Brief Clinical Notes
sphenoidal approaches for pituitary surgery.2 Recent
Could Transcranial Endoscopy
Represent an Alternative to
Craniotomy in Skull
Base Surgery?
Evaristo Belli, MDS, PhD,* Benedetto Longo, MD,†
Filippo Balestra Marini, MD,‡
Claudio Matteini, MD§
Abstract: Craniofacial malformations and upper third facial tumor
surgical management is currently performed by skull base osteot-
omies to allow skeleton mobilization or tumor removal. Cranioto-
mies and retraction of frontal lobes allow wide exposure of ante-
rior skull base.
In the last decades, in keeping with the trend to perform less
invasive surgical approaches, several authors reported endoscopic
approaches for selected cases of skull base surgery, such as closure
of cerebrospinal fluid leaks and transethmoidal and trans-
sphenoidal approaches for pituitary surgery. Recent experience
with transnasal endoscopic procedures improved both techniques
and outcomes and became more common.
The authors present a cadaver study of combined transfacial
transcranial endoscopic approach to skull base. Such an approach
used with minimally invasive surgery principles could represent, in
selected cases (both for neoplastic lesions and malformations), an
alternative to traditional anterior cranial fossa surgical approaches by
wide craniotomies.
Key Words: Craniofacial malformations, craniofacial
tumors, endoscopy, skull base
C raniofacial malformations and upper third facial
tumor surgical management is currently per-
formed by skull base osteotomies to allow skeleton
mobilization or tumor removal. Craniotomies and re-
traction of frontal lobes allow wide exposure of an-
terior skull base.
In the last decades, in keeping with the trend to
perform less invasive surgical approaches, several
authors reported endoscopic approaches for selected
cases of skull base surgery, such as closure of cere-
brospinal fluid leaks1 and transethmoidal and trans-
From the *Maxillo-Facial Surgery Department, II Faculty of “La
Sapienza” University at S. Andrea Hospital, Rome, Italy; †Rome,
Italy; ‡Maxillo-Facial Surgery Department, I Faculty of “La
Sapienza” University, Policlinico Umberto I, Rome, Italy; and
§
Maxillo-Facial Surgery Department, Santa Maria Hospital,
Terni, Italy.
Address correspondence to Dr. Longo Benedetto, 3 Int. 2, Via
Mondino de’Luzzi 00161 Rome, Italy; e-mail: benedettolongo@
hotmail.com
experience with transnasal endoscopic procedures
improved both techniques and outcomes and be-
came more common.
The authors present a cadaver study of com-
bined transfacial transcranial endoscopic approach
to skull base. Such an approach used with minimally
invasive surgery principles could represent, in se-
lected cases (both for neoplastic lesions and malfor-
mations), an alternative to traditional anterior cranial
fossa surgical approaches by wide craniotomies.
Diagnostic and therapeutic-surgical protocols
changed with the large diffusion of endoscopic tech-
niques in several branches of medicine, with an im-
provement of patients’ compliance.3,4
The evolution of endoscopy allowed improve-
ment in diagnosis of and therapy for conditions re-
lated to gastroenterology, urology, pneumology,
and neurosurgery. Some specialties developed
and increased their application field thanks to the
endoscopic techniques,5 and with more prognosis,
the outcome of some pathologies improved drasti-
cally.
Surgical repair of small cerebrospinal fistulas,6
the trans-sphenoidal approach for the pituitary
gland, the transnasal endoscopic treatment of endo-
nasal encephalomeningocele,7 and the removal of
small ethmoid-nasal malignant lesions usually are
performed by the transnasal-transethmoidal endo-
scopic approach.8
More application for endoscopy has been pro-
posed in recent years. Functional endoscopy sinus
surgery represents one of the more brilliant examples
of endoscopy applications.9 Radical surgery for para-
nasal sinusitis is performed less and less often.
Endoscopy allows the resolution, respecting the
physiology of the paranasal sinus and improving
postoperative secretion drainage and ventilation of
the sinuses.
In recent years, an endoscopic technique was
proposed, but not widely performed, to approach
fractured and dislocated condyle10 or blow-out frac-
tures of the orbital wall by a transantral approach.11
In the last 5 years, technical refinements even
allowed applications in microsurgery of the skull
base.
In these recent years, traditional approaches by
craniotomies in the surgical treatment of the cranio-
facial malformations and of the upper facial third
tumors were performed by small frontal cranioto-
mies, to be less invasive and to minimize postopera-
tive cosmetic outcomes.12,13
Thanks to the evolution of endoscopy, indica-
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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 1 January 2005

tions for endoscopy, the experience, and above all,

the new technologies will have a larger and larger
role in the future.
The authors’ aim is to propose a new approach
to the anterior skull base by endoscopy, eventually
combined with a transfacial approach (by open
surgery or endoscopy); such an approach could
be an application of the modern mini-invasive sur-
gery.

