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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 193-197

Access osteotomies of maxillofacial region: A report of three cases


Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Chintareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication13-Dec-2013

Correspondence Address:
Mohammad Akheel
Narayana Dental College and Hospital, Chintareddypalem,Nellore - 524 002, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122985

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  Abstract 

A plethora of pathologies occurs in the cranial base and deep spaces of the neck, the treatment of which poses a surgical challenge owing to the anatomical complexity, difficulty in access, and proximity of vital structures. A multidisciplinary approach is often required in these situations to strike a balance between preventing damage to the vital anatomic structures and complete removal of the lesions. This article describes our experience with three clinical situations that required access osteotomies of maxillofacial region that has facilitated complete to near total removal of the lesions. In the first case, an inferiorly pedicled zygomatic arch osteotomy was done to approach an osteomyelitis of sphenoid bone through the infratemporal fossa. In the second case, paramedian step osteotomy of mandible with mandibular swing was done to remove a lateral pharyngeal wall schwannoma. In the third case, a frontonasoorbital osteotomy was done to approach a lesion at clivus of middle cranial base. All the access osteotomies provided satisfactory exposure of the lesions and were fixed with miniplates, resulting in good restoration of facial skeletal morphology and function. Maxillofacial access osteotomies provide good access to the lesions with minimal surgical morbidity and distortion of facial esthetics.

Keywords: Access osteotomy, clivus, fronto-naso-orbital osteotomy, mandibular swing, osteomyelitis of skull base, zygomatic arch osteotomy


How to cite this article:
Devireddy SK, Kishore K, Gali RS, Kanubaddy SR, Dasari MR, Akheel M. Access osteotomies of maxillofacial region: A report of three cases. Arch Int Surg 2013;3:193-7

How to cite this URL:
Devireddy SK, Kishore K, Gali RS, Kanubaddy SR, Dasari MR, Akheel M. Access osteotomies of maxillofacial region: A report of three cases. Arch Int Surg [serial online] 2013 [cited 2024 Mar 1];3:193-7. Available from: https://www.archintsurg.org/text.asp?2013/3/2/193/122985


  Introduction Top


A plethora of pathologies occurs in the cranial base and deep spaces of the neck, the treatment of which poses a surgical challenge owing to the anatomical complexity, difficulty in access, and proximity of vital structures. A multidisciplinary approach is often required in these situations to strike a balance between complete to near total removal of the lesions and preventing damage to vital anatomic structures. In these clinical situations, access osteotomies of the facial skeleton can be performed to provide better exposure and access. The maxillofacial surgeon plays a vital role in this team comprising of neurosurgeon, head and neck surgeon, and neuroanesthetist for performing facial skeletal access osteotomies owing to a thorough understanding of anatomy and procedural complexities of facial skeletal surgery. It was Von Langenback in 1859, who first performed Lefort I maxillary osteotomy for the removal of a benign nasopharyngeal polyp. [1] A systematic approach to facial access osteotomies for the cranial base lesions has had its origins from the pioneering works of Tessier [2] who has described the techniques of transposition and relocation of middle third of facial skeleton for craniofacial synostosis syndromes. Curioni and Clauser [3] and Janecka [4] introduced the concept of craniofacial dismantling and reassembly in the management of skull base tumors. Since then, many surgical approaches have been developed and refined using both pedicled as well as nonpedicled access osteotomies. We report three such cases of facial access osteotomies of which two were pedicled osteotomies and one was nonpedicled osteotomized bone graft.


  Case Report Top


Case 1

A 61-year-old male patient reported to the department of neurosurgery with a complaint of right-sided hemifacial pain and headache of 22 days duration. His medical history was noncontributory. Clinical examination revealed parasthesia of right upper lip and angle of the mouth, normal mouth opening, and no other functional neurological deficits. Patient's hematological investigations were within normal limits with no coexisting systemic comorbidities. Magnetic resonance imaging (MRI) scan of the brain [Figure 1] showed a hyperintense lesion measuring 3 × 4 cm in the right basitemporal fossa, involving the soft tissues of infratemporal fossa with minimal involvement of right sphenoid sinus suggestive of a neoplastic or an infective lesion (fungal). On the basis of clinical examination, and MRI findings, a provisional diagnosis of meningioma was made.
Figure 1: Pre op MRI showing lesion in infratemporal fossa involving the right side sphenoidal sinus

