Transnasal illumination to guide the craniofacial resection of anterior skull base neoplasms

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Transnasal Illumination To Guide the Craniofacial Resection of Anterior Skull Base Neoplasms Alan R . Cohen, M.D., and Paul B . Tartell, M .D. Departments of Neurosurgery (A .R.C .) and Otolaryngology (P .B .T .), New England Medical Center, Boston, Massachusetts

Cohen AR, Tartell Ell . Transnasal Illumination To Guide the Craniofacial Resection of Anterior Skull Base Neoplasms . Surg Neurol 1993 ;40 :420-3 . The authors describe use of a flexible fiberoptic light source to guide the craniofacial resection of anterior skull base neoplasms . The light is introduced transnasally and serves to outline the perimeter of the tumor, helping to direct the safe placement of intracranial osteotomies and en bloc tumor removal . Brain tumor ; Craniofactal surgery ; Endoscope, light ; Skull base KEY WORDS :

The surgical management of anterior cranial base neoplasms has continued to evolve . Craniofacial techniques initially designed for cosmetic reconstructive surgery have been extended to facilitate removal of tumors at the base of the skull . Collaboration between neurological surgeons and head and neck surgeons has led to the development of a combined transcranial and transfacial approach . This combined craniofacial approach permits radical en bloc resection of aggressive skull base neoplasms . Despite the explosion of interest in skull base surgery, many useful technical tricks have received little attention in the neurosurgical literature . We report a simple technique in which a fiberoptic light introduced transnasally is used to direct skull base osteotomies made transcranially . Transillumination of the skull base enables the operator to circumscribe extensive tumors for en bloc resection and ensures protection of critical neurovascular structures .

Illustrative Case This 64-year-old woman presented with a 3-month history of nasal obstruction and epistaxis . Address reprint requests to.' Alan R . Cohen, M .D ., Department of Neurosurgery, New England Medical Center, 750 Washington Street, Boston, MA 02111 . Received February 10, 1993 ; accepted March 15, 1993 . V 1993

by Elsevier Science Publishing Co., Inc .

Examination

Examination was remarkable for a pink mass visible in the right nostril associated with right unilateral anosmia and proptosis of the right globe . Cranial computed tomography (CT) and magnetic resonance imaging (MRI) scans showed a large enhancing mass filling the right nasal cavity as well as the frontal, ethmoid, maxillary, and sphenoid sinuses (Figure 1 A and 1 B) . Inferiorly, the mass extended to the hard palate . Superiorly there was partial erosion of the cribriform plate, and laterally there was destruction of medial wall of the right orbit with displacement of the right medial rectus muscle . Biopsy of the right nasal mass was performed at another institution and revealed esthesioneuroblastoma . The patient was referred for en bloc tumor resection .

Operation

The patient was positioned supine and placed under general anesthesia via oral endotracheal intubation . A lumbar subarachnoid catheter was introduced for intraoperative and postoperative spinal drainage . A bifrontal craniotomy was fashioned and the frontal lobes were elevated from the anterior cranial base extradurally back to the planum sphenoidale . A soft red vascular tumor was found to have eroded the cribriform plate of the ethmoid bone as well as the frontal bone at the medial aspect of the orbital roof . The tumor did not invade the dura . After the tumor was exposed intracranially, a right subtotal rhinotomy and nasal swing was performed allowing the tumor to be identified in the nasal cavity and paranasal sinuses (Figure 2) . The lamina papyracea had been eroded, and the tumor extended into the medial aspect of the right orbit . Anterior and posterior ethmoidal arteries were ligated and divided . The lacrimal apparatus was cannulated with silastic stents . Osteotomies were made in the nasal, maxillary, and ethmoid bones in preparation for en bloc resection of the tumor . 0090-3019/93/$6.00



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ter of the tumor by the head and neck surgeon, who had a clear view both of the tumor itself and the bony grooves adjacent to the carotid artery and optic nerve . A rigid zero degree straight-forward nasal telescope (Karl Storz, Tuttlingen, Germany) was used intermittently and helped to define the posterior aspect of the exposure from below . The intracranial osteotomies were made by the neurosurgeon, who used osteotomes and a highspeed drill (Anspach) and followed the shining path created by the light introduced from below (Figure 3) . An en bloc resection of the tumor was carried out . The specimen included sphenoid, ethmoid, and frontal bones at the skull base, as well as a sphenoidectomy, ethmoidectomy, medial maxillectomy and frontal sinus exenteraB Figure 1 . (A) Preoperative sagittal T -weighted MRI scan following the

Figure 2 . (A) A lateral rhinotomy is performed using a Weber-Ferguson incision . (B) A flexible surgical light is introduced to transnasally .

administration of intravenous gadolinium DTPA . A large enhancing mass fills the nasal cavity and paranasal sinuses, extending from the skull base rostrally to the hard palate caudally . (B) Preoperative CT scan demonstrating tumor in the right nasal cavity as well as the sphenoid and maxillary sinuses. (C) Postoperative CT scan following en bloc resection of the tumor .

