Temporal bone neoplasms: a report on 20 surgically treated cases

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✓ The surgical resection of neoplasms involving the petrous bone and surrounding areas in 20 patients is reported. Technical advances described include the total resection of several tumors previously considered inoperable due to involvement of dura and brain, petrous internal carotid artery (ICA), the vein of Labbé, and adjacent areas such as the clivus and the cavernous sinus. Areas of reconstruction after resection included the ICA, the seventh and 11th cranial nerves, and the cranial base, often requiring the use of vascularized flaps. There were no intraoperative deaths. Many patients experienced significant temporary morbidity related primarily to wound healing and to lower cranial nerve palsy; however, all but three patients (all with fast-growing malignancies) returned to their preoperative functional status.

During a median follow-up period of 30 months (range 17 to 63 months), the 10 patients with benign tumors and slow-growing malignancies fared well, seven being alive and disease-free. The 10 patients with fast-growing malignancies fared poorly, only two being alive without disease. This outcome appeared to be related to tumor pathology and extent of invasion; both survivors harbored tumors confined to the petrous bone. An anatomical classification system of tumor spread is introduced, which should be considered concomitantly with tumor pathology.

Article Information

Address reprint requests to: Laligam N. Sekhar, M.D., Department of Neurosurgery, Presbyterian-University Hospital, Suite 9402, DeSoto at O'Hara Streets, Pittsburgh, Pennsylvania 15213.

© AANS, except where prohibited by US copyright law.

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    Schematic illustrations showing surgical procedure. Roman numerals denote cranial nerves. A: The frontotemporal-retroauricular-cervical skin flap is rotated forward. The external ear canal has been transected. The facial nerve has been transected just beyond the stylomastoid foramen. The temporomandibular joint has been opened and the mandibular ramus resected. The ninth through 12th cranial nerves and the jugular and carotid vessels are exposed in the neck. B: A temporal and suboccipital craniotomy has been extended over the transverse sinus and lateral posterior fossa. A zygomatic osteotomy and a partial mastoidectomy have been performed. The osseous middle fossa floor has been partially resected to expose second (V2) and third (V3) divisions of the fifth cranial nerve and the greater superficial petrosal nerve (GSPN). The middle meningeal artery has been transected. C: Continuing resection of the osseous middle fossa floor, the eustachian tube, and the tensor tympani muscle has been transected. The ascending and transverse segments of the petrous internal carotid artery (ICA) have been unroofed and the ICA has been mobilized anteriorly. D: The temporal and retrosigmoid dura have been opened. The lateral sinus had been ligated at its junction with the sigmoid, the tentorium has been opened along the inferior edge of the mandibular nerve, trigeminal ganglion, and roof, with the interruption of the superior petrosal sinus. If uninvolved, the superior petrosal sinus drainage into the transverse sinus may be preserved by changing the dural incision lines. The dura has been cut over the cerebellum, the transverse sinus ligated and transected, and a dural flap brought down from over the temporal lobe. The tentorium has been divided from the transverse sinus transection, alongside and behind the petrous ridge, and anteromedially across the superior petrosal sinus. This cut has been connected to an incision in the dura on the middle cranial fossa floor, anterior to the petrous base. The outline of the trigeminal ganglion and roots can be seen through the middle fossa dura. E: With the cerebellum retracted medially, the fifth and seventh through 11th cranial nerves can be seen. The labyrinthine (internal auditory) artery has been transected at its origin from the anterior inferior cerebellar artery (AICA). F: The seventh through 11th cranial nerves have been transected and the underlying dura incised as the posterior border of the en bloc resection of the petrous bone. The petrous bone specimen is then disconnected from any remaining attachments and removed (not shown here). PICA = posterior inferior cerebellar artery.

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    Schematic illustrations showing surgical reconstruction. Roman numerals denote cranial nerves. A: Following resection of the petrous bone and transection of the internal jugular vein, the petrous internal carotid artery (ICA) has been resected and reconstructed with a saphenous vein graft interposed. The seventh and 11th cranial nerves, which had been resected, are cable-grafted. The distal stumps of the ninth and 10th cranial nerves are visualized. The dural defect is reconstructed with a patch. B: The temporalis, sternocleidomastoid (SCM), semispinalis, and splenius capitis (cap.) muscles are sewn to each other and to the dura and beyond the dural patch to seal the dural defect. C: A free rectus abdominis myocutaneous graft has been anastomosed to a branch of the external carotid artery, and the draining vein has been anastomosed to the internal jugular vein. The muscle overlies the dural repair to provide a mechanical barrier as well as bulk to fill the defect.

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    Case 2. Left: Preoperative magnetic resonance image, axial view, with gadolinium enhancement demonstrating infiltration of the left petrous bone, including the apex and lateral clivus. cerebellopontine angle, and the posterior aspect of the middle fossa by the meningioma. Right: Postoperative axial computerized tomography scan showing complete resection of the left petrous bone and tumor in the posterior fossa.

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    Case 8. Preoperative axial computerized tomography “bone window” algorithms demonstrating widespread destruction and expansion of the right petrous and squamous temporal bone due to the myxoma.

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    Case 8. Left: Postoperative right internal carotid artery angiogram revealing a slightly irregular contour following patch graft repair. Right: Postoperative computerized tomography scan, axial view, demonstrating petrous bone resection without evidence of tumor recurrence.

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    Graphs showing pre- and postoperative Karnofsky Performance Scale scores for patients with benign and slow-growing malignant tumors (left) and with fast-growing malignant tumors (right).

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    Superior view of sketch of the clivus and right middle fossa illustrating our classification system of petrous tumors. Grade 1: Tumor infiltrating only a portion of the petrous bone. Grade 2: Tumor infiltrating the entire petrous bone. Grade 2a: Petrous internal carotid artery infiltration. Grade 3: Tumor extending beyond the petrous temporal bone. Grade 3a: Tumor infiltrating adjacent cranial base. Grade 3b: Dural infiltration. Grade 3d: Cavernous sinus infiltration. Grade 3c (infratemporal upper cervical soft-tissue infiltration) is not shown.

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