The role of midfacial degloving in modern rhinological practice

The Selective Role of Open and Endoscopic Approaches for Sinonasal Malignant Tumours

Endoscopic endonasal surgery has been demonstrated to be effective in the treatment of selected cases of sinonasal cancers. However, in cases of locally advanced neoplasms, as well as recurrences, the most appropriate approach is still debated. The present review aims to summarize the current state of knowledge on the utility of open approaches to resect sinonasal malignant tumours. Published comparative studies and meta-analyses suggest comparable oncological results with lower morbidity for the endoscopic approaches, but selection biases cannot be excluded. After a critical analysis of the available literature, it can be concluded that endoscopic surgery for selected lesions allows for oncologically safe resections with decreased morbidity. However, when endoscopic endonasal surgery is contraindicated and definitive chemoradiotherapy is not appropriate, craniofacial and transfacial approaches remain the best therapeutic option.

Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered

OBJECTIVES

To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort.

DESIGN

A retrospective case-series between 2006 and 2019.

SETTING

All patient care was undertaken at a regional skull base referral centre.

PARTICIPANTS

Twenty-one male patients with a median age of 18 (range 16-45 years).

MAIN OUTCOME MEASURES

Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence.

RESULTS

The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence.

CONCLUSIONS

MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

Utility of the Midface Degloving Approach for Extended Exposure in Maxillary Pathologies

Introduction

A generous exposure of the midface region is essential for a comprehensive and thorough execution of midface surgical procedures, especially bilateral procedures. Traditional approaches to the midface the midface like the lateral rhinotomy and Weber-Fergusson/Dieffenbach incision with their modifications leave a visible scar, and they are limited in their unilateral exposure. The midface degloving approach with its exclusive intranasal and intraoral incisions leaves no external scars and lends excellent bilateral exposure of the maxilla, zygoma, paranasal areas and infraorbital margins from one side to the other. The midface degloving approach is mainly used to expose pathologies of the maxilla, nasal cavities, paranasal sinuses, nasopharynx, and the central compartment of the anterior and middle cranial base. This approach can also be used to treat midface trauma and perform high-level osteotomies.

Materials and Methods

We describe the midface degloving procedure for nine cases operated in the Department of Oral and Maxillofacial Surgery over a period of 7 years (2012-2018): seven maxillary tumors and two maxillary cysts.

Results

We obtained excellent exposure for all the cases using this approach. Complications included mild distortion of the lower lateral nasal cartilages and oro-nasal communication.

Conclusion

The midface degloving approach lends excellent surgical access to the midfacial skeleton including the maxilla, the paranasal areas, the maxillary sinus, the zygoma, and infraorbital rims. The advantages of this approach besides its generous exposure, is the excellent cosmesis it provides leaving no external scars.

Midfacial degloving approach for management of the maxillary fibrous dysplasia: a case report

Background

Fibrous dysplasia (FD) is a benign bone lesion characterized by the progressive replacement of normal bone with fibro-osseous connective tissue. The maxilla is the most commonly affected area of facial bone, resulting in facial asymmetry and functional disorders. Surgery is an effective management option and involves removing the diseased bone via an intraoral approach: conservative bone shaving or radical excision and reconstruction.

Case presentation

This case report describes a monostotic fibrous dysplasia in which the patient’s right midface had a prominent appearance. The asymmetric maxillary area was surgically recontoured via the midfacial degloving approach under general anesthesia. Follow-up photography and radiographic imaging after surgery showed the structures were in a stable state without recurrence of the FD lesion. Furthermore, there were no visible scars or functional disability, and the patient reported no postoperative discomfort.

Conclusions

In conclusion, the midfacial degloving approach for treatment of maxillary fibrous dysplasia is a reliable and successful treatment option. Without visible scars and virtually free of postoperative functional disability, this approach offers good exposure of the middle third of the face for treatment of maxillary fibrous dysplasia with excellent cosmetic outcomes.

Better surgical outcome by image-guided navigation system in endoscopic removal of sinonasal inverted papilloma

PURPOSE

The purpose of this study was to validate and compare treatment outcomes for endoscopic resection of sinonasal inverted papilloma (IP) with or without the use of a navigation system.

MATERIALS AND METHODS

A total of 58 patients who underwent endoscopic resection of sinonasal inverted papilloma by a single surgeon from 2007 to 2016 at our institution were retrospectively reviewed. Depending on the use of the navigation system, subjects were divided into two groups: a conventional endoscopic resection group without navigation system (CER group) and a navigation-assisted endoscopic resection group (NER group).

RESULTS

There were 24 patients (41.4%) in the CER group and 34 patients (58.6%) in the NER group. Treatment outcomes showed that navigation-assisted endoscopic resection was a more beneficial surgical technique than conventional endoscopic resection for sinonasal IP. Post-surgical recurrence was noted in seven cases (29.2%) in the CER group and two cases (5.9%) in the NER group. Accordingly, the recurrence rate was significantly less in the NER group compared to the CER group (p = 0.026). There were two cases of complications (8.3%) in the CER group comprising cerebrospinal fluid leak and periorbital fat exposure, while no complications were noted for the NER group (p = 0.167).

CONCLUSION

This study demonstrated that navigation-assisted endoscopic removal of sinonasal IP is helpful for reducing recurrence and avoiding surgical complications. Therefore, navigation systems should be always considered when performing endoscopic removal of sinonasal IP.

