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ABSTRACT: Numerous distinct neoplasms are encountered at the anterior cranial base. Management of these primary tumors and their locoregional recurrences are dictated by the histopathologic diagnosis. We present two unusual cases of extra-axial anterior cranial base malignancies with locoregional recurrence where the recurrent tumor encountered was of a distinct histopathologic type. While rare, this report highlights the possibility of encountering a distinct tumor type in the posttreatment surveillance of patients with anterior cranial base malignancies. Laryngoscope, 2012.
The Laryngoscope 04/2013; · 1.75 Impact Factor
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ABSTRACT: A 46-year-old man presented with persistent right otalgia and hearing loss. Exam was significant for a mildly tender retromandibular mass with intact nonerythematous overlying skin. Computerized tomography with intravenous contrast of the neck revealed 2 relatively well circumscribed masses in the right parotid gland. Although 1 lesion was suspected to be a necrotic lymph node, histologic analysis after superficial parotidectomy demonstrated 2 unique salivary gland tumors. Diagnoses of both sebaceous lymphadenoma and membranous basal cell adenoma were rendered. The occurrence of unique, synchronous, ipsilateral salivary gland tumors is distinctly unusual and this combination of parotid gland neoplasms has not previously been documented. In this report, we present the case with its management, followed by a discussion of the histopathologic nature of each tumor including the possible overlap between these two entities.
Oral surgery, oral medicine, oral pathology and oral radiology. 01/2013;
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ABSTRACT: To describe surgical outcomes and radiographic features of olfactory groove meningiomas treated by excision through the subcranial approach. Special emphasis is placed on paranasal sinus and orbit involvement.
Retrospective review of a series of patients.
Nineteen patients underwent excision of olfactory groove meningioma (OGM) via the transglabellar/subcranial approach between December 1995 and November 2009. Nine patients had previously undergone prior resection at outside institutions, and four had prior radiotherapy in addition to a prior excision. Transglabellar/subcranial surgical approach to the anterior skull base was performed.
Tumor histology included three World Health Organization (WHO) grade III lesions, one WHO grade II lesion, and 15 WHO grade I lesions. Fourteen patients had evidence of extension into the paranasal sinuses, with the ethmoid sinus being most commonly involved. Kaplan-Meier estimates of mean overall and disease-free survival were 121.45 months and 93.03 months, respectively. The mean follow-up interval was 41.0 months, and at the time of data analysis three patients had recurrent tumors. Seven (36.8%) patients experienced a major complication in the perioperative period; there were no perioperative mortalities. Orbit invasion was observed in four patients, with optic nerve impingement in 11 patients. Of these, three patients had long-term diplopia. No patients experienced worsening of preoperative visual acuity.
Olfactory groove meningiomas demonstrate a propensity to spread into the paranasal sinuses, particularly in recurrent cases. Given a tendency for infiltrative recurrence along the skull base, this disease represents an important area of collaboration between neurosurgery and otolaryngology. The subcranial approach offers excellent surgical access for excision, particularly for recurrences that involve the paranasal sinuses and optic apparatus.
The Laryngoscope 11/2011; 121(11):2282-9. · 1.75 Impact Factor
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ABSTRACT: We analyzed the effect of predefined patient demographic, disease, and perioperative variables on the rate of complications in the perioperative period following subcranial surgery for anterior skull base lesion. A secondary goal of this study was to provide a benchmark rate of perioperative mortality and morbidity through comprehensive analysis of complications. Retrospective review of a consecutive series of patients (n = 164) who underwent the transglabellar/subcranial approach to lesions of the anterior skull base between December 1995 and November 2009 in a tertiary referral center. Main outcome measures were perioperative morbidity and mortality. No perioperative mortalities were observed over the period of consecutive review. The overall complication rate was 28.7%, with 30 (18%) patients experiencing major complication. Multivariate analysis revealed that the following variables were independent predictors of perioperative complication of any type: positive margins on final pathology, perioperative lumbar drain placement, and dural invasion. The subcranial approach provides excellent access to the anterior skull base with zero mortality and acceptable morbidity in comparison with other contemporary open surgical approaches. It should be considered a procedure with distinct advantages in terms of perioperative morbidity and mortality when selecting a therapeutic approach for patients with anterior skull base lesions.
