eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Craniofacial Surgery
Anterior Subfrontal Approach - Tumor Removal: Treatment
Updated: Jul 8, 2009
Treatment
Medical Therapy
Generally, chemotherapy is recommended for palliation of unresectable tumors or as part of combination therapy with irradiation (as a radiosensitizer), or as induction therapy of rapidly growing tumors, such as sinonasal undifferentiated carcinomas (SNUC) or poorly differentiated esthesioneuroblastomas or neuroendocrine carcinomas.
Combination therapy, including surgery and radiation, commonly is used because of the extent of the tumors at presentation and the impossibility of resection with true wide margins. The issue of whether preoperative external irradiation is better than postoperative external irradiation remains controversial. Most surgeons prefer to refer the patient for radiation therapy postoperatively (3-6 wk after surgery) because the cure rate offered by either regimen seems similar but increased technical difficulty and potentially greater morbidity are associated with surgery of irradiated tissues.
Surgical Therapy
Surgical planning aims to facilitate a complete resection of the tumor and an adequate reconstruction with minimal morbidity and sequelae. A surgical approach is chosen based on surgeon or patient preferences and on tumor extent, vascularity, and relationship to neurovascular structures. The extirpative phase usually begins with exposure of the tumor. An adequate exposure facilitates a complete resection, preserving normal tissue and protecting important neurovascular structures such as the brain, carotid artery, and cranial nerves.
Finally, the reconstruction should restore the separation of the cranial cavity and the upper aerodigestive tract and provide an adequate cosmetic and functional rehabilitation.
A subfrontal approach facilitates exposure and resection of the cephalic boundary of the tumor with less brain retraction than a transcranial approach (bifrontal craniotomy). It also facilitates the reconstruction of the skull base and preserves the cosmetic profile of the craniofacial region, thus meeting most of the previously mentioned surgical criteria. Endoscopic approaches are associated with less brain manipulation and no brain retraction and, in very select patients, the endoscopic approach offers the possibility of preserving olfaction. Nonetheless, not all tumors are amenable to an endoscopic resection.
Preoperative Details
Perioperative prophylactic antibiotics for 48 hours, sequential compression stockings (ie, prevention of pulmonary embolism), and a secure airway are critical components of the perioperative management of patients requiring an anterior skull base resection for tumors. In general, patients undergoing an anterior skull base resection do not require a tracheotomy. The authors prefer an airway provided by an endotracheal tube wired to a premolar or molar tooth at the beginning of the surgery. The patient usually is extubated at the end of the surgery. However, a tracheotomy is recommended if the patient requires a microvascular free flap reconstruction. Ultimately, the decision to perform a tracheotomy should take into consideration the available personnel and facilities in each institution and the experience of the surgical team.
Intraoperative Details
An anterior subfrontal approach usually involves a combination of incisions used to expose the intracranial and extracranial components of the tumor. A bicoronal incision provides access to the upper face and cranium, and the resultant scar is hidden inside the hairline (see Image 4). A lateral rhinotomy, degloving gingivobuccal incisions, or endoscopy-guided intranasal incisions (endoscopic assisted) are used to complement the cranial exposure (see Images 5-6). In selected patients, such as those presenting with tumors that invade the skin, the incisions can be performed directly at the margins of the tumor.
Markings for a bicoronal incision.
Markings for a lateral rhinotomy incision.
Intraoperative demonstration of a degloving approach.
Intraoperative navigational devices may improve the precision of incisions, craniotomies, and facial osteotomies, limiting the need for wide exposure of important anatomic structures around the tumor. During intraoperative navigation, the surgeon uses a virtual rendering of the tumor and its surrounding anatomy to guide removal, eliminating the need for conspicuous and lengthy incisions or extensive dissection of normal tissues.
The bicoronal incision divides the scalp at the level of the vertex, following a true bicoronal plane extending from the top of one auricle to the top of the other (see Image 4). When the surgical exposure should extend below the level of the glabella, the surgeon may increase the arc of rotation of the bicoronal scalp flap by extending the incision inferiorly, following the preauricular crease down to a level corresponding to the tragal cartilage. Carry the incision through the subcutaneous tissue, galea, and superficial temporal fascia laterally and through the pericranium centrally (ie, between the temporalis muscles). Then, elevate the scalp in a subpericranial plane transecting the pericranium at its junction with the deep temporal fascia, around the superior border of the temporalis muscle (ie, temporal line).
