Subcranial Approach Research Articles

Surgical management of juvenile nasopharyngeal angiofibroma – a series

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor that tends to bleed and occurs in the nasopharynx of pre-pubertal and adolescent males. Surgical therapy is aimed at eradicating or de-bulking the tumour. Approaches range from the lateral rhinotomy, transpalatal, transmaxillary or sphenoethmoidal for small tumors and infratemporal fossa approach when the tumor has a large lateral extension. The midfacial degloving approach, with or without LeFort osteotomy, improves posterior access to the tumor. The facial translocation with Weber-Ferguson incision and coronal or extended anterior subcranial approach facilitates en bloc tumor removal, optic nerve decompression and exposure of the cavernous sinus.

Transglabellar Subcranial Approach for the Management of Nasal Masses With Intracranial Extension in Pediatric Patients

To describe the use of the transglabellar subcranial approach for the management of congenital nasal masses in the pediatric population. Case series. Medical records of 5 patients who underwent resection of congenital nasal lesions via the subcranial approach were reviewed. Five children underwent successful resection of congenital nasal lesions with intracranial extension via the subcranial approach. Lesions resected included nasal dermoids with intracranial extension (n = 3) and encephaloceles (n = 2). Patient age at the time of operation ranged from 13 months to 15 years. All lesions were resected successfully, and there have not been any recurrences. Follow-up has ranged from 1 to 12 years. There has been no apparent negative effect on facial growth in any of these patients. The subcranial approach is an effective technique for the resection of nasal masses with intracranial extension. These lesions have traditionally been managed with lateral rhinotomy, midface degloving, or external rhinoplasty approaches combined with a frontal craniotomy. The subcranial approach offers several advantages over a traditional frontal craniotomy. It provides excellent exposure, minimizes frontal lobe retraction, reduces the likelihood of cerebrospinal fluid leakage, and provides for an excellent cosmetic result. Long-term follow-up in 5 pediatric patients has shown no recurrence or negative effect on craniofacial growth. These factors make the transglabellar subcranial approach a useful and safe technique for the management of nasal lesions with intracranial extension in very young patients.

Combined Subcranial Approaches for Excision of Complex Anterior Skull Base Tumors

To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach. Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured. Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches. Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.

Impact on Survival of Skull Base Involvement in Sinonasal and Nasopharyngeal Tumors

One hundred ninety-nine patients with sinonasal and nasopharyngeal malignant tumors were retrospectively reviewed. One hundred of them presented with ethmoid tumors involving the anterior skull base and underwent different modalities of combined craniofacial surgery (transfrontal or conventional craniotomy, subcranial approach). Five-year actuarial survival was 40%, and was significantly affected by the histology of the tumor, brain involvement, deep soft-tissue involvement of the orbit, involvement of the sphenoid sinus, and postoperative recurrence. Standard staging systems, frontal sinus invasion, involvement of the roof of the ethmoid, or spread into the dura had no significant effect on survival. Only involvement of some critical areas was reliable as a predictor of an unfavorable outcome.

Variations of Approaches to the Anterior Base of the Skull

There are different ways to approach a lesion of the anterior base of the skull depending on its location and extension. We differentiate between extracranial, intracranial, and combined approaches. The extracranial approach can be performed as an endonasal, transfacial subcranial, or midfacial degloving procedure. In addition to the tumor extension and its exposure, the criteria for choosing the appropriate access must include the operative procedure, for example, en bloc resection, piecemeal resection, or additional reconstruction. Furthermore, surgical safety concerning potential complications and radicality play a major role alongside morbidity and aesthetic considerations. Thus transfacial approaches should be avoided if alternative endonasal or midfacial degloving procedures may be performed. If transfacial incisions cannot be avoided, the aesthetic components and relaxed skin tension lines must be considered. The midfacial degloving procedure is a very suitable approach to the paranasal sinuses and the anterior skull base. In particular, the pterygopalatine fossa, the nasopharynx, and the pterygoid process can be well exposed. The surgical exploration reaches far lateral right into the infratemporal fossa. If the ventral region of the anterior base of the skull is involved, midfacial degloving reaches its limit. In these cases, subcranial approaches or the midfacial degloving in combination with a transcranial transfrontal approach are preferable. The transfrontal approach in combination with an otorhinolaryngological access in cooperation with neurosurgeons is necessary if the tumor penetrates the dura or has pushed the dura into the endocranium.

