Reconstruction of upper cranial and cranial base defects utilizing the scalping flap

Reconstruction of midfacial defects by means of a scalping flap has been widely practiced and described in the literature. The advantages of the flap are familiar to surgeons who perform extirpations and reconstruction of the head and neck and include contiguous availability, simplicity of application, and a robust and redundant blood supply. Despite these merits, the flap has not been widely used for reconstructions of large anterior cranial defects or defects of the cranial base. A retrospective review of 11 patients who underwent reconstructions between 1990 and 1995 was performed. In each case, a reconstruction of a large anterior cranial or cranial base defect was carried out. The resulting soft-tissue defect was restored via the scalping flap. In six cases, this was carried out in a single procedure. In five cases, flap division and insetting were carried out in a subsequent procedure, following a 1- to 2-week delay. In all cases, the extirpation and reconstruction were well tolerated, and the average time of hospitalization was 5.9 days and ranged from 3 to 11 days. No major surgical complications occurred. One of 11 patients had a minor complication not requiring surgical intervention. There was one recurrence of a cranial base tumor approximately 2 years following the initial resection and reconstruction. In all cases, the final aesthetic and functional results were acceptable to excellent. Follow-up ranged from 11 months to 5 years. In conclusion, the scalping flap can be effectively utilized for soft-tissue coverage in the reconstruction of anterior cranial and cranial base defects. Use of this simple and versatile flap in craniofacial reconstruction is well tolerated and is associated with a low morbidity, a good aesthetic result, and a short hospital stay.     

Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base

We recommend that every patient with a midline nasal dermoid be evaluated preoperatively by fine-cut CT scan, in the axial and coronal planes, using both bone and soft-tissue algorithms. Because of CT limitations for assessing soft tissue at the cranial base, a complementary thin-section, high-resolution, multiplanar MRI scan should be considered. Transnasal endoscopic excision of midline nasal dermoid should be used if the dermoid is located within the nasal cavity, and there is minimal or no cutaneous involvement. This approach can be combined with a short vertical midline lenticular excision of a cutaneous punctum. Vertical cutaneous excision should be limited; the best location is the nasal tip. Vertical nasal scars over the bony pyramid invariably widen no matter what intradermal suture is used. Endoscopic removal should be considered even if preoperative radiologic studies show extension to the anterior cranial fossa. Endoscopic excision could also be used to resect a dermoid extending between the dural leaves of anterior fossa. However, a combined intra-extracranial approach is necessary if the dermoid is in the falx cerebri. We agree with other authors that frozen sectioning the superior margin of the specimen should be done to ensure that there is no intracranial extension. Valsalva maneuver during endoscopic visualization of the cranial base is a valuable means of ruling out a cerebral spinal fluid leak.     

Complications of craniofacial surgery for tumors involving the anterior cranial base

OBJECTIVE: To evaluate the risk factors for postoperative complications among patients undergoing craniofacial resection for the treatment of anterior cranial base tumors, a retrospective analysis of patients treated in University of Tokyo Hospital between September 1987 and November 1996 was conducted. METHODS: Twenty-nine patients underwent 33 craniofacial resections for tumors involving the anterior cranial base. Twenty-three of the 29 patients had malignant tumors and 6 patients had benign tumors. Anterior craniofacial resection was performed using a combination of intracranial and extracranial approaches. Radiotherapy and neoadjuvant chemotherapy were administrated to some patients. RESULTS: Severe intracranial infections were more common among patients who underwent partial frontal lobectomies (P < 0.03). These infections occurred only in patients who had been treated previously with a craniotomy (P < 0.02) and a total radiation dose of > or =60 Gy (P = 0.06). Neither management of the extracranial structures nor methods of reconstruction of the cranial base showed significant correlation with major postoperative complications. CONCLUSION: Compared with previous reports, craniofacial resection has become a relatively safe and effective procedure for the treatment of tumors involving the anterior cranial base. However, additional care should be taken with patients who have experienced a previous craniotomy, frontal lobe involvement, or radiotherapy with a total dose of > or =60 Gy.     

Hemifacial dismasking flap for anterior skull base tumor--technical note

A new approach to malignant tumor in the anterior skull base using a hemifacial dismasking flap is described. A bicoronal incision is extended unilaterally down to the neck, degloving the craniofacial tissue to widely expose the skeleton underneath, allowing easy resection of an extensive tumor without postoperative scarring of the face. This method has been used successfully on five patients.     

