Craniofacial resection for malignant neoplasms of the skull base: an overview

Anterior skull base reconstruction using an anterolateral thigh free flap

Background

Galeal or temporalis muscle flaps have been traditionally used to reconstruct skull base defects after tumor removal. Unfortunately, these flaps do not provide sufficient vascularized tissue for a dural seal in extensive defects. This study describes the successful coverage of large skull base defects using anterolateral thigh (ALT) free flaps.

Methods

This retrospective study included five patients who underwent skull base surgery between June 2018 and June 2021. Reconstruction was performed using an ALT free flap to cover defects that included the intracranial space and extended to the frontal sinus and cribriform plate.

Results

There were no major complications, such as ascending infections or cerebrospinal leakage. Postoperative magnetic resonance imaging showed that the flaps were well-maintained in all patients.

Conclusion

Successful reconstruction was performed using ALT free flaps for large anterior skull base defects. In conclusion, the ALT free flap is an effective option for preventing communication between the nasal cavity and the intracranial space.

Extended temporalis flap for skull base reconstruction

Traditionally, a galeal flap has been used for skull base reconstruction. In addition to the galeal flap, several other flaps, such as the temporalis muscle flap or the free vascularized flap, can be options for skull base reconstruction, and each option has advantages and disadvantages. Certain cases, however, can be challengeable in the application of these flaps. We successfully managed to cover a skull base defect using an extended temporalis flap. Herein, we present the case and introduce this novel method.

Skull Base Reconstruction in the Pediatric Patient

Introduction  Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Objectives  To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods  Comprehensive literature review and summary of our experience. Results  We advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft-tissue transfer in microvascular technique is the mainstay for reconstruction of large, three-dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor-site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our "workhorse" for dural reconstruction is the double-layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid-sized defects. Conclusions  Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

Anterior Skull Base Defects Reconstructed Using Three-Layer Method: 78 Consecutive Cases with Long-Term Follow-Up

Objectives Anterior skull base defects are potentially lethal and surgical treatment must be performed as soon as possible. The purpose of this study was to evaluate whether our technique is effective or not in long-term period. Design Retrospective chart review of all patients whose data were entered into the Hospital Registry System between 1995 and 2015. Setting/Participants This study was performed at the Gaziantep University School of Medicine, Gaziantep, Turkey, in 2015 and included 78 patients who in the past 20 years underwent three-layer reconstruction surgery for anterior skull base defects at the same university. Main Outcome Measures Among the patients, defects repaired by transcranial approach had the lowest recurrence rate. Overall, successful repair was achieved in 100% of the patients. Results Pure transbasal approach was used as a single procedure on 71 (91%) patients. Combined approaches were used in seven (9%) cases. The extended transbasal approach was combined with a transfacial approach in four patients and with a pterional approach in three patients. Conclusion We encourage the use of three-layer reconstruction and recommend free fascia lata grafts and galeal flaps with vascularized pedicle as sealing material of choice in all types of cases such as tumor and trauma.

Advantage of Extended Craniofacial Resection for Advanced Malignant Tumors of the Nasal Cavity and Paranasal Sinuses: Long-Term Outcome and Surgical Management

OBJECTIVE

Craniofacial resection (CFR) for advanced sinonasal malignant tumors (SNMTs) is mandatory for radical resection. Surgeons must be aware of perioperative complications and long-term outcome because this procedure is extremely invasive, especially when the tumor involves the anterior skull base.

METHODS

Thirty-eight consecutive surgical patients with advanced SNMT of T4 stage or Kadish stage C (31 men and 7 women; mean age, 55 years; range: 19-76 years) treated with CFR in the past 28 years were followed up for 59.4 months. In cases of unilateral orbital extension, en-bloc resection was achieved using several neurosurgical techniques (extended CFR) from 2005 onwards. Herein, we evaluated the safety and effectiveness of surgery by comparing survival data between 2 time periods (first stage: 1984-2004, second stage: 2005-2012).

RESULTS

Squamous cell carcinoma was the most common histological type observed (65.8%), followed by esthesioneuroblastoma (15.8%). Using a combination of adjuvant radiation therapy, the 5-year overall survival and the 5-year disease-specific survival rates were 55.5% and 59.4%, respectively. Sarcomatous histology was a poor prognostic factor. The 5-year disease-specific survival rate was 48.9% in the first stage and improved to 82.1% in the second stage (P = 0.057); this was related to improvements in local control rate.

