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.     

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。     

前、中、侧颅底恶性肿瘤手术径路的探讨

目的：评价前、中、侧颅底手术径路的实用性,可靠性及有效性。方法：自1984年6月至1998年12月,对30例颅底恶性肿瘤患者进行治疗。病变位于前颅底者13例,中颅底2例和侧颅底15例（包括4例中、外耳道癌患者）。累及前颅底者采用发际内大冠状切口并切除部分额骨入颅。或经额窦后壁入颅,然后实行颅面联合切除肿瘤,涉及中、侧颅底肿瘤则采用经颈－下颌入路方法整块切除肿瘤。中、外耳癌则实行颞骨次全切除术。结果：全组30例无手术死亡。无严重并发症,合并脑脊液漏等轻度并发症者6例（20％）,均经保守治愈。全组2年生存率为68％,5年生存率55．56％。结论：上述资料显示所提出的颅底恶性肿瘤手术径路方法安全可靠,适合于大多数前、中、侧颅底恶性肿瘤的治疗,值得推广应用。     

额鼻眶筛入路显微镜下一次性切除11例前颅底沟通瘤

目的 对11例前颅底沟通瘤行额鼻眶筛入路显微手术一次性切除疗效分析。方法 对手术治疗的11例前颅底沟通瘤进行回顾性分析。所有患者术前均行CT或MR检查。均经额鼻眶筛入路与相关科室配合运用显微外科技术一次性切除颅内外肿瘤。结果 全切除9例，次全切2例，手术效果好，无手术死亡及严重并发症。结论 额鼻眶筛入路手术治疗前颅底沟通瘤有利于肿瘤的广泛暴露和切除，多学科联合与显微外科技术对一次性切除颅内外肿瘤有帮助。术中颅底重建是手术的关键步骤之一。     

前颅底恶性肿瘤整块切除及缺损修复方法探讨

本文了介绍２１例前颅底恶性肿瘤整块切除及颅底、颌面部缺损修复治疗方法。根据肿瘤的大小及周围组织侵犯范围，制定了肿瘤部位切除方法的分类，根据其分类来设定肿瘤切除范围及缺损修复方法的选择。本手术方法，不仅能够完整地切除肿瘤，而且可以一期进行肿瘤切除后的颅底、颌面以及硬膜缺损的修复，有效地防止术后脑脊液漏等并发症的发生。本方法特别适用于鼻窦、颌面部恶性肿瘤向颅底侵犯的病例，以及颅底内、外肿瘤需手术切除的病例。本文还特别提出颅底、颌面缺损修复时的并发症及注意事项。     

筛窦及前颅底外科

对侵犯前颅底、颅内的鼻腔、鼻窦肿瘤２３例，施行了根治性手术，其中良性肿瘤５例，恶性肿瘤１８例，使用带蒂帽状腱膜、颅骨膜，重建被切除的颅底骨质和硬脑膜。手术均采用颅面联合切除术，术后无严重并发症，无１例发生脑脊液鼻漏或出现脑脑膜膨出。恶性肿瘤患者３年生存率为４４４％。     

颞骨和颞下窝联合入路侧颅底肿瘤切除术

探讨安全和彻底摘除广侵侧颅底及其相邻区的肿瘤的手术入路和方法。方法通过颞骨和颞下窝联合入路,应用显微外科技术摘除肿瘤,并尽可能维护或重建颅底和颅神经。     

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.     

