Access osteotomies

Approaches to the base of the skull

Le fort I osteotomy approach
Maxillary swing approach Transpalatal approach

Facial translocation approach

Transethmoidal approach Trans septal- trans sphenoidal approach

Le fort I osteotomy approach

Transverse facial osteotomy along the lines of the

le fort I fracture and inferiorly displacing the palate to expose the nasopharynx, clivus, and the sphenoid sinus

 Indications Central skull base lesions Tumours situated in or extending into the

maxillary sinus, the sphenoid sinus or nasopharynx Single access route for exposing the medial compartment of the inferior skull base.

Technique
Incision given in the labiobuccal

vestibule leaving approximatelt 5mm of the mucosa attached.

Reflection of the flap in the

subperiosteal plane upto the level of infraorbital foramen.

Initial bone cuts made anteriorlt,

extending from the pyriform aperture across the medial buttress at the level of the floor of

 The anterior cuts are completed

by cutting across the root of the septum and through anterior nasal spine and maxillry crest below the septum.
The bone cuts across the medial

wall of the maxillary sinus is made.

A curved osteotome is directed

around the back of the maxillary

 The last cut is through the

posterior wall of the maxillary sinus.

The palate should be free of

bony attachments, it will remain attached by the tissues of the soft palate, the periosteum of the posterior wall, and the vessels of the pterygomaxillary fissue.
Exposure of the tumour site by

retraction of the palate in inferior direction.

Complications
Loss of palatal blood supply may result in

necrosis Deviation of the septum Perforation of septum Nasal stenosis Malunion or non union of the osteotomies

Two-piece Le Fort I osteotomy

The full length of the soft and hard palates is

incised just lateral to the uvula and carried to the midline.

This incision extends anteriorly to include the

gingival papilla on the palatal aspect of the central incisors.

The soft palate incision is a fullthickness incision

through oral mucosa, muscle, and nasal mucosa.

 The standard Le Fort I osteotomy is

then performed
A spatula osteotome is then used to

finish the midline split between the central incisors.

Each maxillary half is rotated laterally

with a self-retaining retractor

A mandibulotomy is used if extreme

superior or inferior access is required or if the patient has limited mouth opening.

Maxillary swing approach

To approach anterior skull base Displace maxilla by either rotating it laterally

based on the greater palatine vessels or completely removing the maxilla as a free graft.
Provides exposure of nasopharynx, infra temporal

fossa, skull base in the refion of sphenoid sinus and pterygoid plates

Technique
The incision through the dorsum of the septum,

disconnecting the septum from the nose and cribriform plate is given
The palatal incisions are through the floor of the

nose on the contralateral side

After elevation of palatal mucosa, the hard palate

is cut through the contralateral floor of the nose from posterior to the anterior.

 Septum is detached from the

columela anteriorly
Medial cuts made from pyriform

aperture to the orbital rim.

The cut is angled laterally

either to go through the inferior orbital rim or enter into the maxillary sinus inferior to the rim

 The orbital cuts are then performed

after elevation of the periosteum of orbital floor till inferior orbital fissure.
Posteriorly the floor cuts extend

posterior to the orbital fissure to include the entire roof of maxillary sinus.
The lateral pressure on the maxilla

fracture the pterygoid plate atraumatically and it can be retracted laterally.

Complications
Ischemic damage to the teeth Malocclusion due to improper replacement and

reconstruction Chronic sinusitis, mucocele, mucous cyst formation secondary to injury to the sinus mucosa Transection of the nasolacrimal system Enophthalmos

Transpalatal approach
Four types of variations - retraction of soft palate only - palatal drop

- palatal split
- palatal split with labiomandibular glossotomy

Technique
Palatal drop
The incision made through the mucosa and periosteum down to the palatal bone upto the palatal junction. Muscles of the soft palate divided from hard palate and nasopharyngeal mucosa at the junction.