MATERIALS AND METHODS

A cadaver study was performed, simulating the
physiologic resistance and elasticity of the meninges
and cerebral structures.
A rigid endoscopic optic system of 4 mm in di-
ameter with 0°, 30°, and 45° lenses, according to the
different visual needs, and malleable spatulas in as-
sociation with bevel dissectors different for angling,
depending on the portions of the skull base to be
dissected, were used.
A coronal bilateral scalp flap was elevated in
the frontal subperiosteal plane, preserving pericra-
nium for the reconstruction step. The flap elevation
was carried down to the frontonasal suture in the
midline and bilaterally to the supraorbital rim. A
transcranial pterional approach is performed
through burr holes (Fig 1) of the diameter of 7 to 8
Fig 1 The transcranial endoscopic pterional approach.
Fig 2 Dissection of the dura up to the midline of the
frontal bone.
mm, through which dura mater dissection from the
anterior skull base on the border side of the orbital
roof was performed.
Burr holes allowed introduction of a rigid 4-mm
diameter endoscopic optic system. Dissection and
mobilization of the medial portion of the dura to the
midline of the frontal bone was performed (Fig 2). In
correspondence with the middle portion of the fron-
tal bone, the falx cerebri was elevated with a pro-
gression that went downward to free the crista galli.
A malleable spatula was positioned, and the unglu-
ing of the remaining portion was performed through
an analogous method (Fig 3). The vases were easily
managed with bipolar cautery, and with microscis-
sors a bloodless ungluing can be easily accom-
plished.
The choice of the dissectors (form and angling)
was particularly important.
The preservation of the olfactory fibers of the
ethmoidal planum depends on the pathology. The
dissection of the dura from the frontal bone plane
regarding the glabellar and orbital portion repre-
sented the key to approach of the anterior cranial
fossa, and such dissection must be performed in a
lateral-to-medial and cranial-to-caudal direction,
from the frontal crest to the crista galli, avoiding
dura damage.

