Search

To evaluate the long-term outcome of patients with esthesioneuroblastoma treated with neoadjuvant or definitive radiotherapy (RT).Between 1980 and 2001, 28 patients with histologically confirmed esthesioneuroblastoma underwent RT, with a median dose of 60 Gy (range 38-73). The median age was 58 years (range 16-85). According to the Kadish classification, 4 patients had Stage A, 8 Stage B, and 16 Stage C tumors. Radical resection was performed in 13 cases, in 9 before RT and in 4 after RT because of stable or progressive disease. The outcome analyses included the median age (58 years), Kadish stage, skull base penetration, intraorbital extension, resection status, and total dose (or=60 vs.60 Gy).After a mean follow-up of 68 months, 54% of patients were free of tumor progression. The 5- and 10-year local progression-free survival rate was 81% and 51%, respectively, and the disease-free survival rate was 70% and 25%, respectively. Four of ten deaths (4/10) were intercurrent, resulting in a cause-specific survival of 77% and 69% at 5 and 10 years, respectively. Radical resection offered significantly better local progression-free survival and disease-free survival (p0.02). Skull base penetration (p0.04), intraorbital extension (p0.04), and Kadish C stage (p0.06) were important for impaired disease-free survival.Despite doses up to 73 Gy, radical RT cannot replace radical resection, which classifies esthesioneuroblastoma as rather radioresistant. Because of its biology and the high rates of late recurrence, we recommend a radical strategy with resection, high-dose RT, and simultaneous chemotherapy. We are aware that some tumors qualify for palliative treatment only.

Benign tumors of the ethmoid roof often behave aggressively and necessitate radical en bloc removal. Historically, approaches to this region have included transcranial, transfacial, and a combination of both routes. More recently, approaches have been modified to decrease morbidity and improve functional and cosmetic outcome. The subcranial subfrontal approach, introduced by the senior author (J.R.) in 1978 for the treatment of frontobasilar trauma has been adapted for use in the treatment of benign and malignant tumors of the anterior cranial fossa. It differs from the other craniofacial approaches in that it provides broad exposure of all anterior skull base planes, including intracranial and inferior extensions, with minimal or no frontal lobe retraction. This significantly decreases perioperative morbidity due to frontal lobe edema and shortens intensive care unit and overall hospital stay. Tumor exposure of the ethmoid roof remains excellent and the need for external facial incisions is completely eliminated. Accurate intraoperative planning of tumor resection is facilitated by this approach, while damage to important neurovascular structures is minimized. Technical details of the operative approach including soft tissue dissection, osteotomy planning, and execution and skull base reconstruction are discussed. Cooperation between the otolaryngological and neurosurgical teams is critical to the success of this approach for resection of benign as well as malignant lesions of the ethmoid roof.

The zygomaticomalar complex fracture, also known as the trimalar, tripod, or tetrapod fracture, is a fracture commonly encountered by facial plastic surgeons. Failure to correctly reduce these fractures can lead to facial asymmetry, trismus, diplopia, enophthalmos, and parasthesias. Approaches to the zygomaticomalar complex have been well documented in the literature and include the transconjunctival lateral canthotomy, subciliary blepharoplasty, brow, gingivobuccal, and coronal incisions, or some combination thereof. Fracture fixation is accomplished by the internal placement of miniplates and microplates across properly reduced fracture lines to resist torsional rotation and masticatory distraction. The method of fracture reduction and fixation employed at the University Hospital of Bern, Switzerland, shares much with previously published and accepted methods of medial and lateral buttress reconstruction, but it introduces several original concepts in an attempt to maximize functional and aesthetic outcomes.

Purpose: This study evaluates the long-term results of open reduction without fixation for displaced fractures of the condylar process. Patients and Methods: Clinical and radiologic examinations were performed on 27 patients with 29 operated joints an average of 6.7 years postoperatively. The postoperative result was evaluated on the basis of occlusal and joint function, as well as radiographic assessment of condylar changes. Results: Clinically, satisfactory results were achieved. Radiologically, despite correct intraoperative alignment of the fractured segments, a slight medial deviation of the condylar process was found on the posteroanterior radiograph. However, in only two cases was a 20-degree deviation observed. On final follow-up, 48% of the cases had a normal condylar configuration radiologically, and in the remaining cases, normal function was established even though there were condylar changes. Fully exposed and devascularized condylor processes generally showed more severe changes than those in which partial vascularization was maintained. Conclusion: The surgical management described enables a satisfactory outcome to be achieved with dislocated condylar process fractures.

