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PubMed1997

Surgical treatment of anterior skull base tumours.

Skull base tumours represent a special challenge to surgeons due to the complex anatomy of the area. While small tumours are easy to remove, large lesions can pose complex situations. The most difficult aspects are not only the approach and removal, but specially the repair of the defects created by the resection of the tumour. We present here our experience with the surgical removal of tumours on the anterior skull base. To achieve a good approach, we resort to a bifrontal craniotomy including the cilliar arches. To obtain a skull base bone flap that can be used for repair at the end of the procedure, we remove the roof of the nose and a part of the medial wall and roof of both orbits. While the tumour is removed, the skull base bone flap is autoclaved to kill all tumoural cells. At the end of the procedure this bone flap is replaced, wrapped with a flap of pericranium. Provided no orbit needs to be emptied, no other flap is needed to reconstruct the area. One advantage is that the surgical cavity is not occluded with tissues, thus facilitating early identification of any recurrence. The area can be explored with the aid of an endoscope introduced into the nasal cavities through the nostrils, and in case of doubt, biopsies taken from all suspicious area. Our technique facilitates the repair of the surgical defect, and while not compromising the healing process it has a very low incidence of CSF leaks and infections.

Adolescent↗
PubMed2001

Prevention of postoperative complications in skull base surgery for nasal or paranasal sinus carcinoma invading the skull base.

With recent technical advances in skull base surgery, radical resection of a nasal or paranasal sinus carcinoma invading the skull base can now be achieved. To assure a satisfactory surgical result, it is essential to prevent postoperative infection. In our series of 14 cases, serious postoperative infections occurred in the earliest 10 cases, and only 2 of these patients are still alive. The vascularised abdominal muscle flap for skull base reconstruction was fixed with fibrin glue, but was not adequate to fill the dead space, resulting in cerebrospinal fluid leakage and subsequent meningitis. Once the infection occurred, a free bone flap became the focus of infection. Based on these earlier experiences, we used a ROC fastener system to completely fill the dead space with an abdominal muscle flap, and bone flap was primarily craniectomised in the four most recent cases. With this technique, there were no postoperative infections.

Abdominal Muscles↗
PubMed2000

[Institutionalization of skull base surgery. Development, concept and initial experiences of the interdisciplinary center for skull base surgery of the Leipzig University].

The treatment of complex tumorous, inflammatory, traumatic, vascular processes, or developmental disorders of the skull base increasingly needs the interdisciplinary cooperation of specialties involved in diagnostics or treatment. Due to this inevitable cooperation of different hospital specialties, institutionalization of skull base surgery, organized as a center or working group, seems recommendable. Moreover, such a center may have additional effects on the external representation of skull base surgery, which is also important. On the initiative of 11 departments and institutes of the university hospital of Leipzing, the Interdisciplinary Center of Skull Base Surgery (IZSL) was founded in March 1997. The following aims were proclaimed: improvement of the interdisciplinary clinical treatment of patients with skull base diseases, evaluation of the patient's data, advancement of clinical and experimental research on the field of skull base surgery, as well as the organization of meetings for training and teaching and scientific meetings. Structure, concept, and first experiences of the interdisciplinary center of skull base surgery are discussed.

Germany↗
PubMed2000

A millennium review of skull base surgery.

Skull base surgery is a recent development in our history, in as much as most of the surgical techniques involved have been described within the last century. To provide an historical prospective the author reviews the development of this specialty, arbitrarily dating its beginning some five centuries ago with the work of Leonardo da Vinci. By picking this period we include the origin of scientific anatomy and personages interested in developing new ideas and concepts who were able to leave the stagnant period of the Middle Ages behind. In 1900 surgeons worked alone, with the concept of a skull base "team" not yet existing. Endotracheal intubation and controlled respiration was just being introduced. Intraoperative monitoring of blood pressure, pulse rate and respiration was not yet known. Harvey Cushing was to introduce this concept in the first decade of the last century. This survey traces the origins of modern skull base surgery from its antecedents in the Renaissance to the beginning of this century. A paper of this length can only provide a sampling of themes and personalities; nevertheless, it will give the reader an impressive overview of how far we have come and some ideas of what the future holds.

History, 15th Century↗
PubMed2001

[Gross tumor volume (GTV) and clinical target volume (CTV) in radiotherapy of benign skull base tumors].