Once the supraorbital rims have been exposed, the supraorbital neurovascular bundle is dissected from the supraorbital notches (see Image 7). When a true supraorbital foramen is present, it may be opened inferiorly using a 3- to 6-mm osteotome and mallet. This maneuver allows mobilization and inferior retraction of the supraorbital neurovascular bundles and dissection of the periorbita from the superior or medial orbital walls. Thus, the bicoronal approach exposes the superior cranium and frontal area, glabella, nasal bones, temporalis muscles and temporal fossae, and the superior two thirds of the orbits.
Exposure of the superior orbital rims and glabella. The supraorbital neurovascular bundles have been freed from their canal and are being retracted to facilitate the exposure.
Plan a craniotomy according to the extent of the lesion as a bifrontal craniotomy, a transfrontal sinus craniotomy, or a craniotomy that follows the margins of the tumor (ie, when the frontal bone has been invaded) as depicted in Images 8-10. The craniotomy cuts also can be extended laterally for tumors that extend into the orbit or infratemporal fossa or inferiorly to include the orbital rims (ie, subfrontal approach as a monobloc bone graft). Alternatively, the supraorbital block is removed separately from the craniotomy (see Image 9, Images 11-12). This facilitates inclusion of the posterior orbital roofs in the supraorbital block bone graft.
Craniotomy bone graft including the orbital rims and glabella as a monobloc.
Craniotomy and supraorbital block removed as separate bone grafts.
Surgical specimen after en bloc resection of anterior cranium, ethmoids, septum, and cribriform plate (posterior view).
Neurosurgical view after bifrontal craniotomy. The osteotomies to remove the supraorbital block have been performed, but the rims are still in place.
Neurosurgical view after the supraorbital rims and glabella have been removed, enhancing access to the cribriform plate area.
A lateral rhinotomy may be used to expose the medial maxilla, providing ample exposure for the resection of tumors that extend into the ethmoid sinuses and lateral nasal wall. During the opening of the lateral rhinotomy, the medial attachment of the nasal ala is preserved to prevent subsequent ala retraction and deformity. The subcutaneous tissue and muscles deep to the ala also are preserved. This preserves the alar soft tissue support and enhances the postoperative cosmesis, preventing contraction. The perialar extension of the lateral rhinotomy is not necessary for tumors that are located in the superior sinonasal tract, such as ethmoid or nasal vault tumors.
Gingivobuccal degloving incisions can be used in combination with the bicoronal incision to avoid facial incisions. However, in general, approaching the ethmoid sinuses through a degloving approach is somewhat cumbersome because the cheek flaps are tethered by the infraorbital neurovascular bundles. All the intranasal incisions and osteotomies can be performed using endoscopic guidance, avoiding any type of facial or intraoral incision. The most common osteotomies for the en bloc resection of these tumors correspond to those used for a medial maxillectomy, combined with resection of the cribriform plate and upper septum.
Since the late 1990s, we have forgone the use of a lateral rhinotomy because most tumors amenable to this approach are also amenable to an endoscopic or endoscopic assisted approach. The cranial extent may be removed using a traditional subfrontal approach (endoscopic assisted) or a completely endoscopic endonasal approach.
During a pure endoscopic approach, the tumor is debulked and then removed in a sequential multilayer resection. The middle turbinates are removed, then bilateral maxillary windows, bilateral sphenoidotomies, and a Draf III frontal sinusotomy are completed. These steps expose the tumor origin completely and help to identify the position of the lamina papyracea and the skull base. Removal of the lamina papyracea allows the control of the ethmoidal arteries and serves as an additional margin and tumor devascularization. The tumor origin is the removed in layers sequentially: first the mucosa and tumor, then the bone and then the dura and intradural tumor. Adequacy of the resection of each layer is corroborated by frozen section analysis.