✓ The extended anterior subcranial approach differs significantly from more traditional surgical approaches to the skull base in that it allows a broad inferior access to the anterior skull base planes with tumor exposure from below rather than via the transfrontal route. The authors initially used the subcranial approach in 1978 for the treatment of high-velocity skull base trauma and certain craniofacial anomalies. In 1980 they expanded the indications to include the combined neurosurgical—otolaryngological resection of various skull base tumors. Osteotomy of the frontonasoorbital external skeletal frame provides optimum anterior access to the orbital and sphenoethmoidal planes as well as to the nasal and paranasal cavities while avoiding frontal lobe retraction and the external facial incisions characteristic of transcranial and transfacial approaches. The improved visualization of the anterior skull base and clival—sphenoidal region facilitates en bloc tumor removal, optic nerve decompression, exposure of the medial aspect of the cavernous sinus, and watertight realignment of the anterior cranial base dura. In this report the authors present their experience over the past 13 years with 104 patients who underwent operation via the extended subcranial approach. Because extensive frontal lobe manipulation and external facial incisions are avoided with this approach, intensive care unit and overall hospital stay are reduced, related complications are minimized, and postoperative cosmetic appearance is enhanced. The extended anterior subcranial method is therefore an excellent alternative to traditional transfacial-transcranial skull base approaches for the removal of selected skull base tumors.

Purpose: In this study, the long-term evaluation after surgical treatment of temporomandibular joint with manifested degenerative changes and internal derangement is described. The surgical procedure, including extensive exploration and remodeling of the joint, with interposition of lyophilized human costochondral cartilage, is described. Materials and Methods: Thirty-two cases (37 joints) were evaluated at a mean follow-up time of 3.1 and 8.6 years after the surgical treatment. Results: A significant reduction of dysfunction and pain symptoms was achieved in most cases.

Reconstruction of craniomaxillofacial defects caused by injury, tumor ablation, or congenital deformities can be accomplished by a variety of methods. Nonvascularized (free), vascularized (pedicled), and revascularized (microvascular) bone grafts have been employed for osseous restoration of the upper, mid, and lower facial skeleton. In comprised recipient tissue beds or when rapid functional restoration is desired, revascularized flaps hold certain advantages over their nonrevascularized counterparts. The revascularized flaps used most commonly for craniofacial reconstruction are discussed with regard to anatomy, clinical applications, and aesthetic and functional limitations.

The treatment of zygomatic fractures varies among surgeons, and the cosmetic and functional results are frequently less than optimal. A treatment guideline based on a simple classification of zygomatic fractures is presented. The emphasis is placed on the indications for closed and open reduction, consistent methods of three-dimensional alignment and fixation, and the management of concomitant infraorbital rim and orbital floor fractures. Postoperative results with regard to infraorbital nerve and maxillary sinus dysfunction, malar asymmetry, and orbital complications in the treatment of 1,025 consecutive zygomatic fractures are presented.

• In regard to the multiple problems of reconstruction concerning this fracture pattern, we developed various methods to achieve optimal results. As various vital regions, apart from the nasoethmoidal fractures and aesthetics, are involved, the proposed classification has direct implication for the surgical procedure. Even in intracranial fragment dislocations, cerebral contusion, and elevated intracranial pressure, the subcranial approach, in contrast with the transfrontal access, enables early definitive management of the skull base and the external facial frame in a one-stage procedure. Another method, the symmetrical centripetal compression of the canthal ligaments and naso-orbital bone fragments, enables correct reduction of the telecanthus. The significant reduction of morbidity and complication rate to a minimum confirms the efficiency of our treatment modalities. ( Arch Otolaryngol Head Neck Surg. 1992;118:605-614)

