Surgical Approaches to Resection of Anterior Skull Base and Paranasal Sinuses Tumors

Abstract

IntroductionTumours involving the anterior skull base and paranasal sinuses are challenging to treat because of their relative rarity, the wide diversity of tumour types represented, and the variability in the extent of involved local structures (1).The route of spread of these tumours is determined by the complex anatomy of the craniomaxillofacial compartments. These tumours may invade laterally into the orbit and middle fossa, inferiorly into the maxillary antrum and palate, posteriorly into the nasopharynx and pterygopalatine fossa (PPF), and superiorly into the cavernous sinus and brain. Surgery remains the important modality of treatment of anterior skull base tumours. Combined craniofacial techniques for the resection of tumours of the anterior skull base were first described by Ketcham et al. (2) in 1963. Since then, anterior skull base surgery has evolved greatly, with a better understanding of the anatomy, pathology, imaging and surgical techniques. The craniofacial approach and the subcranial approach have become the standard of care for the treatment of malignant tumours involving the anterior skull base (3-6) and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient-related and tumor-related predictors of prognosis after craniofacial resection (CFR. Recent developments in technology have allowed the use of endoscopic endonasal approaches. Nevertheless, several problems still exist, relating to case selection, histology, cost, patient selection, and the experience of the surgeon. This review focuses on the open surgical resection approaches used for anterior skull base tumours, as used in our institution in the last 20 years. AnatomyThe anterior skull base is a complex anatomical compartment. It can be defined as the portion of the skull base adjacent to the anterior cranial fossa. The anterior skull base boundaries include the medial border that is formed by the cribriform plate, making up the roof of the nasal cavity, the lateral border that is formed by the orbital plates of the frontal bone that form the roof of the orbits and ethmoid air cells, and the posterior border that is formed by the planum sphenoidale and lesser wings of the sphenoid (4).The cribiform plate is traversed by multiple olfactory nerves that extend from the olfactory mucosa to the olfactory bulbs. A bony fissure between the lesser and greater sphenoid wings, the superior orbital fissure, gives passage to cranial nerves III, IV, V and VI and to the superior ophthalmic vein. Superior and laterally lies the optic canal bordered by the body of the sphenoid and by the superior and inferior roots of the lesser sphenoid wing, giving passage to the optic nerve, ophthalmic artery, and sympathetic nerves. However, both the superior orbital fi...

Tumors of the anterior skull base

“…With the adequate exposure, however, comes compromise. This includes the need for adequate reconstruction techniques that can increase the postoperative risk profile of the surgery and in some cases result in a poor cosmetic outcome from a direct facial incision [49,50]. Open surgical resection as described above via the transcranial, transfacial and combined approaches remains the gold standard in removing anterior skull-based lesions, however, endoscopic approaches have been proven to be safe, associated with acceptable outcomes.…”

“…Cranial facial approaches can be used to access large tumors that extend through the skull base into the anterior fossa, paranasal sinuses, lateral into the orbits, inferior to the palate and maxillary sinuses and posterior into the nasopharynx, clivus and infratemporal fossa [49]. By combining the above transcranial and transfacial approaches in one procedure, there is better visualization of the tumor and access can be obtained to the intracranial and extracranial compartments in one operation.…”

Choosing an anterior midline approach to skull base tumors

“…Транскраниальные доступы, использующие бикоронарный разрез и краниотомию, обеспечивают широкий обзор срединных структур, включая передние отделы основания черепа вплоть до ската, базальные отделы лобных долей, полость носа, околоносовые пазухи, медиальные отделы глазниц и предоставляют возможность одномоментного удаления срединных экстра-и интракраниальных новообразований, более комфортного и эффективного контроля кровотечения, многослойной пластики дефекта основания черепа благодаря доступности надкостницы и других местных аутотканей [10,16,19].…”

Timing of surgery and adjuvant radiation therapy for sinonasal malignancies: Effect of surgical approach

“…2 Squamous cell carcinoma (SCC) is the most common histology and carries a poor prognosis with a 5-year overall survival (OS) ranging from 30.2% to 59.5%. [7][8][9][10] Open surgery requires a facial incision and for those undergoing craniofacial resection, a craniotomy. [7][8][9][10] Open surgery requires a facial incision and for those undergoing craniofacial resection, a craniotomy.…”

“…[3][4][5][6] The traditional surgical management of advanced sinonasal tumors with skull base invasion involves open surgical resection via a craniofacial approach, as it offers excellent access and visualization for optimal complete resection. [7][8][9][10] Open surgery requires a facial incision and for those undergoing craniofacial resection, a craniotomy. Although these techniques are effective and in many cases the only appropriate approach, they are associated with significant rates of wound infections and central nervous system complications.…”