颅面联合入路在颅底沟通性肿瘤中的应用

目的探讨颅面联合入路在颅底区沟通性肿瘤治疗中的方法和疗效。方法回顾性分析我院44例经颅面联合入路手术治疗颅底区沟通性肿瘤患者资料,经病理证实恶性肿瘤31例,良性肿瘤13例。位于前颅底区35例,累及前、中颅底区9例。肿瘤切除后造成的硬脑膜缺损用自体组织严密修补,并用额部带蒂复合组织瓣行颅底区组织缺损修复。结果肿瘤全切38例,次全切除3例,部分切除3例,无手术死亡病例。并发症包括脑神经损伤3例,伤口感染2例,出现暂时性脑脊液漏2例,一过性精神症状2例。随访1~6年,10例死于肿瘤复发,失访2例。存活2年以上25例,3年以上17例。结论颅面联合入路是颅底区沟通性肿瘤外科治疗的主要手术入路之一,它是前颅底区(部分可以累及中颅底区)沟通性肿瘤较好的手术入路。     

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。     

前颅底肿瘤手术入路

目的：探讨前颅底肿瘤手术入路,提高手术效果。方法：对37例前颅底肿瘤进行了相应的手术切除,颅面联合入路21例,其中额颅合并鼻侧切开1例,上颌骨内侧部分切除或暂移开切除肿瘤7例,上颌骨切除8例,上颌骨或（和）眶或（和）颌面皮肤切除5例;上颌骨部分或全外旋合并鼻锥转位13例;鼻额翻瓣、额眶入路及面中揭翻各1例。结果：10例良性肿瘤患者均健在,恶性肿瘤患者3、5年存活率分别为81．9％（22／27）、62．9％（17／27）。9年以上无瘤存活1例。结论：除鼻侧切开外不同类型颅面联合入路均能提供良好的肿瘤显露,有利于鼻颅沟通瘤的整块切除。部分或上颌骨全外旋合并鼻锥转位适于切除累及颅底尚未侵及颅内的肿瘤。额鼻共同翻开适于切除额窦发育良好的鼻颅沟通瘤。颅眶入路适于颅眶沟通瘤。面中揭翻应选择应用。     

Transglabellar, transorbital approach for anterior skull base tumors

Transglabellar, transorbital approach through the bottom of the frontal sinus for tumours invading anterior skull base in presented. Exposure was improved by rhinectomy and lateral swing of the nose. The most common tumours in the group of 11 patients were squamous cell carcinoma (4) and olfactory neuroblastoma (4). Skull base was excised en block with partial maxillectomy in 8 patients and with total maxillectomy in 3 patients. Orbitectomy was performed in 6 cases. Dura defect was closed with fascia lata and fibrin glue. No serious complications after surgery developed. Rhinoscopy and computed tomography demonstrated clear cavity and no dura prolapse. Transglabellar, transorbital approach provides good exposure for anterior skull base tumours excision and repair.     

Quality of life following surgery for anterior skull base tumors

OBJECTIVES: To evaluate patients' quality of life (QOL) after surgical extirpation of anterior skull base tumors, to elucidate different QOL domains, and to define possible predictors of functional outcome postoperatively. DESIGN: Retrospective survey. SETTING: University-affiliated medical center. PARTICIPANTS: Sixty-nine patients (76 consecutive cases) who underwent subcranial surgery between 1994 and 2002 for extirpation of anterior skull base tumors. MAIN OUTCOME MEASURE: A multidimensional, disease-specific questionnaire with 39 items was used. Six relevant domains of QOL were assessed: role of performance, physical functioning, vitality, pain, specific symptoms, and impact on emotions. RESULTS: The response rate for completing the questionnaire was 98% (40/41) after excluding patients who died (n = 13), were lost to follow-up (n = 10), and were operated on within 3 months of commencement of the study (n = 5). Thirty patients (74%) reported a significant improvement or no change in overall QOL within 6 months after surgery. The worst impact of surgery on the patients' QOL was on their financial status and emotional state. The most influential factor on QOL was malignancy leading to a significant decrease in the overall score. Radiotherapy, old age, comorbidity, and wide resection also significantly worsened QOL scores of specific domains. CONCLUSION: After subcranial extirpation of anterior skull base tumors, the overall outcome of the patients is good. Old age, malignancy, comorbidity, wide resection, and radiotherapy are negative prognostic factors for these patients' QOL.     

