• Korean Journal of Head & Neck Oncology
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• v.10 no.2
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• pp.137-144
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• 1994

To provide the wide and satisfactory surgical field is essential requirement for en-bloc resection of nasopharyngeal angiofibroma invading central skull base. The new design of the surgical approach to the skull base lesions was developed and described the details of this technique and its usefullness. We compared the usefullness of naso-maxillary approach to that of infratemporal fossa approach in cases of angiofibroma invading skull base. Our experience indicates that the naso-maxillary swing approach is better than lateral approach for the large nasopharyngeal angiofibroma. A new approach. naso-maxillary swing approach. is described.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.41
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• pp.3.1-3.9
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• 2019

Background: The infratemporal fossa (ITF) is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Due to its difficult approach, surgical intervention at the ITF has remained a heavy burden to surgeons. The aim of this article is to review basic skull base approaches and ITF structures and to avoid severe complications based on the accurate surgical knowledge. Methods: A search of the recent literature using MEDLINE (PubMed), Embase, Cochrane Library, and other online tools was executed using the following keyword combinations: infratemporal fossa, subtemporal fossa, transzygomatic approach, orbitozygomatic approach, transmaxillary approach, facial translocation approach, midface degloving, zygomatico-transmandibular approach, and lateral skull base. Aside from our Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial, there have been very few randomized controlled trials. The search data for this review are summarized based on the authors' diverse clinical experiences. Results: We divided our results based on representative skull base approaches and the anatomy of the ITF. Basic approaches to the ITF include endoscopic endonasal, transzygomatic, orbitozygomatic, zygomatico-transmandibular, transmaxillary, facial translocation, and the midfacial degloving approach. The borders and inner structures of the ITF (with basic lateral skull base dissection schemes) are summarized, and the modified zygomatico-transmandibular approach (ZTMA) is described in detail. Conclusions: An anatomical basic knowledge would be required for the appropriate management of the ITF pathology for diverse specialized doctors, including maxillofacial, plastic, and vascular surgeons. The ITF approach, in conjunction with the application of microsurgical techniques and improved perioperative care, has permitted significant advances and successful curative outcomes for patients having malignancy in ITF.

• Journal of Korean Neurosurgical Society
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• v.65 no.3
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• pp.457-468
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• 2022

Objective : The clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. Methods : We retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. Results : Among the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. Conclusion : The EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.

• Archives of Craniofacial Surgery
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• v.16 no.1
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• pp.17-23
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• 2015

Background: Treatment of skull base tumors is challenging due to limited access and presence of important neurovascular structures nearby. The success of a complete tumor resection depends on the extent of tumor exposure and secure field of view. While these tumors are often removed by transcranial endoscopic access, transfacial approach is sometimes required depending on the location and size of the tumor. This study describes various transfacial approaches in patients undergoing skull base tumor resection. Methods: From March to November 2013, 15 patients underwent skull base tumor resection via transfacial accesses at a tertiary institution. Data were reviewed for patient demographics, type of access used, completeness of tumor resection, surgical outcome, and postoperative complications. Results: Two clivus tumor patients underwent transmaxillary approach; three tuberculum-sellae and suprasellar-hypothalamus tumor patients underwent transbasal approach; three clinoid and retrobulbar intraconal orbital tumor patients underwent orbitozygomatic approach; and seven petroclival-area, pons, cavernous sinus, and lateral-sphenoid-wing tumor patients underwent zygomatic approach. In all cases, the upper and lower margins of the tumor were visible. Complete tumor removal consisted of 10 cases, and partial tumor removal in 5. There were no immediate major complications observed for the transfacial portion of the operations. The overall cosmetic results were satisfactory. Conclusion: Plastic surgeons can use various transfacial approaches according to the location and size of skull base tumors to secure a sufficient field of view for neurosurgeons.

• Journal of Korean Neurosurgical Society
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• v.41 no.5
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• pp.347-351
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• 2007

The authors present a new technique for surgery of cholesterol granuloma [CG] at the petrous apex. An epidural middle fossa approach is used to expose and remove the cyst, with silicon tube drainage into the sphenoid sinus via the anterolateral cavernous sinus triangle between the first and second divisions of the trigeminal nerve. This novel method is less invasive skull base approach to the petrous apex and very effective for minimizing recurrence of CGs within the petrous apex.

• Archives of Plastic Surgery
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• v.32 no.2
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• pp.175-182
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• 2005

