Transfacial Approach Research Articles

Editorial: Endoscopic endonasal approach to anterior skull base meningiomas

Since the seminal report of Weiss5 describing use of the transnasal approach to tuberculum meningiomas, a concatenation of the superb expertise brought forward with endoscopic equipment and techniques refined by our colleagues specializing in otolaryngology/head and neck surgery and a corresponding interest by neurosurgeons in the development of transfacial approaches to intradural pathological conditions of the anterior skull base have led to an increasing interest in the use of this approach.1 The paper by Liu et al.3 in this issue of Neurosurgical Focus nicely describes the state of the art, state of technology, and limitations of the transnasal surgical approach to olfactory groove meningiomas. The authors also provide a technical overview of the procedure as done at their institution.

Transfacial Approaches to the Skull Base: The Early Contributions of Harvey Cushing

In this report, we review Dr. Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his early use of craniofacial approaches for malignant pathology of the skull base. Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912, which included three patients who underwent surgical treatment of lesions involving the skull base through craniofacial approaches: two adults and one child (range 3 to 43 years). The main outcome measures were length of stay and condition recorded at the time of discharge. The indications for surgery included osteochondroma of the sphenoid sinus, sarcoma of the maxillary sinus and middle fossa, and osteoma of the frontal sinus. The mean length of stay was 24.5 days (range 7 to 45 days). Cushing employed craniofacial approaches for malignant pathology nearly 40 years before such techniques became widely used. He practiced the fundamentals of skull base surgery, including preferential removal of bone to achieving adequate exposure for resection. In addition, Cushing clearly understood the importance of proximal vascular control in approaching lesions with complex vascular involvement.

Kératokystes (ou tumeurs odontogéniques kératokystiques)

The aim of this study was to describe the management of keratocysts based on our own experience and on a large literature review. Keratocysts are benign odontogenic epithelial tumors. The main aspects of this lesion are described (definition, epidemiology, clinic, radiology, histology, treatment, and prognosis). In small intra-osseous tumors, surgical procedure must be as conservative as possible, most often enucleation. In large tumors with destruction of the cortical bone, or with destruction of coronoid process or notch, extensive resection can be indicated, with sometimes a transfacial approach for an accurate control, especially in soft tissues. Strict follow-up is mandatory because of the high risk of recurrence.

Endoscopic versus Open Clival Chordoma Resection: A Systematic Review

Objective: Microscope-based surgical approaches to the clivus require large openings to allow the passage of sufficient light to the lateral extent of clival chordomas, and have traditionally utilized extensive bone drilling, brain retraction, and manipulation of cranial nerves that lie along the operative trajectory. A ventral approach to the tumor is a more logical trajectory, but transoral approaches are limited by the hard palate, and transfacial approaches may be cosmetically undesirable. The endoscopic transclival approach represents a new paradigm in surgical philosophy, offering a minimal access, maximally aggressive alternative that may be preferable in a subgroup of patients. We performed a systematic analysis of the literature to assess the efficacy and complications of this approach compared with more standard cranial base approaches.

Avoiding Facial Incisions: Combined Transcranial-Transfacial Approaches to the Skull Base

Introduction: Combined craniofacial approaches to the midline skull base have traditionally relied on transfacial techniques to expose aspects of the cranial base not accessible by standard craniotomies. These transfacial approaches have typically been performed via facial incisions and superficial soft tissue flaps for supplementary exposure. The introduction of endoscopy and an improved understanding of cranial base anatomy now permit similar approaches to be done without facial incision. We present our experience with the single-stage combined craniofacial technique without any visible facial incisions for select skull base pathology.

Transnasal, transfacial, anterior skull base resection of olfactory neuroblastoma

Purpose Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria. Materials and methods A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined. Results Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the rerecurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach. Conclusions Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.

“How Much Is Enough?” Endonasal Surgery for Olfactory Neuroblastoma

“How Much Is Enough?” Endonasal Surgery for Olfactory Neuroblastoma

Modified Weber–Fergusson incision with Borle's extension

The Weber–Fergusson maxillectomy incision was first described by Weber in German and later modified by Fergusson 1 Fergusson W. Operation on the upper jaw. A System Of Practical Surgery. J Churchill & Co, London1842 Google Scholar in English. It is one of the most commonly used transfacial approaches to the midface for the resection of maxillary tumours.

