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Pontillo V, Foscolo V, Salonna F, Barbara F, Bozzi MT, Messina R, Signorelli F, Quaranta NAA. Hearing preservation surgery for vestibular schwannoma: a systematic review and meta-analysis. Acta Otorhinolaryngol Ital 2024; 44:S86-S93. [PMID: 38745520 PMCID: PMC11098544 DOI: 10.14639/0392-100x-suppl.1-44-2024-n2900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/31/2024] [Indexed: 05/16/2024]
Abstract
The aim of this systematic review is to analyse the role of hearing preservation surgery for vestibular schwannoma. The complications and hearing outcomes of the single surgical techniques were investigated and compared with those of less invasive strategies, such as stereotactic radiotherapy and wait and scan policy. This systematic review and meta-analysis was performed according to the PRISMA guidelines. All included studies were published in English between 2000 and 2022. Literature data show that hearing preservation is achieved in less than 25% of patients after surgery and in approximately half of cases after stereotactic radiotherapy, even if data on long-term preservation are currently not available.
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Affiliation(s)
- Vito Pontillo
- Otolaryngology Unit, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Valentina Foscolo
- Otolaryngology Unit, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Francesco Salonna
- Otolaryngology Unit, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Francesco Barbara
- Otolaryngology Unit, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Maria Teresa Bozzi
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Raffaella Messina
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
| | - Nicola Antonio Adolfo Quaranta
- Otolaryngology Unit, Department of Translational Biomedicine and Neurosciences (DiBraiN), University “Aldo Moro” of Bari, Bari, Italy
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Concheri S, Deretti A, Tealdo G, Zanoletti E. Prognostic Factors for Hearing Preservation Surgery in Small Vestibular Schwannoma. Audiol Res 2023; 13:473-483. [PMID: 37489378 PMCID: PMC10366768 DOI: 10.3390/audiolres13040042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/11/2023] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE to evaluate recent contributions to the literature on prognostic factors of hearing preservation in small vestibular schwannoma microsurgery. METHODS review of the most recent studies. RESULTS factors such as tumor size, preoperative hearing status, tumor growth rate, tumor origin, surgical approach, radiological characteristics, results of preoperative neurophysiological tests, preoperative symptoms and demographic features have been investigated and some of them reported to be significant in the prediction of hearing preservation. CONCLUSIONS tumor size and preoperative hearing status are the most impactful factors and play a key role in patient selection for hearing preservation surgery. Other features such as fundal extension, tumor origin and impaired ABR could have prognostic value on hearing preservation. Tumor growth rate, preoperative impedance, cVEMPs and age have also recently been found to be significant, but more studies are needed. The role of preoperative tinnitus, vertigo and gender is lacking and controversial, whereas the differences between available surgical approaches have been smoothed out in recent years.
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Affiliation(s)
- Stefano Concheri
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, 35128 Padova, Italy
| | - Alessandra Deretti
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, 35128 Padova, Italy
| | - Giulia Tealdo
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, 35128 Padova, Italy
| | - Elisabetta Zanoletti
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, 35128 Padova, Italy
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Budohoski KP, Rennert RC, Gordon SA, Raheja A, Brandon C, Henson JC, Azab MA, Patel NS, Karsy M, Gurgel RK, Shelton C, Couldwell WT. Factors associated with hearing outcomes after a middle fossa approach in 131 consecutive patients with vestibular schwannomas. J Neurosurg 2022:1-10. [PMID: 36461828 DOI: 10.3171/2022.10.jns221525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs. METHODS In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors. RESULTS Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1-180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05-0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11-0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97-0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes. CONCLUSIONS The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients' risk of hearing loss.