Analytical evaluation of complex anterior approaches to the cranial base: an anatomic study

OBJECTIVE: The purpose of the present study was to evaluate the anatomic areas of the cranial base exposed by different complex anterior approaches. METHODS: Using 20 embalmed cadaveric heads, we executed five different anterior approaches, i.e., Le Fort 1 approach with splitting or down-fracturing of the hard palate, extended maxillectomy, median mandibulotomy with glossotomy, and mandibular swing transcervical approach. Each approach was performed a minimum of three times. The areas of the intra- and extracranial cranial base exposed by each approach were analytically examined by using a numerical grading system to assess the exposure of major anatomic and neurovascular structures. RESULTS: Good exposure of the midline compartment of the cranial base was provided by the median mandibulotomy with glossotomy and by the Le Fort 1 approach with splitting of the hard palate, whereas the mandibular swing transcervical and extended maxillectomy approaches provided good exposure of the lateral compartment of the cranial base. CONCLUSION: Use of the numerical grading system allowed quantification of the exposure afforded by each approach, with respect to the different compartments (midline and lateral) of the intra- and extracranial cranial base, highlighting the differences among the approaches examined.     

Effects of annular cranial vault modification on the cranial base and face

Artificial modification of the cranial vault was practiced by a number of prehistoric and protohistoric populations, frequently during an infant's first year of life. We test the hypothesis that, in addition to its direct effects on the cranial vault, annular cranial vault modification has a significant indirect effect on cranial base and facial morphology. Two skeletal series from the Pacific Northwest Coast, which include both nonmodified and modified crania, were used: the Kwakiutl (62 nonmodified, 45 modified) and Nootka (28 nonmodified, 20 modified). Three-dimensional coordinates of 53 landmarks were obtained using a diagraph, and 36 landmarks were used to define nine finite elements in the cranial vault, cranial base, and face. Finite element scaling was used to compare average nonmodified and average modified crania, and the significance of the results were evaluated using a bootstrap test. Annular modification of the cranial vault produces significant effects on the morphology of the cranial base and face. Annular modification in the Kwakiutl resulted in restrictions of the cranial vault in the medial-lateral and superior-inferior dimensions and an increase in anterior-posterior growth. Similar dimensional changes are observed in the cranial base. The Kwakiutl face is increased anterior-posteriorly and reduced anterior-laterally to posterior-medially. Similar effects of modification are observed in the Nootka cranial vault and cranial base, though not in the face. These results demonstrate the developmental interdependence of the cranial vault, cranial base, and face.     

Surgery of the anterior skull base

Inflammatory disease of the frontal, ethmoid, and sphenoid paranasal sinuses may extend to the adjacent anterior skull base and then intracranially. The potential for this serious complication of sinus disease must be recognized by the primary otolaryngologist-head and neck surgeon, and alternative management strategies must be taken once it is diagnosed. Topics discussed in this article include cranial anatomy, surgical techniques and variations, complications, and special considerations.     

Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial approaches to the cranial base

OBJECTIVE: Intimate to the application of lateral transtemporal approaches to the cranial base are the identification, manipulation, and/or the sacrifice of the venous anatomy of the inferolateral temporal lobe and the superior petrosal sinus and the transection of the tentorium. This study demonstrates the relationship and variability of the venous drainage of the lateral and inferior surfaces of the temporal lobe. METHODS: Twenty-one specially prepared, injected cadaver specimens yielded 40 temporal lobes for examination. The venous systems in these specimens were traced from their origins on the temporal lobe (venous drainage complexes) to the transverse/petrosal sinuses, and the geometry of these venous complexes (venous configuration) was noted. The measurements of each complex's entry to the sinuses were noted. RESULTS: Four distinct venous drainage complexes were identified: 1) the lateral complex, 2) the anteroinferior complex, 3) the medial-inferior complex, and 4) the posteroinferior complex. Three basic venous configurations were found: 1) the candelabra of veins uniting to form one large draining vein, 2) multiple independent draining veins, and 3) venous lakes running in the tentorium before entering the sinuses. The lateral complex, incorporating the classic "vein of Labbé," was present in 100% of the specimens. However, in the majority of cases, it did not represent the dominant venous drainage of the lateral and inferior surfaces of the temporal lobe. CONCLUSION: An understanding of the complexity and diversity of the venous drainage complexes and their configurations is necessary to avoid venous complications during lateral cranial base surgery.     