Endoscopic v/s conventional approach to sino-nasal tumours — What’s the debate?

In the past two decades nasal endoscopy has advanced technologically to offer us magnified vision and better illumination along with better instrumentation. Surgery has traditionally been via the transfacial approaches such as lateral rhinotomy or the Weber Fergueson incision. For disease extension into the skull base traditional approach is a transfrontal craniotomy via either the bicoronal incision or the subcranial Raveh's approach. A combined access via the cranium from above and the transfacial access from below aids in encompassing the tumour all around. Transnasal access is a natural trajectory which leads us directly onto the tumour. The endoscope alone or with the microscope has been utilised to improve the magnification and illumination to aid in tumour removal. Minimal access to the Sinonasal and anterior skull base tumours is proven to be possible and feasible. We now have an additional armamentarium to our existing approaches in management of these tumours. We have to be judicious and see which approach can remove the disease completely maintaining the quality of life of the patient.

Removal of a Cavernous Hemangioma in the Orbital Apex via the Endoscopic Transnasal Approach: A Case Report

The aim of this study is to describe the case of a cavernous hemangioma extending from the orbital apex to the pterygopalatine fossa that was completely removed via an endoscopic transnasal approach. We report the case of a 48-year-old man who presented with right hemianopsia of the left eye. MRI revealed a 1.5 x 1.1 cm mass lesion extending from the infero-medial part of the left orbital apex to the pterygopalatine fossa. Removal of the lesion was performed via the endoscopic transnasal approach. Using this approach, a wide operative view of the entire extent of the lesion from the optic canal to the orbital apex and the pterygopalatine fossa was obtained, and complete removal of the lesion was performed safely. The pathological diagnosis was cavernous hemangioma. The endoscopic transnasal approach is a safe, effective, and less invasive therapeutic modality for the removal of lesions extending from the infero-medial part of the left orbital apex to the pterygopalatine fossa. With appropriate patient selection, this approach improves access and visualization, and it enables performance of operative procedures with much less risk than the conventional microscopic transcranial or transfacial approaches.

LeFort I osteotomy approach to the anterior skull base

Anterior skull base neoplasms require a multispecialty approach for adequate resection and reconstruction. Otolaryngologists are often consulted to help provide access to middle cranial fossa tumors or treat anterior cranial base pathology that arises from the nasal cavity or paranasal sinuses. The LeFort I osteotomy with downfracture of the maxilla is one of many well-described osteoplastic anterior transfacial approaches to access these areas of the skull base. The approach greatly improves visualization of not only the central skull base, but also the infratemporal fossa when the posterior wall of the antrum and the pterygoid plates are removed. We will review proper patient selection, the anatomy, and surgical exposure with modifications of the LeFort I osteotomy, operative procedure, and complications. This approach should be included in the skull base surgeon's repertoire as an intermediate alternative to limited access transnasal, transantral, and endoscopic approaches and wide exposure face-splitting procedures.

Outcome of sinonasal melanoma: Clinical experience and review of the literature

Primary sinonasal malignant melanoma (SNMM) is a rare clinical entity. There is neither a classification nor a staging system nor an evidence-based treatment concept established. Our objective was to find potential risk factors predicting the outcome. Twenty-five patients with histologically confirmed SNMM were consecutively included and retrospectively analyzed. Staging methods were nasal endoscopy, CT, MRI, and positron emission tomography (PET) scan. Patients were selected for a curative or palliative concept. All patients had postoperative follow-up with control-MRI at 3 and 6 months. Restaging was performed when local recurrence occurred. Nineteen patients underwent primary surgery with curative intention; in 16 cases with tumor free margins. Thirteen patients (68%) had transnasal endoscopic surgery, 4 lateral rhinotomy, and 2 transfacial approach with orbital exenteration. Six patients (32%) had palliative therapy and 7 patients (37%) had adjuvant radiotherapy. Despite radical operations, 6 patients (37%) showed local recurrence and 8 patients (50%) developed distant metastasis. In 2 patients with incomplete surgery, regional metastasis was noted. The median disease-free interval was 18 months, and the median overall survival rate was 23 months. SNMMs of the ethmoid and maxillary sinuses have a worse prognosis than other localizations in the nasal cavity; infiltration into the skull base, orbit, or facial soft tissue correlates with a very poor outcome corresponding to the palliative situations. Furthermore, local recurrence insinuates aggressive disease with short survival rate. A main difference from its cutaneous counterpart seems to be a primary tendency to hematogenic spread. Further research is needed to confirm these findings.

