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Access osteotomies

Approaches to the base of the skull
 Le fort I osteotomy approach
 Maxillary swing approach  Transpalatal approach

 Facial translocation approach
 Transethmoidal approach  Trans septal- trans sphenoidal approach

Le fort I osteotomy approach

 Transverse facial osteotomy along the lines of the

le fort I fracture and inferiorly displacing the palate to expose the nasopharynx, clivus, and the sphenoid sinus

 Indications –  Central skull base lesions  Tumours situated in or extending into the

maxillary sinus, the sphenoid sinus or nasopharynx  Single access route for exposing the medial compartment of the inferior skull base.

Technique
 Incision given in the labiobuccal

vestibule leaving approximatelt 5mm of the mucosa attached.
 Reflection of the flap in the

subperiosteal plane upto the level of infraorbital foramen.
 Initial bone cuts made anteriorlt,

extending from the pyriform aperture across the medial buttress at the level of the floor of

 A curved osteotome is directed around the back of the maxillary . The anterior cuts are completed by cutting across the root of the septum and through anterior nasal spine and maxillry crest below the septum.  The bone cuts across the medial wall of the maxillary sinus is made.

 Exposure of the tumour site by retraction of the palate in inferior direction. and the vessels of the pterygomaxillary fissue. . The last cut is through the posterior wall of the maxillary sinus.  The palate should be free of bony attachments. the periosteum of the posterior wall. it will remain attached by the tissues of the soft palate.

Complications  Loss of palatal blood supply may result in     necrosis Deviation of the septum Perforation of septum Nasal stenosis Malunion or non union of the osteotomies .

muscle. and nasal mucosa.Two-piece Le Fort I osteotomy  The full length of the soft and hard palates is incised just lateral to the uvula and carried to the midline.  This incision extends anteriorly to include the gingival papilla on the palatal aspect of the central incisors. .  The soft palate incision is a fullthickness incision through oral mucosa.

 The standard Le Fort I osteotomy is then performed  A spatula osteotome is then used to finish the midline split between the central incisors.  Each maxillary half is rotated laterally with a self-retaining retractor  A mandibulotomy is used if extreme superior or inferior access is required or if the patient has limited mouth opening. .

skull base in the refion of sphenoid sinus and pterygoid plates .Maxillary swing approach  To approach anterior skull base  Displace maxilla by either rotating it laterally based on the greater palatine vessels or completely removing the maxilla as a free graft. infra temporal fossa.  Provides exposure of nasopharynx.

disconnecting the septum from the nose and cribriform plate is given  The palatal incisions are through the floor of the nose on the contralateral side  After elevation of palatal mucosa.Technique  The incision through the dorsum of the septum. the hard palate is cut through the contralateral floor of the nose from posterior to the anterior. .

 Septum is detached from the columela anteriorly  Medial cuts made from pyriform aperture to the orbital rim.  The cut is angled laterally either to go through the inferior orbital rim or enter into the maxillary sinus inferior to the rim .

 Posteriorly the floor cuts extend posterior to the orbital fissure to include the entire roof of maxillary sinus.  The lateral pressure on the maxilla fracture the pterygoid plate atraumatically and it can be retracted laterally. . The orbital cuts are then performed after elevation of the periosteum of orbital floor till inferior orbital fissure.

Complications  Ischemic damage to the teeth  Malocclusion due to improper replacement and reconstruction  Chronic sinusitis. mucous cyst formation secondary to injury to the sinus mucosa  Transection of the nasolacrimal system  Enophthalmos . mucocele.

palatal split  .Transpalatal approach  Four types of variations .palatal drop  .retraction of soft palate only  .palatal split with labiomandibular glossotomy .

exposing . The flap is pushed down. Muscles of the soft palate divided from hard palate and nasopharyngeal mucosa at the junction.Technique Palatal drop The incision made through the mucosa and periosteum down to the palatal bone upto the palatal junction.

