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Transcutaneous Transfacial Approaches to the Anterior Skull Base

Michael J. Kaplan, MD, ~ Michael W. McDermott, MD, 2 Philip H. Gutin, MD, 3 Michael T. Lawton, MD, 2 Nancy J. Fischbein, MD, 4 and Mitchel S. Berger, MD 2

The six-level anatomic classification scheme of transfacial approaches used by the multidisciplinary skull base surgery team at the Barrow Neurological Institute and discussed extensively in these articles is an excellent way to systematically discuss approaches to the anterior and centrar skurr base. Choosing among these options usually involves selecting the best angle of approach in order to minimize brain retraction, as well as optimizing accessibility to structures requiring resection while limiting aesthetic and functional side effects. Have we advanced to the point that we can usually avoid visible transcutaneous facial incisions while not sacrificing the primary goals of tumor resection and minimization of side effects? In this article we will briefly overview the role of transcutaneous approaches to the anterior skull base. Copyright 9 2000 by W.B. Saunders Company

T proaches complex tumors of the anterior, anterolateral,

he goals of the multidisciplinary surgical team that ap-

and central skull base are (1) adequate visualization for three-dimensional tumor resection; (2) minimal brain retraction; and (3) reconstruction, preservation of function, and aesthetics. How to best accomplish these goals and to communicate succinctly the complex overlapping approaches required to do so, has been associated with the introduction of numerous approaches with variations and classification schemes introduced in the literature over the years as authors strive to enhance surgical access, to reduce morbidity,, and to improve communication. In addition to the Barrow classification scheme, which is discussed in other articles in this volume, approaches discussed in the literature also take advantage of angles of approach to limit brain retraction and provide suitable access. Examples include the supraorbital rim approach and the extended subcranial approach introduced by Raveh. 1 Degloving approaches similarly avoid transcutaneous incisions in accessing the paranasal sinuses and clivus. Improved preoperative and intraoperative radiologic evaluation along with increasing surgical experience have contributed to the continuing evolution of surgical techniques. Approaches to the anterior skull base have evolved since the initiaI approach of Smith 2 in 1954 and Ketcham 3,4 in 1963. Initial approaches often combined a bifrontal craniotomy with

modifications of common otolaryngologic approaches that included a lateral rhinotomy and external sphenoethmoidectomy. Skull base surgery today uses many complementary approaches that, in combination, adequately expose the tumor for resection. Frontal brain retraction is minimized by using approaches that provide low inferior direct exposure at the orbital rims when tumors extend posteriorly to the planum sphenoidale. Central facial skin incisions can be minimized by glabellar/extended subcranial approaches that provide adequate access to the sphenoethmoid and medial maxillary areas. Such approaches may require plating of inferior frontal and nasal-maxillary bones. Often all of the paranasal extirpation component of the surgery can be done through a standard low bifrontal craniotomy (supplemented with a supraorbital rim approach if needed) without a complete extended subcranial approach. Some have advocated endoscopic guidance for the paranasal sinus component of the resection. Lateral access to the parapharyngeal space can be accessed via an orbitozygomatic approach, avoiding a central facial scar. Several series 5,6,r,s,9,1~ from different centers, as well as our own, have documented improved local control rates of 50% to 70% or more for a number of malignant histologies (including esthesioneuroblastomas, adenoid cystic carcinomas, adenocarcinomas, and many sarcomas, but less so for undifferentiated sinonasal carcinomas) as well as effective resection of benign tumors and management of selective trauma and cerebrospinal fluid (CSF) leaks using current techniques. Improved radiologic imaging, both preoperatively and for intraoperative guidance, has significantly enhanced accurate surgical planning by allowing consideration of combining several lowmorbidity approaches, resulting in adequate resection but reducing functional loss. Wide use of pericranial-galeal flaps and, when needed, free flaps 12 has reduced the incidence of postoperative CSF leaks and wound or bone infection.