CONCLUSIONS

CFR and postoperative radiotherapy are safe and effective for treating advanced SNMTs. Extended CFR, including radical orbital exenteration, may contribute to good long-term outcomes. A diverse surgical team may help perform radical resection and reconstruction in patients with advanced tumors.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

The use of photodynamic therapy as adjuvant therapy to surgery in recurrent malignant tumors of the paranasal sinuses

BACKGROUND

Malignant tumors of paranasal sinuses and anterior skull base recur frequently after surgery and adjuvant radiotherapy. The vicinity of essential structures limits additional treatment options, such as salvage surgery and re-radiation. We report the feasibility of photodynamic therapy (PDT) as an adjuvant treatment to surgery.

METHODS

Fifteen patients with recurrent tumors of the paranasal sinuses were treated with mtetrahydroxyphenylchlorin (mTHPC) mediated PDT as an adjuvant treatment to salvage surgery. All patients had previously curative radiotherapy. The treated tumors were squamous cell cancer (8), adenocarcinoma (3), undifferentiated carcinoma (2), adenoid cystic carcinoma (1) and radiotherapyinduced sarcoma (1). In five cases there was extension to the skull base. Two approaches of surgery where used, namely in eight cases an open approach, in the other seven endoscopic approach. Complete macroscopic resection with microscopic tumor positive margins was possible in three patients. The remaining twelve patients received debulking surgery followed by PDT.

RESULTS

None of the patients had cerebrospinal fluid leak, meningitis, major bleeding or vision loss. Four patients developed temporary diplopia due to edema of the medial rectus muscle, one patient suffered from extensive necrosis leading to oro-nasal fistula. Complete response was observed in five patients.

CONCLUSION

Photodynamic therapy can be used with relative safety as adjuvant therapy to surgery in recurrent tumors of the paranasal sinuses and the anterior skull base where complete resection is not achievable.

Surgical safety distances in the infratemporal fossa: three-dimensional measurement study

The wedge-shaped infratemporal fossa is a constricted space and has long been a surgical challenge, mainly due to difficulties in access. Three-dimensional (3D) reconstruction of the skull, internal carotid artery (ICA), and internal jugular vein (IJV) was carried out using enhanced computed tomography (CT) data, to measure the safety distances in relation to infratemporal fossa surgery. Fifty enhanced CT datasets were selected to reconstruct 3D images by segmentation technique. The anatomical routes of the ICA, IJV, and the styloid process (SP) were observed. The following were measured: SP length, height of the pterygoid plates (PP height), distances from the pterygoid process (antero-inferior and anterosuperior border) to the leading edge of the ICA (PP-ICA (inferior), PP-ICA (superior)), and distance between the most prominent point of the zygomatic arch and the medial pterygoid plate (Zyg-MPP). The mean measurements of SP length, PP height, and the distances PP-ICA (inferior), PP-ICA (superior), and Zyg-MPP were 30.64 mm, 26.61 mm, 31.16 mm, 34.37 mm, and 51.37 mm, respectively. No significant differences were observed by age group, except the distance of PP-ICA (inferior) on the left side. In centres without intraoperative navigation facilities, proper knowledge of the anatomy, particularly of bony landmarks and the safe distances to nearby neurovascular structures, can provide useful information to ensure safe operations.

Minimal invasive biopsy of intraconal expansion by PET/CT/MRI image-guided navigation: a new method

Intraorbital tumours are often undetected for a long period and may lead to compression of the optic nerve and loss of vision. Although CT, MRI's and ultrasound can help in determining the probable diagnosis, most orbital tumours are only diagnosed by surgical biopsy. In intraconal lesions this may prove especially difficult as the expansions are situated next to sensitive anatomical structures (eye bulb, optic nerve). In search of a minimally invasive access to the intraconal region, we describe a method of a three-dimensional, image-guided biopsy of orbital tumours using a combined technique of hardware fusion between (18)F-FDG Positron Emission Tomography ((18)F-FDG PET), magnetic resonance imaging (MRI) and Computed Tomography (CT).

