Quantification of the Advantages of the Extended Frontal Approach to Skull Base

This anatomic study evaluated the extent that a fronto-orbital osteotomy (FOO) added to a bilateral frontal craniotomy widened the exposure to the midline compartment of the anterior, middle, and posterior cranial fossae. The goal was to determine if osteotomy would significantly increase angles for two targets: the foramen magnum (FM) and anterior clinoid process (ACP). Stepwise dissections were performed on five cadaveric heads. A bilateral frontal craniotomy was made, followed by FOO. After the ethmoids were removed, the planum sphenoidale was drilled to enter the sphenoid sinus. Further drilling exposed the anterior clivus, which was drilled down to FM. Excellent exposure of the basilar artery, vertebral artery, and brain stem was achieved. With and without FOO, angles of exposure were measured for two targets: the ACP and FM. The angle of exposure after FOO increased markedly with an average gain of 76% for the ACP and of 80% for FM. Compared with a conventional bifrontal craniotomy, the addition of FOO increased the surgical exposure and minimized frontal lobe retraction for accessing lesions of the anterior, middle, and posterior cranial fossae.

Brain tumor - extended frontal approach - operative approach - skull base - skull base tumor

REFERENCES

• 1 Davini V, Capuzzo T. Skull base tumors.  J Neurosurg Sci. 1985;  29 65-71
• 2 Fisch U. The infratemporal fossa approach for nasopharyngeal tumors.  Laryngoscope. 1983;  93 36-44
• 3 Fisch U, Pillsbury H C. Infratemporal fossa approach to lesions in the temporal bone and base of the skull.  Arch Otolaryngol. 1979;  105 99-107
• 4 Derome P J. The trans-basal approach to tumors invading the base of the skull. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques: Indications, Methods and Results, 2nd ed. Orlando, FL; Grune & Stratton 1988: 619-633
• 5 Kumar A, Valvassori G, Jafar J, Mafee M. Skull base lesions: a classification and surgical approaches.  Laryngoscope. 1986;  96 252-263
• 6 Maxwell R E, Chou S N. Preoperative evaluation and management of meningiomas. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques: Indications, Methods and Results, 2nd ed. Orlando, FL; Grune & Stratton 1988: 547-554
• 7 Myers D L, Sataloff R T. Spinal fluid leakage after skull base surgical procedures.  Otolaryngol Clin North Am. 1984;  17 601-612
• 8 Ojemann R G, Swann K W. Surgical management of olfactory groove, suprasellar, and medial sphenoid wing meningiomas. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques: Indications, Methods and Results, 2nd ed. Orlando, FL; Grune & Stratton 1988: 531-545
• 9 Sekhar L N, Janecka I P, Jones N F. Subtemporal-infratemporal and basal subfrontal approach to extensive cranial base tumours.  Acta Neurochirurgica. 1988;  92 83-92
• 10 Kawakami K, Yamanouchi Y, Kubota C, Kawamura Y, Matsumora H. An extensive transbasal approach to frontal skull-base tumors.  J Neurosurg. 1991;  74 1011-1013
• 11 Sekhar L N, Nanda A, Sen C N, Synderman C N, Janecka I P. The extended frontal approach to tumors of the anterior, middle, and posterior skull base.  J Neurosurg. 1992;  76 198-206
• 12 Frazier C H. An approach to the hypophysis through the anterior cranial base.  Ann Surg. 1913;  57 145-150
• 13 Derome P, Akerman M, Anquez L et al.. Les tumeurs spheno-ethmoidales. Possibilities d’exerese et de reparation chirurgicales.  Neurochirurgie. 1972;  18(Suppl) 1-164
• 14 Jackson I T, Marsh E R, Hide A. Treatment of tumours involving the anterior cranial fossa.  Head Neck Surg. 1984;  6 901-913
• 15 Jane A J, Park T S, Pobereskin L H, Winn H R, Butler A B. The supraorbital approach: technical note.  Neurosurgery. 1982;  11(4) 537-542
• 16 Cophignon J B, George B, Marchac D, Roux F X. Voie transbasale elargie par mobilization du bandeau fronto-orbitaire median.  Neurochirurgie. 1983;  29 474-477
• 17 Price J C. The midfacial degloving approach to the central skull base.  Ear Nose Throat J. 1986;  65 174-180
• 18 Rosen H M, Simeone F A, Bruce D A. Single stage composite resection and reconstruction of malignant anterior skull base tumors.  Neurosurgery. 1986;  18 7-11
• 19 Ahn H S, Sexton C S, Zinreich S J, Rosenbaum A E. Neuroradiologic techniques in the evaluation of lesions of the skull base.  Ear Nose Throat J. 1986;  65 74-83
• 20 Austin M B, Mills S E. Neoplasms and neoplasm-like lesions involving the skull base.  Ear Nose Throat J. 1986;  65 57-73
• 21 Buren J MV, Ommaya A K, Ketcham A S. Ten years experience with radical combined craniofacial resection of malignant tumors of the paranasal sinuses.  J Neurosurg. 1967;  28(4) 341-350
• 22 Hakuba A, Liu S, Nishimura S. The orbitozygomatic infratemporal approach: a new surgical technique.  Surg Neurol. 1986;  26 271-276
• 23 Persing J A, Jane J A, Levine P A, Cantrell R W. The versatile frontal sinus approach to the floor of the anterior cranial fossa.  J Neurosurg. 1990;  72 513-516
• 24 Uttley D, Moore A, Archer D J. Surgical management of midline skull-base tumors: a new approach.  J Neurosurg. 1989;  71 705-710
• 25 Blacklock J B, Weber R S, Lee Y Y, Goepfert H. Transcranial resection of tumors of the paranasal sinuses and nasal cavity.  J Neurosurg. 1989;  71 10-15
• 26 Boyle J O, Shah K C, Shah J P. Craniofacial resection for malignant neoplasms of the skull base: an overview.  J Surg Oncol. 1998;  69 275-284
• 27 Fliss D M, Zucker G, Cohen J T, Gatot A. The subcranial approach for the treatment of cerebrospinal fluid rhinorrhoea: a report of 10 cases.  J Oral Maxillofac Surg. 2001;  59 1171-1175
• 28 Schramm V L, Myers E N, Maroon J C. Anterior skull base surgery for benign and malignant disease.  Laryngoscope. 1979;  89 1077-1091
• 29 Spetzler R F, Herman J M, Beals S, Joganic E, Milligan J. Preservation of olfaction in anterior craniofacial approaches.  J Neurosurg. 1993;  79 48-52
• 30 Alaywan M, Sindou M. Fronto-temporal approach with orbito-zygomatic removal-surgical anatomy.  Acta Neurochir. 1990;  104 79-83
• 31 Sundaresan N, Shah J P. Craniofacial resection for anterior skull base tumors.  Head Neck Surg. 1988;  10(4) 219-224

REFERENCES

• 1 Spetzler R F, Herman J M, Beals S, Joganic E, Milligan J. Preservation of olfaction in anterior craniofacial approaches.  J Neurosurg. 1993;  79 48-52

REFERENCES

• 1 Sekhar L N, Nanda A, Sen C N, Snyderman C N, Janecka I P. The extended frontal approach to tumors of the anterior, middle, and posterior skull base.  J Neurosurg. 1992;  76 198-206
• 2 Rhoton Jr A L. The foramen magnum.  Neurosurgery. 2000;  47 S115-S193