Surgery of the Skull Base

656 Pages·1998·96.786 MB·English

by  Paul J. Donald

OF THE

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PAUL J. DONALD
Surgery of the
Skull Base

Editor

Paul J. Donald, MD

Professor, Department of Otolaryngology—

Head and Neck Surgery

Director, UCDMC Center for Skull Base Surgery
University of California, Davis

Sacramento, California

Illustrations by Nelva B. Richardson

Lippincott - Raven

P U B L I S H E R
S Philadelphia • New
York
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SECTIONI

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Introduction
Surgery of the Skull Base, edited by Paul J. Donald.
Lippincott-Raven Publishers, Philadelphia © 1998.
CHAPTER 1

History of Skull Base Surgery

PaulJ. Donald

One of the most exciting and challenging fields in modern ANTERIOR FOSSA AND PITUITARY SURGERY
medicine is the rapidly developing discipline of skull base
surgery. Cranial base surgery, as described in this book, prin- Probably the earliest adventures into the skull base were
cipally concerns those disease processes that assault the floor of related to pituitary gland surgery. According to McDonald
the cranium. They may arise from the intracranial structures, and Laws (2), the first attempt at a pituitary operation was by
take origin in the subcranial area, or be primarily of the bone Caton and Paul in 1893 (3). On advice from Sir Victor Hors-
itself. Often the problem, be it of neoplastic, inflammatory, ley (Fig. 1), they approached a pituitary tumor in a patient
vascular, traumatic, or congenital origin, affects the with acromegaly by performing a temporal lobe decompres-
structures on both sides of this bony barrier. Surgery of the sion. They actually did not operate on the hypophyseal tumor
skull base is unique because by its very nature and complexity per se. Horsley (4) himself did about ten resections of hy-
it requires the cooperation of at least two surgical disciplines pophyseal tumors by 1910, mainly for blindness. According to
in a coordinated way to execute a carefully planned and Landolt and Wilson (5), Horsley's first transfrontal operation
smoothly orchestrated sequence of interdependent procedures in 1899 predated Caton and Paul's. He used a transfrontal
to attack lesions in the most intricate area of the body. The route that differs little from the approach used for such
cooperative efforts of the head and neck surgeon or otologist tumors today. Anterior transfrontal subdural techniques were
and neurosurgeon need to be complemented by the skills of demonstrated experimentally by Krause (1) and Kil-liani (6)
the reconstructive surgeon. Without the use of pedicled flaps in the first decade of the 20th century and in 1912. Frazier (7)
and free vascularized tissue, the safe rebuilding of the cranial (Fig. 2) finally used this approach on a patient.
base area would not be possible and, as a direct result, An extracranial assault on the pituitary was first described
manifold complications would arise. by the Italian surgeon Giordano (8). His approach involved
The evolution of surgical techniques has been paralleled the construction of an osteoplastic flap comprising the
by explosive developments in diagnostic radiology. The in- frontal sinus and the nose. All the intranasal structures were
novations of computed tomography, magnetic resonance removed as the approach to the pituitary was made. In 1907,
imaging, and, more recently, positron emission tomography Schloffer (9) did probably the first purely transnasal excision in
have revolutionized our ability to delineate disease processes in which he reflected the external nose to one side, removed the
the intracranial and extracranial compartments to a fine septum and turbinates, and went transsphenoid to remove the
degree. gland. In 1910, Von Eiselsberg (10) used a similar approach
The history of skull base surgery is brief. It began with pi- to Schloffer's, through a so-called "inverted tuning fork
oneers in neurosurgery and head and neck surgery who, with incision" (Fig. 3).
no blood transfusions or antibiotics, intrepidly attempted to In 1909, Cushing (11) (Fig. 4) described his first attempt
correct selected lesions in this formidable area. It is not un- at the transnasal approach to the pituitary. In 1914, he de-
usual to find an expression in a textbook of surgery written scribed the sublabial approach and many of the features of
in 1896 that any lesion adjacent to the skull base was con- the transseptal transsphenoidal operation done today. He
sidered to be "inaccessible" (1). This has been the prevailing used a submucous resection of the nasal septum, thanks to
attitude over the decades, and is a mind set occasionally en- the work of Killian (12), preserving the turbinates and nasal
countered even today. function, a technique in marked contrast to the destructive
procedures of Schloffer and Von Eiselsberg. Cushing used
P. J. Donald: Department of Otolaryngology—Head and Neck this route to the hypophysis for about 20 years. He then ap-
Surgery, and Center for Skull Base Surgery, University of California, parently abandoned the approach because of excess bleeding
Davis Medical Center, Sacramento, California 95817. and went back to the transcranial route.
CHAPTER 1

