Complications of craniofacial resection for tumors involving the anterior skull base

Complications of skull base surgery: an analysis of 30 cases

OBJECTIVES

To evaluate the risk factors for perioperative complications among patients undergoing craniofacial resection for the treatment of skull base tumors.

DESIGN

Retrospective analysis.

PARTICIPANTS

The study group comprised 29 patients with skull base tumors (22 malignant and 7 benign) who underwent 30 craniofacial resections at Hokkaido University Hospital between 1989 and 2006. Of these cases, 21 had undergone prior treatment by radiation (16 cases), surgery (7 cases), or chemotherapy (1 case). Moreover, 19 needed extended resection involving the dura (11 cases), brain (5 cases), orbit (12 cases), hard palate (5 cases), skin (3 cases), or cavernous sinus (2 cases).

MAIN OUTCOME MEASURES

Perioperative complications and risk factor associated with their incidence.

RESULTS

Perioperative complications occurred in 12 patients (40%; 13 cases). There was a significant difference between complication rates for cases with and without prior therapy (52.4% vs. 11.1%). The complication rate for dural resection cases was 81.8%. There was a significant difference between complication rates for cases with and without dura resection. No postoperative mortality was reported.

CONCLUSIONS

Craniofacial resection is a safe and effective treatment for skull base tumors. However, additional care is required in patients with extended resection (especially dural) and those who have undergone prior therapy.

Sinonasal undifferentiated carcinoma: current trends in treatment

Sinonasal undifferentiated carcinoma (SNUC) is a rare and highly aggressive neoplasm of the paranasal sinuses, which has recently been characterized as a distinct pathologic entity. The prognosis for patients with SNUC is poor. Early case reports describe patients with lesions that were clinically advanced at initial presentation and surgically unresectable. Survival was reported in months after treatment with chemotherapy and radiation. As more experience was gained with treatment of SNUC, it was found that aggressive, combined surgical therapy of lesions previously considered unresectable has shown increased survival. We report a case of a 38-year-old man with SNUC originating in the posterior ethmoid, extending into the anterior cranial fossa and orbit, who was treated with preoperative hyperfractionated radiation therapy, chemotherapy, and craniofacial resection.

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 re-recurrent 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.

Perioperative outcomes in patients undergoing the transglabellar/subcranial approach to the anterior skull base

We analyzed the effect of predefined patient demographic, disease, and perioperative variables on the rate of complications in the perioperative period following subcranial surgery for anterior skull base lesion. A secondary goal of this study was to provide a benchmark rate of perioperative mortality and morbidity through comprehensive analysis of complications. Retrospective review of a consecutive series of patients (n = 164) who underwent the transglabellar/subcranial approach to lesions of the anterior skull base between December 1995 and November 2009 in a tertiary referral center. Main outcome measures were perioperative morbidity and mortality. No perioperative mortalities were observed over the period of consecutive review. The overall complication rate was 28.7%, with 30 (18%) patients experiencing major complication. Multivariate analysis revealed that the following variables were independent predictors of perioperative complication of any type: positive margins on final pathology, perioperative lumbar drain placement, and dural invasion. The subcranial approach provides excellent access to the anterior skull base with zero mortality and acceptable morbidity in comparison with other contemporary open surgical approaches. It should be considered a procedure with distinct advantages in terms of perioperative morbidity and mortality when selecting a therapeutic approach for patients with anterior skull base lesions.

Endoscopic endonasal craniotomy in the management of selected ethmoidal malignancies: the University of Pisa experience

The authors reviewed the medical records of patients who had undergone endoscopic endonasal craniotomy in our department between 2005 and 2009. Thirteen patients were included in this study: 12 males and 1 female. Patients were affected by ethmoidal malignancies abutting or involving the anterior skull base. In all the patients the anterior skull base was drilled down. Nine patients underwent dural resection. The procedure always included a skull base reconstruction. Postoperative complications included CSF leak, subdural haematoma and pneumocephalus. Our results show that endoscopic endonasal surgery can be a viable alternative to anterior craniofacial resection in the management of selected ethmoidal malignancies. The limited morbidity and high success rate fit well with the data in the literature and make this treatment option advisable.

Combined Endoscopic Endonasal Surgery and Fractionated Stereotactic Radiosurgery (fSRS) for Complex Cranial Base Tumors—Early Clinical Outcomes

Endoscopic endonasal surgery (EES) has been shown to be a feasible approach to cranial base tumors while reducing post-operative morbidity. Using the endoscopic endonasal approach alone or in combination with open approaches may provide advantages over conventional approaches. However, the balance between maximal resection and minimal injury to neurovascular structures frequently precludes gross total resection (GTR). Consequently, adjuvant radiation therapy may be an important option to improve local control (LC) of residual disease. In this retrospective series, we report clinical outcomes, morbidity, and LC of 40 patients with cranial base tumors treated with EES +/- combined open approach followed by fSRS (CyberKnife, Accuray Inc.). 26 patients had benign disease, 7 had newly diagnosed malignant disease, and 7 had previously resected malignant disease. Surgical outcomes were evaluable in all patients. LC after fSRS was evaluable in 39 patients and defined as no evidence of regrowth by MRI, CT, & physical examination. GTR was achieved in 12/40. Median post-operative length of stay (LOS) was 3 days. In multivariable analysis controlling for anatomic location and malignant histology, post-operative complications (n = 10) were significantly associated with patients having combined open and EES (p < 0.01, OR = 16.9). SRS was delivered in 1–5 sessions to a median marginal dose of 24.9 Gy. Median follow-up was 24.7 months (range, 1.5 to 61 months). LC was achieved in 89.7% (35/39) of evaluable patients. LC was achieved in 11/12 patients who had GTR. Median progression-free survival was 19.7 months (21.0 months for benign tumors (n = 26), 5.8 months for previously resected malignant disease (n = 7), and 21.2 months for newly diagnosed malignant disease (n = 7). Of the 31 patients who had symptomatic disease at presentation, 18 (58%) reported complete symptom resolution, 9 partial, and 4 no improvement. One patient who received two prior courses of radiation therapy developed osteosclerosis (grade III). Other adverse events were erythema (grade I, n = 5), nausea (grade II, n = 2), conjunctivitis (grade II, n = 1). EES followed by fSRS is a safe and effective management strategy for selected cranial base tumors. EES combined with an open surgical approach may result in increased complications. However, initial follow-up offers encouraging results indicating shorter time to recovery, acceptable LC rates compared to conventional approaches, and similar median time to progression for benign and newly diagnosed malignant disease.