Skull Base 07/2011; 21(4):215-22. · 0.66 Impact Factor
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ABSTRACT: To assess the risk of cervical lymph node metastases after definitive treatment for esthesioneuroblastoma (ENB) that did not include elective neck therapy.
This was a retrospective analysis of 26 ENB patients treated at the University of Michigan between 1995 and 2007. Tumor stage was Kadish A in 1 patient, B in 19, C in 5, and unknown in 1. Craniofacial or subcranial resection was performed in 24 patients (92%), with negative margins in 22 (92%). Postoperative radiotherapy (RT) to the primary site was given in 12 patients (46%), and 14 patients (54%) had surgery alone. All patients had clinically N0 disease, and no patient underwent elective neck dissection or radiation. Median follow-up was 72 months.
Local relapse-free survival was significantly better for patients who received postoperative RT compared with those who had surgery alone: 100% vs. 29% at 5 years, respectively (p = 0.005). Five-year disease-free survival was 87.5% in the RT group vs. 31% in the surgery-alone group (p = 0.05). Regional failure was observed in 7 patients (27%), 6 with Kadish Stage B and 1 with Stage C disease. The most common site of nodal failure was Level II, and 3 patients failed in the contralateral neck. Only 3 patients with regional failure were successfully salvaged.
The high rate of regional failures when the neck is not electively treated justifies elective nodal RT in patients with both Kadish Stages B and C. In addition, our experience confirms the beneficial effect on local control of adjuvant RT to the tumor bed.
International journal of radiation oncology, biology, physics 06/2011; 81(4):e255-61. · 4.59 Impact Factor
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ABSTRACT: Multiple treatment options exist for management of adenoid cystic carcinoma of the lacrimal gland. Our objective was to perform an analysis of outcomes in a cohort of patients with adenoid cystic carcinoma of the lacrimal gland treated identically with an orbitocranial approach.
We performed a retrospective review of 7 consecutive patients who presented to a tertiary care academic medical center between 1995 and 2009 with adenoid cystic carcinoma of the lacrimal gland.
All patients were treated with an orbitocranial approach to tumor resection followed by postoperative radiotherapy. The mean and median follow-up times were 39 and 19 months, respectively (range, 7 to 138 months). Six patients had orbital reconstruction using free tissue transfer, and 1 patient had a split-thickness skin graft to line the orbital cavity. Two patients developed distant metastases 18 months and 29 months after surgery and ultimately died with disease. Five patients are alive without disease.
The orbitocranial approach followed by postoperative irradiation achieves excellent local and regional control rates for adenoid cystic carcinoma of the lacrimal gland, although patients remain at risk long-term for distant metastases. Orbital bone removal to obtain adequate margins should be a routine part of tumor resection for these malignancies.
The Annals of otology, rhinology, and laryngology 06/2011; 120(6):397-400. · 1.05 Impact Factor
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ABSTRACT: Embolization of a juvenile angiofibroma (JNA) is commonly performed prior to surgical resection. Traditionally, it has been performed from an intra-arterial approach with particulate material. A novel technique is described in which a JNA was completely devascularized prior to surgical removal by direct percutaneous embolization with only ethylene vinyl alcohol. A midfacial degloving and medial maxillectomy/maxillotomy was then performed and the tumor extirpated with blunt finger dissection and the assistance of an endoscope, with 200 ml of blood loss.
Journal of neurointerventional surgery 06/2011; 3(2):191-3. · 0.92 Impact Factor
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ABSTRACT: To measure the effect of routine perioperative lumbar drain placement during anterior skull base surgery on the frequency of: 1) tension pneumocephalus and 2) total intracranial complications.
Retrospective review of a series of patients (n = 161) who underwent the transglabellar/subcranial approach to lesions of the anterior skull base between December 1995 and November 2009. A retrospective cohort (n = 45) underwent routine lumbar drain placement at the time of skull base surgery. The remainder of the series did not undergo routine perioperative lumbar drain placement.
