Anterior Subfrontal Approach - Tumor Removal Workup

  • Author: Ricardo L Carrau, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Feb 22, 2012
 

Laboratory Studies

Laboratory studies are recommended based on clinical history and are only necessary to exclude endocrine, electrolyte, or coagulation disorders. Preoperative evaluation of these potential problems is critical because they can significantly affect outcome and perioperative management.

According to the extent of the tumor and/or resection, vascularity of the tumor, risk of vascular injury, and preoperative hematocrit, the patient is typed and cross-typed for 2-6 units of packed red blood cells (PRBC).

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Imaging Studies

Imaging using CT scan and/or MRI is recommended to delineate the extent of the tumor, especially in areas that are not amenable to endoscopic examination, such as the cranial cavity, orbit, other paranasal sinuses, and soft tissues of the face, pterygopalatine, and infratemporal fossa.

CT scanning is superior to MRI in defining the bony boundaries, as depicted in the image below.

CT scan coronal view demonstrating an osteosarcomaCT scan coronal view demonstrating an osteosarcoma of the ethmoid sinuses extending to the orbit and anterior cranial fossa.

Use of contrast during CT scanning can help estimate the vascularity of the tumor and demonstrates its relationship to the great vessels and other neurovascular structures such as dura, brain, and cranial nerves.

MRI usually is reserved for patients presenting with invasion of soft tissues, most importantly orbit and brain, as depicted in the images below.

MRI axial view demonstrating extensive invasion ofMRI axial view demonstrating extensive invasion of the frontal lobes by an adenocarcinoma. MRI sagittal view demonstrating invasion of the foMRI sagittal view demonstrating invasion of the fontal lobes by an osteosarcoma.

MRI does not use ionizing radiation and better defines the soft tissue interfaces, demonstrates perineural spread, and differentiates tumor from retained secretions within the paranasal sinuses. For these reasons, MRI is the preferred method to monitor areas that are not amenable to clinical examination. Despite superior soft tissue definition, MRI may not distinguish scar or reconstructive flaps from tumor. This dilemma is elucidated by performing biopsy or sequential imaging to monitor changes or growth and thus corroborate the presence or absence of tumor.

Positron emission tomography (PET) may help to identify the presence of metastatic or recurrent tumor that may escape detection by clinical examination or CT and MRI. Fusion of a PET with a CT or MR provide an anatomic and metabolic correlate which helps to clarify the presence or absence of tumor in complex areas, such as the skull base.

Angiography rarely is necessary during evaluation of patients presenting with tumors of the sinonasal tract and usually is reserved for patients presenting with vascular tumors in which embolization is being considered. Angiography is important for patients who present with sellar or parasellar lesions that approximate, enclose, or invade the internal carotid artery.

When necessary, the vascular anatomy of the affected area (ie, sphenoid sinus invasion) can be assessed by noninvasive methods such as MR angiography (MRA) or CT angiography (CTA), reserving intra-arterial angiography for those patients in whom embolization of the tumor is being considered.

Patients who may need the sacrifice of the internal carotid artery or its branches are studied preoperatively with a cerebral blood-flow test, such as the angiography-balloon occlusion–xenon-CT scan test (ABOX-CT).

Single-photon emission computed tomography (SPECT) with balloon occlusion and transcranial Doppler also provides a reasonably accurate assessment of the adequacy of the blood supply provided by the contralateral internal carotid artery to the ipsilateral cerebral hemisphere. Remember that these studies usually are performed under very controlled circumstances and do not provide information about the status of the cerebral blood flow under stress conditions such as hypotension or hypoxia. In addition, these tests cannot predict embolic phenomena.

A metastatic workup including CT scan of the chest and abdomen and a bone scan is recommended for patients presenting with tumors that metastasize hematogenously, such as sarcomas, melanomas, or adenoid cystic carcinomas.

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Diagnostic Procedures

Patients with sarcomas of the sinonasal tract that invade the dura are advised to undergo a spinal tap for cytologic analysis. These patients should undergo an MRI of the brain and spine to exclude meningeal carcinomatosis or drop metastasis.

Transnasal endoscopic biopsy is the method of choice for sampling tumors of the paranasal sinuses. The authors prefer to defer biopsy until the imaging workup is completed; this avoids interference from surgical artifact caused by the biopsy or by nasal packing, which is often required after sampling a vascular tumor. A punch biopsy often can be performed in the office. However, vascular tumors that require multiple or extensive biopsies (eg, lymphomas, sarcomas, neuroendocrine tumors) are better obtained in the operating room.

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Contributor Information and Disclosures
Author

Ricardo L Carrau, MD, FACS  Professor, Department of Otolaryngology-Head and Neck Surgery, Director of the Comprehensive Skull Base Surgery Program, The Ohio State University Medical Center

Ricardo L Carrau, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, North American Skull Base Society, Pennsylvania Medical Society, and Triological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Emiro E Caicedo-Granados, MD  Assistant Professor, Department of Otolaryngology, University of Minnesota Medical School

Emiro E Caicedo-Granados, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Amol M Bhatki, MD  Attending Physician, Department Of Otolaryngology–Head and Neck Surgery, Co-Director of Skull Base Center, Baylor University Medical Center at Dallas

Amol M Bhatki, MD is a member of the following medical societies: Alpha Omega Alpha and American Rhinologic Society

Disclosure: Nothing to disclose.

Daniel M Prevedello, MD  Assistant Professor, Department of Neurological Surgery, Ohio State University Medical Center

Disclosure: Nothing to disclose.

Amin B Kassam, MD  Consulting Surgeon, The Ottawa Hospital

Amin B Kassam, MD is a member of the following medical societies: American Association of Neurological Surgeons and Ontario Medical Association

Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Stryker Instruments Consulting fee Consulting; NICO Corporation Equity stake Board membership

Specialty Editor Board

Daniel J Kelley, MD  Consulting Staff, Eastern Shore ENT and Allergy Associates and Peninsula Regional Medical Center

Daniel J Kelley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert M Kellman, MD  Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: Revent Medical Honoraria Review panel membership; Synthes Nursing Education Honoraria Other

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Additional Contributors

Carl H Snyderman, MD Professor, Departments of Otolaryngology and Neurological Surgery, University of Pittsburgh Medical Center

Carl H Snyderman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, North American Skull Base Society, Pennsylvania Medical Society, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Phacon Consulting fee Consulting

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CT scan coronal view demonstrating an osteosarcoma of the ethmoid sinuses extending to the orbit and anterior cranial fossa.
MRI axial view demonstrating extensive invasion of the frontal lobes by an adenocarcinoma.
MRI sagittal view demonstrating invasion of the fontal lobes by an osteosarcoma.
Markings for a bicoronal incision.
Markings for a lateral rhinotomy incision.
Intraoperative demonstration of a degloving approach.
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.
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.
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.
Reconstruction of the glabellar area using titanium mesh.
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.
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.
 
 
 
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