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The excision of the lesion in the infratemporal fossa through a zygomatic arch access osteotomy under general anesthesia was planned. Preoperatively before orotracheal intubation, lumbar puncture was done to decrease the intra cranial tension and facilitate the retraction of brain. Right hemicoronal incision with preauricular extension to the intertragic notch was made. Subpericranial dissection with full thickness flap was raised and an inverted L incision on superficial temporal fascia was made to the root of zygoma combined with a subperiosteal dissection anteriorly to expose the zygomatic arch. The attachment of the masseter muscle and investing layer of deep cervical fascia to inferior aspect of the zygomatic arch was not stripped. Then, osteotomy cuts were placed in the posterior aspect of the zygomactic arch and on body of zygoma anteriorly. The zygomatic arch was swung lateroinferiorly pedicled on masseter muscle and fascia. The temporalis muscle was stripped from temporal bone and swung lateroinferiorly on to the mobilized zygomatic arch thus exposing the lesion in the infratemporal fossa [Figure 2].
Figure 2: Zygomatic arch pedicled on masseter. Temporalis swung lateroinferiorly. Lesion exposed in infratemporal fossa. T-temporalis muscle

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The lesion occupying the entire infratemporal fossa was excised. After excision of the lesion, resorption of lateral surface of greater wing of sphenoid and roof of the infratemporal fossa was noticed. The necrotic bony edges of the sphenoid bone were removed exposing the dura which was free of lesion. After achieving hemostasis, temporalis muscle was sutured back. Zygomatic arch was reduced and fixed in position with two-holed, 2 mm titanium miniplates using 2 × 6 mm screws [Figure 3]. Suction drain was inserted and scalp incisions closed in layers.

Histopathological examination of the specimen revealed mucormycosis characterized by fibrocollagenous tissue with granulomas, necrotic foci with fungal hyphae, and sheets of foamy macrophages. A definitive diagnosis of solitary mucormycosis of skull base in an immunocompetent individual was made. Postoperative period was uneventful. Facial nerve functions were normal. Patient was started on systemic amphotericin B therapy with complete resolution of symptoms.
Figure 3: Fixation of osteotomized zygomatic arch with miniplates L-lateral orbital rim, Z-zygomatic arch

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Case 2

A 56 year old male reported to department of oral and maxillofacial surgery with pain and swelling on right side of neck and pain on swallowing for 4 months. The medical history was noncontributory. Clinical examination revealed a 5 × 4 cm swelling in the right posterior submandibular region 1 cm below the inferior body of the mandible with mild tenderness. Patient's hematological investigations were within normal limits. MRI of neck showed a lesion of 5 × 4 cm on lateral pharyngeal wall with a normal chest x-ray. On the basis of clinical and radiological features, it was provisionally diagnosed as schwannoma of parapharyngeal space.

Excision of the lesion through a paramedian step access osteotomy under general anesthesia was planned. Extended submandibular incision was made and dissection of the neck done in layers. Tumor was exposed following lateral retraction of the sternocleidomastod muscle. For complete removal of the tumor and better access, a paramedian step mandibulotomy on right side anterior to the mental foramen was made. The osteotomized proximal segment was swung laterally exposing the floor of the mouth, lateral, and parapharyngeal spaces [Figure 4]. The tumor was accessed and completely excised. After excision of the tumor, the mandible was returned and fixed back to its original position with 2.5 mm, four-holed stainless steel miniplates using 2.5 × 8 mm screws. Suction drain was placed. Neck closure was done in layers. Postoperative period was uneventful. Histopathological examination of the specimen revealed lateral pharyngeal wall schwannoma.
Figure 4: Removal of the lesion with paramedian step mandibular osteotomy with mandibular swing approach. PS- Parapharyngeal space schwannoma

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Case 3

A 40-year old male patient reported to the department of neurosurgery complaining of frontal headache of 3 months. His medical history was noncontributory. On clinical examination, patient had double vision and mild exopthalmus of both eyes. Further neurological examination did not reveal any abnormality. Patient's hematological and biochemical investigations were normal. MRI showed a well-defined lesion in the clivus region at the junction between middle and posterior cranial fossa [Figure 5]. On the basis of clinical and radiological features, it was provisionally diagnosed as clival chodroma.
Figure 5: Pre op MRI Brain showing lesion in clivus region

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The excision of the lesion in the clivus region through a bitemporal approach and frontonasoorbital access osteotomy under general anesthesia was planned. Preoperatively lumbar puncture was done to decrease the intracranial tension and to facilitate the brain retraction. Bicoronal incision was made and subpericranial dissection was done to raise the flap [Figure 6]. Bitemporal craniotomy was done for direct visualization of the lesion. As further brain retraction could not be done to expose the lesion in middle cranial base, a bilateral frontonasoorbital osteotomy was carried out. The posterior table of frontal sinus was then removed with diamond bur and bone ronguer. Anterior and middle cranial fossa with skull base was then visualized. The brain was retracted upward and the lesion was approached from the opening created. The lesion was removed in piece meal.
Figure 6: Elevation of subpericranial fl ap and bilateral pterional craniotomy

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After removal of the lesion, the osteotomized segments were fixed back with 2 mm, two-holed stainless steel miniplates bilaterally with 2 × 6 mm screws. With fenestration of the dura, hemostasis was achieved and suction drain placed. The scalp was closed in layers. Histopathological examination revealed giant cell tumor of clivus.


