Skull Base Surgical Approaches

Factors that determine the type of treatment:

• Location of the tumor
• Size of the tumor
• Type of tumor
• Direction of tumor growth
• Symptoms
• Health of the patient
• Previous treatment (surgery, radiation, chemotherapy)
• Patient / Family choice
• Whether a biopsy or complete tumor resection is planned.

The following surgical approaches are most commonly used by the skull base team. In many cases a multidisciplinary team approach is required for optimal results. Our center has modified many established surgical procedures and developed new surgical approaches to access tumors in the skull base region.

• Various types of craniotomies
• Transcochlear approach
• Translabrynthine approach
• Retrolabrynthine approach
• Far Lateral approach
• Combined approach
• Transsphenoidal
• Transoral
• Transfacial approaches

Transfacial surgical procedures are used for tumors located central and deep within the skull base region. The transfacial surgical approaches have been categorized into levels 1 through 6. They permit wide exposure for visualization of the tumor and critical structures, and usually involve single-staged resection.

Transfrontal (Level 1)
Through a bicoronal incision, a craniotomy and osteotomy of the supraorbital bar is performed to gain access to the anterior cranial fossa and cribriform lesions.

Transfrontal Nasal (Level 2)
Through a bicoronal incision, a craniotomy and removal of the frontonasal section is performed to achieve exposure to the nasopharynx, ethmoid and sphenoid sinuses and anterior approach to the clivus.

Transfrontal Nasal-Orbital (Level 3)
Through a bicoronal incision a craniotomy is performed along with removal of the lateral orbital walls on the frontonasal segment. This allows lateral retraction of the globes in addition to the exposure achieved through a level 2 approach

Transnasomaxillary (Level 4)
A Weber Ferguson facial incision is used to do a bipartition of a LeFort III osteotomy. This approach yields a wide exposure of the entire central skull base from the radix to the cervical spine.

 

Transmaxillary (Level 5)
An intraoral incision is used to perform a LeFort I osteotomy (horizontal maxillary osteotomy) and bipartition to provide access for clival tumors that extend superiorly and for small to moderate nasopharyngeal tumors.

Transpalatal (Level 6)
Through an intraoral incision an osteotomy of the palate is made to gain access to tumors extending into the lower clival region.