Skull base tumours represent about 35 to 40% of all intracranial tumours. There are now many reports in the literature confirming the fact that about 80 to 90% of such tumours are controlled with fractionated radiotherapy. Stereotactic and 3-dimensional treatment planning techniques increase local control and central nervous system tolerance. Definition of the gross tumor volume (GTV) is generally easy with currently available medical imaging systems and computers for 3-dimensional dosimetry. The definition of the clinical target volume (CTV) is more difficult to appreciate; it is defined from the CTV plus a margin, which depends on the histology and anterior therapeutic history of the tumour. It is important to take into account the visible tumour and its possible extension pathways (adjacent bone, holes at the base of skull) and/or an anatomic region (sella turcica + adjacent cavernous sinus). It is necessary to evaluate these volumes with CT Scan and MRI to appreciate tumor extension in a 3-dimentional approach, in order to reduce the risk of marginal recurrences. The aim of this paper is to discuss volume definition as a function of tumour site and tumour type to be irradiated.

Humans↗
PubMed2001

The fronto-orbital osteotomy as plastic-reconstructive approach to the anterior and middle skull base.

Introduction: A combined extra-intracranial access for the operative exploration of tumours of the anterior and middle skull base is indicated when the tumour extends intracranially and simultaneously into the nasal cavity, the paranasal sinuses or the orbit. Methods: Two standardized modifications of the fronto-orbital osteotomy, the fronto-orbito-nasal and the fronto-orbito-zygomatic osteotomy, allow safe removal of skull base tumours in these locations. In extensive skull base tumours, a modified bilateral fronto-orbital-zygomatic osteotomy can be used. Results: Between February 1993 and July 2000 skull base tumours in 111 patients were resected using the presented methods. The most frequent tumour type was meningioma in 29 cases. Complications were encountered in 13 cases (11.7%). Conclusion: The advantages over other approaches are good extra- and intracranial overview and minimal cerebral trauma. Additional transfacial incisions are not usually necessary. Exact repositioning of the fronto-orbital segments leads to optimal aesthetic results. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.

Journal Article↗
PubMed2000

Imaging of postnatal maturation of the skull base.

The skull begins to form when mesenchyme thickens and condenses around the developing brain. At the skull base, most of this mesenchyme derives from neural crest, and some arises from general head mesenchyme. This article reviews the patterns for maturation of the ossification, sutures, and synchondroses in the occipital, the sphenoid, and the orbitoseptal regions, and reports additional data derived from specific study of CT scans of the skull base in children and young adults.

Adolescent↗
PubMed1982

A new measure of growth efficiency: skull base height.

Skull base height increases significantly with better nutrition and health conditions, as seen in comparing 163 nineteenth to twentieth century dissecting-room skeletons (Terry Collection) with 237 modern American middle-class adults (forensic and willed skeletons). The increase parallels the change in pelvic inlet depth index, known to respond sensitively to nutrition, and in stature, and is over six times greater than the general skull size change. Skull base height (porion-basion) is easy to measure with depth gauge and sliding caliper, or by subtraction, and is in adult a sensitive indicator of childhood growth stress.

Age Determination by Skeleton↗
PubMed2005

Cerebral revascularization in skull base tumors.

Skull base tumors involving the carotid artery pose a difficult surgical challenge. The potential for bypass grafting for cerebral revascularization carries inherent risks but may aid in tumor resection and control in those who warrant carotid sacrifice but have inappropriate natural cerebrovascular reserve. We include a review of the literature discussing the indications for carotid resection as part of skull base tumor surgery, indications for cerebral revascularization, balloon test occlusion, graft types and operative technique, complications, and results.

Journal Article↗
PubMed2001

Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan.

We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n = 78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n = 16). The most frequent surgical approach was frontal craniotomy (n = 66), followed by front-temporal craniotomy (n = 54) and infratemporal fossa approach (n = 8). For repair of dura matter, fascia lata was used in 37 cases. galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan-Meier method of nose and paranasal sinus carcinoma (n = 119) was 48%. As for histological classification, the survival rates were both 65%) in adenoid cystic carcinoma (n = 12) and bone soft tissue malignancy (n = 10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n = 11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases. liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment.

Adult↗
PubMed2001

Linac radiosurgery for skull base meningiomas.