  Discussion Top


A myriad of access osteotomy approaches to specific anatomic areas of the skull base and neck have been devised and refined. The choice of surgical approach to the lesions of the cranial base such as infratemporal fossa, sphenopalatine fossa, and deep spaces of neck is based on extent of the lesion, vascularity, and involvement of neurovascular structures. The objective of the surgeon is not only to remove the lesion but also to prevent inadvertent damage to the adjacent vital structures.

Approaches to infratemporal fossa include zygomatic arch osteotomy with or without lateral orbital rim or inferior orbital rim extensions, pedicled or nonpedicled. Inverted L zygomatic bone osteotomy with or without involvement of lateral orbital rim can also be used. In our first case, a hemicoronal incision with a preauricular extension up to the intertragic notch was given; zygomatic arch osteotomy was done pedicled inferiorly on masseter. This permitted stripping temporalis muscle from temporal bone and swinging it lateroinferiorly, thus exposing infratemporal fossa and the lesion. Zygomatic arch osteotomy was first described by Hamlyn et al., [5] to gain access to the infratemporal region. Terasaka et al., [6] and Honeybul et al., [7] have advocated zygomatic arch osteotomy to provide access to infratemporal fossa and multiple regions of skull base. Alvaro et al., [8] reported excellent exposure to the floor of middle cranial fossa and lateral wall of cavernous sinus through transzygomatic approach.

Salins [9] reported that the nose along with anterior wall of maxillary antrum in continuity with the inferior orbital rim can be transposed on a skin pedicle. This procedure can be combined with a Lefort I osteotomy and mandibulotomy to gain access to create space for the delivery of anterior, middle, and retromaxillary skull base lesions. The transfacial lateral rotation technique as described by Altmier [10] gives good access to the retro maxillary area but access is very minimal if the infraorbital area has to be approached.

Lesions located in parapharyngeal, lateral pharyngeal and deep spaces of neck, posterior oral floor, retromaxillary and tonsillar fossa can be accessed by mandibular osteotomies. They include median or paramedian step or vertical mandibulotomy with mandibular swing approach. This osteotomy can be done at symphysis and parasymphysis region anterior to the mental foramen to preserve the neurovascular structures. The advantage of the latter osteotomy is that it avoids the need for dissecting genioglossus, geniohyoid, and anterior belly of digastric muscles. [11] The osteotomy if made in the form of step improves the stability after osteosynthesis. In our second case we did a paramedian step osteotomy with mandibular swing to expose the superior extent of the lateral pharyngeal wall schwannoma. Mandibular swing approach is a versatile approach that can be extended as required to provide increased access fulfilling the criteria of being flexible and extensile. [12]

For increased exposure of the parapharyngeal space, infratemporal fossa and pterygomaxillary region upto the skull base with this approach, a second horizontal osteotomy of the mandibular ramus above the lingula may be necessary. This anterolateral approach was originally described by Attia [13] in 1984. Its disadvantage is the need for tracheostomy. Smith et al., [14] proposed that the access to the parapharyngeal space can be improved by vertical ramus osteotomy with a parasymphyseal mandibulotomy.

Skull base can be approached anteriorly and laterally. In our third case, bitemporal craniotomy was done which was accompanied by frontonasalorbital osteotomy to approach the lesion in the clivus without excessive brain retraction. Raza et al., [15] believe that frontal nasal orbital craniotomy provides access to the floor of the anterior and middle fossa while avoiding excessive brain retraction associated with facial incisions. In addition, this approach is associated with a lower incidence of complications, such as Cerebrospinal fluid (CSF) leak, brain retraction edema, or infection. This approach was initially described by Raveh et al. [16] This technique affords broad access to the orbito-sphenoethmoidal region in addition to the paranasal sinuses. Middle cranial base approaches include Le Fort I maxillary osteotomy, sometimes combined with mandibulotomy and frontonasoorbital osteotomy. When compared with other approaches, Lefort I osteotomy provides excellent exposure for angiofibromas, clivus tumors, and tumors of the nasopharynx, nasal septum, and nasal cavity. Lanz [17] described and performed a midsagittal osteotomy, dividing the inferior segment in to two halves so as to obtain better access to the pituitary gland in middle cranial fossa.