Introduction The major advantages of the subcranial approach as developed by us for intra- and extracranial lesions are particularly obvious in the management of extensive skull base tumors which represent the majority of the 222 cases in our series. Out of these 105 were malignant. The subcranial[for full text, please go to the a.m. URL], ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge; 7th Congress of the European Skull Base Society held in association with the 13th Congress of the German Society of Skull Base Surgery

The most innovative and meaningful recent advances regarding surgery of the cranial base involve the ability to perform a complete resection followed by a water- and airtight reconstruction while minimizing facial incisions and morbidity. Perhaps the first step in this direction took place when the subcranial/subfrontal approach was introduced for anterior skull base surgery. Originally developed by Raveh in 1978 for the management of severe skull base injuries, these approaches were later adapted for the treatment of congenital anomalies prior to their utilization for resection of anterior skull base tumors. The endoscopic approaches are quite practical with promising long-term efficacy for the treatment of most benign, infectious, and inflammatory disorders. The minimal recovery time, functional outcomes, and obvious aesthetic advantages are only tempered by the lack of long-term data regarding the efficacy of these approaches in the treatment of malignancies.

The subcranial approach for the osteotomy of the skull base and orbital roof in cases with hypertelorism is described. Advancement of the fronto-orbital segments is performed, avoiding the transfrontal procedure, thus making frontal lobe retraction unnecessary. The advantages of this method are pointed out.

Reconstruction of the anterior skull base and fronto-orbital framework following extensive tumor resection is both challenging and controversial. Dural defects are covered with multiple sheets of fascia lata that provide sufficient support and avoid herniation. Plating along the skull base is contraindicated. After resection of orbital walls, grafting is necessary if the periosteum or parts of the periorbital tissue had to be removed, to avoid enophthalmus or strabism. Free bone grafts exposed to the sinonasal or pharyngeal cavity are vulnerable to infection or necrosis: therefore, covering the grafts with vascularized tissue, such as the Bichat fat-pad or pedicled temporalis flaps, should reduce these complications. Alloplastic materials are indispensable in cranial defects, whereas microsurgical free tissue transfer is indicated in cases of orbital exenteration and skin defects. The authors review their experience and follow-up of 122 skull base reconstructions following extensive subcranial tumor resection. Most significant complications were pneumocranium in 4.9%, CSF leaks in 3.2%, and partial bone resorption in 8.1%.

In this study, 31 cases with different anterior skull base lesions mandating broad exposure, including the sphenoidal, parasellar, and clival region, were surgically treated using the frameless computer assisted surgery (CAS) system. The contribution of navigated surgery in relation to the broad exposure and direct visualization of this region rendered by the subcranial-subfrontal approach was evaluated. In group I, consisting of extensive tumors, the contribution of CAS was only given in five cases for the exposure of the tumor extensions located to the parasellar sphenoclival complex with concomitant distortion of the anatomic landmarks. No advantages were experienced in the more anterior locations along the ethmoidal compartment and frontal sinus. In the cases in group II, consisting of congenital anomaly implying fronto-orbital advancement and a meningoencephalocele as well as extensive mucoceles, the CAS was only helpful in those cases with an extremely aberrative anatomy in these regions.

Objective: To determine if technetium Tc 99m—labeled macroaggregated albumin selective angioscintigraphy enables estimation of microparticle-arteriovenous shunt in branchial paragangliomas and nasopharyngeal angiofibromas. Design: Technetium Tc 99m—labeled macroaggregated albumin particles with calibrated diameters between 25 and 50 μm were administered during selective catheterization of the feeding arteries in 4 branchial paragangliomas (glomus tumors) and 4 nasopharyngeal angiofibromas. Preliminary measures of the activity of the tumor region and of the lungs were obtained in the angiography suite using a hand-held detector. Without changing the position of the microcatheter, definitive embolization was performed. After endovascular treatment, scintigraphy was performed and the pulmonary shunt index was calculated with the use of a gamma camera and a dedicated computer program. Results: The pulmonary shunt index varied between 0% and 36% for branchial paragangliomas (glomus tumors) and between 82% and 95% for angiofibromas. Conclusions: Our results provide new evidence that the incidence of microparticle-arteriovenous shunt in nasopharyngeal angiofibromas is much higher than in paragangliomas. Arch Otolaryngol Head Neck Surg. 1996;122:1320-1325

Educational objectives: To become acquainted with the multiple aspects induced by high-velocity trauma leading to combined skull-base and facial frame disruption and with subcranial exposure and other new methods for early one-stage management and reconstruction.