.  The incision is extended to hard palate to allow soft palate to retract without tearing.  The soft palate is retracted vertically upto the hard palate. Palatal split  The incision begins just lateral to the base of the uvula. curves immediately back to the midline and then traverses the midline of the soft palate.

soft palate is only attached to the anterior tonsillar pillar and anteriorly to the hard palate mucosa. The muscular attachment of soft palate and nasopharynx is divided.  The posterior aspect of the hard palate is exposed which can be removed exposing the posterior aspect of the septum .

Transpalatal with labiomandibular glossotomy  Involves midline lip incision. mandibular split. . and division of the tongue.

Complications  CSF fistula  Wound complications associated with the posterior pharyngeal wall  Palatal wound problems .

Facial translocation approach  Indications Access to anterior and middle cranial fossa  Advantage Direct access to a neoplasm while providing control of important anatomic structures  Allows for easy and reliable reconstruction with temporalis flap and galea aponeurotica .

 It runs horizontally at the inner canthus which it transects. where it exits to meet the vertical bicoronal or preauricular incision.Technique  The lip split incision begins at the vermillion border and continues along nasal ala and lateral nose. .  It continues at the depth of the inferior lid fornix through the conjuctiva to the lateral canthus.

 The cheek flap is reflected inferiorly to the level of the hard palate after the elevation of the maxillary periosteum and the massteric fascia in a downward direction.  The frontotemporal scalp flap is reflected towards the midline after completion of the bicoronal and transtemporal incisions and appropriate undermining. .

Complications  Scar contracture  Epiphora  Facial paralysis  Non union or malunion at osteotomies .

avoids denervation of the teeth  .working distance shorter than any pituitary approach  .Transethmoidal approach  Most direct and shortest route to the pituitary  Advantages  .line of approach parallels the floor of the cranial fossa .avoids craniotomy  .

 The upper end of incision just below the eyebrow should be kept medial to the superior orbital foramen with the lower end extending 2-3mm below the level of inner canthus.Technique  A modified lynch incision is made midway between the medial canthus and nasal dorsum. .

 The posterior ethmoid sinus is opened and posterior wall removed by a small curette exposing the interior of the sphenoid sinus. The elevation of the periosteum includes the trochlea of the superior oblique muscle after which the orbital periosteum is freed.  The ethmoid labryinth is opened end mucosal lining removed. .

Complications  Orbital hematoma  Diplopia  Blindness .

Transseptal transsphenoidal approach  Advantage :  Avoids facial incision over a highly esthetic region  Provides access to middle cranial fossa .

angling superiorly towards the piriform crests. .  The caudal edge of the nasal septum is exposed and a longitudnal incision is made along its free edge.  Anterior nasal septum is detached from the maxilla as a unit.Technique  A horizontal sublabial incision from canine ridge to canine ridge is made.

leaving the septal acrtilage hinged superiorly. . The quadrangular septal cartilage is disarticulated from its attachment to the vomer inferiorly and to the ethmoid plate posteriorly.  This exposes the ethmoid plate and vomer between its blades.

Complication  CSF leak  Meningitis  Septal deformation  Loss of nasal tip projection  Denervation of the upper incisors .

trans parotid .transcervical .Access to parapharyngeal space Approaches to parapharyngeal space: .trans cervical-transparotid -transoral -transoral.external approach -cervical-transpharyngeal approach .

A superficial parotidectomy is performed. . the superficial lobe can be excised completely and the deep lobe removed as a separate specimen. Alternatively.Trans parotid approach For deep lobe parotid tumours to save facial nerve. at the end of which the superficial lobe is left pedicled inferiorly.

The deep lobe is separated from the posterior border of the ascending ramus and from the TMJ as well as digastric and the bony external auditory meatus.The branches and the main trunk are dissected off the underlying deep lobe. using small scissors and by lifting the nerve with a nerve hook. .

The retromandibular vein is divided and the superficial temporal vein is secured just below the zygomatic arch. . Similarly the ECA is divided at its point of entry to parotid and internal maxillary artery is divided between the deep lobe and the ascending ramus.