The flap is pushed down, exposing

 Palatal split The incision begins just lateral to the

base of the uvula, curves immediately back to the midline and then traverses the midline of the soft palate.
The incision is extended to hard palate

to allow soft palate to retract without tearing.

The soft palate is retracted vertically

upto the hard palate.

 The muscular attachment of soft

palate and nasopharynx is divided, soft palate is only attached to the anterior tonsillar pillar and anteriorly to the hard palate mucosa.
The posterior aspect of the hard

palate is exposed which can be removed exposing the posterior aspect of the septum

Transpalatal with labiomandibular glossotomy

Involves midline lip incision,

mandibular split, and division of the tongue.

Complications
CSF fistula
Wound complications associated with the

posterior pharyngeal wall Palatal wound problems

Facial translocation approach

Indications Access to anterior and middle cranial fossa

Advantage Direct access to a neoplasm while providing

control of important anatomic structures Allows for easy and reliable reconstruction with temporalis flap and galea aponeurotica

Technique
The lip split incision begins at the

vermillion border and continues along nasal ala and lateral nose.
It runs horizontally at the inner

canthus which it transects.

It continues at the depth of the

inferior lid fornix through the conjuctiva to the lateral canthus, where it exits to meet the vertical bicoronal or preauricular incision.

 The cheek flap is reflected

inferiorly to the level of the hard palate after the elevation of the maxillary periosteum and the massteric fascia in a downward direction.
The frontotemporal scalp flap is

reflected towards the midline after completion of the bicoronal and transtemporal incisions and appropriate undermining.

Complications
Scar contracture Epiphora Facial paralysis Non union or malunion at osteotomies

Transethmoidal approach
Most direct and shortest route to the pituitary Advantages - working distance shorter than any pituitary

approach - avoids craniotomy - avoids denervation of the teeth - line of approach parallels the floor of the cranial fossa

Technique
A modified lynch incision is

made midway between the medial canthus and nasal dorsum.

The upper end of incision just

below the eyebrow should be kept medial to the superior orbital foramen with the lower end extending 2-3mm below the level of inner canthus.

 The elevation of the periosteum includes the

trochlea of the superior oblique muscle after which the orbital periosteum is freed. The ethmoid labryinth is opened end mucosal lining removed. The posterior ethmoid sinus is opened and posterior wall removed by a small curette exposing the interior of the sphenoid sinus.

Complications
Orbital hematoma
Diplopia Blindness

Transseptal transsphenoidal approach

Advantage :

Avoids facial incision over a

highly esthetic region Provides access to middle cranial fossa

Technique
A horizontal sublabial incision from

canine ridge to canine ridge is made, angling superiorly towards the piriform crests. The caudal edge of the nasal septum is exposed and a longitudnal incision is made along its free edge. Anterior nasal septum is detached from the maxilla as a unit.

 The quadrangular septal cartilage is disarticulated

from its attachment to the vomer inferiorly and to the ethmoid plate posteriorly, leaving the septal acrtilage hinged superiorly. This exposes the ethmoid plate and vomer between its blades.

Complication
CSF leak Meningitis Septal deformation Loss of nasal tip projection Denervation of the upper incisors

Access to parapharyngeal space

Approaches to parapharyngeal space: - transcervical - trans parotid - trans cervical-transparotid -transoral -transoral- external approach -cervical-transpharyngeal approach

Trans parotid approach

For deep lobe parotid tumours to save facial nerve. A superficial parotidectomy is performed, at the end of which the superficial lobe is left pedicled inferiorly.

Alternatively, the superficial lobe can be excised completely and the deep lobe removed as a separate specimen.

The branches and the main trunk are dissected off the underlying deep lobe, using small scissors and by lifting the nerve with a nerve hook. The deep lobe is separated from the posterior border of the ascending ramus and from the TMJ as well as digastric and the bony external auditory meatus.

The retromandibular vein is divided and the superficial temporal vein is secured just below the zygomatic arch. Similarly the ECA is divided at its point of entry to parotid and internal maxillary artery is divided between the deep lobe and the ascending ramus.