Educational objectives: To acquaint participants with the anatomic relations in this area and the application of these methods to the anterior skull base and to explain the en bloc resection of the tumor optic nerve decompression and the functional and aesthetic reconstruction of the skull base and frontonasoethmoidal area.

• We describe 78 patients with fronto-orbital and sphenoethmoidal tumors surgically treated with the subcranial approach. This approach was developed by us in 1978 primarily for the treatment of skull-base trauma and craniofacial anomalies. Since 1980, we have extended the indications to include tumor resections. This extended anterior exposure of the anterior fossa skull base, including the sphenoidal and clival planes, enables an en bloc tumor removal obviating the transfrontal approach or lateral rhinotomy. In contrast with the conventional transcranial approach, the anterior subcranial approach provides an extended exposure of these locations, avoiding frontal lobe retraction. Reduction of complications, such as recurrent cerebrospinal fluid leaks, postoperative brain edema, damage to cranial nerves, and infection plus decreased hospitalization, are the major advantages of this procedure. ( Arch Otolaryngol Head Neck Surg. 1993;119:385-393)

Experience in the management of 77 isolated orbital floor fractures is presented. The transconjunctival approach was used exclusively to access the orbital floor and lyophilized dura and cartilage were used to reconstruct the floor, when indicated. Follow-up for an average of 36 months showed excellent cosmetic and functional results. A 20% complication rate was noted, which compares favorably with what is reported in the literature. There were no graft extrusions or infections and only one case of graft displacement. These findings support the concept of early treatment of orbital floor fractures, even in “minimally symptomatic” patients. Lyophilized dura and cartilage proved to be safe and effective materials for orbital reconstruction.

The advantages of the subcranial over the transcranial approach for fronto-orbital tumor resection and subcranial exposure of the skull base are described in this paper. The primary reconstruction and fixation of the bone grafts with miniplates or wire ligatures are illustrated. The utilization of lyophilized cartilage for the reconstruction of the orbital roof, as well as the bridging of the defects with Biocement, are pointed out. The reconstruction of the articulate fossa of the temporomandibular joint in extensive resections of tumors in the temporal area is emphasized.

Objective Acute and subacute hemorrhage in the head and neck often represent a life-threatening situation. The goal of this study is to evaluate the indications for and contributions of endovascular techniques in the diagnosis and management of such severe cases. Design Seventy-two patients with acute or subacute intractable hemorrhage of the head and neck were treated over a period of 5 years: 2 patients had experienced trauma; in 6 cases the cause of bleeding was iatrogenic; and in 2 patients intraosseous arteriovenous malformations were manifested. Fifteen patients had tumors, 9 of whom had prior radiotherapy. Forty-seven patients presented with epistaxis (41 idiopathic and 6 during anticoagulation therapy). The endovascular therapy was performed using polyvinyl alcohol particles, fibered platinum or electrolytically detachable coils (Guglielmi detachable coils; Target Therapeutics, Fremont, Calif), a stent, glue (Ethibloc; Ethicon GmbH, Norderstedt, Germany, and Histoacryl; B. Braun Melsungen AG, Melsungen, Germany), or with a combination of these different embolic materials. Results The acute bleeding was successfully controlled in all cases. Fourteen patients (7 with epistaxis, 5 with tumors, and 2 with arteriovenous malformations) had to be embolized more than once before the bleeding could be controlled. The idiopathic, traumatic, iatrogenic, and remaining tumoral cases were treated only once. The long-term morbidity was 1.9%. Conclusions Owing to the recent continuous advances in interventional radiologic techniques, it is possible to treat both acute and subacute life-threatening head and neck hemorrhage most efficiently. In many cases the endovascular therapy complements surgery.

