Transfacial Approaches to the Skull Base

  • D. Uttley
Part of the Advances and Technical Standards in Neurosurgery book series (NEUROSURGERY, volume 23)


Until very recently the skull base and adjacent stuctures were only accessible as a result of severe and sustained brain retraction, which inevitably lead to increased postoperative neurovascular complications, often of a serious and permanent nature. It is a measure of the success of skull base surgery that many of these obstacles to a better outcome have been overcome by means of novel applications of operative techniques, some new, but, more often than not, extant already in the repertoire of disciplines not overtly concerned in transclivai penetration. The major spur to progress has been the evolution of team-work, without which much of this work would never have come to fruition. The conjunction of multiple disciplines to form teams, each bringing complementary expertise to bear on the tasks in hand, has created a tremendous impetus to the development of the complex techniques that are often necessary to achieve optimal exposure of the conditions involving the skull base. It is true to say that there are no areas of the brain’s surface that are denied surgical access, thanks to these recent innovations. The revolution in radiological imaging techniques has been an enormous boon to students of this region. The combination of computerised transverse axial scanning (CT), and magnetic resonance imaging (MRI) has transformed our perceptions of tumour pathology and its consequences. Improved diagnosis has resulted in better patient management, and the imaging techniques are invaluable in charting postoperative progress, both in the immediate phase, and in the long term. The new angiographic MRI sequences have largely supplanted invasive angiography in studying the vascular relationships of skull base tumours, except where fine detail is still required, or embolisation is being considered, and, of course, in those cases where ballon occlusion may be necessary.