Low-profile 1-piece bifrontal craniotomy for anterior skull base approach and reconstruction

OBJECTIVE

The anterior skull base is a location of many pathologic lesions. These pathologic lesions are treated by bifrontal craniotomy and anterior skull base approach, either primarily or combined with facial osteotomies. To obtain wide exposure, low-profile craniotomies are preferred. In this article, we attempt to describe our own technique of frontal craniotomy for anterior skull base approach. In this technique, the frontal bone, frontal sinus, and the superior supraorbital bar are elevated in en bloc fashion.

METHODS

Bicoronal skin incision is followed by dissection and retraction of the skin flap in the epigaleal plan. The pericranial galeal flap is dissected separately in subperiosteal fashion until the superior orbital rim. After dissection and retraction of the tip of the temporal muscles, bilateral pterional key burr holes and 1 or 2 parasagittal burr holes are opened. The sagittal burr hole(s) is placed in the point where the upper horizontal surface of the frontal bone slopes vertically downward the forehead. With the craniotome rotating tip (Midas F2/8TA23, Medtronic Inc, Ft Worth, TX), bone cut is made between the pterional key burr holes, passing through the superior orbital bar and the anterior wall of the frontal sinus. To minimize the brain retraction, the operating microscope is placed beside the head, and exposure from the lateral view angle is obtained. Reconstruction of the defect is performed by using pericranial galeal flap and/or Cortoss (Orthovita, Malvern, PA).

RESULTS

With this approach, wide exposure of the anterior skull base pathologic lesions was achieved with minimal brain retraction. In the postoperative period, patients tolerated this approach well with favorable functional and cosmetic outcomes. No infections or adverse effects related to this technique or Cortoss were observed.

CONCLUSIONS

Anterior skull base pathologic lesions can be widely exposed by low-profile bicoronal craniotomy and anterior skull base approach with minimal brain retraction. This wide exposure allows us to gain more control of the pathologic lesion with better resection and reconstruction, reflected on the prognosis of the patients.

Anterior skull base surgery

The basic principle of anterior skull base surgery is to provide adequate exposure to enable three dimensional resection of skull base tumors. Negative surgical margins, which is within the control of surgeon, is the principle prognostic factor in anterior skull base tumors. Open skull base approaches is the standard of care for malignant anterior skull base tumors. Benign lesions may be resected by alternate minimally invasive approaches. Advances in anterior skull base surgery, in particular the facial translocation approaches allows wide exposure of the tumors with minimal retraction of the brain. The outcome of anterior skull base tumors have steadily increased over the years with disease free survival comparable to other malignant neoplasm of the head and neck region. This review described various surgical approaches and pertaining anatomy and pathology of anterior skull base tumors.

Principles of Skull Base Reconstruction After Ablative Head and Neck Cancer Surgery

“Resection of malignancies of the skull base can result in significant functional and cosmetic morbidity as well as mortality. Reconstructive efforts provide not only functional and cosmetic rehabilitation, but also allow for the avoidance of potentially disastrous complications such as cerebrospinal fluid leak or meningitis. The optimal reconstruction is determined both by a patient based approach and a defect based approach. Skull base defects can be addressed by the separate components of the craniofacial skeleton in which they involve, and therefore the individual reconstructive issues which must be addressed. In this article, we describe an approach to skull base reconstruction and the technical aspects of the available reconstructive options.

Complications after craniofacial resection for malignant tumors: Are complication trends changing?

Objective: To determine the rate and type of complications after craniofacial resection (CFR) during the most recent 10-year period in comparison to a historic control.

Methods: Patients underwent CFR in 1973–1995 (“earlier” period; n = 114) and in 1996–2005 (“later” period; n = 120) before and after a broad-spectrum antibiotic regime was used.

Results: In the later period patients had higher rates of comorbidity, dural invasion, high-grade malignancy, and wide resections ( P < 0.02). Complications were identified in 52 percent of the early and 33 percent of the later groups ( P = 0.002). There was 20 percent decrease in wound complications in the later period ( P < 0.0001), but not in other complications. In the earlier period, complications were evenly distributed between patients younger and older than 50 years. However, in the later period, most complications occurred among elderly patients. Multivariate analysis revealed that a broad-spectrum antibiotic regime was associated with a lower complication rate ( P = 0.02).

Conclusions: Complication rates decreased during the last 10 years due to a decline in wound infections. Broad-spectrum antibiotic coverage probably contributed to this change.

Neuronavigational guidance in craniofacial approaches for large (para)nasal tumors involving the anterior skull base and upper clival lesions

OBJECTIVE

Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension is often challenging. In this relation computer assisted surgical (CAS) guidance might be a useful tool. Here, we explored the use of CAS in an interdisciplinary setting.

METHODS

The surgical series consists of 13 patients who underwent a lateral rhinotomy combined with a subfrontal craniotomy in case of significant intracranial tumor extension. The procedures were planned and assisted by advanced CAS techniques with image fusion of CT and MRI. Tumors included carcinomas (one case associated with an olfactory groove meningioma), esthesioneuroblastoma, chordoma, chondrosarcoma and ganglioglioma.

RESULTS

The application of CAS in the combined approaches was both safe and reliable for delineation of tumors and identification of vital structures hidden or encased by the tumors. There was no perioperative 30-day mortality; however two patients died 5 weeks and 5 months after craniofacial tumor resection due to worsening medical conditions. The most common perioperative morbidity was postoperative wound complication in two cases. Tumors were either removed completely, or subtotal resection was achieved allowing targeted postoperative radiotherapy.

CONCLUSION

Craniofacial approaches with intraoperative neuronavigational guidance in a multidisciplinary setting allow safe resection of large tumors of the upper clivus and the paranasal sinuses involving the anterior skull base. Complex skull base surgery with the involvement of bony structures appears to be an ideal field for advanced navigation techniques given the lack of intraoperative shift of relevant structures.

Endoscopic versus traditional craniofacial resection for patients with sinonasal tumors involving the anterior skull base

OBJECTIVES

With the advent of microdebriders and image guidance systems, endoscope-assisted surgery is now more widely used for the treatment of tumors involving the base of the skull. The aim of this study was to analyze the clinical features of tumors involving the anterior skull base and to evaluate the treatment outcomes according to the surgical approach, which included the traditional craniofacial resection (TCFR) and the endoscopic craniofacial resection with craniotomy (ECFR).

METHODS

Forty-six patients who underwent craniofacial resection from 1989 through 2006 at Seoul National University Hospital and Seoul National University Bundang Hospital were included in this study. Demographics, histology, surgical management, surgical outcomes, complications, and morbidity were analyzed.