Temporal Craniotomy for Surgical Access to the Infratemporal Fossa

We propose a surgical approach for select patients that minimizes morbidity while allowing gross total resection of lesions in the anterior portion of the infratemporal fossa. The approach we describe is an extradural approach through a subtemporal craniectomy or craniotomy with the possible addition of a zygomatic osteotomy. Lesions that have a well-defined capsule and a texture that permits manipulation are ideal for this less invasive approach. We retrospectively reviewed six cases from the primary author (C.B.H.) using a temporal craniectomy or craniotomy alone to resect lesions in the infratemporal fossa. All six cases had good clinical outcomes with no unexpected neurological deficits while achieving gross total resections. The only complication included one cerebrospinal fluid leak that was sealed endoscopically. For select lesions, a less morbid surgical approach via an extradural window through a subtemporal craniectomy or small craniotomy may be preferable to transfacial approaches. Adjuvant use of endoscopic techniques may facilitate surgical exposure and resection of large lesions.

Transfacial approach, pedicled rhinotomy for a clival chordoma: a technical report

Clival chordomas are frequently midline structures. Due to their critical location, invasive nature and aggressive recurrences, skull base chordomas are difficult to manage surgically. We present a case operated on with the pedicled transnasal and transfacial approach. The case presented with neurological deficits as cranial nerve palsy and findings of brainstem compression. The lesion was removed without any neurological deficit. Her deficits related to brainstem compression regressed after surgery. In our case, a large exposure was achieved through a lateral nasal incision in order to excise the tumor totally with acceptable cosmetic results, and a successful outcome was observed during the postoperative follow-up period with the surgical procedure applied.

Endoscopic Anatomy and Approach of the Superior Orbital Fissure

Background: Conventional approaches to the superior orbital fissure are usually represented by modified pterional, fronto-orbital, and fronto-orbitozygomatic, and transfacial approaches. Because the expanded endoscopic endonasal approach is currently a valid, minimally invasive alternative in the cranial base surgeon's armamentarium, and can be used for the treatment of midline and lateral expanded lesions, a detailed knowledge of the anatomy of this region is crucial.

Novel Use of Radiofrequency Plasma Ablation (Coblation) in the Endonasal Resection of a Stage IIIb Juvenile Nasopharyngeal Angiofibroma

Minimally invasive techniques and technologies have enabled endonasal resection of skull base lesions such as juvenile nasopharyngeal angiofibroma (JNA), avoiding, in some cases, open transfacial approaches. In the pediatric population, conventional open approaches are especially concerning because they are not only less cosmetically desirable but may also potentially interrupt facial development. We report the case of a 12-year-old boy who presented with nasal congestion and anosmia and was subsequently diagnosed with Radkowski's Stage IIIb JNA. The tumor was extensive, filling the right nasal cavity with cavernous sinus, sphenoid, clival, orbital, and infratemporal fossa invasion. The patient underwent preoperative interventional angiography with embolization 1 day before surgery. We resected the tumor through an entirely endonasal approach using conventional endonasal dissection techniques augmented with Coblation (ArthoCare ENT, Austin, Texas). We discuss the first reported case, combining Coblation with endonasal resection of a JNA, with particular emphasis on advantages afforded by this novel technology, including low blood loss, improved visualization during dissection, improved mobilization of the tumor during resection, decreased charring of tissues, and significantly decreased operative time. Coblation has the potential to enhance our ability to safely and effectively perform minimally invasive resections in endonasal surgery.