[Variability and age-related features of the anatomy of the midline structures of the anterior skull base]

The article presents the literature data on the structural variability and age-related features of the midline anatomical structures of the anterior skull base (frontal sinus, ethmoid bone, anterior parasellar region, and medial orbital wall). This is the area of surgical interests of neurosurgeons and rhinosurgeons. The study objective is to analyze the literature data on the individual variability and age-related anatomy of these structures. The work is illustrated with original images from the authors' personal archive. The individual anatomical features of eloquent structures in the surgical area (structures within the surgical corridor, key anatomical landmarks, optic tract, internal carotid and ethmoidal arteries, etc.) should be considered in planning surgery in patients of all age groups because they can limit the view and the amount of safe manipulations or increase the risk of complications. The presented data may be useful for neurosurgeons and otolaryngologists whose surgical interests are focused on the midline structures of the anterior skull base.

Management and treatment of sinonasal inverted papilloma

AIMS

The aim of this paper is to describe the surgical experience of 35 patients with Inverted Papilloma (IP) of paranasal sinuses and its recurrence rate after a year of follow-up.

MATERIALS

A retrospective chart review was performed on patients presenting with IP of paranasal sinuses. Thirty-five patients comprised the focus of this study. For all patients was performed a pre-surgery TC, and for more 5 patients it was necessary to perform a Magnetic Resonance (MR) with gadolinium.

RESULTS

Among 35 patients selected, 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open surgery, while 13 patients were managed only with an endoscopic approach, with a minimum of 1 year of follow-up. Our results highlighted that the global percentage of success 12 months after the treatment was 93% and it not vary according to the tipology of the approach used if a radical excision of the lesion is achieved. More in depth, among 35 cases, only 2 patients were found to have recurrences and were treated with coronal and endoscopic approach.

CONCLUSION

It is fundamental to underline that surgery must be carried on in a radical manner to treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are essential to perform a correct and definitive treatment. Also, endoscopic approach can be taken into account when tumors are localized median to a sagittal plan crossing the orbit median wall and when they did not massively compromised paranasal sinus walls.

Salvage surgery for nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a special type of head and neck cancer with a widely variable geographical variation in incidence. The central location of the tumor inside the head coupled with the radiosensitivity of the tumor to radiation made radiation therapy the first choice in primary treatment of NPC. Advances in radiotherapy and chemotherapy have markedly improved the local control of NPC. Unfortunately, a small but significant number of patients still suffered from loco-regional failures that would be amenable to re-treatment. Traditional form of retreatment was to employ a second course of radiation. The efficacy of re-irradiation to treat local of regional recurrent NPC has been suboptimal. Moreover, the local tissue had already received a high dose of radiation and the second radiation could result in radiation toxicities to the local tissue, leading to significant complications.

Surgical salvage, on the other hand, could spare the patients from complications of re-treatment. Due to the difficult access of the nasopharynx, various surgical approaches had been devised for nasopharyngectomy. The maxillary swing approach had the largest published experience with over 300 cases from various centers. In the recent decade, the endoscopic approach with or without robotic assistance had gained popularity for resecting small, centrally located recurrences. This minimally invasive approach further reduced the morbidity for treating locally recurrent NPC.

Nodal recurrences had been a rare entity after the introduction of modern radiotherapy technique and concurrent chemotherapy. Treatment of nodal failure with second radiation has dismal results. Surgical removal of the lymph node harboring the recurrence should be in the form of a formal radical neck dissection. In cases of extensive nodal recurrence where microscopic disease may be present after a formal neck dissection, additional radiotherapy can be delivered with after-loading brachytherapy.

Surgical treatment played a definitive role in salvage of loco-regional failures of nasopharyngeal carcinoma.

The role of Epstein-Barr virus-encoded microRNA BART7 status of resection margins in the prediction of local recurrence after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma

BACKGROUND

Local recurrence is the major cause of treatment failure in patients who undergo surgical salvage of recurrent nasopharyngeal carcinoma (NPC) after radiotherapy. The authors investigated the role of Epstein-Barr virus (EBV)-encoded Bam HI-A rightward transcript 7 microRNA (BART7) status in resection margins in the identification of a subgroup of patients who may benefit from adjuvant reradiation after surgery.

METHODS

One hundred two consecutive patients who had histologically clear resection margins after undergoing nasopharyngectomy for recurrent NPC were studied. The status of EBV microRNA BART7 in resection margins was investigated and correlated with the pattern of subsequent disease recurrence.

RESULTS

After a median follow-up of 64 months, 20 patients (19.6%) developed local recurrence after surgery despite histologically uninvolved margins. The risk of local recurrence in patients with histologically close (<5 mm) and clear (≥5 mm) margins was 31.6% and 12.5%, respectively. In patients with clear histologic margins, those with margins that were positive for EBV microRNA BART7 has a significantly higher chance of developing local tumor recurrence (P = .016) than those with negative molecular margins. The difference was not significant when the histologic clearance at the resection margins was <5 mm.

CONCLUSIONS

Tissue EBV microRNA BART7 is useful for identifying a subgroup of patients with histologically clear margins who are at increased risk of subsequent local tumor recurrence. Postoperative adjuvant treatment is warranted for these patients.

Management of advanced intracranial intradural juvenile nasopharyngeal angiofibroma: combined single-stage rhinosurgical and neurosurgical approach

BACKGROUND

Although intracranial extension of juvenile nasopharyngeal angiofibroma (JNA) occurs commonly, intradural penetration is extremely rare. Management of such tumors is a challenging issue in skull-base surgery, necessitating their removal via combined approaches. In this work, we share our experience in management of extensive intradural JNA.

METHODS

In a university hospital-based setting of 2 tertiary care academic centers, retrospective chart of 6 male patients (5 between 15 and 19 years old) was reviewed. Patients presented chiefly with nasal obstruction, epistaxis, and proptosis. One of them was an aggressive recurrent tumor in a 32-year-old patient. All cases underwent combined transnasal, transmaxillary, and craniotomy approaches assisted by the use of image-guided endoscopic surgery, with craniotomy preceding the rhinosurgical approach in 3 cases.

