Combined subcranial approaches for excision of complex anterior skull base tumors

OBJECTIVE: To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach. PATIENTS: Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured. RESULTS: Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches. CONCLUSION: Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.     

Patient, caregiver, and surgeon perceptions of quality of life following anterior skull base surgery

OBJECTIVE: To estimate the agreement between surgeons' and lay caregivers' quality-of-life (QOL) perceptions of patients undergoing major skull base surgery. DESIGN: Cohort survey of patients who had undergone anterior skull base tumor excision. SETTING: University-affiliated medical center. PARTICIPANTS: Thirty-five patients and their lay caregivers participated in the study. MAIN OUTCOME MEASURES: A triple survey was performed: each patient and his or her caregiver were asked to answer 35 questions related to 6 distinct QOL domains: role of performance, physical function, vitality, pain, specific symptoms, and effect on emotions. The composite health-related QOL of the patients was also rated on an ordinal scale by 3 surgeons who participated in the operation and follow-up. RESULTS: An overall significant agreement was found between patients' and caregivers' scores at the group level (mean scores of each domain) and individual level (patient-caregiver pairs) (r = 0.76, P<.001). There was a minor correlation in the effect on emotions domain and no correlation in the pain domain. We found no correlation between the surgeons' and patients' ratings. The operating surgeons tended to overate their patients' QOL. CONCLUSIONS: The study results show that the surgeon's perception of his or her patient's QOL is not sufficiently accurate to correctly estimate patients' QOL status. These judgments should come from the patient or from the caregiver, whose perception can be used in clinical trials as a proxy for estimation of a patient's QOL.     

Subcranial resection of malignant tumors infiltrating the anterior skull base

BACKGROUND: Survival and quality of life after subcranial resection of malignant tumors infiltrating the anterior skull base should be evaluated. METHODS: Data were acquired retrospectively from patient charts and by telephone interview. Quality of life was assessed with the EORTC QLQ30 and H&N35 modules. RESULTS: From 1996 to 2004, 19 patients (mean age 52 years, 4 woman, 15 men) were surgically treated via a subcranial approach. Fifteen patients suffered from advanced carcinoma, 3 from advanced esthesioneuroblastoma, and 1 patient had a fibrosarcoma. Fifteen patients received adjuvant radiotherapy. During the mean follow-up period of 44 months (12-109 months), 6 patients died, 1 unrelated to the tumor. The probability to survive 5 years was 50 %, the mean survival time was 72 months. Anosmia was reported by 18 of 19 patients. A tension pneumocephalus was observed in 2 patients, one with lethal outcome, decreased vision in 1 patient, loss of vision in 1, persisting diplopia in 1, deep wound infections in 2, and CSF leak in 2 patients. Quality of life was assessed on the average 36 months following end of therapy and did not differ substantially from other patients with head-neck malignancies. CONCLUSION: Most, malignant tumors infiltrating the anterior skull base can be treated curatively. The treatment outcome is well comparable to other head and neck tumors of corresponding stage.     

Evaluation of quality of life and psychiatric morbidity in patients with malignant tumours of the skull base

In general, patients with malignant tumours of the skull base have a poor prognosis. Treatment may have a disfiguring physical and disabling mental effect on patients. To evaluate the effect of treatment on physical and mental quality of life in patients with skull base malignancy, we conducted a cross-sectional patient survey of 18 patients treated for such tumours, using the University of Washington (version 4) quality of life questionnaire and the hospital anxiety and depression scale. The total quality of life score (median value) was 980 (550-1125). Patients with anterior skull base malignancy scored lower than those with lateral skull base malignancy (p=0.003). In general, the worst individual domain scores were: mood (64 per cent); activity (69 per cent); and, specifically for patients with anterior skull base malignancy, taste (54 per cent, p=0.004) and anxiety (60 per cent, p=0.034). One-third of skull base cancer patients were at risk of suffering from mental distress and psychiatric morbidity (indicated as a score of more than seven on the hospital anxiety and depression scale).     

