Infratemporal fossa surgery for malignant diseases

Modified Maxillary-Swing Approach for Resection of Primary Malignancies in the Pterygopalatine Fossa

Background

En bloc resection of malignancies in the pterygopalatine fossa (PPF) poses critical challenges. Using the modified maxillary-swing (MMS) approach, we achieved monobloc removal of primary malignancies in this region. This study provides a detailed account of the surgical techniques and indications used.

Methods

We enrolled seven patients with primary malignancies in the PPF during a period from January 2012 to January 2019 in this retrospective study. After malignancies were confirmed by biopsy as well as evaluation with computed tomography (CT) and magnetic resonance imaging (MRI) scans, all of the patients underwent MMS surgery under general anesthesia to extirpate these tumors. We performed regular postoperative follow-up using CT and MRI scans.

Results

En bloc resection was successfully performed in all cases. We observed negative margins in six cases and positive margins in one patient with adenoid cystic carcinoma, who received postoperative radiotherapy. The most common complication was facial numbness. During the follow-up period (range, 6-69 months), one patient suffered from recurrence, while the others did not.

Conclusion

The advantages of the MMS include a wide surgical field, full exposure, and easy manipulation. We expect this approach to become an alternative to the monobloc resection of malignancies in the PPF that involve the infratemporal fossa, maxillary sinus, nasal cavity, orbit, or oral cavity.

Infratemporal fossa surgical approaches to primary/recurrent malignancies of salivary origin: paradigm surgical shift, patient selection, and oncologic outcomes

PURPOSE OF REVIEW

To review, the surgical approaches available on diagnosing a patient with salivary gland malignancy in the infratemporal fossa (ITF). To comment on patient evaluation and method of treatment selection. To identify and report on patient outcome data and make recommendations on future needs.

RECENT FINDINGS

There is a need to define the anatomic boundaries contents of the ITF, masticator space, parapharyngeal space (PPS), pterygopalatine fossa, ventral skull base, and paramedian skull base, as evidence from publications. The pathological subtypes identified mainly include adenoid cystic and mucoepidermoid carcinomas. The source of these tumours originates from primary disease in the sinonasal tract and nasopharynx superiorly, and the PPS/deep lobe of parotid inferiorly. Current surgical options available, in suitable selected patient, available in tertiary head and neck cancer hospitals, which have available facilities and staffing is the endoscopic endonasal approach. This approach offers patients a 'complete margin-free surgical excision', minimal complications, shorter hospital stay, and no delay with commencement of any adjuvant treatment compared with the traditional 'open transcutaneous' approach.

SUMMARY

The current evidence specifically to the surgical management of salivary gland malignancy involving the ITF is sparse, with great difficult identifying treated patients and their details among a heterogeneous group of patients with many lesions. There is a need for patient data that have specific pathologic conditions to be amalgamated from such centers and publish on outcome events.

Functional morphometry of the pterygoid hamulus. A comparative study of modern and medieval populations

The pterygoid hamulus (PH) is located in the infratemporal fossa and is part of the pterygoid process of the sphenoid bone. Its location on the cranial base and the multitude of anatomical structures whose attachments lie on the surface of the pterygoid hamulus make it of high functional and topographic significance. Due to insufficient literature on the PH morphometry, we decided to study this issue using modern and archaeological material. In total, 99 observations were subjected to quantitative and qualitative analysis (50 - from modern times and 49 - from medieval times). On the basis of the statistical analysis, statistically significant differences in the length of PH were found with respect to age and sex. Statistically significant differences in the PH width were also noticed with respect to sex and the period of origin. The results obtained may help better understand the development mechanism of the pterygoid hamulus bursitis.

Surgical approaches for infratemporal fossa tumor resection: Fifteen years' experience of a single center

BACKGROUND

The aims of this study were to report our center's experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes.

METHODS

Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed.

RESULTS

Sixty-three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular-orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty-seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty-five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty-three patients suffered from complications related to surgery or adjuvant therapy. The three- and five-years survival rates for malignancy were 82% and 66%, respectively.

CONCLUSION

Complete surgical resection of ITF involving tumors is feasible, providing good long-term survival. Multidisciplinary approach is the key for success.

Combined craniofacial approach for the removal of a large trigeminal schwannoma invading the infratemporal fossa

BACKGROUND

Trigeminal schwannomas are rare tumours accounting for 0.07-0.36% of all intracranial tumours and 0.8-8% of intracranial schwannomas. Symptoms and signs of these lesions depend on the site of the tumour, which may compress the nerve of origin or adjacent nerves.

CASE REPORT

We describe a case of a 69-year-old woman with a history of progressively worsening hypoesthesia involving the third division of the trigeminal nerve. A tumour of 5-cm diameter was revealed within the right cranial middle fossa, extending to the lateral wall of the cavernous sinus, the infratemporal fossa and the posterior wall of the maxillary sinus. A combined craniofacial approach was undertaken. A right extended subtemporal craniotomy was performed. The intracranial component of the tumour, originating from the third division of the trigeminal nerve and compressing the cavernous sinus, was removed in total. We proceeded with a Weber-Ferguson approach through which the extracranial component of the tumour was also totally resected. The postoperative computed tomography of the head has shown complete tumour removal. The histopathologic examination revealed a cellular neurinoma. Postoperatively, the patient expressed a transitory palsy of the oculomotor nerve, which resolved within a few weeks. The patient remains free of recurrence with mild hypoesthesia of the third trigeminal branch 5 years after treatment.