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Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Steven A Gordon
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Amol Raheja
- 3Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Cameron Brandon
- 4College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - J Curran Henson
- 5University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Mohammed A Azab
- 6Biomolecular Sciences Graduate Programs, Boise State University, Boise, Idaho
| | - Neil S Patel
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Michael Karsy
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Richard K Gurgel
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Clough Shelton
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Rennert RC, Levy DM, Plonsker J, Steinberg JA, Friedman RA, Crawford JR, Levy ML. Middle fossa approach for a pediatric facial nerve meningioma. J Neurosurg Pediatr 2020; 26:578-582. [PMID: 32858509 DOI: 10.3171/2020.5.peds2034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/19/2020] [Indexed: 11/06/2022]
Abstract
Pediatric cerebellopontine angle (CPA) meningiomas are extremely rare and are usually treated with a retrosigmoid surgical approach or radiation. The authors present the use of a middle fossa approach for the treatment of a symptomatic CPA meningioma in a 22-month-old female. The patient initially presented at 17 months with isolated progressive, long-standing right-sided facial weakness. MRI demonstrated a 5.0 × 5.0-mm right CPA lesion just superior to the cisternal segment of cranial nerve (CN) VII, which demonstrated growth on interval imaging. At 22 months of age she underwent a successful middle fossa craniotomy, including wide exposure of the porus acusticus, allowing for a gross-total resection with preservation of CNs VII and VIII. Pathological analysis revealed a WHO grade I meningioma. The patient remained neurologically stable on follow-up. The middle fossa approach can be used to safely access the CPA in properly selected pediatric patients.
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Affiliation(s)
| | | | | | | | - Rick A Friedman
- 2Surgery, Division of Otolaryngology, Head and Neck Surgery, and
| | - John R Crawford
- 3Neurosciences and Pediatrics, University of California, San Diego, California
| | - Michael L Levy
- 3Neurosciences and Pediatrics, University of California, San Diego, California
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Peng KA, Chen BS, Lorenz MB, Lekovic GP, Schwartz MS, Slattery WH, Wilkinson EP. Revision Surgery for Vestibular Schwannomas. J Neurol Surg B Skull Base 2018; 79:528-532. [PMID: 30456020 DOI: 10.1055/s-0038-1635256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/21/2018] [Indexed: 01/09/2023] Open
Abstract
Objectives To describe clinical outcomes of patients undergoing revision surgery for vestibular schwannomas. Design Retrospective case series. Setting Tertiary private neurotologic practice. Participants Patients who underwent revision surgeries for recurrent/residual vestibular schwannomas between 1985 and 2015. Main Outcome Measures Degree of resection, facial nerve function, cerebrospinal fluid (CSF) leak. Results A total of 234 patients underwent 250 revision surgeries for recurrent/residual vestibular schwannomas. Of these, 86 carried a diagnosis of neurofibromatosis type 2 (NF2). The mean number of prior surgeries was 1.26, and 197 (85%) prior surgeries had been performed elsewhere. The average age at surgery was 43. The most common approach employed at the time of revision surgery was translabyrinthine (87%), followed by transcochlear (6%), middle fossa (5%), and retrosigmoid (2%). Gross total resection was achieved in 212 revision surgeries (85%). Preoperative House-Brackmann facial nerve function was similar in non-NF2 and NF2 groups (mean: 2.7). Mean postoperative facial nerve function at last follow-up was 3.8 in the non-NF2 group and 3.9 in the NF2 group. History of radiation and the extent of resection were not associated with differences in facial nerve function preoperatively or postoperatively. CSF leaks occurred after 21 surgeries (8%), and six (2%) patients required reoperation. Conclusions This is the largest series of revision surgery for vestibular schwannomas to date. Our preferred approach is the translabyrinthine craniotomy, which can be readily modified to include the transcochlear approach for improved access. CSF leak rate slightly exceeds that of primary surgery, and gross total resection is achievable in the vast majority of patients.