The transglabellar/subcranial approach to the anterior skull base: a review of 72 cases

OBJECTIVES: To describe the transglabellar/subcranial approach to the anterior skull base and to compare it with more traditional approaches to craniofacial resection. DESIGN: A retrospective analysis of 72 cases at 2 academic medical centers. The main parameters analyzed were the disease entities treated, the average operating room time, the average amount of blood loss, the number of transfusions, the length of intensive care unit and hospital stays, and complication rates. These were compared with published data for traditional craniofacial approaches. SETTING: All patients were operated on by the authors in collaboration with neurosurgical teams at the State University of New York Upstate Medical University, Syracuse, and the University of Michigan Hospital, Ann Arbor. PATIENTS: The transglabellar/subcranial approach was performed 72 times in 69 patients in this series. Forty-two procedures in 40 patients were performed for malignant disease and 30 procedures in 29 patients were performed for benign entities. Patients' ages ranged from 2 to 78 years. Follow-up ranged from 6 months to 4 years, with a minimum follow-up of 1 year for survivors. RESULTS: There were no operative mortalities. Operating time, average amount of blood loss, length of hospital and intensive care unit stays, and complication rates compared favorably with published results of traditional craniofacial resections. CONCLUSIONS: The transglabellar/subcranial approach to the anterior skull base may be a reasonable technique for the surgical management of lesions in the region of the anterior skull base. It provides excellent exposure of the nasal cavity, the orbits, and the ethmoid and sphenoid sinuses, while allowing wide access to the anterior fossa with a minimum amount of frontal lobe retraction.     

颅底28例病变手术的临床分析

目的：探讨颅底新手术入路的优缺点及注意事项，方法：对２８便颅底病变分别进行扩大颅底入路、经额颞眶弓入路、经岩骨幕上幕下联合入路手术。结果：全切除１８例、次全切除７例、部分切除３例，严重并发症少，无１例死亡。随访５－２９个月，无复发。结论：与传统的手术入路相比较，新手术入路具有显露谅这颅底病变距离短，脑组织牵拉轻，有充分的手术操作空间，可同时切除颅内上的肿瘤等优点。     

儿童颅底肿瘤经鼻内镜外科手术治疗分析

摘要：目的探讨分析鼻内镜手术在治疗儿童颅底肿瘤中的应用。 方法回顾性分析中南大学湘雅医院鼻颅底外科 2010年6月—2019年11月收治确诊为颅底肿瘤并行鼻内镜治疗的患儿共44例,其中鼻咽纤维血管瘤17例,朗格汉斯组织细胞增生症7例,骨化纤维瘤5例,原始神经外胚层肿瘤2例,横纹肌肉瘤2例,脑膜瘤2例,间叶性软骨错构瘤1例,颅咽管瘤1例,表皮样囊肿1例,血管纤维脂肪瘤1例,生殖细胞瘤1例,骨母细胞瘤1例,脊索瘤1例,侵袭性垂体腺瘤1例,纤维瘤病1例。 结果44例患儿中43例在鼻内镜下完全切除,仅1例鼻咽纤维血管瘤分期切除。术后44例均进行定期随访,随访时间3个月至9年。5例失访,其中骨母细胞瘤1例,脑膜瘤1例,横纹肌肉瘤1例,鼻咽纤维血管瘤2例;12例术后接受放化疗,其中朗格汉斯组织细胞增生症7例,原始神经外胚层肿瘤 2例,横纹肌肉瘤1例,脊索瘤1例,生殖细胞瘤1例,随访至今患儿状况良好,均无复发及转移;1例鼻咽纤维血管瘤复发;再次手术后治愈;其余26例患儿术后未见复发。结论鼻内镜颅底手术治疗儿童颅底肿瘤是可行、有效及安全的。     

Endonasal micro-endoscopic tumor surgery: state of the art

BACKGROUND: The aim of the present study was to establish the efficacy of endonasal micro-endoscopic surgery for removal of benign and malignant neoplastic lesions of the paranasal sinuses and the anterior skull base. MATERIAL AND METHODS: This retrospective study evaluated 350 patients with tumors of the paranasal sinuses and the anterior skull base (215 benign and 135 malignant tumors) that were treated surgically at the ENT-Department of the Hospital Fulda gAG between 1993 and 2003. Median follow-up was 65 months. RESULTS: Most frequent entities of benign tumors were osteomas, inverted papillomas and juvenile angiofibromas. Adenocarcinomas, squamous cell carcinomas and esthesioneuroblastomas were most frequently treated in the group of malignomas. 54 % of the benign (n = 118) and 41 % of the malignant tumors (n = 54) were resected exclusively via the endonasal micro-endoscopic approach. Within the follow-up period 3 recurrencies were observed, two inverted papillomas (one was operated endonasally) and one juvenile angiofibroma. In the malignoma group 34 patients died because of tumor disease (16 cases due to recurrencies, 18 cases due to metastases formation). The 5 year survival rate was 66.4 % with respect to the disease-specific survival. The Kaplan-Meier analysis revealed statistically significant differences for the pT stage: pT2 and pT3 tumors have had a 5-year disease-specific survival of 92.3 % and 83.8 %, respectively, compared to 61.5 % of the pT4 tumors. Disease-specific survival also showed differences dependent on histology, tumor site and occurrence, but was without proven significancy. In the patient subgroup who suffered from adenocarcinoma, squamous cell carcinoma or esthesioneuroblastoma the 5-year disease-specific survival was 78.4 % of 29 patients after endonasal resection compared to 66.4 % in 51 patients operated via an external approach. CONCLUSION: The advances in endonasal micro-endoscopic surgery also allow a safe and effective removal of benign and malignant anterior skull base tumors with low morbidity. Thereby, indication is dependent on tumor site and size as well as histology.     