DISCUSSION

Surgery of trigeminal schwannomas may be a very challenging task. Various surgical approaches for trigeminal schwannomas excision have been described. With this combined approach, the tumour was freed from the surrounding tissues and was easily and totally removed.

Malignant Tumors of the Anterolateral Skull Base

OBJECTIVE

Malignancies of the anterolateral skull base are clinically and pathologically distinct from those of the central anterior skull base and the temporal bone. The purpose of this report is to describe the outcomes and complications after skull base surgery and multimodality therapy in a group of patients with anterolateral skull base malignancies.

PATIENT DATA AND METHODS

The mean duration of follow-up for living patients was 57.2 months (median, 56.8 months). The median age of the 52 patients who met the inclusion criteria for this study was 47 years (range, 1–81 years). The most common presenting feature was cranial nerve palsy (60%). Of these cranial nerve palsies, trigeminal neuropathies causing facial numbness were the most common, with V2 being affected in 35%, V3 affected in 33%, and V1 affected in 17%. Abducens neuropathy was present in 14% of patients. The most frequently occurring pathologies after the various sarcomas were squamous cell carcinoma (SCC) and adenoid cystic carcinoma (ACC) in 23% and 14% of patients, respectively. Of the 30 sarcomas, 16 were classified as low grade and 14 were classified as high grade.

RESULTS

Complications of treatments were identified in 16 patients (31%). Ten patients had a single complication, whereas 6 patients experienced multiple complications. The most common complications were a new or worsened cranial nerve deficit (n = 4), pneumonia (n = 4), and flap necrosis (n = 3). Recurrence after the treatment associated with the index surgery occurred in 37 patients (71%). The recurrence was local in 30 patients (58%), both local and distant (metastatic) in 4 patients (8%), and only distant in 3 patients (12%). The median progression-free survival (PFS) was 2.1 years (range, 1.2–3.0 years). Median PFS times of 0.6 and 1.6 years were noted for patients with high-grade sarcoma (HGS) and low-grade sarcoma (LGS), respectively. The mean PFS (median not reached) for the patients with SCC was 4.6 years, whereas the median PFS for patients with ACC was 3.3 years. The overall 2- and 5-year survivals for all patients were 81% and 53% (median, 5.0 years; 95% confidence interval, 3.9–6.1 years), respectively. The median survival for patients with nonsarcomas was 6.9 years, the 2-year survival was 82%, and the 5-year survival was 55%. Patients with HGS survived the shortest time (median, 3.3 years; 2-year, 64%; 5-year, 27%), whereas those patients with LGS had an intermediate survival (median, 5.3 years; 2-year, 94%, 5-year, 72%).

CONCLUSION

It is our belief that anterolateral skull base malignancies comprise a distinct group of tumors. These lesions should be analyzed separately from central anterior skull base lesions and temporal bone malignancies. With a multimodality treatment protocol, acceptable survivals may be obtained that are comparable to results that have been reported for tumors involving less difficult areas of the skull base.

[Mandibular trigeminal schwannoma: case report]

We report one case of peripheral trigeminal schwannoma originated from the mandibular branch (V3) and located inside the infratemporal and pterygopalatine fossae with slight intracranial extension. The tumor was completely removed by a transmaxillary approach. The revision of the literature showed to be a very rare tumor in this location.

Prevention of postoperative complications in skull base surgery for nasal or paranasal sinus carcinoma invading the skull base

With recent technical advances in skull base surgery, radical resection of a nasal or paranasal sinus carcinoma invading the skull base can now be achieved. To assure a satisfactory surgical result, it is essential to prevent postoperative infection. In our series of 14 cases, serious postoperative infections occurred in the earliest 10 cases, and only 2 of these patients are still alive. The vascularised abdominal muscle flap for skull base reconstruction was fixed with fibrin glue, but was not adequate to fill the dead space, resulting in cerebrospinal fluid leakage and subsequent meningitis. Once the infection occurred, a free bone flap became the focus of infection. Based on these earlier experiences, we used a ROC fastener system to completely fill the dead space with an abdominal muscle flap, and bone flap was primarily craniectomised in the four most recent cases. With this technique, there were no postoperative infections.

Zygomatic-transmandibular approach for giant tumors of the infratemporal fossa and parapharyngeal space

OBJECTIVE

The surgical anatomy of the infratemporal fossa and parapharyngeal space is often not properly understood by neurosurgeons, because these areas are more related to other medical disciplines. This article provides a detailed description of the infratemporal fossa and parapharyngeal space anatomy in cadaveric specimens and offers a neurosurgical perspective on a surgical approach that allows wide exposure and complete resection of giant tumors in this location.

METHODS

Ten cadaveric specimens were prepared for anatomic study. Dissections were performed to emphasize the relationship between bone, muscles, and neurovascular structures and to simultaneously expose the middle cranial fossa, the infratemporal fossa, and the parapharyngeal space. Ten patients with giant lesions in these areas (with maximum tumor diameter >8 cm) were treated via this approach.

RESULTS

The main obstacles to approaching the infratemporal fossa and the parapharyngeal space are the zygomatic arch, the parotid gland, the facial nerve, and the ascending ramus of the mandible. Thus, by combining a pterional-zygomatic craniotomy with transmandibular access, working up and down the parotid gland, the exposure is wider and safer. Among the 10 patients treated, tumors were totally resected in 7, subtotally resected in 2, and partially resected in 1. Morbidity was unremarkable, and, in 8 patients, clinical status improved dramatically.

CONCLUSION

The zygomatic-transmandibular approach allows resection of giant lesions in the middle cranial base, when they are invading the infratemporal fossa and parapharyngeal space, with a low morbidity rate.