A new transfacial approach for lesions of the clivus and parapharyngeal space: the partial segmented Le Fort I osteotomy

Transfacial Exposures of the Anterior Skull Base and Cervical Spine: Straightforward "Line-of-Sight" Algorithm for Selection of Approach

ABSTRACT

Surgical treatment for tumors of the skull base remains gross total resection with microscopic negative margins. Sufficient surgical access is paramount to adequate treatment but must be balanced with patient morbidity and protection of vital neurovascular structures. While endoscopic surgery has made transfacial access less common, there are still indications for open transfacial exposure including tumors that involve facial soft tissues, the palate, anterolateral frontal sinus, dural involvement lateral to the mid-pupillary line, tumor recurrence/repeat resection, and/or lack of access to endoscopic equipment or expertise. The authors present a "line-of-sight" algorithm for selection of approach, discuss pre-operative planning, review selected clinical experiences, and discuss the role of microsurgery and prevention of complications.

Le Fort I Down-Fracture for Management of Midface Tumors

OBJECTIVE

To perform an integrative review associating current literature with a clinical series regarding the use of Le Fort I osteotomy for the removal of tumors located in the midface and central region of the skull base.

METHODS

A systematic review was performed through the PubMed, SCOPUS, and Cochrane databases. In addition, 4 different patients operated using the above-cited technique are described in this study.

RESULTS

Initially, 123 articles were found. After the removal of duplicates, and title and abstract reading, 27 articles were selected for data extraction. The Le Fort I surgical approach of tumors was performed in 183 patients.

CONCLUSION

The Le Fort I surgical approach allows lesion exeresis with good visualization, low rates of recurrences and complications, and without aesthetic compromises for the patient.

Clival chordomas: considerations after 16 years of endoscopic endonasal surgery

OBJECTIVE In the past decade, the role of the endoscopic endonasal approach (EEA) has relevantly evolved for skull base tumors. In this study, the authors review their surgical experience with using an EEA in the treatment of clival chordomas, which are deep and infiltrative skull base lesions, and they highlight the advantages and limitations of this ventral approach. METHODS All consecutive cases of chordoma treated with an EEA between 1998 and 2015 at a single institution are included in this study. Preoperative assessment consisted of neuroimaging (MRI and CT with angiography sequences) and endocrinological, neurological, and ophthalmological evaluations, which were repeated 3 months after surgery and annually thereafter. Postoperative adjuvant therapies were considered. RESULTS Sixty-five patients (male/female ratio 1:0.9) were included in this study. The median age was 48 years (range 9-80 years). Gross-total resection (GTR) was achieved in 47 cases (58.7%). On univariate analysis, primary procedures (p = 0.001), location in the superior or middle third of the clivus (p = 0.043), extradural location (p = 0.035), and histology of conventional chordomas (p = 0.013) were associated with a higher rate of GTR. The complication rate was 15.1%, and there were no perioperative deaths. Most complications did not result in permanent sequelae and included 2 CSF leaks (2.5%), 5 transient cranial nerve VI palsies (6.2%), and 2 internal carotid artery injuries (2.5%), which were treated with coil occlusion of the internal carotid artery without neurological deficits. Three patients (3.8%) presented with complications resulting in permanent neurological deficits due to a postoperative hematoma (1.2%) causing a hemiparesis, and 2 permanent ophthalmoplegias (2.5%). Seventeen patients (26.2%) have died of tumor progression over the course of follow-up (median 52 months, range 7-159 months). Based on Kaplan-Meier analysis, the survival rate was 77% at 5 years and 57% at 10 years. On multivariate analysis, the extent of tumor removal (p = 0.001) and the absence of previous treatments (p = 0.001) proved to be correlated with a longer survival rate. CONCLUSIONS The EEA was associated with a high rate of tumor removal and symptom control, with low morbidity and preservation of a good quality of life. These results allow for a satisfactory overall survival rate, particularly after GTR and for primary surgery. Considering these results, the authors believe that an EEA can be a helpful tool in chordoma surgery, achieving a good balance between as much tumor removal as possible and the preservation of an acceptable patient quality of life.