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Affiliation(s)
- Kevin A Peng
- House Clinic, Los Angeles, California, United States
| | - Brian S Chen
- Ear Nose and Throat Surgery Clinic, William Beaumont Army Medical Center, El Paso, Texas, United States
| | - Mark B Lorenz
- Alaska Center for Ear, Nose and Throat, Anchorage, Alaska, United States
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Abstract
CONCLUSION Middle fossa approach (MFA) shows a hearing preservation rate of 86% and facial nerve function was preserved with HB grade I or II in 93%. MFA is a good treatment option for intra-canalicular vestibular schwannomas when surgical excision is needed. BACKGROUND Surgical outcomes of vestibular schwannoma have progressively improved with the advancement of microsurgical instruments. MFA is known to have better chances to preserve hearing, while it has limited access to the posterior fossa, limitation of tumor size, and higher risk of post-operative facial nerve weakness. OBJECTIVES To investigate surgical outcomes and clinical efficiency of MFA in vestibular schwannoma. METHODS A retrospective study was done in 14 patients who underwent MFA for vestibular schwannoma in Asan Medical Center. RESULTS The median age at diagnosis was 46.3 years. At initial presentation, 57% of the patients had vertigo, 43% hearing disturbance, and 64% tinnitus. The mean tumor size was 9.7 mm. The tumors were completely resected in 86% of the patients. Hearing was post-operatively preserved in 12 patients and two patients lost their hearing following surgery. Facial nerve function post-operatively remained unchanged in 12 patients (86%).
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Affiliation(s)
- Woo Seok Kang
- Department of Otorhinolaryngology-Head & Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Shin Ae Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chan Joo Yang
- Department of Otorhinolaryngology-Head & Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Hoon Nam
- Department of Otorhinolaryngology-Head & Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Woo Chung
- Department of Otorhinolaryngology-Head & Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Lesser JCC, Brito Neto RVD, Martins GDSQ, Bento RF. Cochlear Implantation through the Middle Fossa Approach: A Review of Related Temporal Bone Studies and Reported Cases. Int Arch Otorhinolaryngol 2016; 21:102-108. [PMID: 28050216 PMCID: PMC5205528 DOI: 10.1055/s-0036-1582266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 02/16/2016] [Indexed: 10/31/2022] Open
Abstract
Introduction Middle fossa approach has been suggested as an alternative for patients in whom other routes of electrode insertion are contraindicated. Even though there are temporal bone studies about the feasibility of introducing the cochlear implant through the middle fossa, until now, very few studies have described results when cochlear implant surgery is done through this approach. Objective The objective of this study is to review a series of temporal bone studies related to cochlear implantation through the middle fossa and the results obtained by different surgical groups after cochlear implantation through this approach. Data Sources PubMed, MD consult and Ovid-SP databases. Data Synthesis A total of 8 human cadaveric temporal bone studies and 6 studies reporting cochlear implant surgery through the middle fossa approach met the inclusion criteria. Temporal bone studies show that it is feasible to perform cochlear implantation through this route. So far, only two surgical groups have performed cochlear implantation through the middle fossa with a total of 15 implanted patients. One group entered the cochlea in the most upper part of the basal turn, inserting the implant in the direction of the middle and apical turns; meanwhile, the other group inserted the implant in the apical turn directed in a retrograde fashion to the middle and basal turns. Results obtained in both groups were similar. Conclusions The middle fossa approach is a good alternative for cochlear implantation when other routes of electrode insertion are contraindicated.