Large olfactory neuroblastoma (esthesioneuroblastoma) surgically treated with an Altemir technique modification: a case report

Olfactory neuroblastomas are rare malignant tumors that usually occur in the upper nasal cavity. The purpose of this paper is to present a case of a large olfactory neuroblastoma filling the entire nasal cavity, treated with an Altemir technique modification. A 39-year-old woman presented with a large tumor of the nasal cavity. After the laboratory examinations, the tumor was classified as a Kadish stage A olfactory neuroblastoma. The selected treatment was the surgical excision after an Altemir technique modification combined with midfacial degloving and additional radiotherapy. Histopathology revealed a Hyams grade III olfactory neuroblastoma completely removed. Although the patient refused the additional radiotherapy, 18 months postoperatively, there were no signs of recurrence, and the patient shows big improvement on her sense of smell. Large olfactory neuroblastomas filling the entire nasal cavity extending back to the postnasal space can be completely removed using a transfacial approach as the Altemir technique modification is.

Olfactory Neuroblastoma (Esthesioneuroblastoma) Treated by Combined Extensive Transbasal and Transfacial Approach

Introduction: Esthesioneuroblastoma is an uncommon tumor arising from the olfactory epithelium of the nasal cavity. Most cases present clinically with nonspecific findings, such as unilateral nasal obstruction and intermittent epistaxis, and diagnosis can often be directed toward other diseases of the nasal cavity.

Transcranial resection of a large sinonasal juvenile psammomatoid ossifying fibroma

Juvenile psammomatoid ossifying fibroma (JPOF) is a benign but potentially locally aggressive fibroosseous lesion predominantly arising in the paranasal sinuses in children and young adults. Intracranial extension is rare but occurs sometimes. In such cases, tumor resection may often require the combination of neurosurgical and facial approaches. Histological diagnosis remains a challenge because the lesion can be easily mistaken for another fibroosseous lesion or for a meningioma. We report the case of a 12-year-old boy with a JPOF arising from the right paranasal sinuses and extension towards the anterior skull base and the orbit. Despite the tumor had eroded through nasal septum, medial orbit wall, and right maxilla, it could be entirely removed performing an extended frontobasal approach via a bifrontoorbital craniotomy, obviating the need for a transfacial approach. Radiologically and histologically, the lesion could be mistaken either for a meningioma or another type of ossifying fibroma. Histological aspects and alternative surgical approaches to these rare entities are discussed.

The HD-Panoramic Visualization System: a new visualization system for ENT surgery

This work examines the application possibilities of a new visualization system, the Panoramic Visualization System (HD-PVS), in ENT surgery. The Panoramic Visualization System (PVS) is a novel optical system that is neither an endoscope nor a microscope. It has a focal length of 200 mm, a wide field of view and is used together with an HD camera and an HD monitor (HD-PVS). The analysis of the visualization quality took place in laboratory conditions using 4 close-to-surgery scenarios with altogether 40 data points. Further, the system was used on patients in 45 procedures (tympanoplasty, parotidectomy, neck dissection, septumplasty, transfacial approaches). The results were analyzed following the ICCAS workflow-scheme and with standardized questionnaires. In the analysis of the visualization quality, the PVS exhibited the best total evaluation in the lab test in two out of four scenarios. In one of four scenarios, the PVS as well as the microscope achieved the maximum attainable score. In one out of four scenarios, the endoscope attained a better result than the PVS. The microscope was never superior to the HD-PVS in terms of image quality. In four out of five clinical applications, the PVS was evaluated as operational with slight modifications. Most development is needed in middle ear surgery applications. The remaining procedures already benefit in the system configuration examined here, and they were regularly accomplished with support of the PVS. The present study offers a good basis for introducing the PVS to ENT surgery. The advantages over the existing gold standard include lower initial costs for the optical system than for an operating microscope since the HD-video system is often already in place, smaller space requirements than a microscope, equal or at times better visualization quality than the microscope, the possibility of videoendoscopic representation of surgeries in which this was impossible before, and better ergonomic conditions.