• A 10-year experience with surgical treatment of 813 zygomalateral orbital complex fractures is reviewed. Regardless of the type or severity of the fracture pattern, concomitant fractures of the orbital floor and rim were approached exclusively through the transconjunctival approach without a lateral canthotomy. The advantages of this approach compared with the subciliary access are the avoidance of a visible scar and markedly reduced incidence of postoperative lower eyelid complications such as ectropion and edema. Implants of lyophilized dura or cartilage and autogenous bone were used to reconstruct orbital floor defects. Malar asymmetry is a frequent complication of zygoma fractures resulting from inadequate three-dimensional reduction. Methods for accurate reduction and stabilization, indications for closed and open reduction, and management of the fractured infraorbital rim are emphasized. The indications for miniplates vs wire ligatures for the infraorbital rim are discussed. Long-term follow up and evaluation of the results with regard to the fracture pattern, complications, maxillary sinus dysfunction, and facial and orbital symmetry are presented. ( Arch Otolaryngol Head Neck Surg . 1991;117:611-622

The subject of this paper is the evaluation of the advantages pertaining to the THORP (titanium hollow screw reconstruction plate) condylar prosthesis for reconstruction after hemimandibulectomy and exarticulation. The THORP condylar prosthesis is three-dimensionally adjustable, enabling the intraoperative meticulous functional adaptation of the condyle. Various designs of the condyle make it possible to achieve optimal congruency between the articular fossa and condyle. The anchorage of the prosthesis to the stump of the mandible is achieved with perforated hollow-screws rigidly fixed to the plate, thus producing optimal functional stability. The long-term follow-up of eleven cases, reconstructed with this system, confirmed the correct guidance and functional efficiency of this type of condylar prosthesis.

The titanium hollow screw reconstruction plate (THORP) system for reconstruction of lower jaw defects provides a functional stable fixation and is used as a long-term or permanent implant in tumor surgery and in traumatology. The rigid fixation of the head of the screw to the plate, avoiding unphysiologic loads to the bone underneath the plate, and the titanium plasma-coated perforated hollow screws, enabling the development of direct bone-titanium contact as well as the ingrowth of bone into the lumen and perforations, are the major advantages of this system compared to conventional systems. The different surgical methods, such as preservation of the condylar process with only two screws, intra-operative freely adjustable condylar prosthesis, lingual application of the plate, and primary bone transplantation, are described. The evaluation of 62 patients reconstructed with the THORP system between 1981 and 1986 revealed no plate loosening, even in irradiated bone, and showed satisfactory aesthetic and functional results.

The surgical treatment of 26 patients with ankylosis of the temporomandibular joint, as well as various methods and materials used for functional restoration are described. The significance of radical removal of the ankylotic bone, as well as the advantages of the interpositioning of the lyophilized cartilage, are emphasized.

The treatment modalities and results of 346 cases of frontobasal and midface fractures, 194 of which had to be managed by surgery, are reported, and the operative results are evaluated. The importance of an early one-stage operative repair of combined frontobasal-maxillofacial fractures is stressed. The indications for the pure transethmoidal, combined transethmoidal-transfrontal, and single neurosurgical handling of these patients are analyzed. Important surgical modifications that are decisive in the operative management of these fractures are described.

Summary The aim of this paper is to emphasize the advantages of a one-stage, step by step repair of facial skeletal injuries as well as the dural tears and lesions of the anterior fossa, by one and the same team. The methods described permit optimal reduction of the pseudohypertelorism and major displacements in severe combined craniofacial injuries. The simultaneous subcranial exposure of the entire basal region of the anterior fossa obviates the intracranial approach or frontal lobe retraction thus making early stage surgical management feasible. The surgical treatment of these injuries as a single entity, as well as further modifications reduce complications such as recurrent CSF leakage, anosmia, mucocoele or secondary operations for inadequate fracture reduction. The significance of primary meticulous reconstruction of the combined cranial vault and midface fractures for the achievement of normal physiological function of the various systems is particularly highlighted.