Approach
Our own experience and preferences at the University of California, San Francisco (UCSF) favor minimization of central facial incisions for anterior skull base lesions by generally using a low bifrontal craniotomy through which the paranasal sinus component of tumor can be fully resected. A supraorbital rim approach is added when either necessary to expose an orbital tumor or if far posterior exposure is required. We have not to date found it necessary to widely use Raveh's extended subfrontal approach in which the dural component is initially explored from below, but acknowledge its potential advantage. We have often found it possible to do the resection of the paranasal sinus component of the tumor through the skull base exposed after the craniotomy without undue brain
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From the Departments of 1Otolaryngology-Head and Neck Surgery, 2Neurological Surgery, and 4Radiology, University of California, San Francisco, CA; and the 3Department of Neurosurgery, Memorial SloanKettering Cancer Center, New York, NY. Address reprint requeststo Michaeld. Kaplan, MD, Dept. of Otolaryngology-Head and Neck Surgery, UCSF Cancer Center, 2356 Sutter Street, San Francisco, CA 94115. Copyright 9 2000 by W.B. Saunders Company

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Operative Techniques in Neurosurgery, Vol 3, No 1 (March), 2000: pp 53-56

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retraction; postoperative magnetic resonance images (MRIs) have shown a modest incidence of encephalomalacia, with very few patients appearing to have clinically evident sequelae. When necessary, however, this approach will be supplemented by a modified external ethmoidectomy incision. This incision extends toward the medial ala but stops at the axial plane of the inferior limit of the nasal bone (Fig 1). A lateral rhinotomy at the ala and a Weber-Ferguson incision are rarely if ever needed. This extended external ethmoidectomy incision provides access from the inferior clivus superiorly through the sphenoid sinus, sella, ethmoid sinuses, and frontal sinus (Fig 2A). Additionally, lateral access to the pterygomaxillary space and lateral antrum as well as the orbit and medial cavernous sinus is afforded. 13 In the sphenoid sinus one can access posterolateral to the carotid artery and as far lateral as the abducens nerve if necessary (Fig 2B). If more inferior exposure

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Fig 1. Skin incision and underlying bone cuts. The solid line is the common ethmoidectomy incision, which can be extended inferiorly (dashed extension) to the edge of the nasal bone to provide adequate exposure to the maxilla or to improve the angle of approach superiorly. Note that the skin incision need not be extended around the ala to provide the exposure needed. The bone to be excised, outlined by the fine dotted line, can be tailored to the individual situation and need not be replaced. Along the medial orbit, the lamina papyracea inferior to the location of the anterior and posterior ethmoidal arteries is usually resected. The anterior and posterior ethmoid arteries may be preserved or ligated as needed. The optic nerve can then be decompressed if needed.

Fig 2. (A) Superior and inferior limits of exposure are shown on a sagittal Tl-weighted MR image. The superiorly directed a r r o w shows the superior extent of exposure: the angle of view a surgeon would have looking up through the inferior part of his approach through the ethmoid sinuses and frontoethmoid junction. The inferiorly directed a r r o w shows the inferior extent of exposure: the angle of view the surgeon has looking down through the top of the incision through the nasal cavity toward the posterior extent of the hard palate and low nasopharynx. The actual limitations of exposure are dependent on the posterior extent of hard palate, size of sphenoid sinus, and angle of craniocervical junction. Rarely if ever will the full extent of exposure be needed in an individual. Anterior skull base exposure from the frontal sinus to the sella and posterior sphenoid sinus is a common need; clivus and craniocervical junction exposure to the central skull base is another common need this approach may afford. (B) Contralateral limit of posterior exposure is shown on an axial Tl-weighted MR image. Lateral retraction of the globe after resection of the lamina papyracea as well as, if needed, minimal resection of the posterior vomer provides exposure of the posterior contralateral ethmoid sinus, nasopharynx, sphenoid sinus, and carotid artery. Ipsilateral exposure through the ethmoids to the medial orbit and cavernous sinus is straightforward. 54 KAPLAN ET AL

is needed within the paranasal sinuses (or palate), then a transoral approach is combined with the above. Unless involved by tumor, the inferior turbinates can be preserved, which reduces postoperative nasal crusting and discomfort. Transcutaneous supplementation of the craniotomy may be indicated if extensive dissection of the medial orbital periosteum is necessary and orbital preservation is planned (Fig 3). Another indication may be ligation of the anterior and/or posterior ethmoidal arteries to reduce bleeding in the resection of a highly vascular tumor. Some surgeons may also feel more comfortable with a medial maxillectomy done via this approach when the tumor extends within the maxillary sinus medial to the infraorbital foramen. Following tumor extirpation and placement of the pericranial-galeal flap (or if necessary, rectus free flap or other free flap), we pack 10-cm Merocel sponges (Xomed, Jacksonville, FL) beneath a bed of thrombin-soaked Gelfoam (Upjohn, Kalamazoo, MI) pieces to support the pericranial flap and to aid hemostasis.