METHOD AND MATERIAL

We present 6 patients with a total of 7 intraorbital lesions, all of them suffering from diplopia and/or exophthalmos. There were 3 female and 3 male patients. The patients age ranged from 20 to 75 years. One of the patients showed beginning loss of vision. Another of the patients had lesions in both orbits. The decision to obtain image-guided needle biopsies for treatment planning was discussed and decided at an interdisciplinary board comprising other sub-specialities (ophthalmology, neurosurgery, maxillofacial surgery, ENT, plastic surgery). All patients underwent 3D imaging preoperatively ((18)F-FDG PET/CT or (18)F-FDG PET/CT plus MRI). Data was transferred to 3D navigation system. Access to the lesions was planned preoperatively on a workstation monitor. Biopsy-needles were then calibrated intraoperatively and all patients underwent three-dimensional image-guided needle biopsies under general anaesthesia.

RESULTS

7 biopsies were performed. The histologic subtype was idiopathic orbital inflammation in 2 lesions, lymphoma in 2, Merkel cell carcinoma in 1, hamartoma in 1 and 1 malignant melanoma. The different pathologies were subsequently treated in consideration of the actual state of the art. In cases where surgical removal of the lesion was performed the histological diagnosis was confirmed in all cases.

CONCLUSION

There is a wide range of possible treatment modalities for orbital tumours depending on the nature of the lesion. Histological diagnosis is mandatory to select the proper management and operation. The presented method allows minimal-invasive biopsy even in deep intraconal lesions, enabling the surgeon to spare critical anatomical structures. Vascular lesions such as cavernous haemangioma, tumour of the lacrimal gland or dermoid cysts present a contraindication and have to be excluded.

Anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft

Background

Cranial base defects are challenging to reconstruct without serious complications. Although free tissue transfer has been used widely and efficiently, it still has the limitation of requiring a long operation time along with the burden of microanastomosis and donor site morbidity. We propose using a reverse temporalis muscle flap and calvarial bone graft as an alternative option to a free flap for anterior cranial base reconstruction.

Methods

Between April 2009 and February 2012, cranial base reconstructions using an autologous calvarial split bone graft combined with a reverse temporalis muscle flap were performed in five patients. Medical records were retrospectively analyzed and postoperative computed tomography scans, magnetic resonance imaging, and angiography findings were examined to evaluate graft survival and flap viability.

Results

The mean follow-up period was 11.8 months and the mean operation time for reconstruction was 8.4±3.36 hours. The defects involved the anterior cranial base, including the orbital roof and the frontal and ethmoidal sinus. All reconstructions were successful. Viable flap vascularity and bone survival were observed. There were no serious complications except for acceptable donor site depressions, which were easily corrected with minor procedures.

Conclusions

The reverse temporalis muscle flap could provide sufficient bulkiness to fill dead space and sufficient vascularity to endure infection. The calvarial bone graft provides a rigid framework, which is critical for maintaining the cranial base structure. Combined anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft could be a viable alternative to free tissue transfer.

[Craniofacial resection for tumors of paranasal sinuses involving the anterior skull base]

INTRODUCTION

Craniofacial resection is a treatment of choice for paranasal malignant and benign tumors invading the skull base.

THE AIM OF THE STUDY

In this article the authors present the experience in craniofacial resection for malignant tumors invading the anterior skull base.

MATERIALS AND METHODS

The material consisted of four patients operated in the Department of Otolaryngology and Laryngology Oncology CM UMK between 2007 and 2010. The patients were treated for malignant neoplasms of the paranasal sinuses with anterior skull base involvement. THe age range of the group were between 60 and 75 years. Of these patients three were females and one male.

RESULTS

We performed a lateral rhinotomy for laryngological acces for the tumor. The neurosurgeon performed anterior skull base osteotomy at and appropriate site above. The patients recovered uneventfully. The follow up period ranged between 13 and 42 months. The overall 3-year survival for all patients in our series was 66,6%.

CONCLUSIONS

Combined craniofacial resection of tumors of the anterior skull base is an effective approach for the management of these pathologies. This type of approach in elderly patients over 70 years old could be associated with increased mortality and complications leading to poorer outcome.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Quality of Life following Surgery for Malignancies of the Anterior Skull Base

Radical surgery combined with postoperative radiation is recommended to achieve the best outcomes in patients suffering from malignant anterior skull base tumors. However, information on the impact of such treatment on the quality of life of these patients is sparse. This retrospective study evaluated quality of life in patients with anterior skull base malignancies after transdural resection and radiotherapy. At follow-up, 36% of the patients were alive (mean survival time, 39 months). Only 45% of the patients were able to work in their previous occupation a mean of 15 months after surgery. At follow-up, 58% of the patients had a recurrent tumor. The mean quality of life index was 42 points (range, 0 to 100). The lowest values were on the job item, and the highest mean value was on the family item. All patients, dependents, or both would agree to surgery in the future. Based on these findings, quality of life after transdural surgery for the treatment of anterior skull base malignancies seems to be low.

