Victor L. Schramm

COMPLICATIONS OF CRANIOFACIAL RESECTION FOR MALIGNANT TUMORS OF THE SKULL BASE: REPORT OF AN INTERNATIONAL COLLABORATIVE STUDY

Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient‐related and tumor‐related predictors of postoperative morbidity and mortality and set a benchmark for future studies.

Cervical lymph node metastasis after local excision of early squamous cell carcinoma of the oral cavity

A total of 54 patients with stage I and stage II squamous cell carcinoma of the oral cavity were reviewed as to treatment modality, adequacy of treatment, and site of failure. Surgery was employed as the sole initial treatment modality in 52 patients. Forty-three underwent primary tumor excision alone and 9 underwent elective neck dissection at the time of primary tumor excision. The patients who underwent elective neck dissection at the time of excision of the primary tumor had a 3 year survival rate of 88 percent, in comparison to a survival rate of 77 percent in those patients whose initial therapy was directed solely at the primary tumor. A low incidence of local recurrence (2 percent) and a high incidence of neck recurrence (42 percent) were documented in those patients treated by primary tumor excision alone. Patients who underwent salvage neck dissection for recurrent neck node metastases had a 3 year survival rate of 56 percent. This study has documented a high incidence of cervical node recurrence in patients with T1 and T2 squamous cell carcinomas of the oral cavity treated by primary tumor excision alone and a poor survival rate after salvage therapy. A small group of patients who underwent elective neck dissection had a demonstrably high survival rate. These observations lend support to the call for elective neck dissection in patients with stage I and II oral cavity carcinoma but are not conclusive. Therapeutic decisions regarding elective treatment of the neck will continue to be made according to the best judgment and prejudices of the individual surgeon until a prospective, randomized multi-institutional study addressing this specific issue is undertaken.

Craniofacial resection for malignant paranasal sinus tumors: Report of an international collaborative study

Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient‐related and tumor‐related predictors of prognosis after craniofacial resection (CFR).

Chordoma and chondrosarcoma of the cranial base: an 8-year experience

Between 1980 and 1988, 8 patients with chordomas and 9 with low-grade chondrosarcomas involving the cranial base were treated. All the patients were investigated preoperatively and postoperatively with computed tomographic or magnetic resonance imaging scans, according to a standard protocol. The tu

Evaluation of orbital cellulitis and results of treatment.

Optimal management of patients with orbital cellulitis depends on how accurately the disease is classified and on the appropriateness with which antibiotics and surgery are used to treat the disease. Therapy must be adjusted on the basis of the extent of the disease. In order to determine the balance of treatment modalities which is most beneficial for certain disease presentations, we reviewed a series of 303 patients with orbital cellulitis. The anatomical and bacteriological etiology of the disease was determined in each case on the basis of the examination, visual acuity, results of sinus radiography, results of culture, ultrasonography, and computerized tomography. To avoid the 5% complication rate that occurred in this series, an evaluation and treatment protocol is recommended.

Anterior skull base surgery for benign and malignant disease.

Teamwork between the head and neck surgeon and the neurosurgeon utilizing the craniofacial resection technique greatly extends the frontiers of surgery for tumors of the anterior half of the skull base. Tumors for which this technique may be used include benign and malignant tumors arising in the frontal bone or frontal sinus, nasal vault, ethmoid, maxilla, sphenoid or orbit. Selected nasopharyngeal lesions such as angiofibromas with anterior or middle fossa extensions and sphenoid or clival chordomas may also be approached in this manner. This report evaluates the surgical techniques currently in use for managing these tumors, by discussing the benefits of combined resection, technical modifications of the techniques, and the results of using these techniques in 12 patients. The initial results are encouraging.

Operative exposure and management of the petrous and upper cervical internal carotid artery.