INTRODUCTION: Skull base meningiomas present a difficult surgical challenge because of the high potential morbidity of radical surgical extirpation and their low potential for incapacitating symptomatology. The focal character of meningiomas makes stereotactic radiosurgery an attractive adjuvant treatment modality to resection. The purpose of this study was to evaluate the local control rates and complications in 56 patients with base of skull meningiomas undergoing radiosurgery. METHODS: Patients underwent radiosurgery using the dedicated stereotactic linear accelerator at the Brigham and Women's Hospital. Minimal peripheral doses of radiosurgery ranged from 12 to 18.5 Gy (mean 15 Gy). Doses were designed to conform to the frequently irregular tumor volumes using the X-Knife treatment planning system. Multiple isocenters were used when required to increase conformality of dose. For 36 patients (64%), radiosurgery was used as an adjunct to surgery; for 20 patients (36%) it was the primary treatment. RESULTS: Median followup was five years. Nineteen patients (34%) were improved clinically at follow-up; 32 (57%) were unchanged; and 5 patients (9%) developed new or worsened neurologic deficits. Serial imaging studies after radiosurgery showed a reduction in tumor volume in 23 patients (41%); 30 (54%) showed stable disease; 3 patients (5%) had tumors which increased in size (2 being outside the radiosurgery treatment site). The actuarial freedom from progression rate (defined as further tumor growth) was thus 95%, with a median imaging follow-up of 26 months (range, 6-66 months). Although further follow-up is necessary, the results of this series clearly demonstrate that these lesions are feasible for treatment by modern radiosurgical techniques. Linac radiosurgery can stabilize skull base meningiomas, with decreased or unchanged tumor volumes on radiologic follow-up in approximately 95% of patients. Radiosurgery is a low-morbidity, effective technique as adjunct and sometimes primary treatment of small to moderate-sized meningiomas of the skull base.

Adult↗
PubMed2000

Imaging of mucormycosis skull base osteomyelitis.

Skull base osteomyelitis (SBO) is typically bacterial in origin and caused by Pseudomonas, although the fungus Aspergillus has also rarely been implicated. SBO generally arises from ear infections and infrequently complicates sinonasal infection. Rhinocerebral Mucor infection is characteristically an acute, fulminant, and deadly infection also affecting the orbits and deep face and is associated with intracranial complications. Bony involvement is uncommon because of the angioinvasive nature of the fungus. More recently, chronic invasive Mucor sinusitis has been described. We report the unusual clinical and imaging features of a patient with biopsy-proven invasive mucormycosis arising from chronic isolated sphenoid sinus disease, who presented with extensive SBO and a paucity of deep facial, orbital, or intracranial involvement.

Biopsy↗
PubMed2006

Transnasal endoscopy-assisted skull base surgery.

Skull base surgery (SBS), which originated in the 19th century, became refined in the 20th century in parallel with technological advancements and is now in the midst of further refinements largely driven by advances in endoscopic sinus surgery. With the development of modern SBS, lesions that were once inoperable and potentially fatal can now be eradicated successfully by means of endoscopy-assisted procedures that reduce or completely eliminate intracranial trauma, minimize postsurgical morbidity, and make full recovery possible. It is absolutely mandatory to have the appropriate instrumentation for endoscopy-assisted SBS. Among the new technologies available are advanced endoscopes, high-speed suction irrigation drills, digital video cameras, computed tomography and magnetic resonance imaging, and systems for 3-dimensional computer-assisted image-guided surgical navigation. An experienced endoscopic surgeon working with multidisciplinary teams, and using new instrumentation and techniques, can bring SBS to new levels of success in the 21st century.

Angiography↗
PubMedDate not supplied

Evaluation of skull base erosion in nasopharyngeal carcinoma: comparison of plain radiography and computed tomography.

Over a period of 16 months, a total of 175 patients with newly diagnosed nasopharyngeal carcinoma (NPC) were evaluated with plain radiography and computed tomography (CT) of nasopharynx and base of skull. 54 of 175 patients (30.9%) had CT evidence of skull base erosion. Plain radiography failed to demonstrate the skull base erosion in 22 of 54 patients (40.7%) and underestimated the extent of bony involvement in another 21 patients (38.9%). In 14 of 54 patients (25.9%), there was also false suspicion of bony erosion in the plain films in one or more regions of the skull base which was not substantiated by CT and subsequent clinical course. The present study shows that plain radiography lacks sensitivity and specificity in detecting skull base erosion by NPC. CT evaluation of NPC patients should include thin CT sections of base of skull for detection of subtle bone erosion, and this would allow better decision concerning the shielding of the pituitary-hypothalamic axis during radiotherapy for improvement in therapeutic ratio. For the investigation of individuals highly suspicious of harboring NPC, even when the plain radiography is negative, CT should still be performed as this may give the only clue to the presence of a small submucosally spreading NPC.

