Skip to main content

Advertisement

SpringerLink
Log in

A modified frontal–nasal–orbital approach to midline lesions of the anterior cranial fossa and skull base: technical note with case illustrations

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

The frontal–nasal–orbital craniotomy has been utilized for craniofacial abnormalities and resection of tumors involving the anterior skull base. We describe modifications of this technique to approach extra-axial and intradural midline lesions of the anterior fossa with or without involvement of the skull base. A craniotomy was planned with an endoscope and image guidance. A modified frontal–nasal–orbital craniotomy encompassing the entire frontal sinus complex was performed in conjunction with osteotomies incorporating the bilateral superior orbital ridges and nasal septum. Removal of the posterior wall of the frontal sinus was completed if necessary. Dural repair and final reconstruction are detailed. Our initial experience using this approach in five patients harboring lesions of the anterior skull base resulted in adequate exposure of the targeted pathology. There were no complications of the procedure. Cosmetic results were acceptable. We present a detailed account of this procedure via photographs and a video. The frontal–nasal–orbital craniotomy provides access to the floor of the anterior fossa while avoiding excessive brain retraction associated with facial incisions. In addition, this approach is associated with a lower incidence of complications, such as CSF leak, brain retraction edema, or infection. The frontal–nasal–orbital craniotomy is a useful technique for midline lesions of the anterior skull base, and it should be in the armamentarium of neurological surgeons.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Blacklock JB, Weber RS, Lee YY et al (1989) Transcranial resection of tumors of the paranasal sinuses and nasal cavity. J Neurosurg 71:10–15

    Article  CAS  PubMed  Google Scholar 

  2. Fliss DM, Abergel A, Cavel O et al (2007) Combined subcranial approaches for excision of complex anterior skull base tumors. Arch Otolaryngol Head Neck Surg 133:888–896

    Article  PubMed  Google Scholar 

  3. Fliss DM, Zucker G, Cohen A et al (1999) Early outcome and complications of the extended subcranial approach to the anterior skull base. Laryngoscope 109:153–160

    Article  CAS  PubMed  Google Scholar 

  4. Fujitsu K (1994) Basal interfalcine approach through a frontal sinusotomy with vein and nerve preservation. Technical note. J Neurosurg 80:575–579

    Article  CAS  PubMed  Google Scholar 

  5. Gluckman JL (1991) Craniofacial resection. Ear Nose Throat J 70:595–599

    CAS  PubMed  Google Scholar 

  6. Har-El G, Casiano RR (2005) Endoscopic management of anterior skull base tumors. Otolaryngol Clin North Am 38:133–144 ix

    Article  PubMed  Google Scholar 

  7. Hendryk S, Czecior E, Misiolek M et al (2004) Surgical strategies in the removal of malignant tumors and benign lesions of the anterior skull base. Neurosurg Rev 27:205–213

    Article  PubMed  Google Scholar 

  8. Jane JA, Park TS, Pobereskin LH et al (1982) The supraorbital approach: technical note. Neurosurgery 11:537–542

    Article  CAS  PubMed  Google Scholar 

  9. Janecka IP, Nuss DW, Sen CN (1991) Midfacial split for access to the central base. Acta Neurochir Suppl (Wien) 53:199–203

    CAS  Google Scholar 

  10. Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 1—the midline anterior fossa skull base. Minim Invasive Neurosurg 47:1–8

    Article  PubMed  Google Scholar 

  11. Kaplan MJ, Jane JA, Park TS et al (1984) Supraorbital rim approach to the anterior skull base. Laryngoscope 94:1137–1139

    CAS  PubMed  Google Scholar 

  12. Kinnunen I, Aitasalo K (2006) A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach. J Craniomaxillofac Surg 34:405–411

    PubMed  Google Scholar 

  13. McCutcheon IE, Blacklock JB, Weber RS et al (1996) Anterior transcranial (craniofacial) resection of tumors of the paranasal sinuses: surgical technique and results. Neurosurgery 38:471–479 discussion 479–480

    Article  CAS  PubMed  Google Scholar 

  14. Origitano TC, Petruzzelli GJ, Leonetti JP et al (2006) Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management. Neurosurgery 58:ONS-327–ONS-336 discussion ONS-336-327

    Article  Google Scholar 

  15. Panje WR, Dohrmann GJ 3rd, Pitcock JK et al (1989) The transfacial approach for combined anterior craniofacial tumor ablation. Arch Otolaryngol Head Neck Surg 115:301–307

    CAS  PubMed  Google Scholar 

  16. Pinsolle J, San-Galli F, Siberchicot F et al (1991) Modified approach for ethmoid and anterior skull base surgery. Arch Otolaryngol Head Neck Surg 117:779–782

    CAS  PubMed  Google Scholar 

  17. Raveh J, Laedrach K, Speiser M et al (1993) The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 119:385–393

    CAS  PubMed  Google Scholar 

  18. Raveh J, Turk JB, Ladrach K et al (1995) Extended anterior subcranial approach for skull base tumors: long-term results. J Neurosurg 82:1002–1010