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base: The Tel Aviv Experience

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base: The Tel Aviv Experience

Combinations and Modifications of the Subcranial Approach for Extirpation of Large Anterior Skull Base Tumors

The purpose of this paper is to describe the variations and combinations of the subcranial approach used in our institute for extirpation of large anterior skull base tumors.

Intracranial and Orbital Complications of Bony Lesions Involving the Anterior Skull Base and Paranasal Sinuses

Purpose: A spectrum of conditions may be encountered in the sinonasal region and skull base composed of varying proportions of new bone and fibrous tissue such as osteomas, ossifying fibroma, fibrous dysplasia, and osteosarcoma. We present a series of 41 patients with anterior skull base bony tumors, and we focus on the cases with intracranial or orbital complications. Clinically manifested intraorbital and/or intracranial involvements are indications for surgical treatment. The purpose of this study is to describe our experience with the surgical treatment of these rare and serious manifestations of these lesions. Methods: Our cases involved the frontal sinus, orbit, and cribriform area. A retrospective analysis was done using patient's files from the hospital and the outpatient clinic, operative notes, and pre- and postoperative imaging studies. The surgical technique included an anterior frontal sinus wall door, a type A or a type B subcranial approach, and reconstruction with fascia lata, titanium mesh coated with pericranium and plates, calvarial bone grafts, and fascia sling. Results: The age of the patients was 14 to 41 (mean, 25 yrs). Fifteen of the 41 patients presented with serious intracranial or orbital complications (headaches, CSF leak, pneumocephalus, seizures or proptosis, partial ptosis, and rapid visual deterioration). Twenty were males and 21 were females. Fifteen cases were operated using a subcranial approach and in 26 cases, only the anterior wall of the frontal sinus was removed. Complete removal of the tumor was achieved in all cases and all patients are alive. Surgical complications were mostly of short duration. Conclusions: Bony lesions of the anterior skull base can have serious local clinical effects including orbital and intracranial symptomatology. Our experience shows that these lesions are resectable with generally few complications. The subcranial approach provides a wide anatomical exposure and allows the complete resection of these tumors.

Esthesioneuroblastoma: The University of Michigan Experience, 1994 to 2007

Introduction: Esthesioneuroblastoma or olfactory neuroblastoma is a rare malignant neoplasm of the nasal cavity and paranasal sinuses. An optimal treatment regimen remains elusive with surgery, radiation, and chemotherapy all being used in different combinations by different institutions. The most common surgical treatment is craniofacial resection. This report demonstrates our approach to resection of these tumors using a subcranial approach.

A Comprehensive Algorithm for Anterior Skull Base Reconstruction after Oncological Resections

To present our method for anterior skull base reconstruction after oncological resections. One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned. The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n = 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath. A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.

Impact on Survival of Skull Base Involvement in Sinonasal and Nasopharyngeal Tumors

One hundred ninety-nine patients with sinonasal and nasopharyngeal malignant tumors were retrospectively reviewed. One hundred of them presented with ethmoid tumors involving the anterior skull base and underwent different modalities of combined craniofacial surgery (transfrontal or conventional craniotomy, subcranial approach). Five-year actuarial survival was 40%, and was significantly affected by the histology of the tumor, brain involvement, deep soft-tissue involvement of the orbit, involvement of the sphenoid sinus, and postoperative recurrence. Standard staging systems, frontal sinus invasion, involvement of the roof of the ethmoid, or spread into the dura had no significant effect on survival. Only involvement of some critical areas was reliable as a predictor of an unfavorable outcome.

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base

Effects of the Subcranial Approach on Facial Growth and Development

Effects of the Subcranial Approach on Facial Growth and Development

Effects of the subcranial approach on facial growth and development

To analyze the long-term effects of subcranial surgery for anterior skull base tumors on facial growth. Retrospective study (1994 to 2004) in a university-affiliated hospital. Of 108 patients who underwent a subcranial surgical approach for anterior skull base tumors, six adolescents and five young adults fulfilled study entry criteria for age and follow-up data availability (mean, 3.2 +/- 2 years). Cephalometric x-ray films monitored postoperative facial growth. Anteriorly and posteriorly measured horizontal and vertical maxillary growth were compared with normal values. All subjects had superiorly positioned maxillae (shorter in patients with long-standing pathologies). The upper incisor teeth were proclined relative to the cranial base reference planes. All cephalometric changes were within a 10 percent deviation of normal values. Subcranial surgery for these tumors minimally affects vertical facial skeleton growth. Early surgery is essential for unaffected horizontal growth. Guidelines for anterior skull base tumor surgery in adolescents and young adults.