Skull base tumors have been determined inoperable because it is difficult to accurately diagnose the extent of the involvement and to approach and excise the tumor safely. However, recently, the advent of sophisticated diagnostic tools such as computed tomography and magnetic resonance imaging as well as the craniofacial and neurosurgical advanced techniques enabled an accurate determination of operative plans and safe approach for tumor excision. Resection of these tumors may sometimes result in massive and complex extirpation defects that are not amenable to local tissue closure. The purpose of this study is to analyze experiences of skull base reconstruction and to evaluate long term survival rate and complications. All cranial base reconstructions performed from July 1993 to September 2000 at Department of Plastic and Reconstructive Surgery of the Seoul National University Hospital were observed. The medical records were reviewed and analysed to assess the location of defects, reconstruction method, existence of the dural repair, history of preoperative radiotherapy and chemotherapy, complications and causes of death of the expired patients. There were 12 cases in region II, 8 cases in region I and 1 case in region III according to the Irish classification of skull base. Cranioplasty was performed in 4 patients with a bone graft and microvascular free tissue transfer was selected in 17 patients to reconstruct the cranial base and/or mid-facial defects. Among them, 11 cases were reconstructed with a rectus abdominis musculocutaneous free flap, 2 with a latissimus dorsi muscluocutaneous free flap, 1 with a fibular osteocutaneous free flap, 2 with a scapular osteocutaneous free flap, and 1 with a forearm fasciocutaneous free flap, respectively. During over 3 years follow-up, 5 patients were expired and 8 lesions were relapsed. Infection(3 cases) and partial flap loss(2 cases) were the main complications and multiorgan failure(3 cases) by cancer metastasis and sepsis(2 cases) were causes of death. Statistically 4-years survival rate was 68%. A large complex defects were successfully reconstructed by one-stage operation and, the functional results were also satisfactory with acceptable survival rates.

• Journal of The Korean Dental Society of Anesthesiology
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• v.14 no.4
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• pp.227-232
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• 2014

The indication for submandibular intubation is the requirement for intraoperative maxillomandibular fixation (MMF) in the presence of injuries that preclude nasotracheal intubation. Thus, We reported 2 cased of endotracheal intubations via submandibular approach that is applicable in patients with skull base fractures for a reliable general anesthesia. Endotracheal intubation via submandibular approach was applied during general anesthetic procedures for open reduction in three patients with Le Fort II, III or nasoorbitoethmoid (NOE) fractures. No complications due to submandibular intubation, such as infection, postoperative scarring, nerve injury, hematoma, bleeding, or orocutaneous fistula, were observed following submandibular intubation. Endotracheal intubation via submandibular approach is effective in patients with skull base fractures. In our method, the tube connector is removed in orotracheal intubation in order to avoiding the tube removal or displacement. The advantages of this method are very simple, safe, and to provide the good operation field.

• Journal of Korean Neurosurgical Society
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• v.64 no.4
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• pp.619-630
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• 2021

Objective : The skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS. Methods : A total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results. Results : The diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke's cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2-38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001). Conclusion : The use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.

• Journal of Korean Neurosurgical Society
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• v.29 no.1
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• pp.118-125
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• 2000

Objective : Trigeminal neurinomas are rare tumors that may locate in the middle fossa or posterior fossa and straddled both the middle and posterior fossa, according to their origin in the nerve complex. The aim of this study was to analyze the clinical presentation, operative approaches employed and outcome in 15 patients who were treated surgically, with special emphasis on surgical approach. Method : Between 1994 and 1998, a total of fifteen patients were histopathologically identified as neurinomas originating from the trigeminal nerve complex at the tumor clinic in the neuroscience center of the our university. Results : The surgical approach to these tumors depends on their anatomical location and tumor size. Six patients had tumors confined to the middle fossa, five patients had tumors limited to the posterior fossa, and four patients both in middle and posterior fossa components of their tumors. Nine neurinomas were removed via the conventional approach(pterional, subtemporal, suboccipital) and six were excised using skull base approach(transzygomatic subtemporal, orbitozygomatic, transpetrosal). Total resection of the tumor was possible in 10 cases. Total resection of tumor was accomplished in 83% of patients following skull base approach compared with 56% of patients following conventional approach. The surgical outcome was excellent or good in 13 cases, fair in one and, poor in one. There was no operative death. In the immediate postoperative period, aggravation of preoperative facial hypesthesia and 6th cranial nerve palsy were common. Although, these deficits were generally transient, eight patients remained with some degree of trigeminal hypesthesia, two had facial weakness, one neurotrophic keratitis, one diplopia, and one mastication difficulty. Conclusion : Surgical approach to the trigeminal neurinoma depends on the tumor location and tumor size. Skull base approach provides more complete tumor excision without increased morbidity compared to conventional approach. Surgeons have to be meticulous in order to reduce postoperative complication.

• Journal of Korean Neurosurgical Society
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• v.44 no.4
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• pp.273-276
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• 2008

Although adenoid cystic carcinoma (ACC) of the lacrimal gland is a rarely encountered orbital tumor, it invades intracranially more frequently than carcinomas of other glands in the head and neck. A 52-year-old man underwent orbital exenteration and resection of intracranially extended tumor via a fronto-orbito-zygomatic approach in combination with a transfacial approach. Histopathologically, the tumor showed perineural, vascular, and lymphatic invasion. Additionally, he received radiotherapy (60 Gy) and adjuvant systemic cisplatin and 5-fluorouracil chemotherapy due to residual tumor in the orbit and systemic metastases (lung, ribs, and spines). He was free of progression and recurrence at 6 months after treatment. The authors report a case of skull base invasion by an ACC of the lacrimal gland to remind neurosurgeons planning intervention that this disease shows a tendency to invade intracranially.