RESULTS

The number of malignant and benign lesions was 40 and 6 cases respectively. The most common diagnosis was olfactory neuroblastoma occurring in 41% of the cases followed by squamous cell carcinoma and malignant melanoma. Thirty-six patients underwent TCFR, while ECFR was performed with or without adjunctive chemotherapy or radiotherapy in 10 patients. The overall five-year survival rate for patients with malignant tumors of the anterior skull base was 47.4%. Out of 19 patients with olfactory neuroblastomas, 10 patients had TCFR and six among them died of their disease. Nine patients underwent ECFR, and none of them died of their disease. The ECFR group had lower morbidity and cosmetic deformity than did the TCFR group.

CONCLUSION

The ECFR may be considered as an alternative option for the treatment of selected tumors with anterior skull base invasion. This approach offers the advantages of avoiding facial incisions with comparable treatment results.

The Use of Nasopharyngeal Airways for Airway Diversion in Anterior Craniofacial Resection

Background

Tension pneumocephalus is an uncommon, but life-threatening, postoperative complication associated with craniofacial resection. This study was performed to evaluate our institution's experience using nasal trumpets for airway diversion.

Methods

A retrospective chart review was performed of patients who underwent anterior craniofacial resection (ACR) from 2000 to 2006. After Institutional Review Board approval, charts were reviewed with specific attention to short- and long-term complications.

Results

Twenty-two patients have undergone ACR since 2000 and had nasopharyngeal airways postoperatively. Nineteen patients (86.4%) were extubated on the day of surgery. Fourteen patients (63.6%) spent 1 day in an intensive care unit for observation. Nasal trumpets remained in place for an average of 7.3 days and patients had an average hospital stay of 7.4 days. Complications occurred in 14 patients (63.6%), with infection as the most common cause. No cases pneumocephalus, meningitis, epidural abscess, or bone flap loss occurred in this group of patients.

Conclusion

We present the use of nasopharyngeal airways in postoperative ACR patients as a successful method of airway diversion, which can significantly reduce the incidence of postoperative pneumocephalus and related morbidity.

Anterior and middle cranial fossa skull base reconstruction using microvascular free tissue techniques: surgical complications and functional outcomes

Surgical ablation for oncologic disease requiring skull base resection can result in both facial disfigurement and a complex wound defect with exposed orbital content, oral cavity, bone, and dural lining. Inadequate reconstruction can result in brain abscesses, meningitis, osteomyelitis, visual disturbances, speech impairment, and altered oral intake. This study assesses the functional outcomes of patients who undergo anterior and middle cranial fossa skull base reconstruction using microsurgical free tissue transfer techniques. Using a prospectively maintained database, a 10-year, single institution retrospective chart review was performed on patients who had surgery for anterior and middle cranial base tumor resections. The type of resection, reconstruction method, complication rate, and functional outcomes were reviewed. From 1992 to 2003, 70 patients (49 men, 21 women) with a mean age of 54 (age 6-78) underwent anterior and middle cranial skull base tumor resection and reconstruction. The patients were divided into the following groups: maxillectomy with orbital content preservation (n = 21), orbitomaxillectomy with palatal preservation (n = 26), and orbitomaxillectomy with palatal resection (n = 23). The average length of hospital stay was 12.6 days. The vertical rectus abdominis myocutaneous flap was used in the majority of cases to correct midface defects. Two flaps required emergent re-exploration; however, there were no flap failures. Early and late postoperative complications were investigated. Cerebrospinal fluid was observed infrequently (7%) and did not require additional surgical intervention. Intracranial abscesses were encountered rarely (1.4%). Patients who had maxillectomy with orbital preservation and reconstruction had minor ophthalmologic eyelid changes that occurred frequently. Patients who required palatal reconstruction had a normal or intelligible speech (93%) and unrestricted or soft diet (88%). Using a multidisciplinary surgical team approach, there is an increasing role for reconstruction of complex oncologic midface resection defects using microvascular surgical techniques. Early/late complications and functional problems after anterior cranial base resections are uncommon when free tissue transfer is used concomitantly.

Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft

BACKGROUND

Endoscopic repair of small- to medium-sized anterior skull base (ASB) defects using bone, cartilage, fascia, fibrin glue, lipolized dura, and, more recently, acellular dermal allograft have all been described with equal efficacy. The purpose of this study was to review our experience with the use of acellular dermis as the sole graft material in endoscopic reconstruction of large ASB defects.

METHODS

A retrospective chart review of all patients who underwent endoscopic repair of ASB defects at the University of Miami between the years of 2001 and 2006 was conducted. Fifty-six patients were identified who met these criteria. All repairs were performed by a transnasal, endoscopic approach. Outcome measures included success of graft take and incidence of major and minor complications. Dural defect size was defined as small (<0.4 cm), intermediate (0.4-2.0 cm), and large (>2.0 cm).

RESULTS

AlloDerm (AlloDerm. LifeCell Corp. Woodlands, TX) was used as the primary graft material in 30/55 (55%) cases; 16/55 (29%) of the repaired defects were classified as large. Graft success was 97% in the AlloDerm group and 92% in the non-AlloDerm group. The incidence of major and minor complications in the AlloDerm group was 0 and 3.3%, respectively. In the non-AlloDerm group, the incidence of major and minor complications was 4 and 12%, respectively. There were no statistical differences in the complication rates based on the type of repair or defect size.

CONCLUSION

Alloderm can be used successfully to repair ASB defects, including large defects that are >2 cm in size with little or no morbidity.

Surgical outcomes and safety of transnasal endoscopic resection for anterior skull tumors

OBJECTIVE

To report the surgical outcomes and safety of transnasal endoscopic resection (TER) for anterior skull base (ASB) tumors.

STUDY DESIGN AND SETTING

A retrospective chart review to identify patients undergoing TER for ASB tumors at a tertiary care medical center between September 1997 and June 2006.

RESULTS

Nineteen patients underwent TER for ASB tumors without open craniotomy. There were 17 malignant and two benign lesions. Olfactory neuroblastoma was the most common pathology, occurring in 53 percent of patients. One patient recurred locally, resulting in an overall local control rate of 94.7 percent for all neoplasms and 94.1 percent for malignant disease. It should be noted that the tumor control rate may be premature given the small sample size and limited follow-up. Overall, there were 16 complications, but only two of these, an orbital hematoma and a frontal lobe abscess, were considered major complications directly attributable to surgery.

CONCLUSIONS

TER for ASB tumors appears to be safe in properly selected patients. In light of the small sample size and limited follow-up, the major complication rate directly attributable to surgery was 11 percent, and the overall local control rate was 95 percent. A larger multi-institutional series with longer follow-up is warranted.