Transnasal Fiberoptic Illumination The final osteotomies were made intracranially at the anterior skull base . To guide precise placement of the intracranial osteotomies, we introduced a flexible fiberoptic light through the nasal cavity to transilluminate the skull base- The light was directed about the perime-

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Figure 3 . Intrananial osteatomies are guided by transillumination of the skull base from below.

tion . A standard craniofacial closure was performed, which included a vascularized pericranial graft to reconstitute the floor of the anterior cranial fossa. Postoperative Course The patient had an uneventful postoperative course . Pathological examination of the operative specimen showed mucosal melanoma . Follow-up CT confirmed gross total tumor resection (Figure 1 C) . Discussion

Neoplasms of the anterior cranial base have always presented surgeons with a difficult challenge . They frequently extend beyond the geographic horizon of the neurosurgeon working intracranially as well as the head and neck surgeon working transfacially . For this reason it was felt previously that radical resection of these neoplasms was not possible. In 1948, Martin [121 of Memorial Hospital in New York wrote that the surgical excision of cancer of the paranasa sinuses was hazardous, and complete removal "practically impossible since this would involve sectioning portions of the base of the skull ." In 1963, Frazell and Lewis [81, also from Memorial Hospital, reported on a large series of patients with paranasal sinus cancer and wrote that "in most clinics, surgery for cancer of the sinuses has been restricted to preoperative or postoperative drainage, sequestrectomy, or antrostomy for the application of radium applicators, . . . the entire crib-

Cohen and Tartell

friform plate can rarely be resected without grave cerebral complications ." In recent years, a combined craniofacial approach has been used with increased frequency to approach tumors located at the anterior half of the skull base . This combined approach has evolved from a cooperative effort between neurosurgeons and head and neck surgeons . Dandy [3,4] was one of the first to cross the boundary created by the skull base . He popularized a transcranial approach to tumors of the orbit in 1941 and felt this was superior to the existing orbital approaches, especially for tumors situated posteriorly . Cooperation between neurosurgeons and ophthalmologists had already led to combined approaches to the orbit for optic glioma [7, 13,14] . This usually involved an intracranial exposure and sectioning of the optic nerve, sometimes with unroofing of the orbit . An enucleation of the eye was performed at a separate sitting . Smith et al [181 reported the first combined craniofacial resection of a paranasal sinus cancer in 1954 . A neurosurgeon and general surgeon cooperated to perform an en block resection of the anterior cranial base, paranasal sinuses, and orbit in a 58-year-old man with an epidermoid carcinoma of the frontal and ethmoid sinuses. Following a stormy course, the patient recovered and returned to work . In spite of this success, the procedure gained little acceptance at the time. Further refinements were introduced during the next decade, with emphasis on radical resection of the cribriform plate of the ethmoid bone [10,11,221 . This led to an improvement in disease-free survival (61% at 3 years), but complications remained a major concern, with 27 infections reported in a series of 31 patients [10] . Surgeons continued to modify the combined craniofacial approach . In 1969, Terz et al [20] used it to remove cancers that extended into the pterygoid fossa . Although their initial results were poor, they recognized the potential value of this procedure in carefully selected cases . Derome et al [5,6] popularized the "transbasal approach" in the early 1970s and used this to resect a variety of skull base neoplasms . Their operation was an adaptation of the craniofacial approach to orbital hypertelorism developed by Tessier in 1960 [21] . Schramm et al [15,16] improved the skull base reconstruction by using a vascularized pericranial galeal flap based upon the supraorbital arteries, thereby reducing operative morbidity and mortality . Johns et al [91 also noted superior results using vascularized pericranium to protect the dural closure . Shah and Galicich [ 17] reported successful resection of anterior skull base neoplasms with a twoteam approach, emphasizing a formal bifrontal craniotomy to maximize exposure . The combined craniofacial approach has come to be the procedure of choice for



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en bloc removal of aggressive anterior skull base tumors {1,2,19] . Transnasal illumination of the base of the skull is a simple but useful modification of the combined craniofacial approach . We have found it effective in overcoming the surgical barrier formed by the base of the skull . Transillumination enables the surgical team working from below to guide the surgical team working from above . The light path directed by the head and neck surgeon guides the neurosurgeon's placement of osteotomies about the perimeter of the tumor, facilitating en bloc resection . The head and neck surgeon can see normal as well as pathological anatomy and is able to transmit information to the neurosurgeon about the location of the carotid artery, optic nerve, and superior orbital fissure . This information is particularly valuable when osteotomies must extend laterally and posteriorly to circumscribe the tumor . Small endoscopes are helpful in defining difficult tumor margins, especially at the posterior limit of the exposure . Transillumination of the skull base is a simple technique that takes advantage of surgical teamwork and helps facilitate the en bloc resection of skull base neoplasms .

