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Combined middle cranial fossa and preauricular approach to the temporomandibular joint: Report of a case
J Oral Maxillofac Surg 55:&w -852, 1997
Combined Middle Cranial Fossa and Preauricular Approach to the Temporomandibular Joint: Report of a Case KASEY K. LI, DDS, MD,* FEODOR UNG, AB,t MICHAEL J. McKENNA, AND DAVID A. KEITH, BDS, DMD, FDSRCSS
MD,*
Although standard approaches to the temperomandibular joint (TMJ) do not provide wide exposure of the glenoid fossa, routine reconstructive surgery of the joint can usually be performed without much difficulty.
However, wide exposure of the glenoid fossa may be advantageous when it is severely affected by disease processes such as erosion due to an alloplastic implant,‘,* perforation from condylar trauma,3’4 severe ankylosis, or a tumor. The purpose of this case report is to describe the use of combined middle fossa’ and preauricular approach for the management of a recur-
rent giant cell tumor involving the glenoid fossa. Case Report A 36-year-old woman underwent atticotomy and canaloplasty for giant cell tumor of the left temporal bone in 1990. In 1994, a computerized scan showed a lytic lesion consistent with recurrence involving the glenoid fossa (Fig 1). Resection of the recurrent tumor was planned. The operation began with a standard preauricular incision extending superiorly toward the superior temporal line. After exposure of the squamous portion of the temporal bone, a 2- X 2-cm craniotomy was made just above the glenoid fossa (Fig 2). Care was taken to prevent injury to the dura during bone drilling and elevation of the calvarium. After removal of the calvarium, the dura was elevated from the floor of the middle cranial fossa directly above the glenoid fossa.
FIGURE 1. fossa (arrow).
Examination showed
of Oral and Maxillofacial
CT scan showing
lesion
involving
the glenoid
of the dura and the floor of the cranial fossa
no evidence
of tumor
involvement.
The joint space was approached inferiorly. The deep temporal fascia was divided at the level of the zygomatic arch and
the joint
was
entered
by
incising
the
capsule.
After
exposing the glenoid fossa both superiorly and inferiorly, cn bloc resection of the tumor was performed while protecting the dura and the disc with retractors. The cranial bone was then divided using a reciprocating saw and the glenoid fossa was reconstructed using the inner table (Fig 3), and the outer table was used to reconstruct the craniotomy defect. The postoperative course was uneventful. Maxillomandibular fixation was not used, and the patient was discharged on the third postoperative day. At l-year follow-up, mouth opening was 36 mm, left lateral excursion was 8 mm, and right lateral excursion was 6 mm. The occlusion had remained stable.
Received from the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, and the Department or Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA. * Former resident. t Medical student. $ Attending. $ Attending. Address correspondence to Dr Li: Facial Reconstructive Surgery, 750 Welch Rd, Suite 317, Palo Alto, CA 94304. No reprints available. 0 1997 American Association 027%2391/97/5508-0012$3.00/0
Coronal
Discussion Middle fossa craniotomy is a reliable approach for the management of internal auditory canal pathology.’
Surgeons
851
852
MIDDLE
The morbidity of this procedure has been low and, when it occurs, it is associated with opening of the dura, the inner ear, and excessive retraction of the brain.6 It is important to note that when this approach is used to gain access of the superior aspect of the glenoid fossa, minimal elevation of the dura or brain retraction is required. In addition, the dura need not be disrupted. Therefore, the risk of this procedure is similar to a full-thickness cranial bone harvest. Although an intracranial approach to the TMJ has been reported previously,7-9 it was used for the management of a displaced condyle into the middle fossa after facial trauma. We believe the combined approach is also indicated in cases when the glenoid fossa is significantly involved by pathologic processes. The patient presented in this report had a recurrent giant cell tumor located in the skull base closely abutting the temporal lobe. Although regarded as a benign process, the tumor may be locally aggressive, and complete surgical excision is recommended whenever possible.” Therefore, the combined approach was used to ensure visualization for complete removal of the lesion. The combined approach provides wide access to the TMJ and allows excellent visualization and avoidance of vital structures such as the middle meningeal artery and posterior cerebral artery. Exposure of the medial pole of the TMJ is especially superior to the preauricular approach alone. The procedure also en-
CRANIAL
FOSSA
FIGURE 3. Coronal CT scan showing using split cranial bone graft (arrow).