FIG. 2. Charles H. Frazier. (From Horrax GT. Neurosurgery: an
FIG. 1. Sir Victor Horsley. (From Horrax GT. Neurosurgery: an historical sketch. Publication no. 117 of the American Lecture
historical sketch. Publication no. 117 of the American Lecture Series. In: DeBakey ME, Spurling RG, eds. American lectures
Series. In: DeBakey ME, Spurling RG, eds. American lectures in surgery. Springfield, IL: Charles C Thomas Publishers,
in surgery. Springfield, IL: Charles C Thomas Publisher, 1952:78.)
1952:61.)

FIG. 3. A: Von Eiselsberg's incision, one of the earliest subcranial approaches to the pituitary. B: Using this
incision, the nose is reflected to the side; the septum and turbinates are resected and the sphenoid sinuses
exposed. (From Horrax GT. Neurosurgery: an historical sketch. Publication no. 117 of the American
Lecture Series. In: DeBakey ME, Spurling RG, eds. American lectures in surgery. Springfield, IL: Charles C
Thomas Publishers, 1952:3.)
HISTORY OF SKULL BASE SURGERY

FIG. 4. Harvey Gushing. A: In the Hunterian Laboratory, Baltimore, Maryland, in 1912. B: With Otfrid
Foerster, 1930 (Gushing to the left of Foerster). (From Horrax GT. Neurosurgery: an historical sketch.
Publication no. 117 of the American Lecture Series. In: DeBakey ME, Spurling RG, eds. American lectures
in surgery. Springfield, IL: Charles C Thomas Publishers, 1952:73 [A], 105 [B].)
At the same time that Gushing described the transnasal ted by his colleagues to an insane asylum for proselytizing
route to the pituitary, a similar approach was being used by the principles of antisepsis.
the Viennese otolaryngologist, Oskar Hirsch (13,14). Ini- The definitive report that truly launched skull base surgery
tially, the procedure was done entirely transnasally in three for malignant disease was a paper by Ketcham et al. on their
stages (see Fig. 3). Eventually, in 1911, he combined the
stages through a midline sublabial approach. Hirsch emi-
grated to the United States in the 1930s and, in 1952, pub-
lished his results (15) of 425 such procedures, with a 65%
success rate and a 5.4% mortality rate.
Subsequent developments in skull base surgery occurred on
a number of different fronts. The first recorded anterior
craniofacial resection for a tumor was by Dandy (Fig. 5) in
1941 (16). While removing an orbital tumor through an an-
terior cranial fossa approach, he entered the ethmoid bloc in
an attempt to improve exposure and achieve complete resection.
In 1943, Rae and McLean (17) reported a transor-
bital/transcranial removal of a retinoblastoma. However, the
landmark article in anterior cranial base surgery that in-
volved a coordinated transfacial and transcranial approach to
tumor removal was published done in 1954. Klopp, a head
and neck oncologic surgeon from Washington, DC, teamed
up with Smith and Williams (18) to do a planned procedure to
remove what was described as a cancer of the frontal sinus.
The author found that his resection was not well accepted
by his peers—not an uncommon finding in the early days of
FIG. 5. Walter E. Dandy. (From Horrax GT. Neurosurgery: an
skull base surgery, as well as in many other innovative historical sketch. Publication no. 117 of the American Lecture
procedures that have been attempted through the history of Series. In: DeBakey ME, Spurling RG, eds. American lectures
medicine. Even the pioneering Semmelweis was commit- in surgery. Springfield, IL: Charles C Thomas Publishers,
1952:93.)
6 / CHAPTER 1

