Craniofacial resection for anterior skull base tumors

We present the results of treatment of 30 patients with anterior skull base tumors operated on over an 11-year period. At the time of surgery, intracranial invasion was present in 10 patients. Histology revealed epithelial tumors in 18 patients, sarcoma in 6, esthesioneuroblastoma in 4, and 2 miscellaneous histologies. The overall median survival was 5 years and varied according to histology and grade of tumor. Currently malignancies involving the skull base can be successfully resected using a craniofacial approach, with minimum operative mortality. Limited intracranial invasion need not necessarily represent a major contraindication of this procedure if morbidity can be kept to a minimum.     

Craniofacial resection for anterior skull base tumours

Summary This study presents a series of 10 patients with anterior skull base tumours, treated by a team of neurosurgeons and head- and neck surgeons. The series included 7 malignant tumours of the nose and paranasal sinuses and 1 retinoblastoma, all with intracranial extension through the lamina cribrosa. There were also 2 patients with an anterior base meningioma, growing into the ethmoid sinus and the nasal cavity.8 tumours were resected by a combined bifrontal craniotomy and uni- or bilateral rhinotomy. In 2 cases a bifrontal craniotomy alone without facial incision sufficed. The skull base was closed with a pediculated pericranial flap and a split-thickness free skin graft underneath.There were no postoperative problems of wound infection, CSF-leakage or meningitis. Recurrent tumour growth or systemic metastasis occurred in 5 out of 7 patients with malignant tumours, 6 months to 2 years postoperatively.The related literature and especially questions of operative indications and technique, including different possibilities of closure and reconstruction of the skull base, are discussed.     

Craniofacial osteotomies to facilitate skull base tumour resection

In order to expose deeply situated tumours of the skull base in various regions, the concept of osteotomies of segments of the facial skeleton has been developed. The portion of skeleton overlying the tumour is removed, the lesion is resected and the removed bony structure is then reinserted. This has greatly facilitated tumour removal in difficult areas. The advantages of this approach are, to the surgeon, total en bloc resection of deeply situated tumours with few complications; for the patient, an improvement in the quality of the aesthetic result following resection of recurrent or potentially lethal tumours.     

Craniofacial resection for tumors involving the anterior skull base.

A consecutive series of 71 patients who underwent craniofacial resection between 1974 and 1990 for tumors that involved the anterior cranial base was reviewed. A variety of histologic diagnoses was present in this series. The most prevalent sites of origin included the nasal cavity, ethmoid sinus, and frontal sinus. Gross tumor removal was achieved in all patients, with 29 requiring orbital exenteration. Adjuvant radiation therapy was used in 25 patients. Two patients died of postoperative complications and 26 had complications that increased morbidity and length of the hospitalization. Five-year overall survival was 56%, with a median survival of 4.2 years. Local control was observed in 40 of 56 patients with negative margins and 9 of 15 patients with positive margins. There was no difference in survival between previously treated and untreated patients. Survival varied considerably among the various pathologic diagnoses. Survival was related to the extent of disease. Patients with either dural or brain invasion had significantly decreased survival compared to those with no dural invasion. The operative procedure is safe, with acceptable morbidity and mortality, and offers respectable survival in properly selected patients.     

Craniofacial resections for tumors involving the base of the skull

Over a 10 year period, 42 patients with tumors involving the base of the skull underwent operation at our institution. Twenty-six patients had tumors involving the anterior fossa and cribriform plate, 3 patients had tumors involving the anterior fossa and orbit, 3 patients had invasion of the middle fossa, 5 patients had invasion of the temporal bone, and 5 patients had invasion of the clivus. A detailed analysis of the 26 patients who underwent craniofacial resection for tumors invading the anterior fossa cribriform plate region has been presented. Histologic studies revealed epithelial tumors in 18 patients, sarcoma in 6 patients, melanoma in one patient, and ossifying fibroma in one patient. The median survival in this group of patients was 60 months. Survival was influenced by histologic diagnosis. Malignant tumors involving the base of the skull can be successfully resected using a craniofacial approach with minimum morbidity and acceptable operative mortality as demonstrated in this experience. Unfavorable prognostic factors included massive intracranial extension, high grade tumor, and previous treatment failure.     