RESULTS

Adding a transcranial approach to the transnasal and transmaxillary endoscopic approaches provided 2-sided exposure and appreciated access to the huge intradural JNAs. One postoperative cerebrospinal fluid leak and 1 postoperative recurrence at the site of infratemporal fossa were treated successfully. Otherwise, the course was uneventful in the remaining cases.

CONCLUSION

Management of intracranial intradural JNA requires a multidisciplinary approach of combined open and endoscopic-assisted rhinosurgery and neurosurgery, because of greater risk for complications during the dissection. Carotid rupture and brain damage remain 2 catastrophic complications that should always be kept in mind. A combined rhinosurgical and neurosurgical approach also has the advantage of very modest cosmetic complications.

Multivariate analysis of prognostic factors for salvage nasopharyngectomy via the maxillary swing approach

BACKGROUND

The purpose of this study was to investigate the prognostic factors for salvage nasopharyngectomy.

METHODS

A retrospective review was conducted on maxillary swing nasopharyngectomy performed between 1998 and 2010. Univariate and multivariate analyses identified prognostic factors affecting actuarial local tumor control and overall survival.

RESULTS

The median follow-up duration was 52 months. Among the 268 patients, 79.1% had clear resection margins. The 5-year actuarial local tumor control and overall survival was 74% and 62.1%, respectively. On multivariate analysis, tumor size, resection margin status, and gross tumor in the sphenoid sinus were independent prognostic factors for local tumor control. For overall survival, resection margin status, synchronous cervical nodal recurrence, and cavernous sinus invasion had a negative influence on overall survival after surgery.

CONCLUSION

Extent of nasopharyngectomy should be tailored to the individual tumor to achieve clear resection margins. Cavernous sinus invasion is associated with poor survival outcome, and detailed counseling and meticulous surgical planning is crucial in such circumstances.

Exclusive Endoscopic Resection of Juvenile Nasopharyngeal Angiofibroma

Objective

To systematically review the exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma in the literature to define the clinical features in terms of staging and the treatment outcomes in terms of bleeding, recurrence, residual tumor, and complications.

Data Sources

Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles.

Review Methods

The literature was searched by 2 reviewers with the following inclusion criteria: English or French language and exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma. We were only able to perform a meta-analysis on the categorical outcomes using DerSimonian and Laird random effects models.

Results

Ninety-two studies were included with a majority of retrospective studies (54/92; 58.6%). No randomized controlled trials were found. A total of 821 patients were identified. The Radowski classification was the most commonly used (29/92; 31.15%). The mean operative blood loss was 564.21 mL (minimum, 20 mL; maximum, 1482 mL). It was 414.6 mL (minimum, 20 mL; maximum, 1000 mL) and 774.2 mL (minimum, 228 mL; maximum, 1482 mL), respectively, in the group with and without embolization. No conclusion could be made because it was not stratified by tumor stage and because of the absence of randomized controlled trials. The random effect estimate of recurrence was 10% (95% confidence interval [CI], 8.3-11.7). It was 9.3% (95% CI, 7.2-11.5) for complications and 7.7% (95% CI, 5.4-10.1) for residual tumor.

Conclusion

The endoscopic treatment is an evolving modality. It is considered today the treatment of choice. A new classification system based on the endoscopic approach should be proposed in future studies.

Sinonasal tract and nasopharyngeal adenoid cystic carcinoma: a clinicopathologic and immunophenotypic study of 86 cases

Primary sinonasal tract and nasopharyngeal adenoid cystic carcinomas (STACC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. Eighty-six cases of STACC included 45 females and 41 males, aged 12-91 years (mean 54.4 years). Patients presented most frequently with obstructive symptoms (n = 54), followed by epistaxis (n = 23), auditory symptoms (n = 12), nerve symptoms (n = 11), nasal discharge (n = 11), and/or visual symptoms (n = 10), present for a mean of 18.2 months. The tumors involved the nasal cavity alone (n = 25), nasopharynx alone (n = 13), maxillary sinus alone (n = 4), or a combination of the nasal cavity and paranasal sinuses (n = 44), with a mean size of 3.7 cm. Patients presented equally between low and high stage disease: stage I and II (n = 42) or stage III and IV (n = 44) disease. Histologically, the tumors were invasive (bone: n = 66; neural: n = 47; lymphovascular: n = 33), composed of a variety of growth patterns, including cribriform (n = 33), tubular (n = 16), and solid (n = 9), although frequently a combination of these patterns was seen within a single tumor. Pleomorphism was mild with an intermediate N:C ratio in cells containing hyperchromatic nuclei. Reduplicated basement membrane and glycosaminoglycan material was commonly seen. Necrosis (n = 16) and atypical mitotic figures (n = 11) were infrequently present. Pleomorphic adenoma was present in 9 cases; de-differentiation was seen in two patients. Immunohistochemical studies showed positive reactions for pan-cytokeratin, CK7, CK5/6, CAM5.2, and EMA, with myoepithelial reactivity with SMA, p63, calponin, S100 protein and SMMHC. CD117, CEA, GFAP and p16 were variably present. CK20 and HR HPV were negative. STACC needs to be considered in the differential diagnosis of most sinonasal malignancies, particularly poorly differentiated carcinoma, olfactory neuroblastoma and pleomorphic adenoma. Surgery (n = 82), often accompanied by radiation therapy (n = 36), was generally employed. A majority of patients developed a recurrence (n = 52) 2-144 months after initial presentation. Overall mean follow-up was 19.4 years (range 0.4-37.5 years): 46 patients died with disease (mean 6.4 years); 5 were alive with disease (mean 5.4 years), and 35 patients were either alive or had died of unrelated causes (mean 16.3 years). ACC of the SNT is uncommon. Recurrences are common. The following parameters, when present, suggest an increased incidence of either recurrence or dying with disease: mixed site of involvement, high stage disease (stage IV), skull base involvement, tumor recurrence, a solid histology, perineural invasion, bone invasion, and lymphovascular invasion.