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Affiliation(s)
- Juan Carlos Cisneros Lesser
- Department of Otorhinolaryngology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, HC-FMUSP, São Paulo, SP, Brazil; Department of Otorhinolaryngology, Instituto Nacional de Rehabilitación, Mexico City, Mexico
| | - Rubens Vuono de Brito Neto
- Department of Otorhinolaryngology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, HC-FMUSP, São Paulo, SP, Brazil
| | - Graziela de Souza Queiroz Martins
- Department of Otorhinolaryngology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, HC-FMUSP, São Paulo, SP, Brazil
| | - Ricardo Ferreira Bento
- Department of Otorhinolaryngology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, HC-FMUSP, São Paulo, SP, Brazil
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Alkhalili K, Tantawy M, Nageeb MM, Ragaee MA, Alshyal GH, Alcindor DS, Chen DA, Aziz KMA. Role of squamosal suture as a consistent landmark for middle fossa approach craniotomy: an anatomical study. J Neurol Surg B Skull Base 2015; 76:35-8. [PMID: 25685647 DOI: 10.1055/s-0034-1390015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/16/2014] [Indexed: 10/24/2022] Open
Abstract
Objective To establish a consistent surface bony landmark for a middle fossa approach (MFA) lateral craniotomy represented by the squamosal suture (SS). Methods In 60 dried skulls, we assessed the relation between the SS and the external auditory canal (EAC). The lateral portion of the middle cranial fossa floor was also assessed for a possible relation with the anteroposterior diameter (APD) of the squama temporalis (ST). Clinically, we applied our findings on the SS in MFA for different lesions. Results A vertical line at the EAC divided the ST into the anterior part constituting 61% of the APD (i.e., two thirds) and the posterior part forming 39% (i.e., one third). The average ST height was 35.92 mm. The SS posterior limit at the supramastoid crest was located just anterior to the external projection of the petrous ridge in 35 skulls (58%) and exactly corresponded to it in 25 skulls (42%). The APD of the ST equals on average 97% of the APD of the lateral middle cranial fossa. Optimum exposure of the middle fossa was obtained without any further craniotomy extension. Conclusion The SS serves as a consistent natural surface bony landmark for MFA. Optimum craniotomy, two thirds anterior to the EAC and one third posterior, is obtained following SS as a landmark.
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Affiliation(s)
- Kenan Alkhalili
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Mohammed Tantawy
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Mohab M Nageeb
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Mohamed A Ragaee
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Gasser H Alshyal
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Dunbar S Alcindor
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Douglas A Chen
- Department of Otolaryngology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
| | - Khaled M Abdel Aziz
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, United States
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Forbes JA, Rivas A, Tsai B, Ehtesham M, Zuckerman S, Wanna G, Weaver K. Microsurgical localization of the cochlea in the extended middle fossa approach. J Neurol Surg B Skull Base 2013; 73:410-4. [PMID: 24294559 DOI: 10.1055/s-0032-1329621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 06/26/2012] [Indexed: 10/27/2022] Open
Abstract
Objective In the extended middle fossa approach, a portion of the petrous bone known as Kawase's rhomboid can be drilled to expose the posterior fossa through a middle fossa corridor. During this bony resection, the cochlea is placed at risk. The objective of this study was to objectively detail the position of the cochlea in relation to reliable surgical landmarks. Methods Eleven cadaveric specimens were dissected-including six cadaveric heads and five dry temporal bones by means of an anterior petrosectomy with skeletonization of the cochlea. Three anatomic measurements describing the location of the cochlea in relation to the extrapolated intersection of the greater superficial petrosal nerve (GSPN) and facial nerve were recorded. These measurements were then correlated with thin-cut temporal bone computed tomography scans from 25 patients with morphologically normal inner ears. Results In the cadaveric specimens, the anterior border of the membranous basal turn of the cochlea was located an average of 7.56 mm (6.4 to 8.9 mm) anterior to the extrapolated junction of the GSPN and facial nerve, as measured along the course of the GSPN. The medial border of the membranous cochlea (medial margin of basal turn) was located an average of 8.2 mm (6.9 to 8.9 mm) medial to the extrapolated junction of the GSPN and facial nerve, as measured along the course of the facial nerve. The average maximum distance from the extrapolated junction of the GSPN and facial nerve to the membranous cochlea was 9.3 mm (8.2 to 10.3 mm). These anatomic measurements correlated well with radiologic measurements of the same parameters. Conclusion When drilling Kawase's rhomboid, it is useful to locate the extrapolated junction of the GSPN and the facial nerve. Drilling of the anteromedial petrous bone outside of a radius of 12.5 mm from the extrapolated junction of GSPN and facial nerve appears to be associated with a low degree of risk to the cochlear apparatus.