The exposure and operative management of the petrous and upper cervical internal carotid artery (ICA) in 29 patients is detailed. Twenty-seven of these patients had extensive cranial base neoplasms (benign or malignant), 1 had an inflammatory cholesteatoma, and 1 had an aneurysm of the upper cervical ICA immediately proximal to the carotid canal. Preoperative studies useful in the evaluation of these patients included computed tomography, magnetic resonance imaging, cerebral and cervical angiography, and a balloon occlusion test of the ICA with evaluation of neurological status and of cerebral blood flow. The exposure of the upper cervical and petrous ICA was useful to obtain proximal control of the cavernous ICA, aided in the operative approach to extensive petroclival, intracavernous, and parapharyngeal neoplasms, and enabled the total resection of 23 of 27 such tumors. A subtemporal and preauricular infratemporal fossa approach was most commonly used for the exposure of the artery. Intraoperative arterial management consisted of exposure and decompression only, dissection from encasing neoplasm, resection of the invaded arterial segment and vein graft reconstruction, or intentional arterial occlusion. Vascular complications included 1 stroke due to delayed arterial occlusion, 1 stroke and death due to infection spreading from the nasopharynx with bilateral ICA rupture, and 1 pseudoaneurysm formation secondary to wound infection necessitating postoperative balloon occlusion of the ICA. Nonvascular complications included facial nerve paralysis in 10 patients (usually temporary), glossopharyngeal and vagal paralysis in 13 patients requiring Teflon injection of the vocal cord in 9, temporary difficulties with mastication in 9 patients, and wound infection in 3. The surgical exposure and management of the upper cervical and petrous ICA may permit a total operative resection of extensive cranial base neoplasms and is also an alternative for the management of vascular lesions involving these segments of the artery. With malignant neoplasms extending from the nasopharynx, postoperative infection remains a problem and may best be resolved by the use of a vascularized rectus abdominis muscle flap to reconstruct defects of the nasopharynx. Bilateral ICA encasement by neoplasms is also a major problem to be solved. The value of such an aggressive approach to the management of malignant neoplasms remains to be proven.

Extracapsular spread of carcinoma in cervical lymph nodes. Impact upon survival in patients with carcinoma of the supraglottic larynx.

The treatment results and histologic findings in the cervical lymphatics of 96 patients with squamous cell carcinoma of the supraglottic larynx were studied retrospectively. The clinical assessment of the extent of disease in the cervical lymphatics correlated poorly with histologic findings. Forty‐one percent of patients judged to have no evidence of cervical metastases were found to have carcinoma in the cervical lymphatics. Twenty percent of patients judged clinically NO were found to have extracapsular spread of tumor. Patients were subdivided according to the histologic findings in the cervical lymphatics. Three‐year no‐evidence‐of‐disease (NED) follow‐up was available on all patients. Patients with no tumor in cervical lymphatics had a 71% 3‐year NED. By comparison, patients with cervical metastases confined to the lymph node were 79% NED. Patients with histologic evidence of extracapsular spread of tumor were 45% NED (P < 0.05). The use of histologic findings in predicting prognosis and treatment planning is discussed. Cancer 56: 1597‐1599, 1985.

Free Rectus Abdominis Muscle Flap Reconstruction of the Middle and Posterior Cranial Base

A multidisciplinary approach by the neurosurgeon, ENT surgeon, and plastic surgeon has been used in seven patients with extensive tumors involving the middle and posterior skull base. Wide resection of these tumors was accomplished, and the resultant defect of the cranial base was reconstructed using free rectus abdominis muscle flaps. The free muscle flap has been used to reconstruct defects in the posterior and lateral walls of the nasopharynx, obliterate the exposed paranasal sinuses, and cover tenuous dural repairs or dural grafts overlying the temporal lobe and posterior fossa to prevent cerebrospinal fluid leakage and ascending meningitis.

Management of inverted papilloma of the nose and paranasal sinuses

Inverted papilloma of the nose and paranasal sinuses is a neoplastic growth of epithelium which inverts into the underlying stroma rather than proliferating outward from the surface. These neoplasms probably arise from the area of the lateral nasal wall. Inverted papilloma is characterized by its: A. capacity to destroy; B. tendency to recur; and C. association with malignancy.