Craniofacial resection of extensive benign lesions of the anterior skull base

The craniofacial resection operation was developed for the treatment of advanced nasal, paranasal and orbital malignancies. It has been refined in recent years, giving increased cure rates and better palliation when cure is not possible. When used to treat extensive benign lesions involving the anterior skull base, this procedure allows more complete and safer resection with better access for repair and avoidance of major complications of brain damage, cerebrospinal fluid leak and haemorrhage. Presented here is a technique for craniofacial resection. The study demonstrates its effectiveness and low morbidity in treating 10 patients with extensive benign disease.     

Craniofacial trauma

The treatment of combined major dislocations of the face and skull requires a craniofacial team consisting of a plastic maxillofacial surgeon, a neurosurgeon, an anesthesiologist, and radiologists. The best results can only be achieved at the primary intervention both from a functional and an esthetic standpoint. Careful preoperative clinical and radiologic examinations are mandatory to reach these high goals. In primary repair, the cranial approach aims at constructing a monobloc bone flap to suture meningeal tears and to reinforce them with a pericranial graft, to close the cranial base completely using cancellous bone grafts, and to exclude the frontal sinuses. The facial skeleton is repaired by constructing a rigid external facial frame and thereafter progressing centrally finishing with the internal orbitonasal dislocations. The reconstruction aims at a self-stabilizing bone puzzle fixed with interosseous wires, making external fixation unnecessary. Secondary repair requires osteotomies at fracture sites to reposition malunited fractures and the use of autogenous bone grafts for stabilization.

---

Resumen El tratamiento de las dislocaciones combinadas mayores de la cara y del cráneo requiere la participación de un equipo constituido por un cirujano plástico y maxilofacial, un neurocirujano, un anestesiólogo, y radiólogos. Los mejores resultados, tanto desde el punto de vista funcional como del estético, sólo pueden ser logrados con ocasión de la intervención primaria. Es mandatoria, para el logro de estos objetivos, la realización de cuidadosos exámenes clínicos y radiológicos preoperatorios.En la reparación primaria, el abordaje craneano busca la construcción de un colgajo óseo monobloque, la sutura de desgarros meningeos y su refuerzo con un injerto de tejido pericraneano, la obliteración completa de la base craneana utilizando injertos de hueso poroso, y la exclusión de los senos frontales. El esqueleto facial es reparado mediante la construcción de un marco facial rígido externo seguida de la reducción progresiva de las dislocaciones orbitonasales internas. La reconstrucción se propone completar un rompecabezas óseo autoestabilizado con alambres interóseos, lo cual hace innecesaria la fijación externa. La reparación secundaria puede requerir osteotomías secundarias para reposicionar fracturas mal consolidadas y el uso de injertos óseos autógenos para estabilización.

---

Résumé Pour traiter les dislocations majeures de la face et du crâne, il faut une équipe comprenant un chirurgien maxillofacial et plastique, un neurochirurgien, des anesthésistes, et des radiologues. Les meilleurs résultats, tant fonctionnels qu' esthétiques, sont obtenus lorsqu'on opère ces patients d'emblée. Un examen préopératoire clinique et radiologique bien conduit est essentiel pour obtenir ces objectifs.En cas d'intervention primitive, la voie d'abord cranienne est destinée à la réalisation d'un lambeau osseux monobloc, permettant de pratiquer une suture meningée et de la réinforcer par un greffon péricranien, avec fermeture complète de la base du crâne par des greffons d'os spongieux et exclusion des sinus frontaux. Le squellette facial se répare en construisant d'abord un cadre facial externe rigide, complèté de dehors en dedans par le traitement des dislocations orbitonasales internes. L'immobilisation est assurèe par une autocautention interne autobloquante rendant une fixation externe inutile. La réparation sécondaire nécessite des ostéotomies au niveau des foyers des fractures pour repositioner les cals vicieux et des greffons osseux pour assurer la stabilisation.

