subcranial Approach for Anterior Skull Base Pathology (Nasal Encephalocele)

ABSTRACT A modified subcranial approach based upon the procedure first described by Joram Raveh is a viable alternative to standard craniofacial resection for treating pathology of the anterior skull base. It is basically an extradural approach providing wide exposure to the anterior skull base with minimal brain retraction; thus decreasing significantly the morbidity. We present here two cases of a rare benign pathology of anterior skull base-naso-orbito-ethmoid encephalocele wherein this technique was used successfully. How to cite this article Nagpal T. A Subcranial Approach for Anterior Skull Base Pathology (Nasal Encephalocele). Clin Rhinol An Int J 2014;7(1):20-22.

Peculiarities of surgical treatment of craniofacial osteomas

The purpose. To study features of craniofacial osteomas clinical flow and their surgical treatment.Materials and methods. The results of examination and surgical treatment of 14 patients with craniofacial osteomas and 2 — with fibrous dysplasia were analyzed.Results. In 9 patients wide craniotomy (bifrontal and frontotemporal approaches) was performed. At smaller tumor size, in particular, it’s intracranial part, we used subcranial approach (in 5 cases); at deeply located tumor — endoscopic endonasal approach was applied (in 2 cases).Conclusions. Optimal surgical approaches were proposed taking into consideration features of craniofacial osteomas, in particular, their possible giant size and tissue hardness. The possibility to minimize surgical approach was proved.

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&gt;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).