En bloc resection of the temporal bone for middle ear carcinoma extending to the cranial base

En bloc resection of the temporal bone for squamous cell carcinoma of the middle ear was performed by the postauricular transtemporal and retromastoid approaches. The patient was a 70-year-old woman whose tumor extended to the middle and posterior cranial fossae. Temporal and retromastoid craniotomies were carried out, then the temporal dura and the cerebellar dura, and the transverse and sigmoid sinuses were exposed. The temporal dura and the cerebellar dura were opened, and the transverse sinus was ligated at the junction with the sigmoid sinus. After that, the tentorial dura was incised, the incision extending anteriorly to the middle cranial fossa and transecting the superior petrosal sinus. Consequently, a wide view into the middle and the posterior cranial fossae was obtained. In the posterior fossa, cranial nerves VII and VIII were divided. On the other hand, nerves IX, X and XI were preserved at the dural incision on the posterior surface of the temporal bone. Subsequently, in the area of the carotid canal, the temporal bone was drilled toward the medial side of the internal auditory canal and also posteriorly down to the jugular bulb. At this stage, the temporal bone and the soft tissue attachments, such as the middle and posterior cranial fossa dura, and the sigmoid sinus, were separated from the pyramidal apex and the clivus. The dural defect was repaired with a free pericranial graft. A rectus abdominis muscle flap was transferred to reconstruct the defect of the skull base resulting from the temporal bone resection. Postoperative complications like CSF leakage, meningitis and lower cranial nerve damage, were not seen after the treatment. The patient has shown no evidence of recurrence for the 28 months since the surgical treatment, and has not complained of any problems with swallowing or conducting conversations in daily life. With the contribution of recent developments in skull base and reconstruction surgery, more aggressive en bloc resection of the temporal bone can be carried out on patients with advanced middle ear carcinoma. These developments will also make it possible for patients whose prognosis was previously thought to be poor to have a chance for a cure.     

Clinical application of rhombotrapezious island musculocutaneous flap for skull base and/or craniomaxillary operation with malignant tumor

Regional pedicled musculocutaneous flaps are the mainstay of the head and neck reconstruction. They provide a rapid, highly reliable and single-staged technique that is applicable in most cases. The rhombotrapezious island musculocutaneous flap is valuable in the base and craniomaxilloface reconstruction. In this study we updated our experience with the rhombotrapezious island musculocutaneous flap (RTIMF) in 6 cases from 1989 to 1993. Dissections were performed on 9 cadavers, 4 preserved and 5 fresh, yielding 18 pairs or dorsal scapular and transverse cervical artery for evaluation. In the five fresh cadavers, the arteries were selectively cannulated and injected with colored latex. 67% with dorsal scapular and transverse cervical artery commonly arose from the thyro-cervical trunk. 33% with the dorsal scapular artery directly arose from the second part of the subclavian artery. In the period of 1989-1993, 6 rhombotrapezious island musculocutaneous flaps with vascularized pedicle were used for immediate repair in the skull base or craniomaxillary cancer operations. There was no complication of the flaps. Donor site complications were relatively minor. The disturbance in shoulder function was well tolerated. We advocated the incorporation of both the greater and lesser rhomboid muscle to form the compound rhombotrapezious flaps to enhance the vascular supply to the overlying skin. The major advantage of the RTIMF are that it provides a long paddle of thin pliant, hairless skin and muscle that can be rotated as far as the craniomaxilloface and scalp in a single stage. It offers the longest arc of rotation and thus the greatest versatility for the skull base or craniomaxillary reconstruction.     

An approach to an esthesioneuroblastoma of the anterior cranial fossa via the anterior wall of the hypertrophied frontal sinus]

Coenzyme Q10 was administered under placebo controlled blinded crossover conditions to six subjects suffering from type 3 3-methylglutaconic aciduria ('optic atrophy plus'), following a report of benefit. Despite attainment of high plasma levels of coenzyme Q10, no clinical benefit was observed and there was no diminution of urinary excretion of 3-methylglutaconic acid.     

