88 Skull Base Approaches to the Anterior and Middle Cranial Fossa

OBJECTIVEThe anteromedial triangle (AMT) is the triangle formed by the ophthalmic (V1) and maxillary (V2) nerves. Opening of this bony space offers a limited access to the sphenoid sinus (SphS). This study aims to demonstrate the utility of the orbitopterygopalatine corridor (OPC), obtained by enlarging the AMT and transposing the contents of the pterygopalatine fossa (PPF) and V2, as an entrance to the SphS, maxillary sinus (MaxS), and nasal cavity.METHODSFive formalin-injected cadaveric specimens were used for this study (10 approaches). A classic pterional approach was performed. An OPC was created through the inferior orbital fissure, between the orbit and the PPF, by transposing the PPF inferiorly. The extent of the OPC was measured using neuronavigation and manual measurements. Two illustrative cases using the OPC to access skull base tumors are presented in the body of the article.RESULTSVia the OPC, the SphS, MaxS, ethmoid sinus (EthS), and nasal cavity could be accessed. The use of endoscopic assistance through the OPC achieved better visualization of the EthS, SphS, MaxS, clivus, and nasal cavity. A significant gain in the area of exposure could be achieved using the OPC compared to the AMT (22.4 mm2 vs 504.1 mm2).CONCLUSIONSOpening of the AMT and transposition of V2 and the contents of the PPF creates the OPC, a potentially useful deep keyhole to access the paranasal sinuses and clival region through a middle fossa approach. It is a valuable alternative approach to reach deep-seated skull base lesions infiltrating the cavernous sinus and middle cranial fossa and extending into the paranasal sinus.

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Cribriform Adenocarcinoma of the Minor Salivary Gland (CAMSG); A Separate and Malignant Entity

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqaa161.046 ◽

2020 ◽

Vol 154 (Supplement_1) ◽

pp. S24-S24

Author(s):

H Laharwani ◽

T Woods ◽

J Jackson ◽

V Manucha ◽

I Velasco

Keyword(s):

Salivary Gland ◽

Cell Carcinoma ◽

Skull Base ◽

Minor Salivary Gland ◽

Middle Cranial Fossa ◽

Salivary Gland Neoplasm ◽

Left Neck ◽

S 100 ◽

The Face ◽

Cranial Fossa

Abstract Introduction/Objective Cribriform adenocarcinoma of the minor salivary gland (CAMSG) is a recently described salivary gland neoplasm (SGN) that WHO includes under the polymorphous adenocarcinoma (PAC) subheading. CAMSG is reported to occur mostly in the base of the tongue and lingual tonsils. Methods We present a case of CAMSG of buccal mucosa in a 48-year old woman who presented with pain and swelling on the left side of the face that started after tooth extraction. Imaging revealed a large expansile mass (5.8 x 4.3 x 6.1 cm) originating in the left mandibular angle extending into masticator space, maxillary sinus, pterygopalatine fossa, sphenoid, middle cranial fossa, orbit and skull base. Ameloblastoma, primary intraosseous carcinoma, and squamous cell carcinoma were considered. Incisional biopsy revealed a tumor comprised of round to ovoid cells with clear to vesicular nuclei (ground-glass appearance) and occasional mitosis present in irregular solid, cribriform, and microcystic patterns in a hyalinized stroma with the presence of abundant mucin within lobules and stroma. Results Differential diagnosis of secretory carcinoma, hyalinizing clear cell carcinoma, and less likely PAC and mucoepidermoid carcinoma were considered, all inconsistent with the imaging findings. The tumor cells were positive for S100 and negative for CD117, ki67, p63, CD117, and TTF-1. Based on a prominent cribriform pattern, vesicular nuclei, and S-100 expression, a diagnosis of cribriform adenocarcinoma of minor salivary gland origin was rendered. The patient subsequently underwent left partial maxillectomy, left partial mandibulectomy, and resection of the skull base and left neck dissection and was staged as pT4bN0, with negative margins and vascular invasion. The patient underwent radiation therapy and at 6- month follow up was alive and healthy. Clinically and histologically CAMSG overlaps with tumors of both salivary and non-salivary gland origin. Conclusion Recognition of CAMSG as a distinct entity will help in accurate diagnosis and categorization in the WHO classification of SGNs.

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Occurrence of the Foramen of Vesalius and Its Morphometry Relevant to Clinical Consideration

The Scientific World JOURNAL ◽

10.1100/2012/817454 ◽

2012 ◽

Vol 2012 ◽

pp. 1-5 ◽

Cited By ~ 8

Author(s):

Vipavadee Chaisuksunt ◽

Lanaprai Kwathai ◽

Kritsana Namonta ◽

Thanaporn Rungruang ◽

Wandee Apinhasmit ◽

...

Keyword(s):

Skull Base ◽

Surgical Approach ◽

Middle Cranial Fossa ◽

Maximum Diameter ◽

Foramen Ovale ◽

Clinical Consideration ◽

Cranial Fossa ◽

Foramen Of Vesalius

All 377 dry skulls were examined for the occurrence and morphometry of the foramen of Vesalius (FV) both in the middle cranial fossa and at the extracranial view of the skull base. There were 25.9% and 10.9% of FV found at the extracranial view of the skull base and in the middle cranial fossa, respectively. Total patent FV were 16.1% (11.9% unilaterally and 4.2% bilaterally). Most FV were found in male and on the left side. Comparatively, FV at the extracranial view of the skull base had a larger maximum diameter. The distance between FV and the foramen ovale (FO) was as short as2.05±1.09 mm measured at the extracranial view of the skull base. In conclusion, although the existence of FV is inconstant, its occurrence could not be negligible. The proximity of FV to FO should remind neurosurgeons to be cautious when performing the surgical approach through FO.