References 1 . Arbit 11, Shahj : Combined craniofacial resection for anterior skull base tumors, in Rengachary SS, Wilkins RH (eds) : Neurosurgical Operative Atlas . Baltimore : Williams and Wilkins, 1991 :221-31 . 2 . Arita N . Mori S, Hayakawa T, et al : Surgical treatment of tumors in the anterior skull base using the transbasal approach . Neurosurgery 1989 ;24 :379-84 . 3 . Dandy WE : Orbital Tumors-Results Following the Transcranial Operative Attack . New York : Oskar Priest Publications, 1941 :1-168 . 4 . Dandy WE : Surgery of the Brain. Hagerstown : WE Prior Co, 1945 :650-67 . 5 . Derome P : The transbasal approach to rumors invading the base of the skull, in Schmidek HH, Sweet WH (eds) : Operative Neurosurgical Techniques . Indications, Methods, and Results . Philadelphia : WB Saunders, 1988 :619-33 .

6 . Derome P, Akerman M, Anquez L, et al : Les tumeurs sphenoethmoidales, Possibilities d'exerese et reparation chirurgicales . Rapport de la Societe de Neurochirurgie de Lange Francaise . Neurochirurgie 1972 ;15(suppl 1) :l . 7 . Dort N, Meighan S : Intracranial resection of the optic nerve in glioma retinae . Am J Ophthalmology 1933 ;16 :59 . 8 . Frazell EL, Lewis JS : Cancer of the nasal cavity and accessory sinuses . A report of the management of 416 patients . Cancer 1963 ;16 :1293-301 . 9 . Johns ME, Winn HR, McLean WC, et al : Pericranial flap for the closure of defects of craniofacial resections . Laryngoscope 1981 ;91 :952-9 . 10 . Ketcham AS, Hoye RC . Van Buren JM, et al : Complications of intracranial facial resection for rumors of the paranasal sinuses . Am J Surg 1966 ; 112 :591-6 . It . Ketcham AS, Wilkins RH, Van Buren JM, et al: A combined intracranial facial approach to the paranasal sinuses . Am J Surg 1963 ;166:698-703 . 12 . Martin H : Cancer of the head and neck . JAMA 1948 ;137 : 1306-15 . 13 . Rand CW : Glioma of the retina : report of a case with intracranial extension . Arch Ophthalmol 1934 ;11 :982-94 . 14 . Ray BS, McLean JM: Combined intracranial and orbital operation for rerinohlastoma . Arch Ophthalmol 1943 ;30 :437-45 . 15 . Schramm VL Jr : Anterior craniofacial resection, in Sekhar LN, Schramm VLJr : Tumors of the Cranial Base . Diagnosis and Trearmenr. Mount Kisco : Futura Publishing Company, 198'265-78 . 16 . Schramm VL Jr, Myers EN, Maroon JC : Anterior skull base surgery for benign and malignant disease . Laryngoscope 1979 ;89 :1077-91 . 17 . Shah JP, Galicich JH : Craniofacial resection for malignant tumors of the ethmoid and anterior skull base . Arch Otolaryngol 1977 ;103 :514-7 . 18 . Smith RR, Klopp CT, Williams JM : Surgical treatment of cancer of the frontal sinus and adjacent areas . Cancer 1954 ;7 :991-4 . 19 . Sundaresan N, Sachdev V, Krol G : Craniofacial resection for anterior skull base tumors, in Schmidek HH, Sweet WH (eds) . Operative Neurosurgical Techniques . Indications, Methods and Results . Philadelphia: WB Saunders, 1988 :609-18 . 20 . Terz JJ, Alksne JF, Lawrence W Jr : Craniofacial resection for tumors invading the pterygoid fossa . Am J Surg 1969 ;118: 732-40 . 21 . Tesier P : The definitive treatment of orbital hypertelorism by craniofacial or by entracranial osteotumies. Scand J Plast Reconstruc Surg 1973 ;7 :39-58. 22 . Van Buren JM, Ommaya AK, Ketcham AS : Ten years' experience with radical combined craniofacial resection of malignant rumors of the paranasal sinuses . J Neurosurg 1968 ;28 :341-50 .