Maxillofacial access osteotomies facilitate easy and complete removal of lesion in the head and neck region without damaging the adjacent vital structures. This approach is safe and simple and is associated with shorter operation time. The advent of low profile miniplates and screws has made the reestablishment of facial skeletal anatomy easier and faster. These access osteotomies form a major factor for decreasing morbidity rate. A multidisciplinary team approach including maxillofacial surgeons is often required with a systematic planning for the removal of hidden lesions of head and neck.

 
  References Top

1.Von Langenback B. Beitrange zur osteoplastik. In. Goschen A, editor. Die osteoplastiche Resektion des Oberkierers. Deutsche Klink. Berlin: Reimer; 1859.  Back to cited text no. 1
    
2.Tessier P. Total facial osteotomy. Crouzon's syndrome, Apert's syndrome: Oxycephaly, scaphocephaly, turricephaly. Ann Chir Plast 1967;12:273-86.  Back to cited text no. 2
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3.Curioni C, Clauser L. The facial splitting in tumor surgery: Dismantling and reassembly of the face. Abstracts of the 11 th congress of the EACMFS. J Craniomaxillofac Surg 1992;20:27.  Back to cited text no. 3
    
4.Janecka PI. Carcinoma of the base of the skull. Mastery of Plastic and Reconstructive Surgery. New York: Little Brown & Co; 1994. p. 1000-7.  Back to cited text no. 4
    
5.Hamlyn PJ, Meredith AP, Archer DJ. A further approach to the infra-temporal fossa. J Laryngol Otol 1986;100:675-8.  Back to cited text no. 5
    
6.Terasaka S, Sawamura Y, Goto S, Fukushima T. A lateral transzygomatic-transtemporal approach to the infratemporal fossa: Technical note for the mobilization of the second and third branches of the trigeminal nerve. Skull Base Surg 1999;9:277-87.  Back to cited text no. 6
    
7.Honeybul S, Neil-Dwyer G, Lang DA. The transzygomatic approach: A long term clinical review. Acta Neurochir (Wein) 1995;136:111-6.  Back to cited text no. 7
    
8.Campero A, Campero AA, Socolovsky M, Martins C, Yasuda A, Basso A, et al. The transzygomatic approach. J Clin Neurosci 2010;17:1428-33.  Back to cited text no. 8
    
9.Salins PC. The trans naso-orbito-maxillary approach to the anterior and middle skull base. Int J Oral Maxillofac Surg 1998;27:53-7.  Back to cited text no. 9
    
10.Maheshwari GU, Chauhan S, Kumar S, Krishnamoorthy S. Access osteotomy for infratemporal tumors: Two case reports. Ann Maxillofac Surg 2012;2:77-81.  Back to cited text no. 10
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11.Langdon JD, Patel MF. Operative maxillofacial surgery. p. 231-56.  Back to cited text no. 11
    
12.Nair S, Sridhar KR, Shah A, Kumar B, Nayak K, Shetty P. Maxillectomy through mandibulotomy--a retrospective clinical review. J Oral Maxillofac Surg 2011;69:2040-7.  Back to cited text no. 12
    
13.Attia EL, Bentley KC, Head T, Mulder D. A new external approach to the pterygomaxillary fossa and the parapharyngeal space. Head Neck Surg 1984;6:884-91.  Back to cited text no. 13
    
14.Smith GI, Brennan PA, Webb AA, Ilankovan V. Vertical ramus osteotomy combined with a parasymphyseal mandibulotomy for improved access to the parapharyngeal space. Head Neck 2003;25:1000-3.  Back to cited text no. 14
    
15.Raza SM, Conway JE, Li KW, Attenello F, Boahene K, Subramanian P, et al. A modified frontal-nasal-orbital approach to midline lesions of the anterior cranial fossa and skull base: Technical note with case illustrations. Neurosurg Rev 2010;33:63-70.  Back to cited text no. 15
    
16.Raveh J, Vuillemin T, Sutter F. Subcranial management of 395 combined frontobasal-midface fractures. Arch Otolaryngol Head Neck Surg 1988;114:1114-22.  Back to cited text no. 16
    
17.Belmont JR. The Le Fort 1 osteotomy approach for nasopharyngeal and nasal fossa tumors. Arch Otolaryngol Head Neck Surg 1988;114:751-4.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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