Reconstruction
After a subfrontal approach, a pericranial flap is the most common technique used to restore separation of the cranial cavity from the upper aerodigestive tract (see Images 13-14). Elevate the pericranium as a vascularized flap based on the supraorbital vessels. Ensure that the flap created can adequately cover defects that include the cribriform plate, fovea ethmoidalis, and planum sphenoidale (and occasionally the medial orbit).
The authors prefer to elevate the pericranial flap after completion of the extirpative phase of the surgery to avoid desiccation of the flap or accidental tearing or avulsion during resection of the tumor. Following repair of any dural defect, place the pericranial flap beneath the brain and supraorbital and craniotomy bone grafts. Stabilize the craniotomy and orbital bone grafts with titanium alloy adaptation plates (see Image 15). Titanium alloy plates are preferred to wires or sutures because of their superior stability. However, cost and availability may dictate the use of wires and/or sutures.
Defect after resection of the cribriform plate.
Elevation of a pericranial flap.
Fixation of the cranial bone grafts with titanium adaptation plates. Titanium mesh is used to cover bone gaps caused by the loss of bone associated with the craniotomy.
Patients who undergo an endoscopic resection are most often reconstructed with the Hadad-Bassagasteguy flap (nasoseptal flap). The entire mucoperiosteum of one side of the nasal septum is harvested pedicled on the posterior septal arteries. Two parallel incisions are made, one 1-2 cm below the olfactory sulcus and the other at the junction of the floor of the nose and the nasal septum. These incisions can be modified and performed lower and more lateral respectively to respect the oncologic margins.
The inferior incision is extended to follow the free edge of the posterior septum and to follow the posterior choanae toward the lateral nasal wall. The superior incision crosses the rostrum of the sphenoid sinus at the level of its natural ostium. If this flap is not available, a pericranial flap may be harvested with the endoscopic assistance or via bicoronal incision. It is transposed to the defect through an osteotomy at the nasion.
A temporalis muscle flap may be used to reinforce the pericranial flap to protect the eye against the pulsations of the brain in patients who require resection of the orbital roof. A temporalis muscle flap also may be used to reinforce the pericranial flap in patients who require an orbital exenteration.
Free microvascular flaps are reserved for patients in whom the dura mater and/or brain or facial skin has been sacrificed or for patients who required extensive resections including the infratemporal fossa, which result in a large dead space. The most commonly used free microvascular flaps are the rectus abdominis muscle and radial forearm fasciocutaneous flaps.
In patients requiring resection of craniofacial bones (eg, frontal, nasal, facial) that may result in a cosmetic defect, repair the defect with autogenous bone, which can be harvested from the inner table of the craniotomy flap. If the bone defect is extensive or if cranial bone grafts are inadequate, the defect can be bridged with titanium mesh (see Image 16).
Reconstruction of the glabellar area using titanium mesh.
Postoperative Details
Transfer the patient to a neurosurgical intensive care unit (NICU) for continuous cardiac, respiratory, and neurologic monitoring. Stay at the NICU varies but usually extends for 48 hours.
Patients undergo a CT scan with contrast within 24 hours of surgery to detect intracranial complications, such as hematoma, tension pneumocephalus, or brain contusion. Other monitoring is discussed in Complications.
Follow-up
For oncologic follow-up care, the authors advise the patient to return to the outpatient office for clinical examination every 4-6 weeks for the first year, every 6-12 weeks for the second year, every 12-18 weeks for the third year, every 6 months for the fourth and fifth years, and yearly thereafter. Patients may also require debridement of intra nasal crusting that forms until the nasal epithelium regenerates. Imaging of the skull base and brain is an integral part of follow-up care for areas not amenable to clinical examination. The authors prefer to use MRI 3, 6, 12, and 18 months after the surgery and then yearly. Yearly chest radiographs also are advised. This follow-up regimen is adjusted to the nature and aggressiveness of the tumor, use of adjunctive radiation and/or chemotherapy, and patient characteristics such as compliance, reliability, and distance of residence from the hospital/office.