A comprehensive algorithm for anterior skull base reconstruction after oncological resections

OBJECTIVE

To present our method for anterior skull base reconstruction after oncological resections.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Combined craniofacial resection of anterior skull base tumors: long-term results and experience of single institution

In this article, the authors are presenting their experience and the results with combined craniofacial resection of anterior skull base tumors based on a review of 27 constitutive cases. Our data are evaluated in comparison to other major centers in other parts of the world, and possible factors that might influence surgical outcome and survival are discussed. Twenty-seven patients diagnosed with anterior skull base tumors between 1999 and 2009 were treated by combined craniofacial resection. Of these patients, there were 19 males (70, 3%) and eight females (29, 7%). The age ranged between 11 and 75 years (mean = 45.9 ± 17.6 years). The follow-up period ranged between 14 and 123 months (avarage = 74 months). The most common presenting symptoms were nasal obstruction and vision disturbance (11 patients for each -40.7%). Total resection was achieved in 24 patients (89%), while subtotal resection was done in three patients (11%). The most common complication was CSF fistule with rhinorrhea, which occurred in five patients (18.5%). Eight patients had recurrences at the time of this long-term follow-up. There were two mortalities in the early postoperative period and seven deaths in the long-term follow-up (overall mortality, 33.3%). The overall 5-year overall survival for all patients in our series was 70.4%. The 5-year overall survival was 62% for patients with malignant tumors and 100% for patients with benign tumors. Combined craniofacial resection of tumors of the anterior skull base is an effective approach for the management of these pathologies. The effectiveness is clearly demonstrated by the clinical results and outcomes of these patients' groups. The favorable prognosis is enhanced by significantly by total resection with negative tumor margins.

Split calvarial graft to repair the large frontal bone defect

The ideal reconstructive material for cranioplasty is autogenous bone, however if it is not available the use of alloplastic materials is recommended. We present a case of 26-year-male patient who sustained compound depressed fracture of the frontal bone and associated anterior cranial fossa fracture following a road traffic accident. He was managed at hospital where the fractured bone fragments were removed but recently presented with watery discharge from nose (CSF rhinorrhoea) and cosmetic deformity of forehead. We describe the utilization of autogenous local frontal bone split calvarial graft for the reconstruction of the defect.

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.

Quality of life following endonasal skull base surgery

The importance of quality of life (QOL) outcomes following treatments for head and neck tumors are now increasingly appreciated and measured to improve medical and surgical care for these patients. An understanding of the definitions in the setting of health care and the use of appropriate QOL instruments and measures are critical to obtain meaningful information that guides decision making in various aspects of patient health care. QOL outcomes following cranial base surgery is only recently being defined. In this article, we describe the current published data on QOL outcomes following cranial base surgery and provide preliminary prospective data on QOL outcomes and sinonasal morbidity in patients who underwent endonasal cranial base surgery for management of various skull base tumors at our institution. We used a disease-specific multidimensional instrument to measure QOL outcomes in these patients. Our results show that although sinonasal morbidity is increased, this is temporary, and the vast majority of patients have a very good QOL by 4 to 6 months after endonasal approach to the cranial base.

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.

Low complication rates of cranial and craniofacial approaches to midline anterior skull base lesions

OBJECTIVE

Surgery is a cornerstone of treatment for a wide variety of neoplastic, congenital, traumatic, and inflammatory lesions involving the midline anterior skull base and may result in a significant anterior skull base defect requiring reconstruction. This study is a retrospective analysis of the reconstruction techniques and complications seen in a series of 58 consecutive patients with midline anterior skull base pathology treated with craniotomy or a craniofacial approach. The complication rates in this series are compared with other retrospective series and specific techniques that may reduce complications are then discussed.

DESIGN

This is a retrospective analysis of 58 consecutive patients who had surgery for a midline anterior skull base lesion between January 1994 and July 2003. Data were collected regarding pathology, surgical approach, reconstruction technique, and complications.