Stenting of the eustachian tube to prevent otitis media with effusion after maxillary swing approach nasopharyngectomy

OBJECTIVES/HYPOTHESIS

Our previous report recommended that the management of ipsilateral otitis media with effusion (OME) after maxillary swing nasopharyngectomy was observation. The idea of introducing a stent into the eustachian tube (ET) at the nasopharyngeal side after nasopharyngectomy may prevent postoperative OME. The purpose of this study was to examine the feasibility of intraoperative ET stenting and the efficacy of preventing ipsilateral OME formation.

STUDY DESIGN

Prospective cohort study.

METHODS

From 2009 to 2011, 28 patients with nasopharyngectomy via the maxillary swing approach were recruited. Patients with curative resection were recruited (n = 21). ET stenting was performed intraoperatively using a 16-gauge Angiocath (BD Medical Systems, Franklin Lakes, NJ) with dimensions of 1.7 mm × 30 mm. The stent stays inplace indefinitely. The otologic status was evaluated using otoscopy, pure-tone audiogram, and tympanogram at 3 months, 6 months, and 1 year after the surgery. The outcomes were analyzed and compared with historical control.

RESULTS

There were 9 (43%) patients with no OME at 6 months after surgery, and 15 (71%) patients had no OME at 1 year postoperatively. The results were statistically significant (P < .0001) when compared with our historical control of no ET stenting. There was no incidence of adverse effects of the stenting, such as acute otitis media, dislodgement of the stent, otalgia, and nasal pain.

CONCLUSIONS

ET stenting was feasible after nasopharyngectomy. ET stenting prevented a significant number of patients from suffering from ipsilateral OME and alleviated the symptoms of unilateral aural fullness and unilateral conductive hearing impairment up to at least 1 year after the surgery. ET stenting is recommended in all patients after maxillary swing nasopharyngectomy.

Craniofacial resection and its role in the management of sinonasal malignancies

Sinonasal malignancy is rare, and its presentation is commonly late. There is a wide variety of pathologies with varying natural histories and survival rates. Anatomy of the skull base is extremely complex and tumors are closely related to orbits, frontal lobes and cavernous sinus. Anatomical detail and the late presentation render surgical management a challenging task. A thorough understanding of anatomy and pathology combined with modern neuroimaging and reliable reconstruction within a multidisciplinary team is imperative to carry out skull base surgery effectively. While endoscopic approaches are gaining credibility, clearly, it will be some time before meaningful comparisons with craniofacial resection can be made. Until then, craniofacial resection will remain the gold standard for managing the sinonasal malignancies of the anterior skull base, as it has proved to be safe and effective.

Surgical management of large juvenile nasopharyngeal angiofibroma invading the infratemporal fossa with intracranial extradural parasellar involvement in an 8-year-old boy

We present a rare case of a large juvenile nasopharyngeal angiofibroma (JNA) in an 8-year-old boy. Preoperative imaging revealed that the tumor had widely extended to the sphenoid sinus, infratemporal fossa, and cavernous sinus. Following embolization of the feeding vessels, the tumor was successfully removed by a combination of an orbitozygomatic approach and Le Fort I osteotomy under frontolateral craniotomy. An endoscope assisted in the surgery. At 15 months follow-up, the patient was free of the disease with no facial palsy, scars, or malocclusion. JNA is a benign tumor that typically affects adolescent males and is rarely observed during prepuberty. Complete removal of JNA by surgery, the initial therapy, is generally required. However, as in the present case, a large JNA with wide extension requires extended surgery, and such a surgery is more invasive for prepubertal patients. Using an appropriate combination of surgical approaches, a large JNA developed during prepuberty can be safely removed with reduced morbidity.

Transnasal endoscopic management of angiofibroma extending to pterygopalatine and infratemporal fossae

Introduction:

Surgical approaches to the pterygopalatine and infratemporal fossae are complex and cause significant morbidity. The commonest benign tumour to extend to the pterygopalatine and infratemporal fossae is angiofibroma.

Patients and methods:

This prospective study included 15 male patients aged 12–27 years with recurrent, severe epistaxis. After computed tomography and magnetic resonance imaging, a modified Wormald and Robinson's two-surgeon approach was used. Follow up, with endoscopy and magnetic resonance imaging, ranged from two to five years.

Results:

Twelve patients were cured (endoscopically and radiologically). Three patients suffered recurrence, one each in the lateral sphenoid wall, pterygoid canal and infratemporal fossa. Revision surgery was performed, but one patient suffered another recurrence (lateral sphenoid wall with cavernous sinus infiltration) and was referred for gamma knife surgery.

Conclusion:

This endoscopic two-surgeon technique is an excellent approach for managing angiofibroma extending to the pterygopalatine and infratemporal fossae. Our modification markedly decreased morbidity by avoiding septum opening and sublabial incision, and by enabling better haemostasis (via maxillary artery control). Recurrence may be minimised by careful examination of the lateral sphenoid wall, pterygoid canal and infratemporal fossa pterygoid muscles.

Treatment outcomes of juvenile nasopharyngeal angiofibroma according to surgical approach

OBJECTIVE

This is a retrospective study to assess treatment outcomes according to stage and surgical approach in advanced juvenile nasopharyngeal angiofibroma (JNA).