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Affiliation(s)
- Jonathan A Forbes
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Eller JL, Sasaki-Adams D, Sweeney JM, Abdulrauf SI. Localization of the Internal Maxillary Artery for Extracranial-to-Intracranial Bypass through the Middle Cranial Fossa: A Cadaveric Study. J Neurol Surg B Skull Base 2013; 73:48-53. [PMID: 23372995 DOI: 10.1055/s-0032-1304556] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 08/16/2011] [Indexed: 10/28/2022] Open
Abstract
The internal maxillary artery (IMAX) is a promising arterial pedicle to function as a donor vessel for extracranial-to-intracranial (EC-IC) bypass procedures. The access to the IMAX through the anterior portion of the middle cranial fossa floor allows a much shorter interposition graft to be used to create a bypass to the ipsilateral middle cerebral artery and prevents a second incision in the neck. One of the challenges of this technique, however, is the difficulty to find the IMAX through an intracranial approach. The purpose of this cadaveric study is to establish a reliable method to localize the IMAX through a middle fossa floor approach based on skull base bone landmarks. In this study 5 latex-injected fixated cadaveric specimens were dissected bilaterally (providing a total of 10 IMAX dissections) to determine the precise location of the IMAX in the pterygopalatine fossa in relationship to bone landmarks of the middle fossa floor as seen through an intracranial approach. Drilling of the middle fossa floor was undertaken through both the originally described "anteromedial" approach, and a new "anterolateral" approach. Measurements were taken correlating the position of the IMAX to ipsilateral foramen rotundum, ipsilateral foramen ovale, posterior wall of the maxillary sinus, and distal V2 branches. Median and standard deviation were calculated for each dataset. The IMAX was found, within the pterygopalatine fossa, by drilling the greater wing of the sphenoid bone on average 10 mm anteriorly and 5 mm laterally to foramen rotundum, at an average depth of 8 mm. The IMAX was also found inferiorly to the maxillary nerve and laterally to the pterygoid head of the lateral pterygoid muscle. A more laterally oriented approach, consisting of drilling the greater wing of the sphenoid bone from a point perpendicular to foramen rotundum posteriorly to the sphenotemporal suture anteriorly, allowed for a longer segment of the IMAX to be easily identified and exposed facilitating its use as a donor vessel in bypass procedures. This cadaveric study provides a reliable and reproducible set of measurements to localize the IMAX within the pterygopalatine fossa through an intracranial middle fossa approach. The ability to find the IMAX consistently is an important step in exploring the possibility of using the IMAX as a routine donor vessel for EC-IC bypass procedures.
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Affiliation(s)
- Jorge L Eller
- Department of Neurosurgery, Center for Cerebrovascular and Skull Base Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
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Son BC, Lee SW, Kim S, Hong JT, Sung JH, Yang SH. Transzygomatic approach with intraoperative neuromonitoring for resection of middle cranial fossa tumors. J Neurol Surg B Skull Base 2013; 73:28-35. [PMID: 23372992 DOI: 10.1055/s-0032-1304561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 09/01/2011] [Indexed: 10/28/2022] Open
Abstract
The authors reviewed the surgical experience and operative technique in a series of 11 patients with middle fossa tumors who underwent surgery using the transzygomatic approach and intraoperative neuromonitoring (IOM) at a single institution. This approach was applied to trigeminal schwannomas (n = 3), cavernous angiomas (n = 3), sphenoid wing meningiomas (n = 3), a petroclival meningioma (n = 1), and a hemangiopericytoma (n = 1). An osteotomy of the zygoma, a low-positioned frontotemporal craniotomy, removal of the remaining squamous temporal bone, and extradural drilling of the sphenoid wing made a flat trajectory to the skull base. Total resection was achieved in 9 of 11 patients. Significant motor pathway damage can be avoided using a change in motor-evoked potentials as an early warning sign. Four patients experienced cranial nerve palsies postoperatively, even though free-running electromyography of cranial nerves showed normal responses during the surgical procedure. A simple transzygomatic approach provides a wide surgical corridor for accessing the cavernous sinus, petrous apex, and subtemporal regions. Knowledge of the middle fossa structures is essential for anatomic orientation and avoiding injuries to neurovascular structures, although a neuronavigation system and IOM helps orient neurosurgeons.
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Affiliation(s)
- Byung Chul Son
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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