[Anatomy and surgical approaches to the parapharyngeal space]

PURPOSE

Analysis of surgical approaches to primary tumors localized in parapharyngeal space used in Head & Neck Cancer Department, Cancer Center Institute in Warsaw. Description of differences in terminology used to describe fascial compartments of the neck.

MATERIAL AND METHODS

Retrospective analysis of medical records of 8 selected patients who had an operation for primary parapharyngeal space neoplasm. Analysis has been done of operation protocols, diagnostic images, tumor size and histopathology.

RESULTS

Transcervical, transparotid and transmandibular approaches were used with additional rhinotomy and craniotomy in selected cases. Selection of approach should take into account tumor localization, its size and histopathology.

CONCLUSIONS

Planning of surgical procedure for parapharyngeal space tumor should be based upon analysis of diagnostic images and selection of the approach depends on tumor localization, size and histopathology. Differences in terminology of superficial and middle cervical fascial compartments can lead to inappropriate clinical decisions.

A comprehensive analysis of intracranial chordoma and survival: a systematic review

OBJECTIVE

Despite the published information on cranial chordoma, most of the data regarding survival in these patients has come from a single institution. Here, we perform a systematic review of the literature to evaluate across multiple institutions the overall survival after treatment for intracranial chordoma.

MATERIALS AND METHODS

We systematically analysed every study published in English and found a total of over 2000 patients being treated for intracranial chordoma. The overall 5-year and 10-year survivals in these patients were stratified according to the age (<5 years vs. >5 years and  <40 years vs. >40 years), treatment (surgery and radiation vs. surgery alone) and histological findings (chondroid vs. typical). Data were analysed via Pearson chi-square test and student t-test when appropriate.

RESULTS

A total of 560 non-duplicated patients treated for cranial chordoma met inclusion criteria for this systematic analysis. The survival rate among these patients was 63% (299 patients) and 16% (176 patients) for 5-year and 10-year survivals, respectively. There was no difference in overall survival between the two groups when a cut-off age of 40 years was used (<40 years = 50% vs.  >40 years = 51% at 5-year survival; p = 0.1), but when 5 years was used as the cut-off age, then survival was better for patients in the group older than 5 years of age (<5 years = 14% vs.  >5 years = 66%; p = 0.001). There was no difference between 5-year survival in patients with chordoma with histological chondroid features and those with chordoma possessing typical histology (45% vs. 67%; p = 0.06). When patients who only received surgery were compared to those patients who were treated with surgical intervention in combination with adjuvant radiation treatment, no difference in survival rate was found (54% vs. 56% at 5 years; p = 0.8).

CONCLUSION

The results of our systematic study provide data to predict the survival of intracranial chordoma patients across multiple institutions. Our data suggest that patients younger than 5 years of age may be associated with a worse prognosis, and adjuvant radiation therapy and histological type were not associated with the improvement of survival rates.

Emergency removal of a grinding wheel embedded in the midface via modified Le Fort I osteotomy

Le Fort I osteotomy is commonly used to rectify craniofacial deformity in orthognathic surgery and it can be used in approaching a cranial base lesion. This technique has not been well documented in craniofacial penetrating trauma. This article describes a case of midface penetrating injury caused by a grinding wheel. A modified Le Fort I osteotomy was used to remove the foreign object. This surgical approach can be safe and effective when removing foreign bodies in the midface. Good access and adequate exposure can be achieved, which facilitate precise foreign body extraction and achieve reasonable cosmetic results.

Cervical chordoma managed with multidisciplinary surgical approach

BACKGROUND

This paper describes the interdisciplinary management of a 62-year-old man who presented with a cervical chordoma of C2/3. This is a rare neoplasm of the axial skeleton which is usually treated surgically. This is technically challenging due to the surrounding anatomy and requirement for wide exposure. A number of surgical approaches have been described to access the clivus and upper cervical spine.

METHODS

This case involved both the Orthopaedic and Otolaryngology Head and Neck Surgery departments. Trotter's surgical technique was used to gain access for excision of the cervical chordoma and there was collaboration with an Orthopaedic Biotechnology Company in which a bio-model of the spine was created and a corpectomy cage specific to the patient developed.