Microvascular reconstruction of the skull base: a clinical approach to surgical defect classification and flap selection

Skull-base tumor resection and reconstruction produce a major physiologic and anatomic impact on the patient. At our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex cranial base defects involving resection of dura, brain, or multiple major structures adjacent to skull base, including the orbit, palate, mandible, skin, and other structures. The goals of reconstruction are to: (1) support the brain and orbit; (2) separate the CNS from the aerodigestive tract; (3) provide lining for the nasal cavity; (4) re-establish the nasal and oropharyngeal cavities; (5) provide volume to decrease dead space; and (6) restore the three-dimensional appearance of the face and head with bone and soft tissues. Surgical management requires a multidisciplinary effort with collaborating neurosurgical, head and neck, and plastic surgical teams. Successful reconstruction of skull base defects is predicated upon a careful appreciation of the specific region. Defects may be classified based on their anatomic location and loss of volume, support, and skin cover. Free flaps provide reliable, well-vascularized soft tissue to seal the dura, obliterate dead space, cover exposed cranial bone, and provide cutaneous coverage for skin or mucosa.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience

BACKGROUND

Craniofacial resection is the established "gold standard" for surgical treatment of tumors affecting the anterior skull base.

METHODS

This study analyzed 308 patients (220 males, 88 females) who had undergone craniofacial resection for sinonasal neoplasia with up to 25-year follow-up.

RESULTS

An overall actuarial survival of 65% at 5 years and 47% at 10 years was found for the cohort as a whole. For patients with malignant tumors, the 5-year actuarial survival was 59%, falling to 40% at 10 years. For patients with benign pathology, the actuarial survival was 92% at 5 years falling to 82% at 10 years. Statistical analysis again identified brain involvement, type of malignancy, and orbital involvement as the 3 most significant prognostic factors.

CONCLUSION

Analysis of one of the largest single institution cohorts over a 25-year period provides a baseline against which other approaches such as an entirely endoscopic skull base resection must be judged.

Long-term outcome of skull base surgery with microvascular reconstruction for malignant disease

BACKGROUND

Successful resection of malignant skull base disease depends implicitly on the ability to reconstruct the resulting defects in the craniovisceral diaphragm, to support neural structures, and to prevent ascending intracranial infections. Microsurgery reliably achieves these objectives and has increased the scope of curative oncologic surgery. The authors assessed the reconstructive results and the long-term oncologic outcome of patients having skull base surgery with free tissue transfer.

METHODS

A retrospective review of cases between 1989 and 2001 was undertaken. Demographics, histology, surgical management, complications, locoregional control, and survival were analyzed.

RESULTS

Predominantly male patients (n = 53; 62 percent) with an average age of 60 years had microvascular reconstruction following oncologic surgery. There was a preponderance of cutaneous malignancies (56 percent), and most lesions involved the anterior skull base (53 percent). Tumors were mostly resected with a combined intracranial or extracranial approach, and reconstruction was undertaken with radial forearm, rectus abdominis, or latissimus dorsi flaps with 94 percent success. Complications occurred in 23 percent of patients, and no specific risk factors for developing intracranial complications were identified. Specifically, extensive reconstructions did not increase the complication rate. The 5-year locoregional control and survival rates were 74 percent and 60 percent, respectively. A positive resection margin significantly increased the risk of locoregional recurrence and worsened disease-specific survival on Cox regression. Survival was also influenced by grade of malignancy.

CONCLUSIONS

Microsurgery is highly reliable for reconstructing defects resulting from oncologic resections of the cranial base. It can and should be undertaken using a small number of highly dependable flaps.

Craniofacial resection for cranial base malignancies involving the infratemporal fossa

OBJECTIVE

Cranial base malignancies involving the infratemporal fossa have been considered unresectable. Advanced operative techniques have made tumor resection feasible in an en bloc fashion with negative histological margins, but there are limited data regarding outcome analysis in patients who have undergone resection of malignant tumors in this area.

METHODS

At Memorial Sloan-Kettering Cancer Center, 25 patients underwent anterolateral cranial base resections for tumors that involved the infratemporal fossa during a 7-year period. The most common tumors were sarcoma (n = 9), squamous cell carcinoma (n = 6), and adenoid cystic carcinoma (n = 3). The median size of the tumors was 6 cm, and 12 tumors involved the anterior cranial base and/or orbit. Tumor resections were divided into three types. Twelve patients underwent Type 1 dissection for tumors involving only the infratemporal fossa and maxillary sinus; 2 patients underwent Type 2 dissections involving the infratemporal fossa and anterior cranial base; and 11 patients underwent Type 3 dissection, which included the infratemporal fossa, anterior cranial base, and orbit. All patients required free flap reconstruction, 22 of which were rectus abdominis free flaps.

RESULTS

Complications occurred in seven patients, including a single mortality resulting from a myocardial infarction. The 2-, 3-, and 5-year survival rates were 69, 63, and 56%, respectively. The relapse-free survival rates were 47% at 2 and 3 years and 41% at 5 years. Recurrences were local in nine patients and distant in four patients.

CONCLUSION

Despite the extensive nature of many infratemporal fossa tumors, they can be resected with acceptable morbidity. Survival rates approach those of anterior cranial base malignancies without infratemporal fossa involvement.

Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management

OBJECTIVE

During the past decade, applications of anterior and anterolateral cranial approaches for both benign and malignant pathologies have expanded in frequency and application. Complications associated with these procedures impact significantly on patient outcome. The primary aim of this study is to detail the strategies for complication management and avoidance developed from experience with 120 patients who underwent anterior and anterolateral cranial base procedures during the past 14 years.

METHODS

Between July 1990 and February 2004, 62 male and 58 female patients underwent 120 combined (neurological surgery and otolaryngology joint participation) anterior and anterolateral cranial base procedures. Fifty-four percent had malignant pathology, and 46% had benign pathology. The approaches taken were transfacial (10%), extended subfrontal (33%), lateral craniofacial (23%), and anterior craniofacial (35%). Thirty-day morbidity and mortality were analyzed.

RESULTS

Twenty (17%) patients experienced at least one complication. Malignancy and reoperation, regardless of histology, appeared to affect the complication rate. A decline in complications occurred with experience, in part because of changes in management that reflected the complication experience (25% in Patients 0-31, 18% in Patients 32-70, 10% in Patients 71-120). Methodology is detailed for avoidance and management of retraction injury, infection, tension pneumocephalus, cerebrospinal fluid leak, pericranial flap failure, free flap sizing, dural banding, intracranial hypotension, and cerebrovascular events. Individual patient analysis, complications timing, and strategy for management are discussed.

CONCLUSION

Improved patient outcomes for anterior and anterolateral cranial base surgery are, in part, directly related to the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.