FIG. 6. The anterior skull base approach as described by Ketcham et al. A: Transfacial approach. B:
Transcranial approach. (From Ketcham AS, Chretien PB, Schour L, Herdt JR, Ommaya AK, Van Buren JM.
Surgical treatment of patients with advanced cancer of the paranasal sinuses. In: Neoplasia of the head and
neck: a collection of papers presented at the seventeenth annual Clinical Conference on Cancer, 1972.
Sponsored by and held at the University of Texas System Cancer Center, M. D. Anderson Hospital and
Tumor Institute, Houston, Texas. Chicago: Year Book Medical Publishers, 1974:192.)
experience with 19 patients who had an anterior craniofacial invasion or cranial floor involvement in the region of the optic
resection for cancer of the nasal cavity and paranasal sinuses chiasm. The anterior craniotomy and Weber Fergusson
(19). They evaluated 30 patients with advanced paranasal sinus exposure they used are the basis for many anterior fossa ap-
cancer, 22 of whom were failures of past surgery or irradiation. proaches today (Fig. 6). Of the 19 patients operated on, 7
Six of the patients were rejected for surgery because of were not cured of their disease, 9 were disease free at 2 to 75
radiographic evidence of erosion of the sphenoid ridge or months' follow-up, and 3 died of other causes. By 1966, the
pterygoid plates. Two refused surgery, and three were con- same group reported on the complications experienced in a
sidered incurable at the time of craniotomy because of brain group of 31 patients operated on over a 10-year period (20).

FIG. 7. A. D. Cheesman, a head and necK surgeon and pioneer FIG. 8. Paul Tessier, a plastic surgeon, the father of modern
in skull base surgery who described the "key hole" craniotomy craniomaxillary surgery for congenital anomalies.
for tumor exposure.
HISTORY OF SKULL BASE SURGERY / 7
The 3-year and longer survival rate in this group was 61%.
Approximately 80% of patients sustained some form of com-
plication. In 1976, Sisson et al. (21) reported on their 15-year
experience with craniofacial resection for sinus malignan-
cies. They had used craniofacial resection for only 8 cases in a
series of over 100 malignancies of the sinuses. Three of
these patients died of recurrent disease, three were long-term
survivors (2-8 years), and two were being followed and were
disease-free for less than 1 year. In 1973, Millar et al. (22) re-
ported on three cases of ethmoid cancer done in Australia. In
1980, Bridger (23), also from Australia, reported on 15 cases of
craniofacial resection for tumors at this same site. In
Bridger's series, seven patients were alive and disease free at 2
years or more. In 1986, Cheesman et al. (Fig. 7) from Great
Britain reported their 10-year experience with craniofacial
resection for ethmoid carcinomas with intracranial spread
using a small "window craniotomy" (24). They had a 60% 5-
year cure rate.
Attempts were made to improve the exposure of the anterior
fossa, especially in its most posterior extent. This often was FIG. 10. Edwin W. Cocke, Jr., one of the founders of the So-
difficult to achieve without severe retraction of the frontal ciety for Head and Neck Surgeons, who in his mid-70s de-
scribed a novel approach to the skull base through a Le Fort I
lobes using the standard craniotomy. Based on the removal of a
osteotomy.
frontoorbital bandeau used in craniofacial surgery for
congenital craniomaxillary anomalies developed by Tessier
et al. (25) (Fig. 8) and the low frontoorbital technique for by the technique developed by Maniglia and Ramina (29), in
sphenoethmoid tumors described by Derome et al. (26),
which the entire frontal bandeau was removed.
various skull base surgical teams devised more direct ap-
Many others, including Janecka, Cocke (Fig. 10), Robin-
proaches. The extended anterior subcranial approach was de-
son, Panje, and Catilano, have produced variations on these
veloped by Raveh (Fig. 9) in 1978 to manage intracranial
midline approaches, many of which are described in detail in
trauma (27) and then adapted it to tumor resection (28), and is
this book.
excellent for midline lesions. A wider exposure was afforded
POSTERIOR FOSSA-ACOUSTIC TUMORS
Another major area in skull base surgery development
concerns lesions of the posterior cranial fossa. In the early
20th century, the removal of acoustic neuromas was first
done in a systematic manner by Harvey Gushing, the previ-
ously mentioned skull base pioneer in pituitary surgery. Ac-
cording to House (30), the early reports of removal of this
tumor were "meager and sketchy," and the surgery itself
was usually incomplete and attended by a high mortality
and morbidity rate. Horsley, Krause, and Von Eiselsberg
(30) were names frequently associated with these early at-
tempts. In London in 1894, Ballance (31) and Beevor re-
ported the removal of an acoustic tumor with a favorable result.
In America the year before, Starr and McBurney (32)
teamed up for a posterior fossa exploration for such a tumor,
I but were unsuccessful. In the years before Gushing's resec-
tions of these lesions, a common practice was to insert a dis-