RESULTS

Twenty-nine patients underwent surgery for a meningioma (50%). The remainder had frontoethmoidal cancer, mucoceles/invasive nasal polyps, encephalocele, esthesioneuroblastoma, anterior falx dermoid cyst with a nasal sinus tract, or invasive pituitary adenoma. In most patients, a low and narrow two-piece biorbitofrontal craniotomy was used. When possible, the dura was repaired before entering the nasal cavity. Thirteen patients experienced a complication (22%). There was one case of postoperative cerebrospinal fluid (CSF) leak (2%), one case of meningitis (2%), two cases of bone flap infection (3%), and two cases of symptomatic pneumocephalus (3%). There were no deaths, no reoperations for CSF leak, and no patient had a new permanent neurologic deficit other than anosmia.

CONCLUSIONS

Transcranial approaches for midline anterior skull base lesions can be performed safely with a low incidence of postoperative CSF leak, meningitis, bone flap infection, and symptomatic pneumocephalus. Our results, particularly with regard to CSF leakage, compare favorably with other retrospective series.

[Own experience in treatment of patients with advanced tumours of the paranasal sinuses and the orbit, penetrating to the anterior and medial cranial fossa--preliminary report]

AIM

Craniofacial resection provides multidirectional approaches to remove nasal and paranasal tumours that involve the skull base. Vital structures, such as the dura, brain, and blood vessels, can be protected or resected and reconstructed safely. An en bloc excision of the tumour can be accomplished. The purpose of this study was to analyse oncological and functional results of craniofacial resection in our series of patients.

MATERIAL AND METHODS

The medical records of 40 consecutive patients who had undergone craniofacial resection for tumours of the nasal cavity, paranasal sinuses, and adjacent areas were reviewed. The extent of disease, treatment results (the length of disease-free survival), complications, and prognoses were analysed.

RESULTS

Lesions were malignant in 7 patients and benign in the remaining 33. All the patients had dural or intradural involvement. There was no operative death, and the rate of surgical morbidity was 20%. Craniofacial resection is the only surgical approach with acceptable rate of complications in selected patients with tumour comprising the anterior and medial cranial base, nasal cavity, paranasal sinuses, nasopharynx and orbits. Heroic resections are modern surgical procedures challenging both for ENT surgeons and neurosurgeons. The result is satisfactory when they are performed by a multi-specialist team.

Olfactory Groove Meningiomas: Clinical Outcome and Recurrence Rates after Tumor Removal Through the Frontolateral and Bifrontal Approach

OBJECTIVE

Olfactory groove meningiomas account for 8 to 13% of all intracranial meningiomas. Surgical removal is often performed through the bifrontal, unilateral subfrontal (frontolateral), or pterional approach. We report on the clinical outcome and recurrence rate after surgical treatment of olfactory groove meningiomas in our neurosurgical department.

METHODS

A retrospective study was conducted by analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies.

RESULTS

A total of 1800 meningiomas were operated on between 1978 and 2002 in our department. There were 82 patients with olfactory groove meningiomas, including 63 women and 19 men with a mean age of 57.8 years (age range, 33–91 yr). Most patients presented with mental disturbance. Tumors were operated through the bifrontal (n = 46), frontolateral (n = 34), and pterional (n = 2) approaches. Total tumor removal (Simpson Grade 1 or 2) was achieved in most cases (91.2% frontolateral, 93.5% bifrontal). Perioperative mortality was 4.9% (four out of 82 patients, all operated through the bifrontal approach). The overall recurrence rate was 4.9%, with four patients requiring surgery. The mean follow-up period was 63.4 months (range, 4–270 mo).

CONCLUSION

Olfactory groove meningiomas were removed mainly through two different surgical approaches. Even in large tumors, high rates of total tumor resection could also be achieved with low recurrence rates using the simple and minimally invasive frontolateral approach. In recent years, we have preferred to use the frontolateral approach, which provides quick access to the tumor with less brain exposure while still enabling total tumor removal with a low morbidity rate and no mortality.

Endoscopic Techniques in Resection of Anterior Skull Base/Paranasal Sinus Malignancies

OBJECTIVE

The objective of this study was to examine the role of endoscopic approaches to the resection of anterior skull base and paranasal sinus malignancies at one tertiary care medical center.

STUDY DESIGN

The authors conducted a retrospective chart review over a period of 17 years.

