Neurosurgical Review

, 33:63

A modified frontal–nasal–orbital approach to midline lesions of the anterior cranial fossa and skull base: technical note with case illustrations

  • Shaan M. Raza
  • James E. Conway
  • Khan W. Li
  • Frank Attenello
  • Kofi Boahene
  • Prem Subramanian
  • Alfredo Quinones-Hinojosa
Original Article

Abstract

The frontal–nasal–orbital craniotomy has been utilized for craniofacial abnormalities and resection of tumors involving the anterior skull base. We describe modifications of this technique to approach extra-axial and intradural midline lesions of the anterior fossa with or without involvement of the skull base. A craniotomy was planned with an endoscope and image guidance. A modified frontal–nasal–orbital craniotomy encompassing the entire frontal sinus complex was performed in conjunction with osteotomies incorporating the bilateral superior orbital ridges and nasal septum. Removal of the posterior wall of the frontal sinus was completed if necessary. Dural repair and final reconstruction are detailed. Our initial experience using this approach in five patients harboring lesions of the anterior skull base resulted in adequate exposure of the targeted pathology. There were no complications of the procedure. Cosmetic results were acceptable. We present a detailed account of this procedure via photographs and a video. The frontal–nasal–orbital craniotomy provides access to the floor of the anterior fossa while avoiding excessive brain retraction associated with facial incisions. In addition, this approach is associated with a lower incidence of complications, such as CSF leak, brain retraction edema, or infection. The frontal–nasal–orbital craniotomy is a useful technique for midline lesions of the anterior skull base, and it should be in the armamentarium of neurological surgeons.

Keywords

Frontal–nasal–orbital craniotomy Anterior cranial fossa 

Supplementary material

Video 1

Frontal–nasal–orbital craniotomy. A compilation of video clips from different operative cases demonstrating the various steps of the approach (MOV 136 mb)