secting finger between the tumor and the pons in an attempt
to enucleate it. In his own report, Gushing (33) found that
with increasing experience, his mortality rate diminished
from the death of his first patient to 20% after he had done 30
FIG. 9. Joram Raveh, a head and neck and maxillocranial
cases. This was in vivid contrast to the almost 100% mortality
surgeon who described the unique transcranial subcranial
approach to the anterior midline skull base. in other patients operated on by the surgeons of the time.
However, Gushing's greatest contribution probably
8 / CHAPTER 1

was the lucid and comprehensive description of the signs,
symptoms, and natural history of acoustic tumors. Gushing'
s student, Walter Dandy (see Fig. 5), is reputed to be one of if
not the greatest technological neurosurgeon of this century
(30). Disappointed by the incomplete removals and frequent
complications of Gushing's finger dissection technique,
Dandy developed a more refined, painstaking removal of
the tumor and its surrounding capsule. He resected 23
patients in this fashion in his first 9 years of practice and had 5
complete cures, an unheard-of track record at that time (34).
Dandy's 1942 description (35) of acoustic tumor removal
remained the standard approach until the development of the
operating microscope in 1961. Unfortunately, however, this
technique resulted in a total facial nerve paralysis in every
case. For a more detailed and fascinating account of the
development of acoustic tumor surgery, House's excellent
section in his two-volume monograph on acoustic tumors
should be consulted (31).
The operating microscope was first used in clinical
surgery by Nylen (Fig. 11) in 1921 (36) to drain an acute
suppurative otitis media by myringotomy. This was a uniloc-