Endoscopic Management of Sinonasal Malignancy

The advent of rigid telescopes has revolutionized the management of rhinologic disease. These instruments have been used as a diagnostic and therapeutic tool for paranasal sinus inflammatory diseases since the 1970s. Endoscopic techniques have been used for treating increasingly complex intranasal pathology, including nasolacrimal duct obstruction, cerebrospinal fluid leaks/encephaloceles, dysthyroid orbitopathy, and optic neuropathy. Recently, endoscopic techniques have also been used successfully to manage selected tumors, including inverted papilloma, angiofibromas, and hypophyseal tumors. This article reviews patient evaluation strategies, surgical techniques, and outcomes data for the minimally invasive endoscopic resection.

Craniofacial resection for malignant tumours involving the anterior skull base

Ethmoid malignant tumours are rare, but nearly all at least approach or involve the lamina cribrosa. An anterior craniofacial resection is almost always mandatory for a radical resection. While almost everything has been written about technical details, few studies reported meaningful analysis about prognostic factors and long-term results, for a series of reasons: the infrequency of these tumours, the variety of histologies, small patients cohorts presented by each author, a medley of untreated and pre-treated patients, the lack of a universally accepted classification. We perform a review of the literature in the light of our experience of 330 anterior craniofacial resections for ethmoid malignant tumours. We present our classification of ethmoid malignant tumours (called INT, Istituto Nazionale Tumori). It turned out to be more prognostic than AJCC-UICC classification.

Complications of craniofacial resection for malignant tumors of the skull base: report of an International Collaborative Study

BACKGROUND

Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient-related and tumor-related predictors of postoperative morbidity and mortality and set a benchmark for future studies.

METHODS

One thousand one hundred ninety-three patients from 17 institutions were analyzed for postoperative mortality and complications. Postoperative complications were classified into systemic, wound, central nervous system (CNS), and orbit. Statistical analyses were carried out in relation to patient characteristics, extent of disease, prior radiation treatment, and type of reconstruction to determine factors that predicted mortality or complications.

RESULTS

Postoperative mortality occurred in 56 patients (4.7%). The presence of medical comorbidity was the only independent predictor of mortality. Postoperative complications occurred in 433 patients (36.3%). Wound complications occurred in 237 (19.8%), CNS-related complications in 193 (16.2%), orbital complications in 20 (1.7%), and systemic complications in 57 (4.8%) patients. Medical comorbidity, prior radiation therapy, and the extent of intracranial tumour involvement were independent predictors of postoperative complications.

CONCLUSIONS

CFR is a safe surgical treatment for malignant tumors of the skull base, with an overall mortality of 4.7% and complication rate of 36.3%. The impact of medical comorbidity and intracranial tumor extent should be carefully considered when planning therapy for patients whose tumors are amenable to CFR.

A Standardized Regimen of Antibiotics Prevents Infectious Complications in Skull Base Surgery

OBJECTIVES/HYPOTHESIS

Craniofacial surgery has been associated with a significant improvement in disease outcome for patients with skull base neoplasms. Despite this improved survival, complications remain considerable. One major source of complications is infectious events. The current study was designed to evaluate a prospectively designed antibiotic regimen and its impact on the incidence and severity of infectious complications. This regimen was compared with a group of historic controls in which antibiotics were administered on an ad hoc basis. The specific objectives/hypothesis were to determine 1) the incidence and severity of infection in a group of patients treated with a nonstandardized antibiotic regimen undergoing craniofacial resection, and 2) whether the use of a prospectively designed, three-drug, broad spectrum antibiotic is associated with a reduced incidence and severity of infections.

STUDY DESIGN

A single-arm, prospective antibiotic regimen consisting of ceftazidime, flagyl (metronidazole), and vancomycin (CMV) was compared with a historic control of patients treated with nonstandard antibiotic therapy (nonCMV), all of whom underwent craniofacial resection. Outcome measures focused on incidence of infection, severity of infection, and operative mortality.

METHODS

In July 1990, a retrospective review (1973-1990) was performed of craniofacial resection. Beginning in July 1990, a prospective database (1990-2003) has been maintained. Demographics, prior therapy, anatomic site of origin and extent of disease, pathology, standard surgical data, and postoperative therapy were detailed. Antibiotic data were collected from chart review. Complications, focusing on infectious complications, were identified and categorized. Culture results and whether the inciting infection was sensitive or resistant to perioperative antibiotics were noted. Length of hospital stay was tabulated. Disease outcome, including incidence of postoperative mortality, was maintained for each patient.

RESULTS

A total of 211 patients underwent craniofacial resection from 1973 to 2003. Major medical comorbidities were present in 53 (25%) patients, and 96 (46%) had prior therapy. The standardized antibiotic therapy (CMV) was used in 90 patients, and the nonstandardized antibiotics (nonCMV) were used in 107 patients. Free flap reconstruction was the sole surgical factor associated with a marked reduction in complications. Infectious wound complications were 11% within the CMV group versus 29% in the nonCMV regimen (P = .002). Moreover, the severity of infections was greatly diminished in the CMV group (P = .0001). With use of a multivariate analysis, the only factor which was predictive of infectious complications was the use of CMV. Patients who received nonCMV antibiotic therapy faced a risk of infection that was 2.5 times higher than those who received CMV. Hospital stay in days and operative mortality were both adversely affected by the use of nonCMV antibiotic therapy.

CONCLUSIONS

The data supports the hypothesis that the use of a three-drug, broad spectrum antibiotic regimen in skull base surgery reduces the incidence of infectious complications and appears to reduce operative mortality. Broad spectrum coverage of Gram-positive, Gram-negative, and anaerobic pathogens leads to a marked reduction in infectious complications. Broad spectrum antibiotic coverage avoids many infectious complications and ultimately had a positive impact on patient outcome, quality of life, and, potentially, survival.

Pericranial Wrapping of the Frontal Bone after Anterior Skull Base Tumor Resection

BACKGROUND

Classic craniofacial resection and the subcranial approach are well-established techniques for the removal of tumors involving the anterior skull base. These techniques require frontal craniotomy to allow broad exposure of the anterior cranial fossa, a procedure that may be further complicated by local infection and osteomyelitis or because of a reduction in tissue perfusion and direct communication between the osteotomy and the contaminated nasoethmoidal cavity. The authors present a new method for wrapping of the frontal bone segment with a pericranial flap with the intention of preventing these serious complications.

METHODS

By means of this new approach, the frontonaso-orbital bone segment is removed, the frontal sinus bone is cranialized, and the frontonaso-orbital segment is repositioned in its original anatomical place following tumor extirpation. Wrapping is accomplished by a double-sided covering of the bone segment with the pericranial flap. This vascularized tissue is guided underneath the bony segment to cover the intranasal surface and then is externalized over the entire frontal area. The frontonaso-orbital segment and its overlying pericranial flap are fixed with the prebent titanium plates.