The titanium-coated hollow screw and reconstruction plate system (THORP) was used in 7 selected patients; 3 of whom underwent simultaneous bone grafting and implantation of titanium fixtures for dental reconstruction.The advantages of the system with an excellent anchorage and no loosening of the screws, the possibility of lingual application of the plate and reconstruction with a three-dimensionally free adjustable condylar prosthesis, are well demonstrated in our series with an observation period up to 2 1/2 years

Experience in the management of 916 fractures of the mandible stimulated us to develop new methods and surgical techniques for functionally-stable intraoral internal plate osteosynthesis. The development of a fixation bar which is adapted to the alveolar process of the fractured mandible enables a compression of this area prior to the plate osteosynthesis. This procedure facilitates the plate application from the intraoral approach so that in 358 cases all types of fractures of the body, angle and ascending ramus can be reduced using this access, and not only the selected favourable cases. A new plate and screws of our own design have been successfully used in cases with comminuted multifragmentary and defect fractures. The rigid fixation of the head of the screws to the plate produces an optimal functional stability compared with conventional systems. The combination of the advantages of an external fixation device and those of stable internal osteosynthesis produces a long term functional stability even in cases with extensive defects where delayed consolidation is to be expected; tilting and loosening of the screws or resorption of the compact bone underneath the plate do not occur. Thus the extraoral approach and visible skin incisions can be avoided. This procedure is time sparing and less traumatic to the soft tissues compared with the extraoral approach. The extremely low complication rate in 358 fractures managed by plate osteosynthesis using the intraoral approach confirms the efficiency of this method.

In the usual reconstruction of maxillary contour, the grafts are usually exposed to the antral or nasal cavities. This leads to postponed remodelling and a higher rate of resorption and sequestration. To avoid exposure of the grafts, the buccal fat pad is rotated into the maxillary sinus and lined to the bone grafts. The vascularized buccal fat pad not only contributes to a better integration of the bone grafts but also enables the restoration of normal physiologic function of the maxillary sinus.

One hundred three patients underwent a modified sagittal ramus split osteotomy of the mandible. Maintenance of the temporomandibular joint relationship prior to the procedure was achieved postoperatively by using a three-dimensionally adaptable fixation bar. Techniques were also developed to avoid damage to the inferior alveolar nerve during the osteotomy and application of lag screws. These procedures avoided the disadvantages of lag screw osteosynthesis, and reduced relapse.

A newly developed material, which we call biocement, consisting of bisphenol-a-glycidyl methacry-later` (‘epoxide methacrylate’) as organic matrix and Bio-ceramic Battelle, Bioglass Hench and/or pentacalcium hydroxide triphosphate (‘tri-calcium phosphate’) powder as filling particles is presented. In an extension of previous experiments, various types of this biocement, containing different admixtures of paniculate matter, were employed to test their usefulness in head surgery, in particular maxillo-facial reconstruction, on dogs and a rhesus monkey. Encouraging results were obtained with regard to (a) fixing a titanium alloimplant under some degree of mechanical stress; (b) covering a defect in the skull cap, including the closure of an artificially induced meningeal fistula with liquorrhea; and (c) reconstruction of defects in the anterior wall of frontal sinuses. Spescial emphasis is placed on direct contact between biocement and bone, interdigitations between these two, reactions of meningeal tissue, ...

This publication concerns two cement forming tumours - the centrally cementifying fibroma and the true cementoma. The centrally cementifying fibroma is a rare tumour and has been considered an entity for some time. Our case presents a lesion of a size and a homogeneous histological structure rarely encountered. The operative procedure is also discussed. The progression from the radiolucent to the radio-opaque stage could be observed radiologically in the case of a cementoma.

The bridging of mandibular defects following tumor resection presents special problems. This stimulated us to look for a stable implant fixation method, particularly for use in irradiated tissues. We therefore developed the titanium hollow screwreconstruction plate system (THRP system) and have used it successfully during the last four years. I-4 The application of the THRP system as well as other conventional reconstruction plates is done on