Mandibulotomy
Indications :
For large neoplasms,

Malignancies,
Highly vascular tumours, Lesion that require proximal and distal control of

ICA

Midline mandibulotomy(mandibular swing approach)

Resection of oral cavity and

oropharyngeal malignancies Access to oropharynx, retropharynx, parapharyngeal space, superior cervical vertebrae and skull base, and floor of the mouth.

Technique
A staggered incision is carried through the lower lip which

may take the form of a V on its side or alternatively a vertical line drawn to the upper part of the protuberance of the chin, with a curve thereafter which surrounds and hugs the contour of the chin to its lower extremity
- At the point of chin the incision inclines downwards and

laterally preferably in a skin crease just above the hyoid bone and ends at the anterior border of sternomastoid . - The submandibular part of the incision is deepened through the platysma and the submandibular gland is removed

- The midline of the mandible is then split - The mucosal incision is then carried out inside the mandible and deepened to include the division of mylohyoid close to its insertion into the mandible.

 The incision in the mucous

membrane is continued onto the anterior faucial pillar ending on the soft palate
The osteoplatic flap containing the

mandible is retracted as far out as possible and the tumor is separated from the adjacent structures by blunt dissection and excised

Lateral mandibulotomy Double mandibular osteotomy

osteotomy in parasymphyseal region and horizontally in ascending ramus superior to mandibular foramen
- mandible can be retracted laterally with attached masseter and cheek.

Subcutaneous mandibulotomy
- resection of tumours more than 5cm located in

superior medial PPS,

done by midline mandibulotomy and division of

mylohyoid, anterior belly of digastrics, and geniohyoid muscle allow mandibule to be rotated superolaterally;
avoids morbidity of intraoral and lip split incisions

and need for tracheostomy.

Complication of mandibulotomy Malocclusion Non union Loss of dentition IAN injury Need for lip split incision, tracheostomy, NG tube

Palatopahryngeal approach
for excision of :-

- parapharyngeal tumours which are benign, medially bulging, - relatively avascular, - extra-parotid and - free from the contents of carotid sheath.
Trans oral approach to superomedial parapharyngeal space .Otolaryngologyhead and neck surgery(2006) 134,466-470

 An incision extending from the

posterior edge of the hard palate, passing along the lateral edge of the soft palate and the nasopharynx.
This incision in palate is laterally

placed, thus avoiding damage to the ascending palatine artery, palatine vein and the greater palatine neurovascular bundle, hence preserving the blood supply and sensation of soft

 Trans oral approach contraindicated for: hemorrhage Damage to cranial nerves Tumor spillage Decreased exposure

Trans oral approach to superomedial parapharyngeal space .Otolaryngology-head and neck surgery(2006) 134,466-470

Infratemporal approach
- can be used for malignant tumors involving the skull base or jugular foramen.
- This approach can be combined with frontotemporal

craniotomy for removal of tumors with significant intracranial extension. - A parotidectomy incision with cervical extension is extended superiorly into a hemicoronal scalp incision.

- The temporalis muscle is elevated to expose the

glenoid fossa, which is removed laterally.

- The temporomandibular joint can be displaced

inferiorly, or the mandible condyle can be transected for improved exposure.

- Orbitozygomatic osteotomies are performed, and the

infratemporal skull base and distal carotid are exposed.

Thank you

Refrences
Tyler M. Lewark. Le Fort I Osteotomy and Skull Base

Tumors.A Pediatric Experience. Arch Otolaryngol Head Neck Surg/Vol 126, Aug 2000 Lt Col BK Prasad et al .Palato-pharyngeal Approach to the Parapharyngeal Space. MJAFI 2004; 60 : 407409 Willaim Lawson, The Versatility Of Median Labiomandibulotomy. Bull. N.Y. Acad. Med. Vol. 62, No. 8, October 1986 Transmaxillary approach to the cranial base: an evaluation of 11 cases. Rev Bras Otorrinolaringol 2008;74(5):652-6.