The surgery of benign and malignant neoplasms adjacent to or involving the skull base

Orbito-rhino-antro access osteotomy for anterior skull base lesions

Even with advent of endoscopic assisted surgeries the access osteotomy plays an important role for accessing the pathological lesions of anterior skull base since beginning of the era of surgery. This report introduces the orbito-rhino-antral access osteotomy for the removal of juvenile nasio angio fiboma extending in to the cranial base. This osteotomy provides good access to the lesion with lesser morbidity and without hampering the occlusion as in lefort osteotomies. It is safe, easy and faster to perform. Osteotomised segment is easy to replace and gives ease for the surgeon to access without any hindrance. The osteotomised segment act as free graft and there are no complications postoperatively even after 48 mnth of follow-up.

Complications of anterior craniofacial resection

BACKGROUND

The complications associated with anterior craniofacial resections for benign and malignant tumors were reviewed in 104 patients treated between January 1981 and June 1996.

METHODS

Information regarding patient characteristics, histologic type, history of prior therapy, extent of the disease, extent of surgical procedure, and type of reconstruction were entered in a microcomputer database. To better understand and stage postoperative complications, we divided them into early (<14 days) and late (>14 days) according to the time of presentation, into major and minor depending on the morbidity potential of complication, and into local and systemic ones. Comparison between risk factors associated with complications was made using chi-square analysis with Yates' correction for continuity. Survival analysis was performed using the Kaplan-Meier product limit method.

RESULTS

There were 8 (7.6%) postoperative deaths, with only 1 occurring from systemic complications. Complications occurred in 53 (48.6%) patients. Local major complications occurred in 49 (45%) patients, local minor in 29 (26.6%), and systemic in 11 (10%). Early complications occurred in 40 (38.5%) patients and late complications in 13 (12.5%) patients. These complications developed during a period ranging from 1 day to 5 months. More than one complication occurred in a number of patients. Bacterial contamination leading to local septic complications was the principal cause of morbidity, accounting for 54.7% (29/53) of complications. Major complications included meningitis in 8 patients associated with cerebrospinal fluid leak in 7, cerebral abscess in 2, sepsis in 1, and subdural hemorrhage in 1, all of which resulted in death except for one case. The extent of the craniofacial resection (p = .011) was the most important factor associated with major complications. Invasion of the dura and the type of reconstruction of the anterior skull base were the most important factors related to cerebrospinal fluid leakage (p = .048 and p = .032) and meningitis (p = .011).

CONCLUSION

Contemporary surgical approaches and methods of reconstruction have enabled skull base surgeons to extend their cranial base resections and increase the 5-year survival rates of patients. Nevertheless, significant complications persist. Knowledge and high index of suspicion together with early recognition of these complications are essential for effective management of patients undergoing craniofacial resection. The factors related to major complications found in this study stressed the need to develop more effective methods to prevent contamination of intracranial structures.

Tumors of the skull base: outcome and survival analysis of 77 cases

We reviewed our experience with combined approaches to lesions that transcend the bones of the skull base. Seventy-seven skull base procedures were performed on 73 patients during a 10-year period from 1982 to 1992. There were 34 patients (44%) with region lesions (anterior), seven patients (9%) with region II lesions (anterior-lateral), 25 patients (32%) with region III lesions (lateral-posterior), and 11 patients (14%) with lesions that invaded more than one anatomic site. The histopathology in this series was quite variable, with 22 patients (29%) having squamous cell carcinoma and eight patients (10%) having basal cell carcinoma. Forty-one patients had surgery by an anterior approach and 38 patients had lateral approaches, with 18 undergoing an infratemporal approach and 29 undergoing temporal bone resections. Overall, 44% of the patients had a postoperative complication. Survival of this heterogeneous group of patients is 79% at 2 years and 71% at 4 years, with those patients with region II disease having a statistically significant poorer prognosis with no survivors at 4 years.