Combined pterional-anterolateral approaches to cranial base tumors

Advanced tumors of the paranasal sinuses, parotid gland, orbit, parapharynx, and cranial cavity may invade the infratemporal fossa by direct extension or through natural anatomic pathways. The inability to control disease involving this region is reflected by the unacceptably high recurrence rates for both intracranial and extracranial neoplasms. Between 1983 and 1986, a pterional (or subtemporal) approach was combined with such conventional anterolateral procedures as a mandibulopharyngectomy, maxillectomy, orbitectomy, and parotidectomy in 13 patients with advanced skull base lesions. The tumor origin was extracranial in ten cases and intracranial in three patients. Seven of the neoplasms were malignant and six were histologically benign. Complete tumor removal was achieved in all patients. Repair of the ablative defect was achieved with a temporalis myogenous flap in ten patients, and primary closure or distant myocutaneous flaps in the remaining three patients. Postoperative complications included three lateral nasocutaneous fistulae secondary to temporalis myogenous flap necrosis and isolated cases of stroke, cerebral edema, pneumocephalus, and cerebrospinal fluid rhinorrhea. Twelve patients are alive without evidence of disease at a mean interval of 25 months. The remaining patient died from lung metastases 11 months after surgery.