Malignant Glomus Tumors

Objectives/Hypothesis: To ascertain the incidence of malignancy in a large glomus and skull base series and to compare the clinical course of such patients with those who do not have malignant skull base lesions. Study Design: Retrospective review of all skull base surgery cases treated at the Otology Group between 1970 and 1995. Results: In a series of 175 jugulotympanic glomus tumors, 9 cases (5.1%) were identified. The surgery required for their extirpation is more extensive than nonmalignant glomus tumors. Attendant deficits and mortality from these procedures are accordingly greater. Five-year survival in this limited population was 72%. Prolonged periods of survival are possible with distant metastases. Conclusions: This rate of malignancy should advocate against a watchful, waiting approach. Radiation therapy is not advocated as a primary modality for this type of tumor, as it may lead to recurrence/persistence with either subsequent malignant degeneration and metastases or local recurrence.     

Early outcome and complications of the extended subcranial approach to the anterior skull base

Objectives: To present the technique of the extended subcranial approach to the anterior skull base and to review the results in 55 patients who underwent the procedure. Study Design: Retrospective review of the records of 55 patients who underwent the extended subcranial approach to the anterior skull base between 1994 and 1998 for the treatment of various neoplasms originating in the nasal cavity, nasopharynx, paranasal sinuses, orbit, or meninges, as well as for the repair of complex craniofacial trauma and/or cerebrospinal fluid (CSF) leak. Preoperative patient evaluation and the surgical technique are also reviewed. Methods: Patient records were retrospectively reviewed and tabulated for age, sex, and indications for procedure, with special focus on early outcome and complications. Results: Twenty-six patients underwent oncologic resections, 22 patients had reduction of complex fronto-naso-orbital and skull base fractures, and seven patients had repair of CSF leak. Significant complications in the oncologic group consisted of one hematoma requiring needle aspiration and two cases of temporary nontension pneumocephalus. In the fracture group, one patient died because of extensive intracerebral damage and multiorgan failure, and one patient had nontension pneumocephalus coupled with CSF leakage and one patient had temporary nontensisn pneumocephalus. The most common late complication in all three groups was anosmia. Conclusions: Based on their review, the authors conclude that the extended subcranial approach to the anterior skull base is a safe, versatile, and effective procedure for the surgical treatment of various pathological conditions involving the anterior skull base.     

头颈外科神经外科联合手术治疗颅底沟通肿瘤

目的 介绍头颈外科与神经外科合作处理颅底沟通肿瘤的经验和优势.方法 回顾性分析2005年7月至2008年7月头颈外科和神经外科联合制定手术方案并共同实施手术54例(良性21例,恶性33例)颅底沟通肿瘤的临床资料,其中前颅底19例,侧颅底12例,中央颅底17例,后颅底(颈静脉孔区)6例.结果 本组颅底沟通肿瘤均一期手术切除.良性肿瘤全切除20例,近全切除1例;恶性肿瘤肉眼全切除25例,6例鼻窦、鼻咽、腮腺恶性肿瘤及2例脊索瘤近全切除.无手术死亡病例,恶性肿瘤并发症13例,其中术后出血2例.随访8～43个月,良性与恶性肿瘤中位随访时间分别为19.1及21.0个月,恶性患者失访3例.21例良性肿瘤复发1例.33例恶性肿瘤中复发12例,死亡9例(其中1例死于心脏病),Kaplan-Meier法统计3年生存率与无瘤生存率分别为53.0%及52.7%.结论 头颈外科和神经外科合作有利于提高颅底沟通肿瘤的手术切除率从而提高治疗效果.     

Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms

BACKGROUND: The endoscopic resection of the cribriform plate during minimally invasive endoscopic resection (MIER) of the anterior skull base neoplasms may result in large anterior skull base defects. The objective of this study is to describe techniques for the management of skull base defects after MIER. METHODS: Retrospective analysis was performed on patients undergoing MIER and skull base reconstruction between April 2000 and August 2005. RESULTS: Fourteen patients underwent endoscopic resection of anterior skull base tumors and reconstruction during the study period. The mean age was 57.4 years (range, 26-84 years). The sex distribution was eight men and six women. The specific indications for resection included 11 malignant and 3 benign neoplasms. Ten patients received adjuvant therapy, and in two instances this occurred before surgery. In all instances, the dura was exposed; however, only 10 cerebrospinal fluid (CSF) leaks were encountered intraoperatively. Reconstruction of the skull base was successfully performed, most commonly in a multilayer fashion, using an array of materials including cartilage, fat, acellular dermal graft, and mucosal free grafts. Lumbar drain placement was used in seven cases for an average of 5.6 days. No postoperative CSF leaks occurred. The mean follow-up was 18.0 months (range, 1-56 months). CONCLUSION: This report describes methods for the reconstruction of the skull base after MIER. Reconstitution of the skull base barrier can be achieved through application of principles for surgical repair of CSF rhinorrhea.     

扩大鼻外额窦进路切除前颅底肿瘤术式探讨

目的：探讨前颅底额眶筛区肿瘤切除的最佳手术入路。方法：采用扩大鼻外额窦进路术式对28例累及前颅底额眶筛区的肿瘤患者行肿瘤切除术。结果：经随访,8例良性肿瘤至今无复发或死亡,20例恶性肿瘤中,1年生存率95．0％（19／20）,3年生存率61．5％（8／13）,5年生存率57．1％（4／7）。结论：该术式术野暴露充分,手术时首先自前颅底剥离肿瘤阻断瘤体在颅底的血供,出血少,手术视野清晰,操作便捷,切除肿瘤彻底,重建颅底方便,手术创伤小,术后反应轻。该术式是切除前颅底额眶筛区肿瘤的较好手术入路。     

Pediatric Neurotologic Skull Base Surgery

The objectives of neurotologic skull base surgery are complete resection of the lesion and high-grade function following surgery. There is a perception that these goals are more difficult to achieve in children than in adults. Skull base disease in children and adolescents is rare. Of the 292 skull base tumors treated from 1970 to 1995 by The Otology Group in Nashville, 15 were in patients 21 years of age or younger, with only 5 patients under 10 years old. In this retrospective study, the authors review these 15 cases and compare them to their adult series. The pathology encountered in the 15 young patients with skull base tumors included 8 glomus lesions and 4 schwannomas. In these patients, 13 tumors occurred sporadically, and 2 tumors were related to neurofibromatosis type 2. Advanced-stage disease and malignancy were prevalent in this younger patient group. All patients underwent excision of their skull base tumor, with one procedure considered a subtotal resection. As compared with an adult glomus tumor series, postoperative cranial nerve function and complication rates were generally worse in the young glomus patients. However, postoperative function and complications were consistent with the extensive procedures required for the treatment of advanced disease. Despite the advances that have been made in imaging and treatment modalities, this study illustrates the need for more timely diagnosis in younger patients with skull base tumors. Laryngoscope, 106:1205-1209, 1996     

Radionecrosis of the frontal lobe as a consequence of malignant ethmoid tumor management: incidence,diagnosis, risk factors,prevention and management

Malignant ethmoid tumors are treated by surgery followed by radiotherapy. This study aimed to evaluate the incidence, risk factors and outcome of radionecrosis of frontal lobe and determine preventive measures. Retrospective study of ethmoid malignancies treated from 2000 to 2011. All patients underwent surgery with/without anterior skull base resection using endoscopic or external approaches followed by irradiation (mean dose 64 Gy). Median follow-up was 50 months. Eight of 50 patients (16 %) presented with fronto-basal radionecrosis, connected to duraplasty, with a latent interval of 18.5 months. Although asymptomatic in six, radionecrosis triggered seizures and required surgery in two cases. Survival was not impacted. Risk factors included dyslipidemia, occurrence of epilepsy and dural resection. Radionecrosis may result from the combination of anterior skull base resection and radiotherapy for the treatment of ethmoid malignancies. Preventive measures rely on improving the duraplasty and optimization of the Gy-dose delivery.     

Recovery period of sinonasal quality of life and its associated factors after endoscopic endonasal approach for anterior skull base tumors

Background: Although endoscopic endonasal approach (EEA) for skull base tumors showed a good prognosis in sinonasal quality of life (QOL), what factors have influence on QOL is still in question.

Aim/Objectives: To investigate the recovery of sinonasal QOL after EEA for anterior skull base tumors and find its prognostic factors.