 Highly vascular tumours.  Lesion that require proximal and distal control of ICA .Mandibulotomy Indications :  For large neoplasms.  Malignancies.

Midline mandibulotomy(mandibular swing approach)  Resection of oral cavity and oropharyngeal malignancies  Access to oropharynx. parapharyngeal space. superior cervical vertebrae and skull base. and floor of the mouth. . retropharynx.

At the point of chin the incision inclines downwards and laterally preferably in a skin crease just above the hyoid bone and ends at the anterior border of sternomastoid .The submandibular part of the incision is deepened through the platysma and the submandibular gland is removed . with a curve thereafter which surrounds and hugs the contour of the chin to its lower extremity .Technique  A staggered incision is carried through the lower lip which may take the form of a ‘V’ on its side or alternatively a vertical line drawn to the upper part of the protuberance of the chin. .

The mucosal incision is then carried out inside the mandible and deepened to include the division of mylohyoid close to its insertion into the mandible. .The midline of the mandible is then split ..

 The incision in the mucous membrane is continued onto the anterior faucial pillar ending on the soft palate  The osteoplatic flap containing the mandible is retracted as far out as possible and the tumor is separated from the adjacent structures by blunt dissection and excised .

Lateral mandibulotomy Double mandibular osteotomy – osteotomy in parasymphyseal region and horizontally in ascending ramus superior to mandibular foramen . .mandible can be retracted laterally with attached masseter and cheek.

anterior belly of digastrics.  done by midline mandibulotomy and division of mylohyoid. and geniohyoid muscle allow mandibule to be rotated superolaterally. .resection of tumours more than 5cm located in superior medial PPS.  avoids morbidity of intraoral and lip split incisions and need for tracheostomy.Subcutaneous mandibulotomy  .

Complication of mandibulotomy Malocclusion  Non union  Loss of dentition  IAN injury  Need for lip split incision. NG tube . tracheostomy.

Trans oral approach to superomedial parapharyngeal space .parapharyngeal tumours which are benign.free from the contents of carotid sheath.Palatopahryngeal approach  for excision of :- . . .relatively avascular.Otolaryngologyhead and neck surgery(2006) 134.466-470 . medially bulging.extra-parotid and .

hence preserving the blood supply and sensation of soft . passing along the lateral edge of the soft palate and the nasopharynx.  This incision in palate is laterally placed. An incision extending from the posterior edge of the hard palate. thus avoiding damage to the ascending palatine artery. palatine vein and the greater palatine neurovascular bundle.

Otolaryngology-head and neck surgery(2006) 134. Trans oral approach contraindicated for:  hemorrhage  Damage to cranial nerves  Tumor spillage  Decreased exposure Trans oral approach to superomedial parapharyngeal space .466-470 .

.A parotidectomy incision with cervical extension is extended superiorly into a hemicoronal scalp incision.can be used for malignant tumors involving the skull base or jugular foramen.This approach can be combined with frontotemporal craniotomy for removal of tumors with significant intracranial extension.Infratemporal approach . . .

The temporomandibular joint can be displaced inferiorly. . and the infratemporal skull base and distal carotid are exposed. or the mandible condyle can be transected for improved exposure.The temporalis muscle is elevated to expose the glenoid fossa. .Orbitozygomatic osteotomies are performed. . which is removed laterally..

Thank you .

Med.A Pediatric Experience. Le Fort I Osteotomy and Skull Base Tumors. . Bull. 62. Aug 2000  Lt Col BK Prasad et al . The Versatility Of Median Labiomandibulotomy. MJAFI 2004. Arch Otolaryngol Head Neck Surg/Vol 126.74(5):652-6.Palato-pharyngeal Approach to the Parapharyngeal Space. 8. October 1986  Transmaxillary approach to the cranial base: an evaluation of 11 cases. No. Rev Bras Otorrinolaringol 2008. N.Refrences  Tyler M. 60 : 407409  Willaim Lawson.Y. Acad. Lewark. Vol.