APPROACH
glenoid
TO
THE
TMJ
fossa reconstruction
ables total reconstruction of the glenoid fossa using autogenous cranial bone without a secondary harvesting procedure. The fully constructed glenoid fossa provides a vertical stop for the condyle, avoiding the need for maxillomandibular fixation and allowing early physical therapy to prevent TMJ dysfunction. References
FIGURE 2. Schematic fossa craniotomy (arrow).
drawing
showing
the location
of middle
1. Berarducci JP, Thompson DA, Scheffer RB: Perforation into middle cranial fossa as a sequel to use of a Proplast-Teflon implant for temporomandibular joint reconstruction. .I Oral Maxillofac Surg 48:496, 1990 2. Smith RM, Goldwasser MS, Sabol SR: Erosion of a TeflonProplast implant into the middle cranial fossa. J Oral Maxillofat Surg 51:1268, 1993 3. Baldwin AJ: Superior dislocation of the intact mandibular into the middle cranial fossa. J Oral Maxillofac Surg 48:623, 1990 4. Engevall S, Fischer K: Dislocation of the mandibular condyle into the middle cranial fossa: Review of the literature and report of a case. J Oral Maxillofac Surg 50:524, 1992 5. House WF: Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa. Laryngoscope 71:1363, 1961 6. Shelton C, Brackmann DE, House WF, et al: Middle fossa acoustic tumor surgery: Results in 106 cases. Laryngoscope 99:405, 1989 7. Sandler NA, Ozaki WH, Ochs MW, Marion DW: Intracranial reduction of an intact mandibular condyle displaced into the middle cranial fossa. .I Oral Maxillofac Surg 54:506, 1996 8. Doane HF: Dislocation of the right mandibular condyle into the middle cranial fossa. J Oral Surg 21:510, 1963 9. Stoltman HF: Fracture dislocation of the temporomandibular joint: Report of two cases. .I Neurosurg 22:100, 1965 10. Hirsch1 S, Katz A: Giant cell reparative granuloma in the temporal bone. Arch Otolaryngol 100:380, 1974
Combined Middle Cranial Fossa and Preauricular Approach to the Temporomandibular Joint: Report of a Case KASEY K. LI, DDS, MD,* FEODOR UNG, AB,t MICHAEL J. McKENNA, AND DAVID A. KEITH, BDS, DMD, FDSRCSS
MD,*
Although standard approaches to the temperomandibular joint (TMJ) do not provide wide exposure of the glenoid fossa, routine reconstructive surgery of the joint can usually be performed without much difficulty.
However, wide exposure of the glenoid fossa may be advantageous when it is severely affected by disease processes such as erosion due to an alloplastic implant,‘,* perforation from condylar trauma,3’4 severe ankylosis, or a tumor. The purpose of this case report is to describe the use of combined middle fossa’ and preauricular approach for the management of a recur-
rent giant cell tumor involving the glenoid fossa. Case Report A 36-year-old woman underwent atticotomy and canaloplasty for giant cell tumor of the left temporal bone in 1990. In 1994, a computerized scan showed a lytic lesion consistent with recurrence involving the glenoid fossa (Fig 1). Resection of the recurrent tumor was planned. The operation began with a standard preauricular incision extending superiorly toward the superior temporal line. After exposure of the squamous portion of the temporal bone, a 2- X 2-cm craniotomy was made just above the glenoid fossa (Fig 2). Care was taken to prevent injury to the dura during bone drilling and elevation of the calvarium. After removal of the calvarium, the dura was elevated from the floor of the middle cranial fossa directly above the glenoid fossa.
FIGURE 1. fossa (arrow).
Examination showed
of Oral and Maxillofacial
CT scan showing
lesion
involving
the glenoid
of the dura and the floor of the cranial fossa
no evidence
of tumor
involvement.
The joint space was approached inferiorly. The deep temporal fascia was divided at the level of the zygomatic arch and
the joint
was
entered
by
incising
the
capsule.