METHODS

We retrospectively evaluated 20 JNA patients diagnosed and treated at our hospital. We only enrolled advanced disease with Radkowski stages greater than I and with minimum follow-up of 1 year (range 1-8.5).

RESULTS

Recurrence or remnants were observed in 7 patients out of 20 patients (35.0%) who underwent primary surgical resection of advanced JNA and the mean interval to recurrence was 15.6 months (range 6-38). A recurrence rate according to a different stage was as follows: 33.3% in stage IIa, 33.3% in stage IIb, 50.0% in stage IIc and no recurrence in stage III. An endoscopic approach was chosen in 4 patients among these patients, four were classified as stage IIb tumors, one as a stage IIc tumor, with a recurrence rate of 25.0%, but no recurrence found in stage IIa disease. A midfacial degloving approach was used in 7 patients, with a recurrence rate of 42.9% and maxillary swing approach was taken in 3 patients with complete control. Postoperative complications required interventions occurred in 14.8%, more in the invasive maxillary swing or infratemporal fossa approaches.

CONCLUSIONS

Although selecting minimal invasive or invasive approaches is equivocal, we recommend using the endoscopic approach or a midfacial degloving approach for the treatment of JNA extended to the pterygopalatine fossa. For stage III, aggressive surgery is preferable to guaranty a complete resection even if postoperative complications are more frequent. For a stage IIc, we could choose between a minimally invasive approach or a more aggressive one balancing between the possibility of salvage surgery in the future and the occurrence of postoperative healing problems.

A modified midfacial degloving approach for the treatment of unilateral paranasal sinus tumours

PURPOSE

The midfacial degloving approach (MFDA) is the primary option for the removal of benign and malignant sinonasal tumours. However, the classic MFDA does not compensate for the fact that most benign and malignant paranasal sinus (PNS) tumours are unilateral and the incisions may lead to some unnecessary complications?. Surgical exposure is limited to the upper and deep part of the PNS. Modifications of the classical MFDA that minimize complications and improve surgical field exposure are warranted.

PATIENTS

The medical records of 27 consecutive patients who had undergone surgery using a modified MFDA for treatment of unilateral benign or malignant tumours from 2000 to 2006, were reviewed.

RESULTS

We developed and performed a modified MFDA utilizing a hemigingivobuccal incision, a transfixion incision, mucosal detachment of the pyriform aperture and separation of the upper lateral cartilage from the nasal bone in 27 patients with unilateral benign (85%) or malignant (15%) PNS neoplasms. Adequate surgical exposure was achieved in all cases. No technical problems and no intraoperative complications related to the surgical procedure were encountered.

CONCLUSION

Our modified MFDA provides sufficient surgical exposure for the removal of unilateral malignant or benign PNS tumours with few surgical or cosmetic complications.

Perioperative problems and treatment of a teenager with a juvenile angiofibroma refusing blood transfusion

OBJECTIVES

Juvenile angiofibroma is a benign, non-encapsulated neoplasm, consisting of vascular and connective tissue. Its main feature is a local malignancy. In its clinical course it destroys adjoining structures, without metastasizing. It appears rarely, and is mainly found in boys at puberty. Among theories about the aetiology of juvenile angiofibroma, we must consider a haematoma-like lesion, an angioma with an extended fibrous component, or type of inflammatory allergic polyp. In the development of the lesion the participation of hormonal disorders on the pituitary gland-gonad axis is also suggested. According to the latest research, juvenile angiofibroma is regarded as a developmental defect, affecting the embryonic vascular network surrounding the sphenoid bone.

METHODS

If the patient or his/her parents refuse blood transfusion and use of blood products, it is necessary to apply modifications in the routine perioperative treatment. In the case of the patient refusing blood and blood products transfusion because of their beliefs, it is possible to get consent to use different, highly processed products like albumins or a cryoprecipitate, as well as applying some blood-saving techniques.

CONCLUSIONS

1. Removal of juvenile angiofibroma with minimal bleeding is possible. 2. Applying erythropoietin and iron preparations prior to surgery increases erythropoiesis and reduces the risks in transfusion. 3. Applying intraoperative normovolaemic haemodilution is a safe method and allows avoidance of transfusion of blood-derived products.

Modified midfacial degloving approach for sinonasal tumors

A perfect surgical approach to nasal cavity and paranasal sinus tumors should provide a broad exposition preserving the important structures with no cosmetic defect. Midfacial degloving (MD) technique provides good exposure without incisions and scars in the face. Classic MD technique includes rhinoplasty incisions. However, combination of the facial plastic skills of the rhinoplasty techniques with an oncologic approach limits its popularity. We modified the classic technique, which is performed without classic rhinoplasty incisions. The surgical approaches to 55 patients with benign and malignant sinonasal neoplasms are reviewed, and the modification of MD technique performed without rhinoplasty incisions is described. The study includes 41 male and 13 female patients with both benign and malignant sinonasal neoplasms. The ages of the patients were between 9 and 78 years with a mean age of 41.15 years. Follow-up of the patients ranged from 2 to 96 months with a mean of 31.7 months. Most of the cases were angiofibroma and inverted papilloma. Modified MD approach was used for all patients, and in 6 cases, the technique was combined with subcranial approach. We successfully resected the tumors in all of the patients. The most frequently encountered complaint in the postoperative period was temporary nasal crusting and epistaxis. An important complication was the rupture of subpetrous part of the internal carotid artery in one patient and also a temporary facial palsy in another one. Palatal dysfunction, oroantral fistula, or vestibular stenosis, which are significant complications of MD, were not observed in any of our cases. In this modified technique, rhinoplasty incisions are not used; therefore, the duration of operation is shortened, the technique becomes easier, and the incisions of the rhinoplasty procedure, which could cause circular stenosis, are avoided.

