Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms

A subtemporal-preauricular infratemporal fossa approach to remove 22 large neoplasms involving the lateral and posterior cranial base is detailed. The areas from which a neoplasm could be removed by this approach included the sphenoid and clival bone; the medial half of the petrous temporal bone; the infratemporal fossa; the nasopharynx; the retro- and parapharyngeal area; the ethmoid, sphenoid, and maxillary sinuses; and the intradural clivus-foramen magnum area. The pathology of the neoplasms included benign tumors such as meningioma, malignant cartilaginous neoplasms such as chordoma, and other malignant lesions such as nasopharyngeal carcinoma. This approach offers many advantages over other anterior and lateral approaches to the lateral and posterior cranial base: these include minimal brain retraction; direct access to the ipsilateral petrous and upper cervical internal carotid artery; reconstruction of extensive cranial base defects, often with the use of a vascularized rectus abdominus flap; preservation of the hearing conduction mechanism when it is not involved by tumor; and the maintenance of excellent facial nerve function postoperatively. The use of an anterior extradural approach (transethmoidal) and of an intradural approach (frontotemporal or retromastoid), either concurrently or separately, is necessary in some patients to effect total tumor removal. The most serious complication in this series was the death of a patient due to postoperative infection and bilateral carotid artery rupture, which may have been avoided by the use of a rectus abdominis muscle flap for reconstruction. Among the 21 surviving patients, 18 had a good outcome, two had a fair outcome, and one with preexisting neurological deficits had a poor outcome. One of the surviving patients with a chordoma died of pulmonary metastases 1 year later, without evidence of local recurrence. The length of postoperative follow-up evaluation in these patients is insufficient to make any judgment about the effectiveness of this surgical approach in achieving a cure or long-term control of the tumors described.