After
exposing the glenoid fossa both superiorly and inferiorly, cn bloc resection of the tumor was performed while protecting the dura and the disc with retractors. The cranial bone was then divided using a reciprocating saw and the glenoid fossa was reconstructed using the inner table (Fig 3), and the outer table was used to reconstruct the craniotomy defect. The postoperative course was uneventful. Maxillomandibular fixation was not used, and the patient was discharged on the third postoperative day. At l-year follow-up, mouth opening was 36 mm, left lateral excursion was 8 mm, and right lateral excursion was 6 mm. The occlusion had remained stable.
Received from the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, and the Department or Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA. * Former resident. t Medical student. $ Attending. $ Attending. Address correspondence to Dr Li: Facial Reconstructive Surgery, 750 Welch Rd, Suite 317, Palo Alto, CA 94304. No reprints available. 0 1997 American Association 027%2391/97/5508-0012$3.00/0
Coronal
Discussion Middle fossa craniotomy is a reliable approach for the management of internal auditory canal pathology.’
Surgeons
851
852
MIDDLE
The morbidity of this procedure has been low and, when it occurs, it is associated with opening of the dura, the inner ear, and excessive retraction of the brain.6 It is important to note that when this approach is used to gain access of the superior aspect of the glenoid fossa, minimal elevation of the dura or brain retraction is required. In addition, the dura need not be disrupted. Therefore, the risk of this procedure is similar to a full-thickness cranial bone harvest. Although an intracranial approach to the TMJ has been reported previously,7-9 it was used for the management of a displaced condyle into the middle fossa after facial trauma. We believe the combined approach is also indicated in cases when the glenoid fossa is significantly involved by pathologic processes. The patient presented in this report had a recurrent giant cell tumor located in the skull base closely abutting the temporal lobe. Although regarded as a benign process, the tumor may be locally aggressive, and complete surgical excision is recommended whenever possible.” Therefore, the combined approach was used to ensure visualization for complete removal of the lesion. The combined approach provides wide access to the TMJ and allows excellent visualization and avoidance of vital structures such as the middle meningeal artery and posterior cerebral artery. Exposure of the medial pole of the TMJ is especially superior to the preauricular approach alone. The procedure also en-
CRANIAL
FOSSA
FIGURE 3. Coronal CT scan showing using split cranial bone graft (arrow).
APPROACH
glenoid
TO
THE
TMJ
fossa reconstruction
ables total reconstruction of the glenoid fossa using autogenous cranial bone without a secondary harvesting procedure. The fully constructed glenoid fossa provides a vertical stop for the condyle, avoiding the need for maxillomandibular fixation and allowing early physical therapy to prevent TMJ dysfunction. References
FIGURE 2. Schematic fossa craniotomy (arrow).
drawing
showing
the location
of middle
1. Berarducci JP, Thompson DA, Scheffer RB: Perforation into middle cranial fossa as a sequel to use of a Proplast-Teflon implant for temporomandibular joint reconstruction. .I Oral Maxillofac Surg 48:496, 1990 2. Smith RM, Goldwasser MS, Sabol SR: Erosion of a TeflonProplast implant into the middle cranial fossa. J Oral Maxillofat Surg 51:1268, 1993 3. Baldwin AJ: Superior dislocation of the intact mandibular into the middle cranial fossa. J Oral Maxillofac Surg 48:623, 1990 4. Engevall S, Fischer K: Dislocation of the mandibular condyle into the middle cranial fossa: Review of the literature and report of a case. J Oral Maxillofac Surg 50:524, 1992 5. House WF: Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa. Laryngoscope 71:1363, 1961 6. Shelton C, Brackmann DE, House WF, et al: Middle fossa acoustic tumor surgery: Results in 106 cases. Laryngoscope 99:405, 1989 7. Sandler NA, Ozaki WH, Ochs MW, Marion DW: Intracranial reduction of an intact mandibular condyle displaced into the middle cranial fossa. .I Oral Maxillofac Surg 54:506, 1996 8. Doane HF: Dislocation of the right mandibular condyle into the middle cranial fossa. J Oral Surg 21:510, 1963 9. Stoltman HF: Fracture dislocation of the temporomandibular joint: Report of two cases. .I Neurosurg 22:100, 1965 10. Hirsch1 S, Katz A: Giant cell reparative granuloma in the temporal bone. Arch Otolaryngol 100:380, 1974