Humans↗
PubMed2001

Intraoperative magnetic resonance imaging for skull base surgery.

OBJECTIVES/HYPOTHESIS: Skull base surgery has evolved over the past several decades. Major improvements in the imaging of skull base pathology led to better target localization and better surgical planning. The objectives of this study were to assess the use of intraoperative magnetic resonance (MR) imaging in the management of a series of patients with skull base pathology. We hypothesized that high-quality intraoperative MR imaging would have an impact on surgery in this patient group. STUDY DESIGN: Prospective, non-randomized, cohort study. METHODS: Thirty-one patients with skull base lesions underwent surgery in a 1.5-Tesla intraoperative MR suite. The concepts of a moving magnet, high magnetic field strength, and radiofrequency coil design are presented. RESULTS: Eleven of 31 patients had the course of surgery significantly altered by the information acquired from the images obtained during surgery. CONCLUSIONS: Intraoperative MR imaging is a valuable adjunct to skull base surgery. One third of patients had altered surgery as a result of this adjunct. Intraoperative MR imaging is of particular value in the treatment of pituitary adenomas and benign skull base tumors.

Adenoma↗
PubMed2006

Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction.

Lateral skull base defects following tumor ablation are ideally reconstructed with microvascular free tissue transfer. Although the rectus abdominis free flap is the workhorse in skull base reconstruction, it has a number of drawbacks. Anecdotal reports have indicated that fasciocutaneous free flaps may be useful alternatives in selected cases. Patients undergoing lateral arm (4 cases) or anterolateral thigh (8 cases) fasciocutaneous free flap reconstruction of lateral skull base defects between 1999 and 2005 were therefore reviewed. Twelve consecutive patients (4 males, 8 females) with a mean age of 63 years (range, 39 to 74) underwent such reconstruction following resection of lateral (11 cases) and anterolateral (1 case) skull base lesions. Eight patients had squamous cell carcinoma, 3 had infection or osteoradionecrosis, and 1 had adenoid cystic carcinoma. The duration of surgery (from induction of anesthesia to exit from the operating room) averaged 14.5 hours (range, 10 to 19.5 hours). All donor sites were closed directly. All the flap transfers were successful, with minimal reconstructive and donor site morbidity. During the follow-up period (average, 18 months; range, 2-48 months), 2 patients died of metastatic disease, and another 2 died of other unrelated causes. The remaining 8 patients are alive and disease free. It is concluded that lateral arm and anterolateral thigh fasciocutaneous free flaps should be considered as viable reconstructive options for lateral skull base ablative defects.

Adult↗
PubMedDate not supplied

Endoscopically assisted anterior cranial skull base resection of sinonasal tumors.

The traditional approach to sinonasal tumors involving the base of skull has been the anterior craniofacial resection. Endoscopic techniques have created the potential to approach the intranasal aspect of skull base lesions without external incisions and still develop an en bloc resection when removed. We report our initial experience with skull base neoplasms in which the otolaryngic portion of the standard resection was accomplished instead through an endoscopic approach. The nature of lesions favorable for this approach and associated technical issues are discussed. Although we do not consider this approach a replacement for the traditional anterior craniofacial resection, it is an important adjunct in the skull base surgeon's armamentarium.

Adenocarcinoma↗
PubMed1999

Magnetic resonance imaging of the central skull base.

The central skull base is an anatomically complex region whose foundation is the sphenoid bone. It includes the sphenoid sinus, clivus, and sella turcica, as well as adjacent soft tissues such as the cavernous sinuses and nasopharynx. The central skull base may be affected by pathologies intrinsic to the sphenoid bone or by processes that arise in adjacent soft tissue and extend centrally to affect the central skull base. In general, this region is optimally imaged with magnetic resonance scanning, although in some cases computed tomography can provide complementary information. In this review, we will discuss a variety of pathologies that can affect the central skull base, such as neoplasms, infections, trauma, congenital malformations, and a variety of miscellaneous pathologies. We will discuss processes that can mimic neoplasia, such as aggressive polyposis and chronic inflammatory disease. For each pathology we will review clinical and imaging findings.

Diagnosis, Differential↗