RESULTS

To date, the authors have performed 20 subcranial operations for resection of malignant tumors of the anterior skull base using this technique. None of these patients developed bone flap necrosis or osteomyelitis following radiotherapy. In the authors' hands, the rate of osteoradionecrosis was significantly lower in patients undergoing malignant subcranial tumor resection with pericranial wrapping than in those operated on before the study was activated (0 percent versus 20 percent, respectively; p = 0.056).

CONCLUSIONS

Pericranial wrapping is suitable for patients undergoing extirpation of anterior skull base tumors and for whom perioperative radiotherapy is recommended and for patients who have undergone multiple surgical procedures.

Vascular Anatomy of the Anteriorly Based Pericranial Flap

OBJECTIVE:

The purpose of this study was to examine the vascular supply of the anteriorly based frontal pericranial flap to determine whether separating the pericranium from the galea above the orbital rim would devascularize the pericranial flap.

METHODS:

The arteries supplying and the veins draining the frontal pericranial flap were examined in 17 adult cadavers using ×3 to ×30 magnification. The arteries were examined on 25 sides and the veins on 16 sides.

RESULTS:

The main trunk and superficial branches of the supraorbital and supratrochlear arteries, which course in the galea-frontalis muscle layer, give rise to the deep branches that supply the pericranium. These pericranial branches may arise in the orbit or at the level of or above the orbital rim. Pericranial arteries that arose above the level of the orbital rim and would be divided in separating the galea and pericranium were found in 28% of the sides examined. Pericranial veins that coursed above the orbital rim and would be divided in separating the galea-frontalis muscle layer from the pericranial layer were found in 43.8% of the sides examined.

CONCLUSION:

In preparing a pericranial flap based anteriorly on the supraorbital rim, the separation of the galea-frontalis muscle layer from the pericranium layer should not extend into the 10 mm above the supraorbital rim if the arterial and venous pedicle of the pericranial flap is to be preserved.

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation

INTRODUCTION

Malignancies of the nasal and paranasal sinuses are uncommon tumors, accounting for only 3% of all aerodigestive tract neoplasms. Despite advances in surgical techniques and continued evolution of adjuvant therapies, the 5-year mortality remains unusually high at greater than 50%. In 1996, we begin utilizing a novel strategy in the treatment of advanced sinonasal carcinomas. This consisted of neoadjuvant selective intra-arterial cisplatin with concurrent radiation therapy (acronym RADPLAT) followed by a conservative craniofacial resection. We now report our results for 11 patients treated with this regimen.

METHODS

Between July 1996 and April 2003, 11 patients with advanced sinonasal malignancies underwent treatment utilizing the RADPLAT protocol followed by a planned surgical resection via a craniofacial approach. Patient charts, operative notes, follow-up clinic notes, and pre- and post-operative imaging studies were reviewed in detail for each subject.

RESULTS

Histopathological analysis of the tumors revealed seven squamous cell carcinomas (64%), two adenocarcinomas (18%), one adenoid cystic carcinoma (9%), and one sinonasal undifferentiated carcinoma (9%). T4N0M0 disease was present in nine patients (81%), and two patients had T3N0M0 disease (19%). Survival was calculated using the Kaplan-Meier method with an overall survival of 81% at 5 years and a progression-free survival at 5 years of 67%. Mean follow-up is 57.2 months ranging from 12 to 95 months.

CONCLUSIONS

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation results in a significant improvement in survival. This can be done safely with high response rates and excellent loco-regional control in T3 and T4 disease. Although are results are encouraging, there is a need for a cooperative, multi-institutional, prospective study.

Craniofacial resections in the elderly: an outcome study

Object. The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort.

Methods. All patients 70 years of age or older undergoing CFR at the M. D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR.

There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%) (p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%) (p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04).

Conclusions. In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.

Adénocarcinomes de l’ethmoïde : expérience nantaise (80 cas)

OBJECTIVE

To present results of a retrospective analysis of eighty cases of ethmoid adenocarcinoma. Carcinologic and surgical results of anterior skull base resection via the transfacial approach are presented.

METHODS

Tumors were classified as 5% T1, 23% T2, 31% T3, 21% T4a and 20% T4b. Thirty-four patients were treated via a paralateronasal approach without skull base resection. Anterior skull bas resections were performed via the transfacial approach for 26 patients and by combined neurosurgical approach for 21.

RESULTS

Mean follow-up was 4.8 years. Survival rate was 63.4% at 5 years and 57.9% at 8 years. Forty-two patients were alive and disease-free at last follow-up. Three patients were alive with recurrence. The rate of local recurrence was 38.8%. Complications occurred in 20% of the patients who had a transfacial approach. Complications appeared to be less frequent than with the combined approach.

CONCLUSION

Prognosis is related to local control and could be improved by using skull base resection more systematically. In our experience this can be managed by a transfacial approach with similar carcinological results and less complications than the combined approach.

[Anterior craniofacial resection: oncologic outcome and complications in a series of 111 cases]

INTRODUCTION

Anterior craniofacial resection is a standardized procedure for the treatment of ethmoid and frontal orbital tumors with intracranial invasion.

METHODS

A retrospective review of 111 patients with sinonasal tumors involving the anterior skull base who underwent combined craniofacial surgery.

RESULTS

The most frequent pathological entity was adenocarcinoma (54 cases) and other epithelial tumors (29 cases). Five year actuarial survival according to the Kaplan-Meier method was 40%. Survival was affected by the histology of the tumor, brain involvement, and deep soft tissue involvement of the orbit. The UICC staging system did not show statistical prognostic significance. Complications occurred in 39 (35.1%) patients, resulting in 4 (3.6%) postoperative deaths. Major complications included cerebrospinal fluid leak in 18 patients, meningitis in 10, infection in 9, stroke in 4, and pneumocephalus in 4. The extent of the craniofacial resection was the most important factor associated with major complications.

CONCLUSIONS

Despite the advanced stage of most of the patients, anterior craniofacial resection succeeded in terms of an acceptable survival rate. Nevertheless, significant complications were observed although in most patients were not life-threatening and had no negative impact on the quality of life.