Transcranial combined neurorhinosurgical approach to the paranasal sinuses for anterior skull base malignancies

OBJECTIVE

Various transcranial and transfacial approaches have been described and each claims to provide the best exposure to the anterior skull base. Similarly, each approach claims the best outcomes following the resection of anterior skull base malignancies. We have always advocated a combined neurorhinological approach for the management of paranasal sinus malignancies that infiltrate the skull base, such as esthesioneuroblastomas.

MATERIALS AND METHODS

At the outset, the technique was developed on cadaver specimens, imitating the limitations that might be imposed in the real-life situation when undertaking endoscopic sinus surgery. Additional exposure of the anterior cerebral fossa was achieved using a classical bifrontal approach. Starting with endoscopic or microscopic unroofing of the ethmoids, all relevant landmarks were identified. The frontal, sphenoid, and maxillary sinuses were then opened using endoscopic techniques.

RESULTS

The dissections proved that a broad exposure of the anterior skull base could be combined with clear endoscopic visualization of the nasal cavity and of all the paranasal sinuses from above. This facilitated complete eradication of lesions from the sinuses cavities, their walls, and the intracranial tumor.

DISCUSSION

The combined neurorhinosurgical transcranial approach to the anterior skull base and nasal and paranasal sinuses, avoiding trans-facial approaches, enables a multidiciplinary team to resect malignant tumors of the anterior skull base directly without unnecessary destruction of facial structures. It appears to provide better access than other more destructive methods like midfacial degloving or subfrontal approaches. Our single-stage approach also facilitates safe and effective reconstruction of the skull base. The technique can be employed for tumors of all sizes and is also used for orbital resections and decompression of the optic nerve and chiasma.

[Safe extirpating of AFJ after preoperative tumor obliteration with tissue adhesive glue]

The purpose of this work is to present the method of operating juvenile nasopharyngeal angiofibroma with the use of preoperative obliteration with tissue adhesive glue (Histoacryl). Authors described the case of 15 years old patient, who was admitted to ENT Department because of epistaxis, nasal obturation and returning headaches. To explain this problem, the routine diagnostics CT and angio-CT scan was applicated. Angiography confirmed well vascularized tumor supplied from facial and palatine arteries. Therapy based on the obliteration of tumor vessels with the glue-tissue was applied. As the next step the tumour was surgically extirpated. The application of this method gave a very good, simply bloodless operation effects. It allows a very good, simple and fully precise tumor extirpation. The extirpation of AFJ which is a highly vascularized tumor with the previous obliteration of the supplying vessels is a safe procedure and results in complete removal of the tumour.

Endoscopic assisted antral window approach for type III nasopharyngeal angiofibroma with infratemporal fossa extension

OBJECTIVES

To assess the efficacy and safety of endoscopic assisted antral window approach in advanced nasopharyngeal angiofibroma with infratemporal fossa extension.

MATERIALS AND METHODS

Sixteen cases diagnosed as juvenile nasopharyngeal angiofibroma type III with infratemporal fossa extension were surgically managed using endoscopic assisted antral window approach (group A) and compared with another group of similar number that were managed using endoscopic assisted midfacial degloving (group B). Inclusion criteria were type III JNA with infratemporal fossa extension and a minimum follow-up of 2 years. Operative time, blood loss, adverse events and recurrences were recorded in all cases.

RESULTS

The amount of blood lost in group A was significantly less than group B. The operative time of group A was significantly less than group B. No major complications were seen in both groups. Twenty-eight patients showed complete tumor clearance. Four recurrences were seen: two in group A and two in group B.

CONCLUSION

Endoscopic assisted antral window approach provides a safe, reliable, effective and minimally invasive technique in management of type III JNA with infratemporal fossa extension. Preoperative embolization is a safe measure in the experienced hands that helps to reduce intraoperative blood loss and improves the quality of the surgical field.

[Transpalatal approach for juvenile angiofibroma]

INTRODUCTION

Juvenile nasopharyngeal angiofibromas (JNA) are highly vascular, locally invasive tumours which originate in the sphenopalatine foramen. Several surgical approaches are described for this tumour. The aim of this study was to evaluate the transpalatal approach for juvenile angiofibroma.

MATERIAL AND METHODS

In a group of 22 patients with JNA transpalatal approach was employed. A retrospective patients notes review was done. Extension of tumour, complications of surgery and recurrences were analyzed.

RESULTS

In 17 patients the tumour was confined to the nasal cavity and the nasopharynx. In 5 patients the tumour invaded the sphenoid sinus. No complications were observed after surgery. Two (9%) patients had recurrence.

CONCLUSION

Transpalatal approach is best suited to small tumours (Andrews grade I and II) limited to the nasopharynx, nasal cavity and sphenoid sinus.

Juvenile nasopharyngeal angiofibroma stages I and II: a comparative study of surgical approaches

OBJECTIVE

The aim of this study was to compare different surgical options used for removal of stages I and II juvenile nasopharyngeal angiofibromas (JNAs). Treatment morbidity was evaluated through blood loss, surgery duration, postoperative hospitalization and outcome. Moreover, an effort was made to explore the role and limits of endoscopic surgery.

MATERIALS AND METHODS

20 male patients (mean age 14.9 years) were treated for JNA using three different surgical approaches in the Department of Otolaryngology of the University of Athens between May 1998 and January 2007. 9 patients were managed using endoscopic approach, while 5 were treated through midfacial degloving. A transpalatal approach was performed in remaining 6 patients. Preoperative angiography with embolization was performed in all 9 patients who underwent endoscopic removal and in 3 patients treated by midfacial degloving technique.

