Preservation of olfaction in anterior craniofacial approaches

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✓ Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit.

Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.

Article Information

Address reprint requests to: Robert F. Spetzler, M.D., c/o Editorial Office, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Illustration of the skull anatomy showing the initial circumferential cribriform plate osteotomies. A = anterior osteotomy, B and C = parasagittal osteotomy, and D = posterior osteotomy. Additional lines indicate intended osteotomy cuts for removal of the frontonaso-orbital unit. Right: Illustration demonstrating removal of the frontonaso-orbital unit.

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    Left: The amount of exposure and direction needed to make the final cut to release the intact cribriform unit is shown. The trabeculae are cut uniformly, leaving a generous cuff of mucosa intact on the cribriform plate. Right: Illustration demonstrating the exposure of the posterior cribriform plate needed and the direction of the osteotomy made.

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    Intraoperative photograph (left) and illustration (right) looking into the frontal fossa after the frontonaso-orbital unit has been replaced. The cribriform unit is returned to its normal position where it will be surrounded by pericranium.

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    Magnetic resonance (MR) T1-weighted images in Case 1. Left: Sagittal MR image demonstrating the location of the angiofibroma and its extension inferiorly in the nasopharynx and superiorly up to the skull base. Center and Right: Sagittal (center) and coronal (right) enhanced MR images demonstrating the extent of tumor removal. The cribriform plate complex has been returned to its normal position (black arrow). The enhanced sphenoid sinus mucosa is indicated by the arrowhead and the remaining nasal turbinate by the white arrow.

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    Intraoperative photograph (left) and illustration (right) showing the frontal fossa from a superior view. The frontonaso-orbital unit has been removed, and the cribriform plate-olfactory complex is behind the retractor. The tumor and mucosa are beneath the suction tip and the right orbit is beneath the retractor.

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