Thin-plate spline analysis of the cranial base in subjects with Class III malocclusion

The role of the cranial base in the emergence of Class III malocclusion is not fully understood. This study determines deformations that contribute to a Class III cranial base morphology, employing thin-plate spline analysis on lateral cephalographs. A total of 73 children of European-American descent aged between 5 and 11 years of age with Class III malocclusion were compared with an equivalent group of subjects with a normal, untreated, Class I molar occlusion. The cephalographs were traced, checked and subdivided into seven age- and sex-matched groups. Thirteen points on the cranial base were identified and digitized. The datasets were scaled to an equivalent size, and statistical analysis indicated significant differences between average Class I and Class III cranial base morphologies for each group. Thin-plate spline analysis indicated that both affine (uniform) and non-affine transformations contribute toward the total spline for each average cranial base morphology at each age group analysed. For non-affine transformations, Partial warps 10, 8 and 7 had high magnitudes, indicating large-scale deformations affecting Bolton point, basion, pterygo-maxillare, Ricketts' point and articulare. In contrast, high eigenvalues associated with Partial warps 1-3, indicating localized shape changes, were found at tuberculum sellae, sella, and the frontonasomaxillary suture. It is concluded that large spatial-scale deformations affect the occipital complex of the cranial base and sphenoidal region, in combination with localized distortions at the frontonasal suture. These deformations may contribute to reduced orthocephalization or deficient flattening of the cranial base antero-posteriorly that, in turn, leads to the formation of a Class III malocclusion.     

Anatomic reconstruction of the posterolateral cranial base with titanium micromesh for combined transpetrosal approach: technical note

OBJECTIVE: We describe a new technique for the anatomic closure of the posterior petrosectomy defect after the combined supra-infratentorial transpetrosal approach for petroclival lesions. METHODS: With this technique, a titanium micromesh, tailored according to the defect of the drilled petrous bone and contoured to the outer appearance of the posterolateral cranial base, is used to cover the petrosectomy area. The mesh is fixed to the cranium and to the repositioned bone flap with titanium microscrews. RESULTS AND CONCLUSION: To date, this technique has proven to be simple and rapid and has been used in 10 patients who were operated on for various tumorous and vascular lesions of the petroclival region. Excellent cosmetic results were achieved, and no technique-related complications occurred.     

Staphylococcus aureus isolation from the lesions, the hands, and anterior nares of patients with atopic dermatitis

Staphylococcus aureus colonization is common in atopic dermatitis (AD) and can exacerbate the disease. Some patients with atopic dermatitis may act as a reservoir for S. aureus transmission to others. This study compared S. aureus colonization in atopic dermatitis patients and their caregivers with control patients and their caregivers. Quantitative cultures were obtained from the lesions, clinically normal skin, hands, and anterior nares of 100 patients with atopic dermatitis, 100 controls with other cutaneous disorders, and 200 caregivers. The AD patients had significantly greater presence of S. aureus from lesional and clinically normal skin, as well as the hand. Significantly increased carriage of S. aureus was found in the anterior nares of caretakers of AD patients compared with control caretakers. Topical corticosteroid use did not affect recovery of S. aureus. There was a significant correlation between recovery of S. aureus from lesional skin and recovery from the anterior nares and hands. The nares and hands may be important reservoirs and vectors for autotransmission of S. aureus to lesional skin and for transmission to patients with AD.     

Atypical central nervous system lymphoma at the cranial base: report of four cases

OBJECTIVE AND IMPORTANCE: Primary central nervous system lymphoma is a disease with increasing incidence. Atypical presentations are becoming more frequent. CLINICAL PRESENTATION: Three patients bearing cavernous sinus lesions presented initially with periorbital pain and diplopia. Tolosa-Hunt syndrome was the initial presumptive diagnosis for two patients, and meningioma was the diagnosis for the third patient. A fourth patient presented with left ear pain, and a mass in the left internal auditory canal was thought to represent an acoustic neuroma. INTERVENTION: For all four patients, an operative pathological diagnosis was obtained and was compatible with central nervous system lymphoma. All patients were treated with osmotic blood-brain barrier disruption with intra-arterial chemotherapy using a methotrexate-based regimen. CONCLUSION: All four cases included atypical presentations of lymphoma. These cases again illustrate that a correct diagnosis cannot be obtained based only on imaging and clinical findings.     