颅面联合进路切除前颅底肿瘤

目的：探讨累及前颅底或颅内脑组织的鼻腔鼻窦癌的手术切除途径及方法。方法：经颅面联合进路行显微外科连续整块切除累及前颅底或颅内脑组织的鼻腔鼻窦癌15例,其中5例仅累及前颅底,10例累及前颅底至颅内额叶脑组织。硬脑膜缺损应用大腿阔筋膜修补。结果：15例均作了术后随访,随访时间最长为10年,最短2年。其中4例为初治患者,11例为综合治疗后局部复发患者。9例无瘤生存2年以上,2年无瘤生存率为60．00％。11例接受此手术行拯救外科治疗,其中6例无瘤生存2年以上,2年拯救成功率为54．55％。结论：经颅面联合进路行显微外科连续整块切除累及前颅底或颅内脑组织的鼻腔鼻窦癌是可行的。     

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.     

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.     

Resection of cancer of the tongue base and tonsil via the transhyoid approach

OBJECTIVE: To assess whether transhyoid resection of the tongue base and tonsil lesions is an effective approach to tumors involving this region compared with more traditional anterior surgical approaches that arbitrarily involve either segmental resection or division of the mandible. STUDY DESIGN: Retrospective review. METHODS: Since 1988, we have used a combined transhyoid and transoral approach to resect lesions involving the tongue base, tonsil, or both. Forty-one patients were identified who underwent surgical resection of lesions involving this region via this combined approach during this period. A stage-matched group of 41 patients was also identified in which patients underwent resection via traditional composite or mandibulotomy approaches and was used as a basis for comparison. Factors assessed included status of surgical margins, postoperative complications, degree of postoperative dysphagia, and long-term outcome. RESULTS: Comparison between the two groups revealed similar rates of negative surgical margins. Levels of postoperative dysphagia, notably severe primarily in patients with either T4 or recurrent disease, were also similar between groups. Complication rates, especially with regard to fistula occurrence and mandible-healing problems, were significantly lower in the transhyoid group. Analysis of long-term outcome revealed similar patterns with regard to disease status in both groups. CONCLUSIONS: The combined transhyoid and transoral approach is an effective surgical option for a number of lesions affecting the tongue base, tonsil, or both. Although similar to other approaches with regard to postoperative function and disease outcome, the transhyoid approach is associated with decreased postoperative morbidity. However, tumors that extend to involve the mandible or pterygoid musculature or skull base are probably best suited for traditional approaches that involve division of the mandible.     

Giant juvenile nasopharyngeal angiofibroma: management by skull-base surgery

From 1977 to 2001, 5 patients were seen with giant angiofibromas that had intracranial penetration. Three of these had involvement of the cavernous sinus with angiographic evidence of significant blood supply to the tumor. We attempted complete tumor removal in all patients via a skull-base procedure.The infratemporal fossa/middle fossa approach was used in 3 patients, an anterior craniofacial approach in 1, and an anterior subcranial approach in 1. Complete tumor removal was achieved in 4 patients and incomplete excision in 1. The latter was attempted with an anterior subcranial approach but required an infratemporal fossa/middle fossa approach for completion because of unanticipated cavernous sinus involvement. The patient declined further surgery. This was the only patient who had persistent disease. Preoperative and intraoperative management, blood loss, complications, and residual effects are described.     

扩大鼻外额筛窦进路切除额眶筛区肿瘤

目的探讨额眶筛区肿瘤切除的手术入路。方法于患侧行扩大鼻外额筛窦进路,根据肿瘤范围大小向鼻侧或沿眉弓向外延长切口,可充分暴露前颅底、额眶筛区甚至眶外上缘区域肿瘤。结果自1998年1月～2003年12月收治的累及前颅底额眶筛区的肿瘤28例使用上述术式。经随访,其中8例良性肿瘤至今无复发,20例恶性肿瘤中,1年生存率95%(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,出血少,手术视野清晰,操作方便,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。