Complications
Wound
Scalp necrosis
Necrosis of the scalp flap is rare. Patients who have been irradiated preoperatively and who also undergo a galeal flap or galeopericranial flap procedure are at risk for this complication because elevation of the flap superficial to the galea compromises the blood supply to the remaining scalp. Prolonged use of hemostatic clamps at the scalp (eg, Raney clamps) also can result in necrosis. Debridement and reconstruction using posteriorly based scalp flaps often are required to close the resultant defect.
Wound infection
Infection of the bone and/or soft tissue is most commonly the result of faulty technique (with inadequate separation of the cranial or orbital bone grafts from the sinonasal tract) or a noncompliant patient. Necrosis of the scalp exposing the bone grafts, although rare, also can lead to a wound infection. Correction of the primary problem (eg, communication with the sinonasal tract, loss of flap), debridement (usually requiring the removal of the bone flaps), and prolonged antibiotics for osteomyelitis (45 d, guided by culture and sensitivities) are the treatments of choice.
Postoperative bleeding
Postoperative bleeding is usually self-limited or easy to control with the use of topical vasoconstrictors and/or packing with hemostatic materials or self-expanding sponges. Significant postoperative bleeding most commonly arises from a branch of the internal maxillary or anterior ethmoidal arteries. If easily identifiable, the vessel may be clipped under endoscopic assistance. Angiography with embolization is reserved for patients in whom the bleeding site is not readily apparent, such as patients who underwent a reconstruction using a microvascular free flap.
Postoperative bleeding from branches of the internal carotid artery (eg, ethmoidal, ophthalmic) is not usually amenable to embolization and may lead to intracranial hematomas, requiring surgical exploration.
Intracranial
Tension pneumocephalus
Intracranial air under pressure acts as a space-occupying lesion that compresses the brain parenchyma, causing neurologic deficits, such as lethargy, disorientation, slow mentation, or hemiparesis. A CT scan without contrast can help confirm the diagnosis (see Image 17). Initial treatment consists of aspiration of the air using a needle placed through a burr hole or osteotomy gap. In rapidly deteriorating or unstable patients, this measure can be lifesaving. Recurrent tension pneumocephalus is rare and is usually associated with inadequate cranionasal separation (ie, loss of the reconstructive flap) or a noncompliant patient who blows the nose. Recurrent pneumocephalus may require bypassing the airway (ie, tracheotomy, intubation) and/or surgical exploration to close any communication between the cranial cavity and the sinonasal tract.
CT scan axial view demonstrating a tension pneumocephalus. In the author's experience, this is the most common major complication after an anterior craniofacial resection.
Cerebrospinal fluid leak
Postoperative cerebrospinal fluid (CSF) leaks after traditional techniques are initially managed conservatively with bed rest, stool softeners, and a lumbar drain (50 mL q6-8h). Persistence of the leak beyond 1 week indicates need for surgical repair. However, surgical exploration may be indicated as an initial therapy if loss of the reconstructive flap or dehiscence of the dural repair is suspected.
Patients with postoperative CSF leaks after endoscopic approaches are taken back to the operating room immediately. Usually, the leak is limited to a small area in which the graft failed to take or was displaced by the pulsation of the brain.
Meningitis/abscess
Meningitis, like pneumocephalus, CSF leak, and osteomyelitis, is usually the result of inadequate separation of the cranial cavity from the sinonasal tract. However, meningitis can occur in the absence of a CSF leak, and its presentation may be atypical due to use of perioperative prophylactic antibiotics. A CT scan followed by a lumbar puncture can help confirm the diagnosis. The treatment of choice is intravenous antibiotic therapy with adequate CSF penetration. Persistent communication between the cranial cavity and the upper aerodigestive tract should be closed as soon as the patient is stable enough to tolerate the surgery.
Management of intracranial/cerebral abscesses is similar to treatment of meningitis. However, abscesses usually require drainage. Epidural abscesses usually require the removal of contaminated free bone grafts. This creates a deformity that can be corrected in a secondary surgery.
Cerebral edema/contusion
This complication usually occurs as a result of overenthusiastic brain retraction (see Image 18). Systemic corticosteroids, correction of hemodynamic problems, and electrolyte/fluid balance are essential to avoid further brain injury brought by the parenchymal swelling and subsequent increased intracranial pressure. Consider medical prophylaxis for seizures in the presence of a contusion of the brain parenchyma or if brain had to be removed as part of the oncologic surgery.