RESULTS

Findings demonstrated that endoscopic approach, assisted by preoperative embolization, lead to less intraoperative blood loss, shorter duration of surgical procedure, shorter length of hospital stay and no complications, compared with the conventional techniques.

CONCLUSIONS

Our data suggest that with proper patient selection, endoscopic resection of stages I and II JNA, when it is performed after embolization of the feeding vessels, is remarkably bloodless and precise and may be preferable to traditional open approaches.

Management of inverted papillomas of the nose and paranasal sinuses

PURPOSE

Inverted papillomas (IPs), although histologically benign, are aggressive lesions that may recur after an excision. The objective of this study was to compare the surgical treatment options for IPs with an emphasis on the experience of our institution with midfacial degloving (MFD) and medial maxillectomy.

MATERIALS AND METHODS

A retrospective review of the charts of patients with IP treated by MFD and medial maxillectomy was performed. An analysis of the recurrence rates of IPs in the literature for endoscopic surgery and lateral rhinotomy was also performed.

RESULTS

Ninety-eight medial maxillectomy procedures via MFD were performed for IPs with a minimum of 2 years' follow-up (median = 5.1 years). Two patients were found to have recurrences (2.1%). The literature review revealed an average recurrence rate of 15.7% for lateral rhinotomy as compared with that of 19.6% for endoscopic surgery.

CONCLUSION

Midfacial degloving balances acceptable cosmetic results with low recurrence rates. It allows for adequate exposure and resection without the scar of a lateral rhinotomy incision.

Endoscopic surgery for juvenile nasopharyngeal angiofibroma: where are the limits?

PURPOSE OF REVIEW

This article will examine recent publications on the endoscopic management of juvenile nasopharyngeal angiofibromas.

RECENT FINDINGS

The use of an endoscopic approach to resect small juvenile nasopharyngeal angiofibromas is supported by excellent results from a number of operative series published in recent years. Large juvenile nasopharyngeal angiofibromas continue to present a considerable surgical challenge, with most being resected by traditional open approaches. However, the results achieved after the endoscopic resection of large tumours have been reported for a small number of cases. This review focuses on the outcome of these cases, which would seem to compare favourably to open series, and the advances in instrumentation and techniques, that facilitate the endoscopic removal of large juvenile nasopharyngeal angiofibromas.

SUMMARY

Improvements in preoperative assessment and preparation, operative technique, and instrumentation potentially enable the endoscopic removal of most juvenile nasopharyngeal angiofibromas.

Endoscopic management of benign tumors extending into the infratemporal fossa: a two-surgeon transnasal approach

OBJECTIVES/HYPOTHESIS

Preliminary results of the endoscopic two-surgeon technique for the management of benign infratemporal fossa tumors are presented.

METHODS

Four patients with juvenile nasopharyngeal angiofibroma, a patient with an inverting papilloma, and a patient with a maxillary nerve schwannoma were reviewed. The average age was 22.7 years; the male-to-female ratio was 5:1. The endoscopic anatomy and surgical technique are presented.

RESULTS

The two-surgeon technique allowed complete resection of all six tumors extending into the infratemporal fossa. There has been no recurrence of tumor within the infratemporal fossa, after a mean follow-up of 31.3 months (SD = 11.2 mo).

CONCLUSION

The two-surgeon transnasal technique allows benign infratemporal fossa tumors to be resected endoscopically.

Endoscopic management of anterior skull base tumors

Anterior craniofacial resection has become a standard procedure for management of lesions of the anterior skull base. During the last 2 decades, modifications of the classic anterior craniofacial resection have been reported. With the introduction of endoscopic sinus techniques and instrumentation, surgeons have begun to use endoscopic approaches for management of anterior skull base lesions. This article describes endoscopic modifications of anterior craniofacial resection.

Cancer of the nasal cavity and paranasal sinuses

Sinonasal malignancies continue to have poor survival rates. Disease-related mortality is usually the result of disease recurrence and progression at the primary site despite aggressive therapy. Complete surgical excision with postoperative radiation therapy remains the standard of care for resectable lesions. Improved reconstructive techniques have increased our ability to aggressively clear locally advanced disease in this anatomically challenging region, while reducing associated functional and cosmetic morbidity. Intensive multimodality treatment regimens coupled with newer medical technology may ultimately improve the long-prevailing poor prognosis of these tumors.

Endoscopic-assisted midfacial degloving approach for type III juvenile angiofibroma

BACKGROUND

Open surgery is the mainstay treatment for juvenile angiofibromas (JAF). Midfacial degloving approach provides good exposure to the target area with excellent cosmoses. Endoscopic techniques have been used for the removal of some small JAF.

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy and outcome of endoscopic-assisted midfacial degloving approach as a route for removal of type III juvenile angiofibroma.

PATIENTS AND METHODS

Fifteen young male patients with type III JAF (based on Fisch classification by computed tomography (CT) and magnetic resonance imaging (MRI) or both), were operated on by endoscopic-assisted midfacial degloving approach. Pre-operative angiography and embolization were performed in two patients. The surgical technique is described in details.

RESULTS

Apart from a case developed cerebrospinal fluid (CSF) rhinorrhea intraoperatively there were neither major operative nor post-operative complications. CSF leak was repaired through the same approach successfully in the same set. Thirteen patients had complete tumor clearance with no residual or recurrence during the follow-up period which ranged from 6 months to 6 years. Recurrence was detected early by endoscopic examination in two cases (3 and 8 months post-operatively) and confirmed by CT and MRI. Endoscopic transnasal removal of the recurrent JAF was done successfully under local anesthesia in the first patient and under general anesthesia in the second with no recurrence during the follow-up period.