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Endoscopic Reconstruction of the Middle Cranial Fossa Through a Subtemporal Keyhole Using a Pedicled Deep Temporal Fascial Flap

Operative Neurosurgery ◽

10.1227/neu.0b013e31822fedbb ◽

2011 ◽

Vol 70 (suppl_1) ◽

pp. ons157-ons162 ◽

Cited By ~ 1

Author(s):

Mika Komatsu ◽

Fuminari Komatsu ◽

Antonio Di Ieva ◽

Tooru Inoue ◽

Manfred Tschabitscher

Keyword(s):

Skull Base ◽

Middle Cranial Fossa ◽

Pedicled Flap ◽

Temporal Muscle ◽

Temporal Fascia ◽

Fresh Cadaver ◽

Fascial Flap ◽

Csf Leakage ◽

Cranial Fossa ◽

Temporal Fascial Flap

Abstract BACKGROUND: Reconstruction of the skull base is essential to prevent postoperative leakage of cerebrospinal fluid (CSF). However, a reliable method of reconstructing the middle cranial fossa via a subtemporal keyhole is not available. OBJECTIVE: To determine whether less invasive reconstruction of the middle cranial fossa under endoscopic guidance with a pedicled deep temporal fascia approach via a subtemporal keyhole is feasible and useful. METHODS: The middle cranial fossa in 4 fresh cadaver heads was reconstructed with a 4-mm 0° rigid endoscope. RESULTS: A subtemporal skin incision (subtemporal incision) was followed by 2 small skin incisions (temporal line incisions) made on the superior temporal line. The endoscope was inserted through the temporal line incisions, and then the deep temporal fascia was separated from the superficial temporal fascia and temporal muscle under endoscopic view. A pedicled flap was harvested from the subtemporal incision and applied to the middle cranial fossa after subtemporal keyhole craniotomy. The pedicled deep temporal fascial flap was flexible, long, and large enough to overlay skull base defects. CONCLUSION: This purely endoscopic technique using a pedicled deep temporal fascial flap provided reliable reconstruction of the middle cranial fossa through a subtemporal keyhole. This technique would also be applicable in preventing CSF leakage or treating traumatic, acquired nontraumatic, or congenital encephalocele in the middle cranial fossa.

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Arachnoid cyst with extraordinary extracranial extension in the skull base as a result of an iatrogenic defect of the middle cranial fossa floor: Case report and literature review

Journal of Cranio-Maxillofacial Surgery ◽

10.1016/j.jcms.2009.03.005 ◽

2010 ◽

Vol 38 (4) ◽

pp. 284-287 ◽

Cited By ~ 5

Author(s):

Dimitrios Koutsimpelas ◽

Wibke Mueller-Forell ◽

Peter Stoeter ◽

Otto Hey ◽

Wolf J. Mann

Keyword(s):

Case Report ◽

Literature Review ◽

Skull Base ◽

Arachnoid Cyst ◽

Middle Cranial Fossa ◽

Cranial Fossa ◽

Iatrogenic Defect

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The Extended Middle Cranial Fossa Approach for the Treatment of Skull Base Lesions

10.1055/s-0039-1679720 ◽

2019 ◽

Author(s):

Noga Lipschitz ◽

Gavriel Kohlberg ◽

Joseph Breen ◽

Myles Pensak ◽

Mario Zuccarello ◽

...

Keyword(s):

Skull Base ◽

Middle Cranial Fossa ◽

Middle Cranial Fossa Approach ◽

Skull Base Lesions ◽

Cranial Fossa

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Anterior and Middle Cranial Fossa Skull Base Reconstruction Using Microvascular Free Tissue Techniques

Annals of Plastic Surgery ◽

10.1097/sap.0b013e3181715707 ◽

2008 ◽

Vol 60 (5) ◽

pp. 514-520 ◽

Cited By ~ 34

Author(s):

Ernest S. Chiu ◽

Dennis Kraus ◽

Duc T. Bui ◽

Babak J. Mehrara ◽

Joseph J. Disa ◽

...

Keyword(s):

Skull Base ◽

Middle Cranial Fossa ◽

Skull Base Reconstruction ◽

Cranial Fossa

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Temporal Lobe Encephalocele Appearing as a Lytic Lesion of the Skull Base and Pterygoid Process

Ear Nose & Throat Journal ◽

10.1177/014556130308200411 ◽

2003 ◽

Vol 82 (4) ◽

pp. 269-275 ◽

Cited By ~ 7

Author(s):

William E. Bolger ◽

Christine Reger

Keyword(s):

Skull Base ◽

Brain Tissue ◽

Unusual Case ◽

Middle Cranial Fossa ◽

Ethmoid Sinus ◽

Lytic Lesion ◽

Middle Fossa ◽

Pterygoid Process ◽

Cranial Fossa ◽

Uncommon Condition

Meningoencephalocele is an uncommon condition in which brain tissue, meninges, or both protrude through a defect in the anterior cranial fossa and into the ethmoid sinus or nasal cavity. Much less often, brain tissue, meninges, or both protrude through a defect in the middle cranial fossa and into the sphenoid sinus. We report an unusual case of a middle fossa encephalocele that appeared as a lytic lesion of the skull base. The patient was treated successfully via a unique endoscopic transpterygoid approach—that is, an endoscopic approach through the maxillary sinus and pterygopalatine fossa and into the pterygoid process.

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