Orbital
Epiphora
A dacryocystorhinostomy (DCR) diminishes the incidence of epiphora after resection of the medial maxilla. DCR is performed by marsupializing the lacrimal sac upon its transection from the lacrimal duct. Occasionally, a DCR closes, requiring lacrimal stenting (eg, Crawford tubes) or even a revision DCR. Another cause of epiphora is failure to restore the medial canthus, causing laxity and failure of the lacrimal pump mechanism. Similarly, a lax lower eyelid caused by paralysis of the facial nerve or failure to fix the lateral canthus may lead to lagophthalmos and epiphora. Tarsal strip surgery and lateral canthopexy are indicated to resolve this problem.
Extraocular muscle limitation
Diplopia caused by dissection of the trochlea, postoperative edema, or removal of the orbital walls occurs in most patients but is self-limited, lasting fewer than 4 weeks. However, physicians should consider other causes for diplopia.
Reconstructive grafts over the orbital walls may entrap the medial, lateral, or inferior rectus muscles, resulting in restriction of the range of motion and leading to diplopia. Intraorbital dissection, such as that required when the periorbita is resected, or surgery of the cavernous sinus may injure the motor innervation of these muscles. A forced duction test helps to differentiate these problems.
Enophthalmos
Enophthalmos is the result of expansion of the volume of the orbital cavity due to resection of the orbital walls and is more pronounced if the periorbita is injured or resected. Preventing this complication by reconstructing the orbital walls with autogenous bone or titanium mesh (ie, rigid reconstruction), which is depicted in Image 18, is best.
CT scan axial view of a frontal lobe contusion after an anterior craniofacial resection. A subfrontal approach was not used, resulting in the need for brain retraction with the subsequent trauma.
Blindness
Unexpected blindness after an anterior craniofacial resection is the result of injury to the optic nerve or its blood supply. High-dose steroids and immediate optic nerve decompression are indicated.
Endocrine/Electrolyte Abnormalities
Endocrine abnormalities
Hyponatremia (serum sodium <130 mg/dL) can be produced by excessive fluid replacement or by the syndrome of inappropriate antidiuretic hormone (SIADH), which usually is caused by cerebral edema. SIADH is usually self-limited and may be treated by fluid restriction. Neurologic symptoms, such as disorientation, irritability, changes in consciousness or mentation, and seizures, require administration of hypertonic (3%) sodium chloride solution.
Conversely, ischemia or traction injury to the hypothalamus may lead to diabetes insipidus (DI), which is caused by insufficient production of the antidiuretic hormone. DI is manifested by the inability to concentrate urine, leading to the voiding of large volumes, hypernatremia, and hypovolemia. Serum sodium greater than 145 mg/dL and a urine specific gravity greater than 1.020 mg/dL confirm the diagnosis. Aggressive fluid replacement and aqueous vasopressin (2.5 U q4h) is the initial treatment.
Closely monitor patients with diabetes mellitus, especially if corticosteroids are being administered. Regular insulin, administered following a sliding scale, is commonly required to control the glycemia.
Electrolyte deficits
Other electrolyte disorders, such as hypocalcemia, hypomagnesemia, and hypophosphatemia, may be encountered in patients who require extensive skull base surgery. Replacement of these electrolytes should be immediate, using calcium gluconate 10% (10 mL at <1 mL/min), phosphate solution (10-15 mmol of sodium phosphate in 250 mL of 5% dextrose solution over 6 h), and magnesium sulphate (2-4 g in 100 mL of isotonic sodium chloride solution over 30 min). Because of the length of some cranial base surgeries, these electrolyte deficiencies may develop intraoperatively or during the immediate postoperative period. This is especially true in patients requiring transfusion of more than 5 units of PRBC.
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Further Reading
Keywords
tumor removal, anterior subfrontal approach, tumor, anterior craniofacial resection, anterior cranial base surgery, anterior skull base surgery, tumor resection, anterior craniofacial resection, endoscopic anterior skull base surgery