As at other institutions, 8 our complications have become less frequent with increased experience. Between 1986 and 1993, operative mortality was 2%; since 1994, there have been no deaths. The incidence of CSF leaks before 1993 was 13%; since 1994, it is less than 2%. Serious central nervous system deficits (including cerebrovascular accidents, unanticipated blindness, and autonomic dysfunction) occurred in 4% of cases before 1993 compared with 3% since 1994. Meningitis or brain abscess has occurred in 2% of cases in both periods of time. Loss of the anterior bone flap secondary to osteomyelitis occurred in 8% of cases before 1993, but since 1994 we have had no such cases. The difference in bone flap survival may be attributed to increased use of free flaps in reconstruction following resection of previously radiated recurrent tumors or to better immobilization of the bone flap with small plates rather than wire. The incidence of intracranial hematoma has gone from 2% to 0%. Although statistically insignificant, this decrease parallels our impression that clinically apparent encephalomacia secondary to brain retraction is also less

Fig 3. (A) Sagittal Tl-weighted image in a 42-year-old woman with an esthesioneuroblastoma with transdural extension shows a large soft tissue mass in the nasal cavity, paranasal sinuses, and anterior cranial fossa. (B) Coronal Tl-weighted image postgadolinium shows the nasal cavity and ethmoid components of the mass, as well as the large intracranial component. There is also bilateral orbital invasion, right greater than left. (C) Coronal T~-weighted image postgadolinium obtained 1 week following initial resection approached solely via a low bifrontal craniotomy. Note that exposure from above to both medial orbits and the entire sphenoethmoidal area, as well as the medial maxilla bilaterally, is possible. The postsurgical MRI correlated with a question raised on pathologic assessment of a positive margin located solely along the right orbit (arrowheads). Because exposure along the medial orbit posteriorly is sometimes improved with a transcutaneous ethmoid incision, this area below the skull base reconstruction was re-explored via an ethmoidectomy approach: microfoci of additional tumor were noted. The patient is doing well following postoperative irradiation without any evidence of residual or recurrent disease.

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frequently encountered. Medical complications such as pneumonia, arrhythmias, and myocardial infarction have remained steady at 10%.

Discussion
Ivo Janecka and his team have been instrumental in clarifying ways in which cranial, facial, vascular, and neural structures may be moved as units with minimal morbidity. Their classification of facial translocation approaches uses the concept of modular craniofacial disassembly. TM By attaching eponyms to a series of increasingly expanded approaches, communication and comparison are facilitated. Janecka describes the manipulation of modular composite facial units with functional neurovascular integrity, facilitating aesthetic reconstruction. Results in terms of cure rates and incidence of complications have been outstanding. Joram Raveh, in numerous articles since 1978, described and popularized the extended subcranial approach to the anterior skull base. h was used initially for fractures and later for tumors35,16 He pointed out the advantages of this approach in terms of the broad inferior exposure and minimal brain retraction. Others i7,t8,19,2~as well have reported good results using this subcranial approach for tumors, fractures, and management of selected CSF leaks. This approach avoids a visible facial skin incision, sometimes preserves olfaction, and, compared with traditional bifrontal craniotomy, has been reported to reduce length of stay in an intensive care unit, overall hospital length of stay, and complications. 2~ The anatomic classification scheme of transfacial approaches used by the muhidisciplinary skull base surgery team at the Barrow Neurological Institute is discussed extensively in these articles. Other authors have presented other schema, similarly grouping them through anatomic routes of entry and emphasizing where one route or another has an advantage with regard to surgical access per se or reducing side effects compared with another popular or standard approach. Many of these schema may serve as an excellent way to systematically discuss approaches to the anterior and central skull base. A center may opt to adopt one of the abovementioned schema, or its own, as an organizing or teaching tool. However, the keys to achieving good results are familiarity with a wide array of approaches and multidisciplinary experience. With familiarity and experience, the advantages and disadvantages of different approaches can be discussed by the multidisciplinary team for each individual patient, and the options can then be discussed with the patient. Often several similar approaches might be considered, with judgment necessary as to which approach in particular will be best suited to the individual patient. This judgment may be based on prior irradiation or surgical intervention in the patient. The judgment may also be based in part on the patient's evaluation of which set of risks are more palatable. For example, the facial scar associated with an external ethmoidectomy incision versus the risk of oroantral fistula and vestibular stenosis associated with degloving approaches. The surgeon's own familiarity, preference, and results with one approach over another are also important considerations.