Transglabellar/subcranial surgical approach to the anterior skull base, with or without routine perioperative lumbar drain placement.
Routine placement of perioperative lumbar drains was an independent predictor of tension pneumocephalus (P =.022, odds ratio = 11.22 [1.218-103.3]). In addition, this practice was also associated with an increased risk of intracranial complications overall (P =.025, odds ratio = 2.623 [1.104-6.233]).
Routine placement of perioperative lumbar drain may be associated with an increased risk of tension pneumocephalus and intracranial complications during surgery of the anterior cranial base.
The Laryngoscope 03/2011; 121(3):468-73. · 1.75 Impact Factor
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ABSTRACT: We present our experience with sinonasal undifferentiated carcinoma at the University of Michigan over 13 years and review prior published data. We conducted a retrospective review of 19 patients who presented to a tertiary care academic center multidisciplinary skull base clinic with sinonasal undifferentiated carcinoma between 1995 and 2008. Overall survival was 22% at 5 years, and the estimated 5-year distant metastasis-free survival was 35%. At 2 years, local control was 83%, regional control was 50%, and distant control was 83%. Local control was best in those patients treated nonsurgically, as was median survival, though this was not statistically significant. Nodal disease in the neck, either at presentation or at recurrence, was noted in 26% of patients. Survival for sinonasal undifferentiated carcinoma remains poor. It is possible that up-front radiation or chemoradiation will lead to better local control rates, though surgery remains a mainstay of treatment. In all cases, the cervical nodes should be addressed with primary treatment.
Skull Base 03/2010; 20(2):61-7. · 0.66 Impact Factor
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ABSTRACT: The trans-oral approach allows direct access to pathologies of the anterior craniocervical junction. However, the classic midline incision of the posterior pharyngeal wall can be surgically burdensome and limits lateral exposure. We reviewed the medical records of nine patients undergoing the trans-oral approach. The sites of the pathology ranged from the clivus to C2, and surgical exposure ranged from the clivus to C3. Each operation utilized an inferiorly based flap. None of the patients experienced vascular or neurologic complications, and no patient had a cerebrospinal fluid fistula, pseudomeningocele, or meningitis postoperatively. The trans-oral approach with an inferiorly based flap can therefore be safely and effectively performed with minimal oropharyngeal and neurologic morbidity. Not only does a U-shaped flap allow adequate exposure from the lower half of the clivus to C3, a flap improves lateral exposure, provides a clear operating field, and allows superficial mucosal closure not directly overlying the operative field.
Journal of Clinical Neuroscience 02/2010; 17(4):464-8. · 1.25 Impact Factor
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Archives of ophthalmology 01/2010; 128(1):144-6. · 3.86 Impact Factor
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ABSTRACT: This article reports on the presence of an anatomic feature of the extracranial skull base that may result in internal carotid artery injury if secure and complete pterygomaxillary separation is not achieved before maxillary downfracture in the Le Fort I osteotomy. The extracranial skull base of 129 adult skulls and 10 pediatric skulls was examined in the region near the foramen lacerum. This region was inspected for the presence or absence of a bony protrusion that projected posteriorly from the base of the sphenoid, lying inferior to the foramen lacerum. The bony protrusion was present bilaterally in 71% of the adult skulls and 60% of the pediatric skulls. The protrusion was a bony "spike" that pointed posteriorly and was located inferior to the foramen lacerum on the extracranial skull base. Due to its size, shape, and location, the bony protrusion described in this study poses considerable risk to the internal carotid artery if the protrusion is displaced superiorly through the foramen lacerum. In the Le Fort I osteotomy, secure and complete pterygomaxillary separation is crucial to avoid injury to the internal carotid artery during maxillary downfracture.