    Article  CAS  PubMed  Google Scholar 

  19. Raveh J, Vuillemin T (1988) Advantages of an additional subcranial approach in the correction of craniofacial deformities. J Craniomaxillofac Surg 16:350–358

    CAS  PubMed  Google Scholar 

  20. Raveh J, Vuillemin T (1990) Subcranial–supraorbital and temporal approach for tumor resection. J Craniofac Surg 1:53–59

    Article  CAS  PubMed  Google Scholar 

  21. Raveh J, Vuillemin T, Sutter F (1988) Subcranial management of 395 combined frontobasal–midface fractures. Arch Otolaryngol Head Neck Surg 114:1114–1122

    CAS  PubMed  Google Scholar 

  22. Raveh J, Winkelmann F (1978) A method for management of midfacial fractures (author’s transl). Hno 26:304–306

    CAS  PubMed  Google Scholar 

  23. Ross DA, Marentette LJ, Moore CE et al (1999) Craniofacial resection: decreased complication rate with a modified subcranial approach. Skull Base Surg 9:95–100

    Article  CAS  PubMed  Google Scholar 

  24. Sekhar LN, Nanda A, Sen CN et al (1992) The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg 76:198–206

    Article  CAS  PubMed  Google Scholar 

  25. Solero CL, DiMeco F, Sampath P et al (2000) Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations. Neurosurgery 47:1296–1304 discussion 1304–1295

    Article  CAS  PubMed  Google Scholar 

  26. Vuillemin T, Raveh J (1990) Subcranial approach for the correction of hypertelorism. J Craniofac Surg 1:91–96

    Article  CAS  PubMed  Google Scholar 

  27. Zabramski JM, Kiris T, Sankhla SK et al (1998) Orbitozygomatic craniotomy. Technical note. J Neurosurg 89:336–341

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Shaan M. Raza, James E. Conway, Khan W. Li, Frank Attenello & Alfredo Quinones-Hinojosa

  2. Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Prem Subramanian

  3. Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Kofi Boahene

  4. The Johns Hopkins Neuro-Oncology Surgical Outcomes Research Laboratory, Baltimore, MD, USA

    Shaan M. Raza, James E. Conway, Khan W. Li, Frank Attenello & Alfredo Quinones-Hinojosa

  5. Brain Tumor Stem Cell Laboratory, Department of Neurosurgery and Oncology, 1550 Orleans Street, Cancer Research Building II Room 247, Baltimore, MD, 21231, USA

    Alfredo Quinones-Hinojosa

Authors
  1. Shaan M. Raza
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. James E. Conway
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Khan W. Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Frank Attenello
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kofi Boahene
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Prem Subramanian
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Alfredo Quinones-Hinojosa
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alfredo Quinones-Hinojosa.

Additional information

Comments

Federico G. Legnani, Francesco DiMeco, Milan, Italy

In this study, the authors extensively described pro et contra of a modified approach for resecting midline lesions of the anterior cranial fossa with involvement of the skull base. The subcranial approach proposed provides access to the floor of the anterior fossa while avoiding excessive brain retraction and facial incisions. The presence of an intra-operative endonasal endoscope is of aid in tumor resection, especially for the components that extend posteriorly into the sphenoid sinus or inferiorly into the nasopharynx.

We agree with the authors’ attitude advocating aggressive tumor resection. In our Institution, in collaboration with the Istituto Nazionale Tumori, Milan, we probably have the largest mono-institutional series in the world. Our surgical technique is based on a classic transcranial and transfacial combined approach. We perform surgery in close cooperation with a maxillo-facial surgeon, allowing us to perform a standard anterior craniofacial resection as a routine operation lasting usually less than 3 h. We use loupes and microscope without endoscope. We established this final technique after more than 400 cases over 22 years. The choice of a combined approach comes from the need of an “en block” gross total resection that we demonstrated being a relevant variable on patients’ survival.

Even though the modified approach proposed in this study has been performed on a small number of cases, this novel technique should be considered as an option for lesions involving this anatomic region, and it should be included within the armamentarium of skull base surgeons.

The paper is interesting and well written, and clarifies its clinical relevance; therefore, we feel that it can be a great contribution to the literature. A larger case series with a longer follow up is needed to evaluate the role of this modified approach on patients’ survival and quality of life.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Frontal–nasal–orbital craniotomy. A compilation of video clips from different operative cases demonstrating the various steps of the approach (MOV 136 mb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Raza, S.M., Conway, J.E., Li, K.W. et al. A modified frontal–nasal–orbital approach to midline lesions of the anterior cranial fossa and skull base: technical note with case illustrations. Neurosurg Rev 33, 63–70 (2010). https://doi.org/10.1007/s10143-009-0222-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-009-0222-4

Keywords

Search

Navigation