RESULTS

This approach allowed excellent visualisation of the tumour and the unique cage and plate achieved immediate stability and long term fusion.

CONCLUSION

An interdisciplinary approach should be used in the management of upper cervical chordomas to facilitate tumour resection and reduce the potential for recurrence.

Quantification of clival and paraclival exposure in the Le Fort I transmaxillary transpterygoid approach: a microanatomical study

OBJECT

The authors describe a modified Le Fort I maxillotomy with medial and posterior antrectomy and removal of the pterygoid plates, aimed at improving the lateral surgical exposure during open transmaxillary surgery for pathological conditions involving the clivus. A cadaveric microanatomical study was conducted to compare the planimetric exposures allowed by the transmaxillary transpterygoid (TMTP) approach and the standard Le Fort I maxillotomy (STM).

METHODS

Six cadaveric specimens that had been fixed with glutaraldehyde and injected with latex were dissected to obtain morphometric measurements after both TMTP and STM approaches. The anatomical areas exposed by the surgical approaches were calculated using ImageJ 1.37a software.

RESULTS

As expected, the TMTP approach allowed for a greater surgical exposure, with an incremental area exposed ranging from 4.9 to 7.6 cm(2) (mean ± standard deviation 6.4 ± 1.2 cm(2), 95% CI 5.4-7.4 cm(2)). The amount of additional anatomical area visualized, as recorded as a percentage increase after the TMTP approach when compared with the STM approach, ranged from 83 to 109% (mean 99%).

CONCLUSIONS

The lateral surgical exposure allowed by the STM approach is limited by the pterygoid plates. The TMTP approach significantly improves the exposure of the anatomical regions lateral to the clivus, allowing access to the pterygopalatine and medial infratemporal fossae. In comparison with the STM, the TMTP approach allows for a surgical exposure that is nearly double. The authors conclude that the TMTP approach provides a significant improvement in the surgical exposure of the lateral paraclival areas, when compared with the STM approach.

Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma

Cranial chordomas are rare tumors that have been difficult to study given their low prevalence. Individual case series with decades of data collection provide some insight into the pathobiology of this tumor and its responses to treatment. This meta-analysis is an attempt to aggregate the sum experiences and present a comprehensive review of their findings. We performed a comprehensive review of studies published in English language literature and found a total of over 2,000 patients treated for cranial chordoma. Patient information was then extracted from each paper and aggregated into a comprehensive database. The tumor recurrences in these patients were then stratified according to age (<21 vs. >21 years), histological findings (chondroid vs. typical) and treatment (surgery and radiation vs. surgery only). Data was analyzed via Pearson chi-square and t-test. A total of 464 non-duplicated patients from 121 articles treated for cranial chordoma met the inclusion criteria. The recurrence rate among all patients was 68% (314 patients) with an average disease-free interval of 45 months (median, 23 months). The mean follow-up time was 39 months (median, 27 months). The patients in younger group, patients with chordoma with chondroid histologic type, and patients who received surgery and adjuvant radiotherapy had significantly lower recurrence rate than their respective counterparts. The results of our systematic analysis provide useful data for practitioners in objectively summarizing the tumor recurrence in patients with cranial chordomas. Our data suggests that younger patients with chondroid type cranial chordoma treated with both surgery and radiation may have improved rates of tumor recurrence in the treatment of these tumors.

Transmaxillary approach to the cranial base: an evaluation of 11 cases

Surgical access to the skull base is always difficult, especially because of the noble anatomic structures present there. Maxillary osteotomy provides direct view to the clivus region and the neck spine, and it also bears less morbidity when compared to the many other accesses described in the literature.

Aim

to assess 11 patients submitted to transmaxillary osteotomy, describing the surgical technique and postoperative results and complications.

Materials and Methods

A retrospective study involving eleven patients submitted to transmaxillary approach to the brainstem. We studied dental occlusion, trans and postoperative bleeding, bone necrosis and soft tissue alterations. All followed the same surgical protocol and were followed up for two years.