Skull Base 07/2009; 19(4):273-7. · 0.66 Impact Factor
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ABSTRACT: Objectives: Analysis of outcomes of a cohort of patients with esthesioneuroblastoma. Design: Retrospective cohort analysis. Setting: Patients presenting with esthesioneuroblastoma from 1994 to 2006 in a tertiary care academic medical center. Patients: Fifteen consecutive patients diagnosed as having esthesioneuroblastoma were treated during this time period using a subcranial resection. The mean follow-up is 75 months (range, 2 to 240 mos). Results: The overall survival was 100% and the overall disease-free survival was 49% and 24% at 5 and 15 years, respectively. Patients treated with radiation therapy following surgical resection had a 5- and 15-year disease-free survival of 83.3% compared with a 5- and 15-year disease-free survival of 26.7% and 0%, respectively, for patients whose initial treatment was surgery alone. The mean time to recurrence was 82.1 months. None of the patients had a decrease in Karnofsky Performance Score following subcranial resection. Conclusions: Patients with esthesioneuroblastoma whose initial treatment consists of surgical resection followed by radiation therapy have a longer disease-free survival than patients treated with surgery alone. However, initial treatment modality did not have an effect on survival. Long-term, close follow-up is necessary to identify recurrences, which can be treated with a high degree of success.
Skull Base Surgery 04/2009; 19(2):133-40. · 0.66 Impact Factor
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ABSTRACT: To evaluate the use of transglabellar/subcranial approach for surgical resection of periocular second non-ocular tumors in retinoblastoma patients.
Seven retinoblastoma patients with periocular second tumor involving anterior skull base underwent surgical resection by transglabellar/subcranial approach in a single center. The medical records of these patients were retrospectively evaluated.
The most common presenting symptom in retinoblastoma patients with periocular second tumor was difficulty in maintaining the prosthesis in three patients (43%), followed by epistaxis in one (14%), palpable orbital mass in one (14%), persistent periocular swelling in one (14%), and visual loss in one (14%) patient. Periocular second tumors were leiomyosarcoma in three (43%) patients, osteosarcoma in three (43%), and sphenoid wing meningioma in one (14%) patient. Surgical resection by the transglabellar/subcranial approach was the only treatment in one (14%) patient with sphenoid wing meningioma and was combined with chemotherapy in three (43%) patients, and with both external beam radiotherapy and chemotherapy in three (43%) patients. Surgical margins were negative in three (43%) patients and microscopically positive in four (57%) patients. Complications were minor, including cerebral spinal fluid (CSF) leak in one (14%) patient and CSF leak and subgaleal hematoma in one (14%) patient. After 31 months mean follow-up, three (43%) patients were alive and four patients (57%) were dead.
Retinoblastoma patients with periocular second tumors have a poor prognosis. The transglabellar/subcranial approach can be used for surgical resection of periocular second tumor involving skull base with low morbidity.
Orbit (Amsterdam, Netherlands) 02/2008; 27(4):285-91.
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ABSTRACT: Craniopharyngiomas (CPs) are benign tumors that almost always occur in a suprasellar location, making complete resection difficult and often necessitating radiotherapy. A case of CP presenting in an unusual location in an 8-year-old boy highlights the goals of CP treatment.
An 8-year-old boy sought treatment for symptoms of nasal obstruction and snoring. He also had a history of mild developmental delay, and his father had a thyroglossal duct cyst resected in his own youth. After tonsillectomy and adenoidectomy failed to improve the patient's symptoms, nasal endoscopy and biopsy revealed an intranasal CP. After this treatment, he experienced chronic thin brown nasal discharge. Magnetic resonance imaging further revealed tumor invading the sphenoid body and the clivus and that the tumor had no intracranial extension.
The child underwent surgical resection via a Le Fort I osteotomy approach. Complete resection was accomplished based on intraoperative frozen section pathological examination and postoperative magnetic resonance imaging results.
CP with no intracranial extension is a very rare but benign tumor. We recommend vigorous attempts to resect such tumors completely to minimize the chance of recurrence and the possible need for radiotherapy. Although radiotherapy controls CP growth quite well, it has its own risks that should be avoided if possible. Cranial base techniques may facilitate total resection.
Neurosurgery 05/2007; 60(4):E780-1; discussion E781. · 2.79 Impact Factor
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ABSTRACT: Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation.
This study is a case series of 20 patients (14 males, 6 females, aged 8-79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim.
The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures.
Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications.