METHODS

Patients undergoing anterior skull base resections for malignancies over a 17-year period were reviewed. Data were collected on each patient with respect to the pathology of the tumor and approach used as well as demographic and follow-up information.

RESULTS

A total of 78 patients were treated at a tertiary care medical center for malignancies of the paranasal sinuses and anterior skull base. The most common diagnosis was squamous cell carcinoma occurring in 33% of the cases. The remaining pathologies included esthesioneuroblastoma (23%), adenoid cystic carcinoma (15%), melanoma (3%), sinonasal undifferentiated carcinoma (3%), lymphoma (5%), nasopharyngeal carcinoma (4%), and other tumor types (14%). Endoscopic techniques were used extensively in this population of patients. Combined approaches using a sublabial/transmaxillary approach and coronal approaches were used when indicated and complemented the endoscopic approach. A majority of patients were without evidence of disease at the end of this review. Using endoscopic techniques allowed for acceptable cosmetic results and facial incisions were used minimally.

CONCLUSION

With complete endoscopic surgical resection followed by radiation therapy, local recurrence, morbidity, and cosmetic deformity have been minimized. The microscopic view provided by endoscopic techniques, with or without complementary approaches, allows for complete tumor removal.

The radical transbasal approach for resection of anterior and midline skull base lesions

OBJECT

Craniofacial surgery can be performed to treat midline and anterior skull base lesions by creating a bicoronal scalp incision without the need for an additional transfacial procedure. Originally described as the transbasal approach, several modifications for further exposure of the skull base have been described. The authors present data on the application and outcomes of a modified transbasal approach. The radical transbasal approach consists of a bifrontal craniotomy and a frontoorbitonasal osteotomy.

METHODS

Between 1992 and 2002, 41 patients (28 male and 13 female patients with a mean age of 38.3 years [range 7-77 years]) underwent 44 radical transbasal procedures. Twenty-three malignant and 18 benign lesions involving the midline skull base were treated. These cases were reviewed retrospectively. Gross-total resection of 30 lesions was achieved. Seven lesions were resected subtotally and six partially; one lesion was debulked. Complications occurred in 26 (59.1%) of the 44 operations and mostly consisted of cerebrospinal fluid leakage. The surgery-related mortality rate was 6.8% (three patients). Based on their pre- and postoperative Karnofsky Performance Scale scores, 86.4% of patients improved or remained the same.

CONCLUSIONS

The radical transbasal approach increases the midline craniofacial corridor by allowing the globes to be safely retracted laterally. It also enhances exposure of the maxillary sinus from above. The morbidity and mortality rates associated with this procedure are high but consistent with the known rates for craniofacial surgery. This approach is best suited for the treatment of anterior skull base tumors that extend into the nasal cavity, orbit, ethmoid sinus, nasopharynx, and upper clivus. The approach may allow resection of tumors involving the maxillary sinus area without the need for an additional transfacial approach.

Quantification of the advantages of the extended frontal approach to skull base

This anatomic study evaluated the extent that a fronto-orbital osteotomy (FOO) added to a bilateral frontal craniotomy widened the exposure to the midline compartment of the anterior, middle, and posterior cranial fossae. The goal was to determine if osteotomy would significantly increase angles for two targets: the foramen magnum (FM) and anterior clinoid process (ACP). Stepwise dissections were performed on five cadaveric heads. A bilateral frontal craniotomy was made, followed by FOO. After the ethmoids were removed, the planum sphenoidale was drilled to enter the sphenoid sinus. Further drilling exposed the anterior clivus, which was drilled down to FM. Excellent exposure of the basilar artery, vertebral artery, and brain stem was achieved. With and without FOO, angles of exposure were measured for two targets: the ACP and FM. The angle of exposure after FOO increased markedly with an average gain of 76% for the ACP and of 80% for FM. Compared with a conventional bifrontal craniotomy, the addition of FOO increased the surgical exposure and minimized frontal lobe retraction for accessing lesions of the anterior, middle, and posterior cranial fossae.

Anterior skull base surgery

This article focuses on selected key anatomic considerations in anterior skull base surgery, briefly reviews common pathologies of the paranasal sinuses, and provides an overview of surgical approaches, complications, and results.