References

  1. 1.
    Blacklock JB, Weber RS, Lee YY et al (1989) Transcranial resection of tumors of the paranasal sinuses and nasal cavity. J Neurosurg 71:10–15CrossRefPubMedGoogle Scholar
  2. 2.
    Fliss DM, Abergel A, Cavel O et al (2007) Combined subcranial approaches for excision of complex anterior skull base tumors. Arch Otolaryngol Head Neck Surg 133:888–896CrossRefPubMedGoogle Scholar
  3. 3.
    Fliss DM, Zucker G, Cohen A et al (1999) Early outcome and complications of the extended subcranial approach to the anterior skull base. Laryngoscope 109:153–160CrossRefPubMedGoogle Scholar
  4. 4.
    Fujitsu K (1994) Basal interfalcine approach through a frontal sinusotomy with vein and nerve preservation. Technical note. J Neurosurg 80:575–579CrossRefPubMedGoogle Scholar
  5. 5.
    Gluckman JL (1991) Craniofacial resection. Ear Nose Throat J 70:595–599PubMedGoogle Scholar
  6. 6.
    Har-El G, Casiano RR (2005) Endoscopic management of anterior skull base tumors. Otolaryngol Clin North Am 38:133–144 ixCrossRefPubMedGoogle Scholar
  7. 7.
    Hendryk S, Czecior E, Misiolek M et al (2004) Surgical strategies in the removal of malignant tumors and benign lesions of the anterior skull base. Neurosurg Rev 27:205–213CrossRefPubMedGoogle Scholar
  8. 8.
    Jane JA, Park TS, Pobereskin LH et al (1982) The supraorbital approach: technical note. Neurosurgery 11:537–542CrossRefPubMedGoogle Scholar
  9. 9.
    Janecka IP, Nuss DW, Sen CN (1991) Midfacial split for access to the central base. Acta Neurochir Suppl (Wien) 53:199–203Google Scholar
  10. 10.
    Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 1—the midline anterior fossa skull base. Minim Invasive Neurosurg 47:1–8CrossRefPubMedGoogle Scholar
  11. 11.
    Kaplan MJ, Jane JA, Park TS et al (1984) Supraorbital rim approach to the anterior skull base. Laryngoscope 94:1137–1139PubMedGoogle Scholar
  12. 12.
    Kinnunen I, Aitasalo K (2006) A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach. J Craniomaxillofac Surg 34:405–411PubMedGoogle Scholar
  13. 13.
    McCutcheon IE, Blacklock JB, Weber RS et al (1996) Anterior transcranial (craniofacial) resection of tumors of the paranasal sinuses: surgical technique and results. Neurosurgery 38:471–479 discussion 479–480CrossRefPubMedGoogle Scholar
  14. 14.
    Origitano TC, Petruzzelli GJ, Leonetti JP et al (2006) Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management. Neurosurgery 58:ONS-327–ONS-336 discussion ONS-336-327CrossRefGoogle Scholar
  15. 15.
    Panje WR, Dohrmann GJ 3rd, Pitcock JK et al (1989) The transfacial approach for combined anterior craniofacial tumor ablation. Arch Otolaryngol Head Neck Surg 115:301–307PubMedGoogle Scholar
  16. 16.
    Pinsolle J, San-Galli F, Siberchicot F et al (1991) Modified approach for ethmoid and anterior skull base surgery. Arch Otolaryngol Head Neck Surg 117:779–782PubMedGoogle Scholar
  17. 17.
    Raveh J, Laedrach K, Speiser M et al (1993) The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 119:385–393PubMedGoogle Scholar
  18. 18.
    Raveh J, Turk JB, Ladrach K et al (1995) Extended anterior subcranial approach for skull base tumors: long-term results. J Neurosurg 82:1002–1010CrossRefPubMedGoogle Scholar
  19. 19.
    Raveh J, Vuillemin T (1988) Advantages of an additional subcranial approach in the correction of craniofacial deformities. J Craniomaxillofac Surg 16:350–358PubMedGoogle Scholar
  20. 20.
    Raveh J, Vuillemin T (1990) Subcranial–supraorbital and temporal approach for tumor resection. J Craniofac Surg 1:53–59CrossRefPubMedGoogle Scholar
  21. 21.
    Raveh J, Vuillemin T, Sutter F (1988) Subcranial management of 395 combined frontobasal–midface fractures. Arch Otolaryngol Head Neck Surg 114:1114–1122PubMedGoogle Scholar
  22. 22.
    Raveh J, Winkelmann F (1978) A method for management of midfacial fractures (author’s transl). Hno 26:304–306PubMedGoogle Scholar
  23. 23.
    Ross DA, Marentette LJ, Moore CE et al (1999) Craniofacial resection: decreased complication rate with a modified subcranial approach. Skull Base Surg 9:95–100CrossRefPubMedGoogle Scholar
  24. 24.
    Sekhar LN, Nanda A, Sen CN et al (1992) The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg 76:198–206CrossRefPubMedGoogle Scholar
  25. 25.
    Solero CL, DiMeco F, Sampath P et al (2000) Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations. Neurosurgery 47:1296–1304 discussion 1304–1295CrossRefPubMedGoogle Scholar
  26. 26.
    Vuillemin T, Raveh J (1990) Subcranial approach for the correction of hypertelorism. J Craniofac Surg 1:91–96CrossRefPubMedGoogle Scholar
  27. 27.
    Zabramski JM, Kiris T, Sankhla SK et al (1998) Orbitozygomatic craniotomy. Technical note. J Neurosurg 89:336–341CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Shaan M. Raza
    • 1
    • 4
  • James E. Conway
    • 1
    • 4
  • Khan W. Li
    • 1
    • 4
  • Frank Attenello
    • 1
    • 4
  • Kofi Boahene
    • 3
  • Prem Subramanian
    • 2
  • Alfredo Quinones-Hinojosa
    • 1
    • 4
    • 5
  1. 1.Departments of NeurosurgeryJohns Hopkins School of MedicineBaltimoreUSA
  2. 2.OphthalmologyJohns Hopkins School of MedicineBaltimoreUSA
  3. 3.Otolaryngology-Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreUSA
  4. 4.The Johns Hopkins Neuro-Oncology Surgical Outcomes Research LaboratoryBaltimoreUSA
  5. 5.Brain Tumor Stem Cell Laboratory, Department of Neurosurgery and OncologyBaltimoreUSA

Personalised recommendations