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Otolaryngology Head and Neck Surgery 01/2005; 131(6):958-63. · 1.72 Impact Factor
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ABSTRACT: Although various options exist for restoration of the orbital defect in complex craniofacial resections, the aesthetic appearance and functional result of the orbit are optimized when the bony orbital architecture, orbital volume, and facial contour are specifically addressed. The study describes an approach using free tissue transfer for restoration of the native orbital aesthetic subunit.
Retrospective case series.
Nineteen patients (male-to-female ratio, 14:5; mean age, 52 y [age range, 8-79 y]) in the study period between 1997 and 2001 had orbital defects that could be classified into one of the following categories: 1) orbital exenteration cavities only, 2) orbital exenteration cavities with resection of less than 30% of the bony orbital rim, or 3) radical orbital exenteration cavities with resection of overlying skin and bony malar eminence. Group 1 had reconstructions with fasciocutaneous forearm flaps; group 2, with osseocutaneous forearm flaps; and group 3, with osseocutaneous scapula flaps.
Eighteen of 19 patients achieved a closed orbital reconstruction with restoration of the orbital aesthetic subunit. Among 16 patients with more than 4 months of follow-up, 10 patients had minimal or no resulting facial contour deformity and 8 patients engaged in social activities outside the home on a frequent basis. Five of the nine patients who were working before their surgery were able to return to work.
Patients with complex midface defects involving the orbit can undergo free tissue transfer and have successful restoration of the native orbital aesthetic subunit without an orbital prosthesis.
The Laryngoscope 11/2004; 114(10):1706-13. · 1.75 Impact Factor
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ABSTRACT: Head and neck adenoid cystic carcinoma (ACC) is a malignancy of the salivary and lacrimal glands with a variable growth pattern and propensity for perineural spread. Involvement of the skull base indicates a poor prognosis. Despite surgical resection and adjuvant radiotherapy, tumor recurrence and metastases are common. The urokinase-type plasminogen activator and its receptor (uPAR) have an important role in tumor invasion and metastasis. The expression of uPAR is predictive of poor outcomes in many tumors. This study examines the expression of human uPAR in ACCs involving the skull base.
To determine uPAR expression in ACCs of the skull base by immunohistochemical analysis and compare expression with tumor histologic findings and clinical outcomes.
Analysis of uPAR in archival ACC specimens and a retrospective medical chart review.
Multidisciplinary cranial base program at a university medical center with tertiary referral pattern.
Ten (83%) of 12 tumors stained positive for uPAR. Three of 3 patients who died of ACC and 6 of 6 patients alive with disease expressed uPAR. Only 1 of 3 patients free of disease was uPAR positive.
In most patients with ACC of the skull base, uPAR was expressed. Its expression seems to be a negative prognostic factor. However, the small study sample limits our observations. Additional study of uPAR expression in ACC at other anatomic sites is required.
Archives of Otolaryngology - Head and Neck Surgery 03/2003; 129(2):215-8. · 1.63 Impact Factor
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Lawrence J Marentette
Archives of Facial Plastic Surgery 6(2):136. · 1.65 Impact Factor
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ABSTRACT: Ossifying lipomas, characterized by their independence of bony connection to the skeleton, are extremely rare benign neoplasms. They have primarily been described in adults older than 50 years of age and occur in the head and neck region. The etiology is unknown. Excision is the preferred treatment. The objective of this study is to report the case of a rare ossifying lipoma immediately anterior to C1 to C2, requiring a transoral approach for excision.
The case of an adolescent with a retropharyngeal mass is described.
A 15-year-old female patient presented with an asymptomatic parapharyngeal mass detected on routine physical examination. Computed tomography and magnetic resonance imaging noted a calcified, left-sided, parapharyngeal mass, approximately 3×2×2 cm, anterior to C1 and C2, most consistent with a benign osseous lesion. A transoral approach was used to excise the mass. Histologic examination demonstrated an ossifying lipoma. Postoperative imaging confirmed complete excision. The postoperative course was unremarkable, and the patient has had no recurrence at 6-month follow-up.
This case demonstrates that a transoral approach to a lesion anterior to C1 to C2 in an adolescent can be safe, complete, and effective.
Case Report, level 5.
Journal of pediatric orthopedics 31(5):e53-6. · 1.23 Impact Factor