     

Subcranial approach in the surgical treatment of anterior skull base trauma

Summary Fractures of the anterior skull base, because of the regions anatomical relationships, are readily complicated by neurological damage to the brain or cranial nerves. This review highlights the use of a subcranial approach in the operative treatment of injuries of the anterior skull base and compares it to the more traditional neurosurgical transcranial approach. The extended anterior subcranial approach takes advantage of the specific features of injuries in this region and allows direct access to the central anterior cranial base in order to repair fractures, close CSF fistulae and relieve of optic nerve compression. It avoids extensive frontal lobe manipulation. The success of the approach in achieving the aims of surgery with low morbidity is reviewed.     

Penetrating trauma of the internal carotid artery at the base of the skull

A 42-year-old female sustained a partial transection of the internal carotid artery at the base of the skull from a stab wound of the external ear. The clinical presentation and technical aspects of the surgical treatment are presented. The lesion could not be repaired and was successfully treated by ligation. The various techniques of operative exposure of challenging and unusual high carotid injuries which can be employed to eliminate the risk of cerebral embolism, false aneurysm formation, or carotid artery thrombosis associated with conservative management are reviewed.     

Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base

OBJECT: Skull base fractures are often associated with potentially devastating injuries to major neural arteries in the head and neck, but the incidence and pattern of this association are unknown. METHODS: Between April and September 2002, 1738 Level 1 trauma patients were admitted to St. Joseph's Hospital and Medical Center in Phoenix, Arizona. Among them, a skull base fracture was diagnosed in 78 patients following computed tomography (CT) scans. Seven patients had no neurovascular imaging performed and were excluded. Altogether, 71 patients who received a diagnosis of skull base fractures after CT and who also underwent a neurovascular imaging study were included (54 men and 17 women, mean age 29 years, range 1-83 years). Patients underwent CT angiography, magnetic resonance angiography, or digital subtraction angiography of the head and craniovertebral junction, or combinations thereof. RESULTS: Nine neurovascular injuries were identified in six (8.5%) of the 71 patients. Fractures of the clivus were very likely to be associated with neurovascular injury (p < 0.001). A high risk of neurovascular injury showed a strong tendency to be associated with fractures of the sella turcica-sphenoid sinus complex (p = 0.07). CONCLUSIONS: The risk of associated blunt neurovascular injury appears to be significant in Level 1 trauma patients in whom a diagnosis of skull base fracture has been made using CT. The incidence of neurovascular trauma is particularly high in patients with clival fractures. The authors recommend neurovascular imaging for Level 1 trauma patients with a high-risk fracture pattern of the central skull base to rule out cerebrovascular injuries.     

Anterior skull base fractures

Anterior skull base trauma evaluation and management has historically been difficult to systematically study secondary to the relative rarity of its occurrence, associated major morbidity and high mortality, and poor radiographic techniques. It has only been recently that improved care has allowed for decreased morbidity and mortality. The advent of computed tomography imaging techniques has led to anatomic characterization and detailed study of injury patterns. This article reviews current techniques for evaluation and management of the associated sinonasal, orbital, and neurologic sequelae of anterior skull base injuries.     

Malignant skull base tumors

A multidisciplinary approach to the treatment of malignant cranial base tumors has resulted in improved resections with less morbidity and a greater potential for cure. An improved understanding of the complex anatomy has allowed the development of new surgical approaches and improved methods of reconstruction. The authors' experience with the treatment of malignant neoplasms of the cranial base is reviewed, with emphasis on biologic behavior of this diverse group of neoplasms.