Reconstrução tridimensional da face nos tumores avançados com invasão da fossa craniana anterior

OBJETIVO: Analisar as indicações cirúrgicas e o seguimento pós operatório, ressaltando as complicações e efetividade da abordagem multidisciplinar, para os tumores avançados da base do crânio. MÉTODO: Análise retrospectiva de 46 prontuários de pacientes submetidos à ressecção de tumores invadindo a fossa craniana anterior e reconstruídos com retalhos microcirúrgicos, operados entre março de 1990 e julho de 2002. Todos os pacientes foram operados pelo núcleo de cirurgia de base do crânio do INCA. RESULTADOS: As estruturas mais envolvidas na ressecção foram por ordem: a órbita (76,5%), seio maxilar (76,5%), seio esfenoidal (63,8%), paredes da cavidade nasal (59,5%) e palato (42,5%). A dura-máter estava acometida em 32,6% dos casos. A reconstrução microcirúrgica utilizando os retalhos do músculo reto abdominal foi empregada em 93,5 % dos casos. A taxa de sucesso dos transplantes livres foi de 97,8%. As complicações ocorreram em 58,6% dos pacientes e as mais freqüentes foram: infecções locais (21,7%), fístulas liquóricas (15,2%), meningite (6,5%) e hematoma (6,5%). CONCLUSÕES: A reconstrução com técnica microcirúrgica permite que se realizem ressecções alargadas destes tumores com limites seguros e índices de complicações aceitáveis, permitindo a estes pacientes uma melhoria da qualidade de vida e da sobrevida, com baixo índice de recidiva.

Skull base reconstruction

Reconstruction of skull base defects following tumor resection is of paramount importance in avoiding serious and life-threatening complications. Cranial base surgery has evolved and outcomes have steadily improved as increasingly reliable reconstructive techniques have been adapted to repair the challenging wounds in this complex anatomic region. The most significant development has been the introduction and refinement of microvascular free tissue transfer to the skull base over the past 15 to 20 years. Free flaps can reliably provide the requisite tissue to not only seal the intracranial space from the subjacent cavities, but also to restore complex craniofacial defects that often result from skull base tumor excision. Advances in alloplast technology have also expanded the armamentarium available to the reconstructive surgeon. In particular, bone substitutes, titanium hardware, and resorbable plate fixation have been shown to be very efficacious when used in carefully selected situations. Finally, tissue sealants and adhesives have become widely used as an adjunctive method to achieve a water-tight dural repair.

Removal of ethmoidal malignant tumors by the isolated paralateronasal approach with resection of the cribriform plate and the dura mater

OBJECTIVE

A series of ethmoidal tumors was resected by an entirely extracranial approach through a lateral rhinotomy incision, with partial maxillectomy and removal of the cribriform plate and dura mater from below.

METHODS

Thirty-four consecutive patients (32 male, 2 female; mean age 64 years, range 45-78) with malignant tumors of the ethmoid sinus were operated by this technique between July 1998 and February 2002. All had complete tumor resection, including the cribriform plate and the dura mater. Excision was performed en bloc 23 times (68%). Although cerebral involvement was encountered in four cases (T4 IC), this technique was adequate for tumor resection, together with corticectomy when necessary. The method used for tumor resection and rebuilding of the anterior skull base is described in detail.

RESULTS

There were no immediate postoperative deaths. One patient developed pneumococcal meningitis with cerebrospinal fluid leakage as a result of a technical error and required further surgery. Four patients presented a confusion syndrome that regressed during the hospital stay, 2 complained of transient diplopia, and 4 had hematoma of the abdominal wall. Mean follow-up of 10.4 months (1-41 months) is still too short to reach definitive conclusions about oncologic results.

CONCLUSIONS

This approach is particularly suitable for removal of tumors in contact with or invading the cribriform plate. Tumor resection is as extensive as with the traditional mixed approach, but does not require the frontal lobes to be drawn aside.

Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience

INTRODUCTION

Few studies have examined prognostic factors that have an impact on outcomes in anterior skull base surgery by multivariate analysis.

METHODS

We retrospectively examined our institution's skull base experience from 1973-2000.

RESULTS

During this time, 166 patients underwent an anterior skull base resection for malignancy (median age, 53 years; range, 6-92 years). The 5-year relapse-free and disease-specific survival was 41% and 57% (median follow-up, 53 months). Multivariate analysis found that dural invasion, primary histologic diagnosis, and margin status had a significant impact on relapse-free and disease-specific survival.

CONCLUSIONS

These data indicate that patients with anterior skull base malignancies are treated successfully with skull base surgery. Patients demonstrating adverse prognostic variables such as dural invasion, adverse histologic findings, and/or positive margins should be considered for the addition of adjuvant therapy or innovative therapies as they become available in the future.

Anterior Skull Base Surgery Without Prophylactic Airway Diversion Procedures

OBJECTIVE: Although anterior skull base surgery has become a relatively safe and effective procedure, postoperative complications remain a serious problem. One of the most devastating complications of anterior skull base procedures is tension pneumocephalus (TP). In order to prevent TP, authors have recommended the use of prophylactic airway diversion procedures, such as prolonged endotracheal intubation or prophylactic tracheostomy. However, these procedures may mask neurologic deterioration, delay treatment, and prolong rehabilitation. The purpose of this study was to determine the need for airway diversion procedures in anterior skull base surgery.

STUDY DESIGN: Eighty-five patients underwent anterior skull base operations through the subcranial approach without prophylactic airway diversion. Sixty-four patients underwent resection of tumors, 12 patients underwent repair of cerebrospinal fluid leak, 6 patients underwent surgery due to anterior skull base fungal infections, and 3 patients underwent anterior skull base reconstruction procedures.

RESULTS: The complication rate of TP was 1.2% (1/ 85). This complication rate is similar to that previously reported for operations performed with airway diversion procedures.

CONCLUSION: Prophylactic airway diversion procedures are unnecessary in routine anterior skull base operations. Airway diversion should be indicated only when factors that might predispose the patient to risk of TP have been identified (ie, chronic cough or obstructive pulmonary diseases).

Anterior cranial base reconstruction using free tissue transfer: changing trends

INTRODUCTION

A consecutive series of 135 patients undergoing resection for malignant tumors involving the anterior cranial base between 1976 and 1999 was reviewed.

PATIENT AND METHODS

In the years from 1976-1991, free-tissue transfer was used in 5 of 76 or 6.6% of cases, whereas free-tissue reconstruction was used in 24 of 59 or 40% of cases in the years 1992-1999. Of those cases reconstructed with free-tissue transfer in 1976-1991, 60% (three of five) underwent a complex resection defined as involving dura, brain, or more than one major structure adjacent to skull base. Of those patients reconstructed with conventional (pericranial or pericranial/galeal) pedicled flaps in this time period, 35% (25 of 71) underwent a complex resection. From 1992-1999, 75% (18 of 24) of patients reconstructed with free-tissue transfer received a complex resection, whereas only 6% (2 of 35) of patients reconstructed by other means received a complex resection.

OUTCOMES

For those patients reconstructed by free-tissue transfer, there were no instances of flap loss. Comparison of these two time periods was notable for a similar patient composition in terms of age, histologic findings, and extent of resection. Major complication rates for patients who are reconstructed with free-tissue transfer for anterior cranial base resections (31%) are similar compared with patients who have been reconstructed with conventional pedicled flaps (35%). This was noted despite an increased extent and complexity of resection in those patients who underwent free-tissue transfer reconstruction (72%) compared with those patients reconstructed by more conventional means (26%) p <.001.