Skull Base Tumors: A Comprehensive Review of Transfacial Swing Osteotomy Approaches

Numerous techniques have been proposed for the resection of skull base tumors, each one unique with regard to the region exposed and degree of technical complexity. This study describes the use of transfacial swing osteotomies in accessing lesions located at various levels of the cranial base. Eight patients who underwent transfacial swings for exposure and resection of cranial base lesions between 1996 and 2002 were studied. The mandible was the choice when wide exposure of nasopharyngeal and midline skull base tumors was necessary, especially when they involved the infratemporal fossa. The midfacial swing osteotomy was an option when access to the entire clivus was necessary. An orbital swing approach was used to access large orbital tumors lying inferior to the optic nerve and posterior to the globe, a region that is often difficult to visualize. Gross total tumor excision was possible in all patients. Six patients achieved disease control and two had recurrences. The complications of cerebrospinal fluid leak, infection, hematoma, or cranial nerve damage did not occur. After surgery, some patients experienced temporary symptoms caused by local swelling. The aesthetic result was considered good. Transfacial swing osteotomies provide a wide exposure to tumors that occur in the central skull base area. Excellent knowledge of the detailed anatomy of this region is paramount to the success of this surgery. The team concept is essential; it is built around the craniofacial surgeon and an experienced skull base neurosurgeon.

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.

Development of a cancer-specific anterior skull base quality-of-life questionnaire

OBJECT

The goal of this study was to develop a disease-specific, multidimensional quality of life (QOL) assessment instrument for patients undergoing surgical extirpation of anterior skull base tumors.

METHODS

This investigation included 35 patients who had been surgically treated for more than 3 months before the study was begun. Relevant QOL questions were generated from a review of the literature and interviews with health professionals, patients, and their caregivers. The initial multidimensional, 80-item questionnaire was reduced to a 35-item questionnaire by using standard psychometric criteria. Six relevant domains were identified using factor analysis: performance, physical function, vitality, pain, specific symptoms, and influence on emotions. The internal consistency of the instrument had a correlation coefficient of 0.8 and a reliability coefficient (test-retest reliability) of 0.9. The validity of the construct was assessed by testing whether the clinical variable of the patient influenced his QOL domain score as hypothesized. Patients older than 60 years of age had significantly poorer scores in the domains of performance and physical function than younger patients. Patients with malignant tumors had significantly poorer scores in the domains of specific symptoms, influence on emotions, physical function, and performance compared with patients with benign tumors. Radiotherapy was associated with poorer scores in the domains of specific symptoms and influence on emotions. Comorbidity was associated with poor physical function scores. Using the final questionnaire, we prospectively evaluated the QOL of 12 additional patients before they underwent surgery and again between 5 and 6 months postoperatively to test the utility and validity of the instrument further. Again, significantly poorer QOL scores were recorded for patients with malignancy.

CONCLUSIONS

The proposed questionnaire appears to be sufficiently reliable and valid in estimating a patient's QOL after extirpation of anterior skull base tumors. The instrument can be used in face-to-face interviews and via electronic or regular mail.

New TNM staging criteria for head and neck tumors

Cancers of the head and neck have always represented a unique perspective in cancer staging. Not only are these lesions numerous in terms of anatomic sites of origin, but, unlike most other major cancers, they frequently and readily lend themselves to adequate clinical assessment by visual inspection and palpation, which greatly facilitates documentation by the trained clinician. In addition, their location often involves treatment programs that focus on nonsurgical organ-preservation strategies, and thus anatomic and histological data for comprehensive pathologic staging are often not available. Nevertheless, the processes involved in surgical decision-making and radiotherapy treatment planning require meticulous assessment and documentation of the extent of locoregional disease. For all these reasons it is especially important to perform reliable and accurate pretreatment clinical staging of head and neck cancers. Also, many patients who succumb to head and neck cancer do so as a result of locoregional disease. Therefore, the staging system must take into account detailed local anatomic features that dictate management, since the degree of involvement of these structures by tumor may be as important as distant metastasis in threatening survival. For this reason the most recent cancer staging classification (6th edition) of the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC) includes new criteria for the more advanced cases (e.g., T4 categories and stage IV disease). These criteria reflect the fact that in heterogeneous populations there is a realistic opportunity for cure in some patients but not in others. This review summarizes the criteria used in the new TNM for head and neck tumors, and outlines the rationale behind the current changes. It also provides some guidance regarding optimal source data to facilitate classification in the registry setting. In addition, the need for additional changes in the future is recognized.