Material and Methods: The study enrolled 250 patients undergoing EEA for anterior skull base tumors over 3 years. Sinonasal QOL was evaluated via sinonasal outcome test (SNOT-22) during 6 months. Age, gender, previous surgery, surgical extent, tumor pathology, combined surgical procedures, and surgical complications were analyzed.

Results: There were 101 male and 149 female with average 48.6?±?16.1 years old. SNOT-22 increased from baseline (median 17.0; Q₁–Q₃ 8.25–30.0) to postoperative 1 and 3 months (27.0; 15.0–36.0; p < .001 and 20.5; 11.0–32.0; p?=?.021, respectively) and it returned to the baseline within 6 months. Reconstruction with calcium hydroxyapatite and postoperative mucosal edema had a negative impact on the recovery (p =?.016 and .010, respectively), after adjustment for the baseline scores and postoperative months.

Conclusions and Significance: Sinonasal QOL was recovered within 6 months. Avoidance of calcium hydroxyapatite could prevent delayed recovery. Surgeons should carefully manipulate nasal mucosa to minimize postoperative mucosal edema.     

Possibilities and limitations of endoscopic management of nasal and paranasal sinus malignancies

Over the last decade, the use of rigid endoscopes in surgery of tumorous lesions of the nose, paranasal sinuses, nasopharynx and anterior skull base has extended and diversified. Endoscopic surgical approaches for malignant lesions are very controversially discussed as of today, yet. From 1989-1999 we have treated 43 patients with invasive/destructive tumors of the paranasal sinuses and the anterior skull base strictly endoscopically, transnasally. These included 5 patients with juvenile angiofibromas and 36 patients with various malignant tumors, one with a large invasive macroadenoma of the pituitary and one case of a craniopharyngeoma. The age range was 3 months to 82 years. Whereas the very first patients were approached endoscopically in a palliative intention, we have started endoscopic surgery for selected malignancies with curative intention in the last years. Histologically, patients with various carcinoma differentiation were operated (n = 18), as well as patients with malignant melanoma (n = 5), esthesioneuroblastoma (n = 8), clivus chordoma (n = 3), immature teratoma (n = 1) and leiomyosarcoma (n = 1). Our first results appear to indicate, that outcome is at least equal to standard external approaches, however with excellent functional terms and significantly better overall quality of life. The limitations result from the anatomical spread of the tumor, when extensive infiltration of orbit, dura/brain and other vital structures exist. However, in experienced hands, endoscopic surgery in this region can be rather radical, bone and even dura of the anterior skull base can be resected as can the periorbit, and all structures reconstructed in the same session. Endoscopic techniques lend themselves very well to cooperation with neighbouring specialities like neurosurgery. In individual cases, gamma-knife therapy has proven an extremely helpful adjunctive. With this combined approach, all 8 patients with esthesioneuroblastoma are alive and free of disease with a mean observation time of 37.2 months. We will therefore continue to use this procedure in selected cases as a reliable alternative to external approaches in the future. However we recommend, that these techniques are only applied at centers, where all other surgical approaches can be performed, should need for this arise.     

Factors affecting survival of patients with tumors of the anterior skull base

Fifty-four patients with primary neoplasms of the anterior skull base were treated by craniofacial resection with curative intent. The most common tumor was esthesioneuroblastoma (24), followed by squamous cell carcinoma (10). The overall 2-year and 5-year survivals were 75% and 49%, respectively. High-grade tumors, grades 3 and 4, had a poorer prognosis. Tumor size, dural involvement, sphenoid sinus involvement, age, and sex had no significant influence on survival when examined by multivariate survival analysis. Sixteen complications were noted in the postoperative period. Cerebrospinal fluid leakage occurred in 2 patients and loss of frontal bone occurred in 4. There were no operative or perioperative deaths. Craniofacial resection permits surgical resection of the majority of anterior skull base tumors with acceptable morbidity.     

采用翻揭或拆装扩大术野 行颅底深部肿瘤切除术

目的探讨切除颅底深部肿瘤的手术途径。方法根据肿瘤位置不同，分别采用(1)上颌窦前壁拆 装；(2)颧弓拆装；(3)鼻锥翻揭；(4)上颌骨翻揭；(5)下颌骨翻揭；(6)唇下面中部翻揭。结果62例患者术中 视野暴露充分，肿瘤能完整大块切除，术后头面部畸形不明显，器官功能维护良好。3年生存率为86.1％，5 年生存率为66.7％。结论对颅底深部肿瘤依据不同位置采用翻揭或拆装手术途径，既能使手术野最大暴 露，又可将损伤降到最低程度，符合现代颅底外科手术原则。