CONCLUSIONS

Endoscopic-assisted midfacial degloving approach for removal of type III JAF enables the surgeon to gain the advantages of midfacial degloving approach with extensive exposure of the surgical field. Employing an endoscope, offers safe dealing with serious intraoperative complications like CSF leak. Post-operative follow-up by endoscopic nasal examination can detect early recurrence, which can be confirmed by CT and MRI.

The role of midfacial degloving approach for maxillary cysts and tumors

PURPOSE

The midfacial degloving approach has been used as a surgical approach to gain access to regions of the midface that would otherwise require external incisions. This article describes the role of this technique for various maxillary lesions.

PATIENTS AND METHODS

Thirteen patients underwent the midfacial degloving technique for 8 maxillary benign lesions and 5 malignant lesions. This procedure uses 4 basic incisions: 1) sublabial incision, 2) bilateral intercartilaginous incisions, 3) septocolumellar-complete transfixion incisions, and 4) bilateral piriform aperture incisions extending to the vestibule.

RESULTS

All patients successfully underwent the planned procedures after the midfacial degloving technique for the treatment of benign or malignant lesions without significant complications. Postoperative sequelae were nasal crusting and infraorbital hypesthesia, both of which resolved.

CONCLUSIONS

The midfacial degloving approach offers good exposure of the mid third of the face with excellent cosmetic results. This approach may be combined with downfracture of the maxilla for access to expose and resect sinonasal malignancies. The midfacial degloving technique is a viable procedure with low morbidity and excellent cosmetic outcomes.

Impact of unilateral sinus surgery with resection of the turbinates by means of midfacial degloving on nasal air conditioning

OBJECTIVE/HYPOTHESIS

One of the most important functions of the nose is the climatization of inspired air. The aim of the investigation was to determine the influence of radical sinus surgery with complete resection of the turbinates and the lateral nasal wall by means of midfacial degloving as treatment for inverted papilloma on the nasal humidification and heating of inspired air.

STUDY DESIGN

Retrospective study.

METHODS

Humidity and temperature were measured in the nasopharynx during normal respiration by means of a miniaturized thermocouple device and a humidity sensor for continuous detection. Eight patients after prior unilateral sinus surgery by means of midfacial degloving for a one-sided inverted papilloma were enrolled into the study. The humidity and temperature data of the surgically treated side were compared to the values of the healthy side that was not surgically treated. Active anterior rhinomanometry and acoustic rhinometry were performed.

RESULTS

At the end of inspiration, absolute humidity and temperature values in the nasopharynx were statistically significantly lower on the surgically treated side compared with the side that was not surgically treated.

CONCLUSIONS

Radical sinus surgery with resection of the turbinates by means of midfacial degloving seems to disturb the climatization of the inspiratory air in the nasal cavity. Reduced absolute humidity and temperature may contribute to crusting, bleeding, and nasal dryness as frequent complaints of patients after aggressive sinus surgery with resection of the turbinates.

Tumors of the skull base in children: review of tumor types and management strategies

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.

The midfacial degloving procedure for nasal, sinus, and nasopharyngeal tumors

The midfacial degloving approach is more technically involved than a lateral rhinotomy and requires a basic level of proficiency and understanding of closed rhinoplasty incisions and anatomy of the nose, paranasal sinuses, and skull base structures. Current applications of the midfacial degloving procedure have allowed expansion of indications for this technique through the use of complementary endoscopic and subcranial approaches, permitting the exposure and removal of extensive skull base lesions without disfiguring facial incisions. Fundamental in these approaches is the basic midfacial degloving exposure, which is discussed in this article, along with the applications for treatment of skull base lesions.

Craniofacial approaches to tumors of the anterior skull base

An approach that combines extracranial and intracranial components-termed a craniofacial approach-allows en bloc extirpation of paranasal malignancies that abut or penetrate the skull base. When combined with radiotherapy, cure rates for such tumors rose from near zero in the 1950s to 39% to 86% by 2000, with the higher rates reflective of esthesioneuroblastomas, well-differentiated adenocarcinomas, vasoformative tumors, and meningiomas. Transfacial tumor access can involve a transnasal (endoscopic or with magnification loupes) exposure, a midfacial degloving, or a lateral rhinotomy, depending on tumor location and size. Adjunctive exposures for tumors penetrating the nasopharynx, pterygomaxillary fossa, or sphenoid include the lateral facial split and the mandibular swing. The standard transcranial accesses are a sub-basal variation of frontal craniotomy, which encompasses en bloc the superior orbital rims, the nasion, and the lower frontal bones; or, a frontotemporal craniotomy with mobilization of the lateral orbital rim and the zygoma.

Recurrence and its avoidance in juvenile angiofibroma

OBJECTIVE

Angiofibroma is a highly vascular lesion for which a wide range of surgical approaches has been recommended. Irrespective of the approach, a significant and often rapid recurrence rate is reported in all major series.

AIM

To consider the impact of lessons learned from imaging on the recurrence rate of angiofibroma.

MATERIAL AND METHODS

From a cohort of 90 male patients with histologically proven angiofibroma, 40 individuals were studied. The recurrence rate in 20 cases treated before March 1998 was compared with that in 19 cases treated thereafter. In the latter group, an additional exploration of the basisphenoid had been undertaken.

RESULTS

The two cohorts were comparable in age range (7-27 y and 11-24 years, respectively), and all had been treated by midfacial degloving. In the first group, 8 recurrences occurred which were multiple in 1 patient. In the next 19 patients, the area of the pterygoid canal was meticulously explored and the basisphenoid drilled to remove all residual tumor. No recurrences have occurred in this group during a follow-up of between 6 months to 3 years.

CONCLUSION

Meticulous removal of angiofibroma infiltrating the pterygoid canal and basisphenoid is paramount to avoid "recurrence."