156
 TRANSCRANIAL ENDOSCOPY IN SKULL BASE SURGERY / Belli et al
Fig 3 The dissection performed on both sides of the fron-
tal bone.
Ungluing and dissection were performed in the
ethmoidal portion of the skull base under endoscopic
control with an anterior-to-posterior direction.
After dura dissection, the frontal lobes were
gently retracted, and skull base osteotomies could be
performed.
Osteotomy shape depends on pathology. Oste-
otomies can allow mobilization of the splanchnocra-
nium in malformative pathologies. In neoplastic sur-
gery, complex craniotomies can be performed to
approach the underlying anatomical structures that
must be removed or to perform en bloc removal of
skull base together with malignancies.
After bone segment removal, detection of the
eventual dural fistulas and their reparation with du-
ral grafts (according to the position and the dimen-
sions of the leakage) was possible through direct or
endoscopic visual.
CONCLUSIONS
The refinement and evolution of endoscopic tech-
niques and the surgical instruments during the last
20 years have extended endoscopic methodology to
the surgery of all anatomical closed hollows.
Skull base surgery for malformations or neo-
plasms is submitted to a common surgical con-
cept: exposure and protection of cerebral paren-
chyma.
Thus, the skull base, especially in its anterior
portion, represents the anatomical plan of separation
among the splanchno- and the neurocranium that the
maxillofacial surgeon must resect to mobilize or to
remove complex structures of the splanchnocranium.
Cerebral lobe retraction is done to preserve the
parenchyma during the skull base dissection, so ex-
posure of the meninges and the frontal lobes repre-
sents a necessity for the exposure and the dissection
of the skull base.
Endoscopy has been widely applied to skull
base surgery during the last decade.
In the last few years, thanks to the use of the
neuronavigation system,14,15 such endoscopic meth-
ods have been applied to the surgery of the cerebral
ventricles, to close small fistulas of the rhinobase,
and to remove benign or malignant lesions of the
skull base by the transnasal approach (see the in-
verted papilloma),16 situations not easily approached
by traditional surgery.
The authors’ cadaver study aimed to investigate
possibilities in applying the endoscopic method to
the dissection of the cerebral parenchyma from the
anterior skull base without iatrogenic dura damages.
After several attempts performed through frontal
minicraniotomies, we performed a dissection of the
skull base through the holes in the pterional area.
Afterward, it has been possible to effect, under en-
doscopic visual control, dissection and ungluing of
the dura from the anterior portion of the skull base,
starting from the frontal crest to the clinoid pro-
cesses, to the cribriform plate, and to the back intra-
cranial portion of the rotundum, lacerum, and ovale
foramen.
Osteotomies have even been performed under
endoscopic visual control, preserving the dura. Such
an approach allowed some orbital quadrantectomies
of Tessier,17,18 Le Fort IV type osteotomy to mobilize
the orbital-maxillo-malar complex. With such an ap-
proach, deemed suitable for the exposure of the skull
base and the possibility of locating key points for the
ungluing, satisfactory anatomical preparations final-
ized to the osteotomies and mobilization of the or-
bital bone borders were obtained. A further attempt
has been done to perform some osteotomies with the
purpose of proceeding to the removal of the orbital-
ethmoidal-skull base complex. Such osteotomies al-
lowed the en bloc removal of the anatomical com-
plex, so traditional craniotomies were not required,
limiting the dissection of the cerebral tissue and the
associated complications.
This approach tangential to the skull base mini-
mized the insult to cerebral tissue.
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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 1 January 2005
This preliminary report could represent a first
step toward additional studies on the application of
endoscopy for approaching the skull base. Based on
the positive results obtained, perhaps an evolution
from an experimental phase to a clinical phase could
be proposed in the near future.
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158
Chronic Expanding Hematoma
in the Temporal Region
Hideyuki Tada, MD, PhD, Mitsuo Hatoko, MD, PhD,
Aya Tanaka, MD, Satoshi Yurugi, MD, Hiroshi Iioka, MD,
Katsunori Niitsuma, MD
Abstract: A rare case of chronic expanding hematoma in the right
temporal region that developed into a large mass over the course
of 12 years is reported. The patient, who had a history of blunt
trauma to her right temporal region at the age of 4 months, noticed
a slowly growing mass at the same site over the last few months.
Computed tomography revealed a well-circumscribed subcutane-
ous tumor. The tumor was completely resected. Histopathologi-
cally, the diagnosis of chronic expanding hematoma was con-
firmed.
Key Words: Chronic expanding hematoma, temporal
region, histological examination
M ost hematomas subside spontaneously without
any clinical problems, but a few cases persist
for a long time. Reid et al1 advocated that these cases
be referred to as chronic expanding hematoma.
Chronic expanding hematoma is a rare persistent en-
tity that can manifest as a space-occupying lesion.
Chronic expanding hematoma may potentially
present at various locations. There are several reports
of chronic expanding hematoma located in the in-
trathoracic cavity or extrathoracic cavity after tho-
racic surgery.2–5 In some instances, chronic expand-
ing hematoma occurred in the soft tissue. Chronic
expanding hematoma has been reported to occur in
the thigh,6 leg,6 buttock,7 and neck.8 There are no
reports of chronic expanding hematoma occurring in
the soft tissue of the craniofacial region, however. In
this report, we describe chronic expanding he-
matoma in the right temporal region that developed
over the course of 12 years.
CASE REPORT
A 12-year-old girl presented with a complaint of a
painless expanded subcutaneous mass in her right
temporal region. She had received blunt trauma to
the right temporal area at the age of 4 months. For 12
years, this subcutaneous mass had shown repeated
enlargement and reduction. She was not bothered by
From the Division of Plastic Surgery, Nara Medical University,
Nara, Japan.
Address correspondence to Dr Tada, Division of Plastic Sur-
gery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara,
634-8522 Japan; e-mail: h-tada@topaz.ocn.ne.jp.