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base: The Tel Aviv Experience

Outcome and Complications of the Extended Subcranial Approach to the Anterior Skull Base: The Tel Aviv Experience

A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach

Lesions of the anterior cranial fossa are still a challenge for the surgeon. Since Joram Raveh introduced the concept of a subcranial approach in 1978 it has been used in the treatment of lesions extending into the anterior cranial fossa. Our experience with the subcranial approach during the past 8 years at Turku University Central Hospital is described. Fifty-nine consecutive patients underwent surgery using the subcranial approach for treating various benign and malignant neoplasms, for repair of frontobasal-midfacial fractures, and for repair of cerebrospinal fluid leaks. Patient records were retrospectively reviewed, with special focus on surgical technique, early outcome, and complications. Nineteen of the patients were operated on because of combined fronto-naso-orbital and skull base fractures, 37 were tumour cases, and 3 patients required surgical repair for cerebrospinal fluid leakage. Significant complications consisted of two cases of meningitis. However, they were successfully treated with antibiotics. The most common late complaint was olfactory nerve dysfunction (44), other late complications such as diplopia (4), enophthalmos (2), scar tissue in the nasal cavity (2), and trigeminal nerve dysfunction (2) were also encountered. The subcranial approach affords exposure to the orbital, sphenoethmoidal, and clivus regions, as well as to the nasal and paranasal cavities. On the basis of this review, it is concluded that it is a safe and effective approach for treating lesions involving the anterior skull base.

O.073 Anterior skull base lesions treated by subcranial approach

O.073 Anterior skull base lesions treated by subcranial approach

P.215 Resection of a tumour of the parapharyngeal space with double mandibulotomy and coronoidectomy

Neoplasms affecting the anterolateral and lateral skull base have different sites of origin and histology, and its resection is technically difficult. The purpose of this study was to describe the surgical outcome and overall and disease-free survival of patients who had anterolateral and lateral skull base procedures for treatment of neoplasms with and without adjuvant therapy.A retrospective study was performed on 26 patients who underwent anterolateral or lateral skull-base procedures through subcranial approaches such as maxillectomy with ethmoidectomy, osteoplastic maxillotomy, transmandibular, infratemporal, and transtemporal/infratemporal techniques for treatment of neoplastic diseases. Twenty-one cases were malignancies, with no evidence of metastasis. These approaches were combined frequently with a transbasal, pterional, subtemporal, or temporo-occipital craniotomy. Survival and disease-free intervals were evaluated with the Kaplan-Meier product limit method.Nine cases were maxillary antrum malignancies with extension to the middle fossa and/or infratemporal fossa, 7 with nasopharyngeal neoplasms, 3 malignant lesions in the infratemporal fossa, and 3 with auditory canal carcinomas. The rest had miscellaneous diagnosis. Major morbidity occurred in 15% of cases. Perioperative mortality was 0. From 21 cases with malignancies, 4 had recurrences and the overall survival was 78% at 36 months of follow-up.Anterolateral and lateral skull-base surgery is done with low morbidity and no operative mortality. The oncologic results are better than those reported in the literature probably because of a stringent selection of cases, although a longer follow-up period is required.

Commentary

We present a combined approach for the removal of large tumors involving the skull base, called the “combined pterional-subcranial approach.” Use of the subcranial approach allows for a wide exposure of nearly the entire anterior skull base, from the cribriform roof of the ethmoid labyrinth posteriorly to the sphenoid and clivus, and laterally to the orbital roofs, with relatively little retraction of the brain. Addition of a unilateral pterional approach adds exposure to the most lateral aspect of the ipsilateral orbit, the retro-orbital region, as well as the sellar and chiasmatic regions. Dissection in the region of the cavernous sinus is also made easier by this combined technique. We review the background of these 2 surgical approaches and describe the technique of the combined approach.

Retinal detachment after subcranial resection of an anterior skull base tumor

The subcranial approach has emerged as a safe and effective procedure for resection of tumors of the anterior skull base. This approach allows excellent exposure of the nasal cavities, the paranasal sinuses, and the orbit 1 I also enables a wide approach to the anterior cranial fossa, while applying minimal retraction of the frontal lobes. Complications of this procedure are acceptable and comparable to the classical transfacial transcranial approac 2