ular microscope that lacked the three-dimensional visualization
surgeons enjoy today. Holmgren (37), who had been doing FIG. 12. W. F. House, the first modern otoneurosurgeon.
labyrinthine procedures for otosclerosis, quickly developed
the binocular microscope for middle ear surgery in 1922. In
single greatest catalysts to modern otologic and neurooto-
1953, the Zeiss Company produced the prototype of the
logic surgery.
operating microscope that is universally used today. From its
However, it was not technology that spawned modern
original use in otology, the microscope rapidly became
neurootology. Credit must undoubtedly be given to the
incorporated into ophthalmologic surgery, neuro-surgery,
courageous, pioneering genius of William House (Fig. 12).
and finally plastic surgery—all specialties that were to become
Disturbed by the disappointing results of the standard ap-
important elements of the skull base surgery team. The
proach to acoustic tumors developed by Dandy, he strove to
microscope revolutionized otology and was one of the
design an operation that would extirpate the tumor while
saving the function of the facial nerve. After practicing on
cadaveric specimens in a makeshift temporal bone laboratory
that he and his brother, Howard, constructed in their garage,
he set out to do the first otomicroscopic approach to an
acoustic neuroma. Attempts using the transtemporal approach
had been made in the past. In 1904, Panse (38) developed an
approach through the temporal bone, beginning with a
radical mastoidectomy, followed by removal of the
labyrinth, cochlea, and facial nerve, done with a mallet and
gouge. Heavy bleeding and cerebrospinal fluid leakage pre-
dictably accompanied these procedures. Buix, Zange, and
Schmiegelow (30) were among the few surgeons over the
next 13 years who performed a small number of these dan-
gerous procedures through the ear. At this time, a few heroic
surgeons (34) did a combined postoccipital and
translabyrinthine procedure, but, because of the high mortality
rate, this approach was discontinued.
In 1961, House and B. B. Doyle, a neurosurgeon, did the
first resection of an acoustic neuroma using the operating
microscope. Because it was unprecedented for an otolaryn-
gologist to do this type of surgery, the neurosurgery community
presented no little resistance to House's desire to remove
this tumor. After considerable debate, the first
FIG. 11. C. O. Nylen, an otologic surgeon who was the first to
describe the operating microscope. otoneurosurgical skull base team did the operation through
HISTORY OF SKULL BASE SURGERY / 9
the middle fossa approach. The tumor was incompletely re-
moved and a combined suboccipital and middle fossa tran-
sotic approach was unsuccessful on two successive occa-
sions, and the patient died 6 years later. The middle fossa
appeared at the time to be a good route for facial nerve ex-
posure, but inadequate for tumor removal. After eight at-
tempts at the middle fossa route, sometimes accompanied by
the suboccipital approach, House decided to redesign the op-
eration and modified the original approach of Panse using
the microscope, drill, and suction irrigation. He was able to
preserve the facial nerve, the posterior canal wall, and the
tympanic membrane. House and Doyle came to a serious dis-
agreement over approaches, and their association dissolved in
1963. William Hitselberger (Fig. 13) then joined with
House to form a solid, long-lasting relationship that was the
nucleus of the first true skull base team.
The history of the evolution of acoustic tumor surgery
would be incomplete without the story of the return to the
modified Dandy approach by modern neurosurgeons and
neurootologists. The transotic approach, by its very nature,

destroys hearing; the removal of the bony and membranous
labyrinth eliminates all vestiges of hearing on that side. In FIG. 14. Mansfield F. W. Smith, an otologist who was among
the first to adapt the posterior fossa approach to acoustic tumor
days gone by, when by the time the diagnosis was made most
removal and preserve hearing.
patients had little or no useful hearing in the affected ear, the
loss of remaining hearing acuity was of little consequence (a
position voiced by numerous otologists even today). As clin- The reactivation of interest in the suboccipital retrosig-
icians became more aware of this diagnosis, and computed moid approach was stimulated by a desire to salvage hearing.
tomography and magnetic resonance imaging improved, The translabyrinthine approach developed by House pre-
their ability to detect small tumors in patients whose hearing served facial nerve function in most cases. Dandy, in his re-
was intact markedly improved. Hearing preservation now port in 1941 on 46 cases operated on with his modification of
became more important. Gushing's suboccipital approach, reported that 34 of these
patients had "good hearing" (36). However, most patients
had no postoperative facial nerve function. Rand and Kurze
(39, 40) modified Dandy's operation, preserving the facial
nerve in 100% of cases when tumors were less than 2 cm in
diameter, and reported these results in 1965. They called
their operation the "suboccipital transmeatal approach."
They also described preserving the vestibular and cochlear
nerves in small intercanalicular tumors (41), but questioned
the advisability of the operation in such small neoplasms.
Sterkers (42) began hearing preservation surgery in 1969 and
reported only a 10% favorable hearing result when he and his
team used either the middle fossa or retrosigmoid approach.
Smith (Fig. 14) et al. (43) modified the Rand procedure and
began to popularize it in the early 1970s. Since then, consid-
erable controversy has continued to surround the question of
the optimal approach for acoustic neuroma removal, and the
quality and utility of hearing when preservation is done.
MIDDLE FOSSA
A history of modern skull base surgery would be very
much amiss without mention of one of the premier skull base
surgeons of our time, Ugo Fisch (Fig. 15). With his back-
FIG. 13. William Hitselberger, the neurosurgeon who with
House created the first skull base surgery team in North ground in head and neck oncologic surgery, he extended the
America. limits of otologic surgery into the area of the infratemporal