CONCLUSION

In our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex anterior cranial base defects involving resection of dura, brain, or multiple major structures adjacent to local skull base, including the orbit, palate, and other structures. Complication rates for patients reconstructed with free-tissue transfer techniques is similar to those patients reconstructed by conventional techniques, despite an increase in complexity of resection in this group.

The role of hair shaving in skull base surgery

OBJECTIVE

We sought to evaluate surgical wound infection rates in patients undergoing skull base surgery without hair removal.

METHODS

We undertook a retrospective study of 175 skull base operations performed without hair removal. Anterior operations were conducted via the subcranial approach (n = 120) and lateral or posterior procedures via various approaches (n = 55). Wounds were examined daily during hospitalization and at routine outpatient follow-up (8 to 45 months) and classified according to the Center for Disease Control and Prevention guidelines.

RESULTS

The overall surgical wound infection rate was 1.1% (2 of 175): 0.8% (1 of 120) for anterior and 1.8% (1 of 55) for lateral or posterior procedures. It was similar for clean operations (lateral and posterior) and clean-contaminated (anterior) procedures and was less than or similar to the rates reported for skull base procedures with hair removal. No wound infection occurred among the infected (trauma, fungal infections, and brain abscess) patients.

CONCLUSIONS

Skull base surgery without hair removal is safe and not associated with increased risk of wound infection. The method may prevent additional psychologic stress, promote restoration of the patient's self-image, and accelerate his or her return to normal life.

Pericranial flap for closure of paramedian anterior skull base defects

OBJECTIVE

We sought to examine the position of a pericranial flap reconstruction of anterior skull base defects with respect to the original floor of the anterior cranial fossa.

STUDY DESIGN

A retrospective chart and radiology review of 17 patients (1993-2001) with pericranial flap reconstruction for anterior skull base defects and 17 controls was performed.

RESULTS

At 6 or more months after surgery, the new positions of the pericranial flaps ranged from 5 mm above to 11.3 mm below the positions of the original cribriform plates. There were no complications related to the pericranial flaps such as hemorrhage, flap loss, or brain herniation except for 2 (11.8%) cerebrospinal fluid leaks, 1 of which required operative correction.

CONCLUSION

Pericranial flap reconstruction is a reliable method with low morbidity for closure of the most common skull base defect from the craniofacial resection that entails removal-unilateral or bilateral-of the fovea ethmoidalis, cribriform plate, and/or superior septum. This flap creates a watertight seal between the extradural space and the nasal cavity, prevents clinically significant brain herniation, and is associated with a low rate of cerebrospinal fluid leakage even without postoperative lumbar subarachnoid drainage of the cerebrospinal fluid.

Free tissue transfer and local flap complications in anterior and anterolateral skull base surgery

BACKGROUND

Advances in reconstructive techniques over the past two decades have allowed the resection of more extensive skull base tumors than had previously been possible. Despite this progress, complications related to these cases remain a concern.

METHODS

Univariate and multivariate analyses were used to determine the relationship of host, tumor, defect, treatment, and reconstructive variables to wound and systemic complications after anterior and anterolateral skull base resections. The study included 67 patients receiving local flap (LF) or free tissue transfer (FTT) reconstructions during an 8-year period.

RESULTS

Overall, 28% of patients had a major wound complication, and 19% had a major systemic complication. LF and FTT flaps had similar rates of wound complications. LF reconstructions were associated with late wound breakdown problems, and FTT flap complications were primarily acute surgery-related problems.

CONCLUSIONS

The surgical reconstruction of skull base defects should be planned on the basis of the ability of the technique to attain safe closure and maintain integrity after radiation therapy.

Microvascular free tissue transfer in reconstructing skull base defects: lessons learned

OBJECTIVE

To demonstrate the effectiveness of microvascular free tissue transfer in reconstructing complex skull base defects.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted identifying patients with anterior or lateral skull base defects, or both, who underwent microvascular free flap reconstruction. Appropriate demographic, pathological, and preoperative and postoperative clinical data were collected and analyzed.

RESULTS

Thirty-five patients with skull base defects were identified, including 8 women (Mean age, 43.9 y; age range, 28-75 y) and 27 men (mean age, 57.9 y; age range, 19-85 y). Defects were secondary to trauma in two cases, whereas the remaining 33 cases were secondary to ablative procedures for a variety of malignant tumors, of which squamous cell carcinoma was the most common (n = 18). The average defect surface area was 89.3 cm(2), and 36 free flaps were used. The most commonly used flap was the rectus myocutaneous (n = 20); however, six different flap types were employed, including three radial forearm fascial flaps. In all, there were seven flap-related complications and there was one total flap loss. A total of 43 postoperative complications occurred in 23 patients, with the most common complications being grouped as intracranial (n = 10), orbital (n = 9), and cardiac (n = 9). The perioperative mortality rate was 5.7%, and the average hospital stay was 13.5 days (range, 7-37 d).

CONCLUSIONS

The use of microvascular free tissue transfer for reconstruction of complex skull base defects has proven highly successful in the large series presented in the current study. The versatility and reliability of free flaps for such reconstruction are discussed, and helpful hints are given to minimize the complication rate.

[Use of median fronto-naso-orbital flap to decrease the incidence of complications in patients undergoing craniofacial resection]

BACKGROUND

Resection of malignant neoplasms invading the anterior cranial base is performed with craniofacial resection (CFR) with acceptable results in complication rates and oncologic outcomes. However, still there are series with major morbidity in up to 40% of patients, and mortality of 5%. A retrospective study was performed to evaluate the results in terms of morbidity, mortality, function and aesthetics using a median fronto orbital flap (MFOF).

METHODS

The MFOF was used in 28 consecutive patients who presented to the Head and Neck Service from 1992 to 1999, in the Instituto Nacional de Cancerología, Mexico City, and was combined with a superior rhinotomy for en bloc resection of the ethmoid complex in the last 12 cases. 89% of patients had malignant neoplasms.

RESULTS

1 death occurred in this series (3%) and the global morbidity was 35%. Aesthetics and function were good to excellent. Percentages of tumor-free survival for malignant lesions was 76% and 41% at 2 and 5 years follow up, respectively.

CONCLUSION

CFR is a safe approach for treatment of neoplasms of the anterior skull base. MFOF mobilization decreases complication rates and gives superb exposure for en bloc resection of tumors invading the ethmoidomaxillary complex specially when combined with a superior rhinotomy. A positive impact on quality of life was obtained.

Management of malignant tumors of the anterior and anterolateral skull base

OBJECT

Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior-anterolateral cranial base resections for malignant disease.

METHODS

The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed.

CONCLUSIONS

Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.