craniotomy with or without a supraorbital rim approach offers excellent exposure from the frontal sinuses superiorly to the mid-clivus inferiorly and can reach laterally to the cavernous sinus and carotid artery, orbit, and lateral antrum. This approach can be combined with an orbitozygomatic approach to reach the infratemporal fossa and middle cranial fossa. It is an extension of an approach highly familiar to all otolaryngologists. One disadvantage is a small facial incision, but one that heals with a minimally obtrusive and well-camouflaged scar. Its possible advantages include familiarity and wide applicability as well as minimization of central facial plating and low overall morbidity.

References
1. Johns ME, Kaplan MJ, Jane JAet al: Supraorbital rim approach to the anterior skull base. Laryngoscope 94:1137-1139, 1984 2. Smith RR, Klopp CT, Williams JM: Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer 7:991-994, 1954 3. Ketcham AS, Wilkins RH, Van Buren JM, et al: Acombined intracranial approach to the paranasal sinuses. Am J Surg 106:698-703, 1963 4. Van Buren JM, Ommaya AK, Ketcham AS: Ten years' experience with radical combined craniofacial resection of malignant tumors of the paranasal sinuses. J Neurosurg 28:341-350, 1968 5. Janecka IP, Sen C, Sekhar LN, et al: Cranial base surgery: results in 183 patients. Otolaryngology Head Neck Surg 110(6):539-546, 1994 6. Janecka IP, Sen C, Sekhar L, et al: Treatment of paranasal sinus cancer with cranial base surgery: results. Laryngoscope 104(5 Pt 1):553-555, 1994 7. Irish JC, Gullane PJ, Gentili F, et al: Tumors of the skull base: outcome and survival analysis of 77 cases. Head and Neck 16(1):3-10, 1994 8. O'Malley BW Jr, Janecka IP: Evolution of outcomes in cranial base surgery. Seminars in Surgical Oncoiogy 11(3):221-227, 1995 9. McCaffrey TV, Olsen KD, Yohanan JM, et al: Factors affecting survival of patients with tumors of the anterior skull base. Laryngoscope 104(8 Pt 1):940-945, 1994 10. Boyle JO, Shah KC, Shah JP: Craniofacial resection for malignant neoplasms of the skull base: an overview. J Surg Oncol 69:275-284, 1998 11. Shah JP, Kraus DH, Arbit E, et al: Craniofacial resection for tumors involving the anterior skull base. Otolaryngol Head Neck Surg 106:387393, 1992 12. Clayman GL, DeMonte F, Jaffe DM, et al: Outcome and complications of extended cranial-base resection requiring microvascular freetissue transfer. Otolaryngology Head Neck Surg 121 (11):1253-1257, 1995 13. Lalwani AK, Kaplan MJ, Gutin PH: The transsphenoethmoid approach to the sphenoid sinus and clivus. Neurosurgery 31:1008-1014, 1992 14. Janecka IP: Classification of facial translocation approach to the skull base. Otolaryngology Head Neck Surg 112:579-585, 1995 15. Raveh J, Turk JB, Ladrach K, et al: Extended anterior subcranial approach for skull base tumors: long-term results. J Neurosurg 82:1002-1010, 1995 16. Raveh J, Laedrach K, Speiser M, et al: The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Otolaryngol Head Neck Surg 119:385-393, 1993 17. Sekhar LN, Nanda A, Sen CN, et al: The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg 76:198-206, 1992 18. Fliss DM, Zucker G, Cohen A, et al: Early outcome and complications of the extended subcranial approach to the anterior skull base. Laryngoscope 109:153-160, 1999 19. Jung TM, Terkonda RP, Haines SJ, et al: Outcome analysis of the transglabellar/subcranial approach for lesions of the anterior cranial fossa: a comparison with the classic craniotomy approach. Otolaryngology Head Neck Surg 116:642-646, 1997 20. Moore CE, Ross DA, Marentette LJ: Subcranial approach to tumors of the anterior cranial base: analysis of current and traditional surgical techniques. Otolaryngology Head Neck Surg 120:387-390, 1999 KAPLAN ET AL

Conclusion
A transcutaneous transfacial approach via a modified external ethmoidectomy incision in association with a low bifrontal
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