Results

after treatment, all the patients improved in their clinical status and had no neurological complication, trans and postoperative hemorrhage or major complications were seen. Among the complications, two patients had incomplete maxilla fracture, two had laceration of their nasal mucosa and one had, as late complication, an oral-sinusal fistula.

Conclusion

Transmaxillary osteotomy provided proper access to the clivus for brainstem decompression with low rate of complications in this series.

Transmaxillary and transmandibular approach to a C1 chordoma

STUDY DESIGN

Case report.

OBJECTIVES

To demonstrate the efficacy of a transmaxillary and transmandibular approach in achieving a wide view and the aggressive resection of a retropharyngeal chordoma originating from C1.

SUMMARY OF BACKGROUND DATA

Although aggressive surgical resection has been recommended for the treatment of chordomas, wide exposure of the tumors in the upper cervical region is a challenge.

METHODS

A 19-year-old man presented with a large ossified retropharyngeal chordoma (6 cm in diameter) originating from the right side of the anterior arch of C1, and extending from the clivus to the C2/3 intervertebral disc level in the sagittal plane. A posterior occipitocervical (O-C3) fusion with an iliac bone graft was first performed. Ten days after the fusion, the tumor was resected using a mandible and tongue midsplitting approach combined with a Le Fort I (transmaxillary) osteotomy, which allowed us to expose the entire tumor. The tumor was hard and immovable because of ossification. The main part of the tumor was resected from the anterior arch of C1, and then the C1 anterior arch was resected en bloc. The retropharyngeal wall was reconstructed using a vascularized radial forearm flap. Radiation therapy (60 Gy) was performed after surgery.

RESULTS

No local recurrence or metastasis was observed 3 years after the operation. The patient had no complaints and has returned to his previous job as a manual laborer.

CONCLUSIONS

A transmaxillary and transmandibular approach allowed us to obtain a complete view of a large immovable chordoma located ventral to the upper cervical spine. This enabled us to resect totally the tumor into 2 pieces without major complications or sequelae. This approach is useful for the resection of large tumors located in the median upper cervical spine.

Tratamiento quirúrgico de la impresión basilar mediante osteotomía tipo Le Fort I segmentada. A propósito de un caso

The expansive lesions, whether tumoral or not, originated at the level of the anatomical region of the skull base (SB), show a great histologic variety and clinicaly they cause a variable chronic neurological disfunction. Surgical treatment appears to be the best therapeutic option. An exhaustive knowledge of the topographic anatomy of this area is the mandatory in order to design an appropriate surgical strategy. In many cases, a narrow cooperation with specialists is necesary. As in any other surgical activity, a complete excision of the lesion and an optimal functional and aesthetic rehabilitation, without complications, is the challenge of the surgical team. The approach to the anatomical area of the SB is not single, but is based on a number of procedures, although none of them could be considered the best, or without technical difficulty or any complications. Within the group of transoral approaches, the Le Fort I-Palatal split (LFPS) technique has been considered by different authors an excellent way to approach the clivus and the occipito-vertebral joint. We report the case of a patient, treated in cooperation with the Department of Neurosurgery of our hospital. He was clinical and radiologically diagnosed of basilar impresion with bulbar compression, and the MRI revealed the presence of a located extradural fibrous injury above the odontoid apophysis. Therefore we chose the use of a LFPS to approach this lesion. With an optimal surgical field, a complete excision of the lesion was obtained. The postoperatory result in the subsequent follow-up was highly satisfactory.

Nasopharyngectomy for recurrent nasopharyngeal carcinoma: an innovative transnasal approach through a mid-face deglove incision with stereotactic navigation guidance

Traditional approaches to nasopharyngectomy for the treatment of recurrent nasopharyngeal carcinoma carry considerable complications. This paper presents an innovative transnasal approach with stereotactic navigation guidance through a mid-face deglove incision which has been done for 15 patients with minimal morbidity. All patients had resumed their oral diet within a week, and were discharged within 10 days. The intraoral wound had healed within a week. The only complications were a mild degree of saddling of the nasal dorsum in one patient and temporary facial numbness that resolved within six weeks in three. Tumour had been resected with clear margins in 12/15, in the other three being stuck to the carotid artery.