Anterolateral and lateral skull-base approaches for treatment of neoplastic diseases

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Diagnosis and management of esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon malignant neoplasm of the nasal vault that in the past was considered benign or low-grade malignant. Surgical approaches in the main were transnasal, with a high recurrence rate and ultimate patient death. With the modern imaging of CT and MRI, should the patient be willing and fit enough, esthesioneuroblastoma currently should be approached using a craniofacial resection. Large tumors should be considered for preoperative chemotherapy and postoperative radiotherapy. Local tumor recurrence is not uncommon and is generally related to the attention to local anatomic dissection. Neck metastases, when they present, should be excised using a modified neck dissection. Distant metastases may present at any time during the course of the disease, generally within 36 months, and may respond to local radiotherapy or systemic chemotherapy. Five-year survival currently appears to be optimized by surgery followed by postoperative radiotherapy and is approximately 65%.

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.

Cranial-base surgery: a reconstructive algorithm

Skull-base surgery is associated with a high risk of cerebrospinal fluid (CSF) leak, infection, and functional and aesthetic deformity. Appropriate reconstruction of cranial-base defects following surgery helps to prevent these complications. Between March 1998 and May 2000, 28 patients (age: 1-68 years) underwent reconstruction of the anterior and middle cranial fossae. The indications for surgery were tumours, trauma involving the anterior cranial fossa, midline dermoid cysts with intracranial extension, late post-traumatic CSF leak, craniofacial deformity and recurrent frontal mucocoele. We used local anteriorly based pericranial flaps (23 flaps, alone or in combination with other flaps), bipedicled galeal flaps (seven patients) and free flaps (nine patients; radial forearm fascial/fasciocutaneous flaps, rectus abdominis muscle flap and latissimus dorsi muscle flap). Follow-up has been 4-24 months. We had no deaths, no flap failure and no incidence of infection. Complications included two CSF leaks, three intracranial haematomas and one pulsatile enophthalmos. All patients had a very good aesthetic result. We present an algorithm for skull-base reconstruction and comment on the design and vascularity of the bipedicled galeal flap. The monitoring of intracranial flaps and the difficulties of perioperative management of free flaps in neurosurgical patients are also discussed.

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.

Malignant tumors of the skull base

Malignant tumors of the skull base have traditionally been difficult to control because of adjacent crucial anatomical structures and because of the inherent difficulty in accessing/resecting tumors and reconstructing surgical defects. Techniques in craniofacial surgery for malignant tumors of the skull base have advanced significantly since their first description. Advances in neuroimaging, surgical technique, perioperative care, and adjuvant treatment have contributed to improved results. Because the majority of malignant tumors requiring craniofacial resection involve the anterior skull base, this review focuses mainly on state-of-the-art surgical techniques as well as pertinent variations, complications and results.

Skull base reconstruction after anterior subcranial tumor resection

Object

The goal of this study was to demonstrate the efficacy of a simple and reliable technique for anterior skull base and craniofacial reconstruction in patients who have undergone excision of tumors via the subcranial approach.

Methods

There were 63 patients who had undergone 71 anterior skull base resections of tumors via the aforementioned approach. Twenty-nine cases (41%) involved malignant tumors and 42 (59%) involved benign tumors. Reconstruction of the anterior skull base was performed by a single team who used double-layer fascial graft. Limited dural defects were reconstructed using the temporalis fascia, whereas large anterior skull base defects were reconstructed using a fascia lata sheath. Reconstruction was achieved without the support of bone graft or titanium mesh and without pericranial, galeal, or free flaps. Pericranial flap wrapping of the frontonasoorbital segment was performed to prevent osteoradionecrosis if postoperative radiotherapy was planned. The incidence of cerebrospinal fluid (CSF) leakage, intracranial infection, and tension pneumocephalus was 5.6%. Histopathological examination of fascia lata grafts obtained in patients who had undergone a second procedure demonstrated integration of vascularized fibrous tissue to the graft, as well as local proliferation of a newly formed vascular layer embedding the fascial sheath.

Conclusions

The use of a double-layer fascial graft alone was adequate for prevention of CSF leakage, meningitis, tension pneumocephalus, and brain herniation. The double-layer fascial flap provided a simple and reliable means for anterior skull base reconstruction after en bloc resection of both malignant and benign tumors.