The developing anterior skull base: CT appearance from birth to 2 years of age

PURPOSE: To describe the normal CT appearance of the developing anterior skull base in children 24 months of age and younger. METHODS: A retrospective review of the CT examinations of a healthy population of 61 subjects newborn through 24 months of age was performed. Two investigators independently reviewed the examinations, making measurements and observations regarding the length of the skull base, ossification pattern, and development of the crista galli, perpendicular plate of the ethmoid bone, and fovea ethmoidalis. RESULTS: At birth, the anterior skull base is largely cartilaginous. Ossification begins in the roof of the ethmoidal labyrinth laterally and spreads toward the midline. By 6 months of age, 50% of the anterior skull base has completely ossified. This percentage steadily increases over the first 2 years of life, and by 24 months, 84% of the anterior skull base is completely ossified, with a cartilaginous gap anteriorly in the region of the foramen cecum, the residual unossified portion. Ossification of the crista galli and perpendicular plate of the ethmoid bone begins around 2 months of age, shows a steady increase in ossification to 14 months of age, then increases little to 24 months of age. The fovea ethmoidalis begins development by 6 months of age, with the anterior portion the most developed in 82% of the population. CONCLUSION: The timing and pattern of ossification we observed differ somewhat from that reported in prior radiologic and anatomic studies, with the earliest bony bridging of the ethmoidal complex to the crista galli seen as early as 2 months of age. Development of the anterior skull base follows a predictable and orderly pattern that is important for understanding how to avoid errors in interpreting CT examinations through this region.     

Treatment of recurrent anterior dislocation of the shoulder with pectoralis minor muscle-bone flap]

We treated 10 patients with recurrent anterior dislocation of the shoulder by transplantation of pectoralis minor muscle-bone flap transplanted to the upper part of the humerus. All patients were followed-up for an average 31 months and no recurrent was found. We consider that the muscle beily exerts a protective effect like a barrier on the weak anterio inferior region of the shoulder and increases the force for extending the shoulder and lifting the arm. The operation is based on biomechanics. Meanwhile, suturing the laxative joint capsule and repairing the weak anteroinfeior region of the shoulder is more beneficial to prevent from redislocation of the humerus head.     

Indications for middle ear obliteration within the scope of cochlear implant management

BACKGROUND: Cochlear implants have gained worldwide acceptance as a reliable method of rehabilitation of profoundly hearing-impaired patients. Due to thorough patient selection major postoperative complications rarely occur and are flap related in most cases. Deafness can develop during chronic suppurative otitis media, either coincidentally or secondary to the medical treatment; normally this condition is regarded as a contraindication for cochlear implantation. In cases with a mastoid cavity after surgical treatment for cholesteatoma, the electrode covered only by the epithelial lining will likely become exposed or extruded. Therefore we suggest the obliteration of the middle ear cleft with abdominal fat and the blindsac closure of the external ear canal before cochlear implantation in these conditions. PATIENTS: The average age of our 12 patients was 48 years, whereas the youngest was 2 1/2 years of age. Due to chronic inflammatory ear disease. 11 patients had a mastoid cavity on both ears. Eight patients had a cholesteatoma, the chronic bone destroying process in the temporal bone of two female patients was considered as a fibroinflammatory pseudotumor. The child had a congenital deafness in both ears with a Mondini dysplasia in CT scan. She had already developed two episodes of pneumococcal meningitis which was caused by a defect in the stapes footplate through which a liquor-filled cystic sac herniated in the middle ear. Because of a massive liquorrhoea after opening of the sac, we decided to obliterate the middle ear cleft after successful insertion of the electrode array. RESULTS: All active electrodes of 10 Nucleus implants (Cochlear) and two Clarion devices (Advanced Bionics Corp.) were successfully inserted in the cochlea of the 12 patients. After an average follow-up of 15 months, a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a fibroinflammatory pseudotumor developed a massive inflammatory reaction in the implanted ear two months after cochlear implantation, which could not be controlled by conservative treatment. The implant had to be removed and local conditions settled after administration of immunosuppressive treatment with cyclophosphamide. The patient received a new implant seven months ago. CONCLUSIONS: Implantation of a foreign body in a potentially infected space which communicates intracranially means a surgical challenge which can be managed by obliteration of the middle ear after subtotal petrosectomy with abdominal wall fat combined with a reliable closure of the external ear canal. In case of massive inflammation we would prefer a two-stage procedure.