Skull Base Sphenoid Sinus Inferior Petrosal Sinus Craniocervical Junction Transsphenoidal Approach 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Alonso WA, Black P, Connor GH et al (1971) Transoral transpalatal approach for resection of clivai chordoma. Laryngoscope 81: 1626–1631PubMedCrossRefGoogle Scholar
  2. 2.
    Ammirati M, Ma J, Cheatham ML, Mei ZT, Bloch J, Becker DP (1993) The mandibular swing-transcervical approach to the skull base: anatomical study. J Neurosurg 78: 673–681PubMedCrossRefGoogle Scholar
  3. 3.
    Arbit E, Patterson RH Jr (1981) Combined transoral and median labiomandibular glossotomy approach to the upper cervical spine. Neurosurgery 8: 672–674PubMedCrossRefGoogle Scholar
  4. 4.
    Archer DJ, Young S, Uttley D (1987) Basilar aneurysms: a new transclivai approach via maxillotomy. J Neurosurg 67: 54–58PubMedCrossRefGoogle Scholar
  5. 5.
    Arriaga MA, Janecka IP (1989) Surgical exposure of the nasopharynx: anatomic basis for a transfacial approach. Surg Forum 40: 547–549Google Scholar
  6. 6.
    Biller HF, Shugar JMA, Krespi YP (1981) A new technique for wide field exposure of the base of the skull. Arch Otolaryngol Head Neck Surg 107: 689–702Google Scholar
  7. 7.
    Bohlman HH (1979) Acute fractures and dislocations of the cervical spine an analysis of three hundred hospitalised patients and review of the literature. J Bone Joint Surg Am 61: 1119–1142PubMedGoogle Scholar
  8. 8.
    Casson PR, Bonnano PC, Converse JM (1974) The midface degloving procedure. Plast Reconstr Surg 53: 102–113PubMedCrossRefGoogle Scholar
  9. 9.
    Chiari O (1912) Ueber eine Modifikation der Schlofferschen Operation von Tumoren der Hypophyse. Wien Klin Wochenschr 25: 5–6Google Scholar
  10. 10.
    Cook RJ, Uttley D, Wilkins PR, Archer DJ, Bell BA (1994) Prolactinomas in men masquerading as invasive skull base tumours. Br J Neurosurg 8: 53–57CrossRefGoogle Scholar
  11. 11.
    Crockard HA, Calder I, Ransford AO (1990) One stage transoral decompression and posterior fixation in rheumatiod atlanto-axial subluxation. J Bone Joint Surg Br 72B: 682–685Google Scholar
  12. 12.
    Crockard HA, Sett P, Geddes JF, Stevens JM, Kendall BE, Pringle JS (1991) Damaged ligaments at the cranio-cervical junction presenting as an extradural tumour: a differential diagnosis in the elderly. J Neurol Neurosurg Psychiatry 54: 817–821PubMedCrossRefGoogle Scholar
  13. 13.
    Curioni C, Padula E, Toscana P, Maraggia A (1984) The maxillo-cheek flap. Presented at the 7th Congress EAMFS, ParisGoogle Scholar
  14. 14.
    Delgado TE, Garrido E, Harwick RD (1981) Labiomandibular transoral approach to chordomas of the clivus and upper cervical spine. Neurosurgery 8: 675–679PubMedCrossRefGoogle Scholar
  15. 15.
    Derome PJ (1988) The transbasal approach to tumours invading the skull base. In: Schmidek HH, Sweet WH (eds) Operative neurosurgical techniques, vol 1. Grune and Stratton, New York, pp 619–633Google Scholar
  16. 16.
    Drommer RB (1986) The history of the “1e Fort I osteotomy”. J Maxfac Surg 14: 119–122CrossRefGoogle Scholar
  17. 17.
    Fang HSY, Ong GB (1962) Direct approach to the upper cervical spine. J Bone Joint Surg Am 4: 1588–1604Google Scholar
  18. 18.
    Fisch U, Pilsbury HC (1979) Infratemporal fossa approach to lesions in the temporal bone and base of the skull. Arch Otolaryngol Head Neck Surg 105: 99–107CrossRefGoogle Scholar
  19. 19.
    Fox JL (1967) Oliteration of midline vertebral artery aneurysm via basilar craniectomy. J Neurosurg 26: 406–412PubMedCrossRefGoogle Scholar
  20. 20.
    Fujitsu K, Kuwabara T (1985) Zygomatic approach for lesions in the interpeduncular cistern. J Neurosurg 62: 340–343PubMedCrossRefGoogle Scholar
  21. 21.
    Gilsbach J, Eggert HR (1983) Transoral operations for cranio-spinal malformations. Neurosurg Rev 6: 199–209PubMedCrossRefGoogle Scholar
  22. 22.
    Greenberg AD (1968) Atlanto-axial dislocations. Brain 91: 655–684PubMedCrossRefGoogle Scholar
  23. 23.
    Griffith HB, Veerapen R (1987) A direct transnasal approach to the sphenoid sinus. J Neurosurg 66: 140–142PubMedCrossRefGoogle Scholar
  24. 24.
    Guiot G (1978) In: Fahlbusch R, Werder KV (eds) Treatment of pituitary adenomas. Thieme, StuttgartGoogle Scholar
  25. 25.
    Halstead EA (1910) Remarks on the operative treatment of tumors of the hypophysis with the report of two cases operated on by an oro-nasal method. Surg Gynecol Obstet 10: 494–502Google Scholar
  26. 26.
    Hamberger CA, Hammer G, Norlen G, Sjogren B (1961) Transantrosphenoidal hypophysectomy. Arch Otolaryng (Chicago) 74: 2–8CrossRefGoogle Scholar
  27. 27.
    Hardy J, Wigser S (1965) Transsphenoidal surgery of pituiary fossa tumors with televised radioflouroscopic control. J Neurosurg 23: 612–619PubMedCrossRefGoogle Scholar
  28. 28.
    Henderson WR (1939) The pituitary adenomata: a follow-up study of the surgical results in 338 cases (Dr. Harvey Cushing’s Series). Br J Surg 26: 811–921CrossRefGoogle Scholar
  29. 29.
    Hernandez Altemir F (1986) Transfacial access to the retromaxillary area. J Maxfac Surg 14: 165–170CrossRefGoogle Scholar
  30. 30.
    Hirsch O (1910) Endonasal method of removal of hypophyseal tumors. With report of two successful cases. JAMA 55:772–774CrossRefGoogle Scholar
  31. 31.
    Holliday MJ (1986) Lateral transtemporal-sphenoid approach to the skull base. Ear Nose Throat J 65: 153–162PubMedGoogle Scholar
  32. 32.
    House WF, Hitselberger WE (1976) The transcochlear approach to the skull base. Arch Otolaryngol Head Neck Surg 102: 334–342CrossRefGoogle Scholar
  33. 33.
    Hout WM, Arafah BM, Salazar R, Selman W (1988) Evaluation of the hypothalamic-pituitary-adrenal axis immediately after pituitary adenectomy: is perioperative steroid therapy necessary? J Clin Endocrinol Metab 66: 1208–1212PubMedCrossRefGoogle Scholar
  34. 34.
    Huelke DF, O’Day J, Mendelsohn RA (1981) Cervical injuries suffered in automobile crashes. J Neurosurg 54: 316–622PubMedCrossRefGoogle Scholar
  35. 35.
    Hurwitz LJ, Shepherd WHT (1966) Basilar impression and disordered metabolism of bone. Brain 89: 223–233PubMedCrossRefGoogle Scholar
  36. 36.
    James JA (1967) Transethmosphenoidal hypophysectomy. Arch Otolaryngol 86: 256–264PubMedCrossRefGoogle Scholar
  37. 37.
    James D, Crockard HA (1991) Surgical access to the base of skull and upper cervical spine by extended maxillotomy. Neurosurgery 29: 411–416PubMedCrossRefGoogle Scholar
  38. 38.
    Janecka IP, Sen CN, Sekhar LN, Arriaga MA (1990) Facial translocation: a new approach to the cranial base. Otolaryngol Head Neck Surg 103: 413–419PubMedGoogle Scholar
  39. 39.
    Kanavel AB (1909) Removal of tumors of the pituitary body by an infranasal route. JAMA 53: 1704–1707CrossRefGoogle Scholar
  40. 40.
    Kennedy DW, Papel ID, Holliday M (1986) Transpalatal approach to the skull base. Ear Nose Throat J 65: 125–133PubMedGoogle Scholar
  41. 41.
    Krespi YP, Har-el G (1988) Surgery of the clivus and anterior cervical spine. Arch Otolaryngol Head Neck Surg 114: 73–78PubMedCrossRefGoogle Scholar
  42. 42.
    Krespi YP, Sisson GA (1984) Transmandibular exposure of skull base. Am J Surg 148: 534–538PubMedCrossRefGoogle Scholar
  43. 43.
    von Langenbeck B (1859) Beitrage zur Ostéoplastic—die osteoplastische Resektion des Oberkiefers. In: Reimer, Goshen A (eds) Deutsche Klinik, BerlinGoogle Scholar
  44. 44.
    Laws ER Jr (1985) Cranial chordomas. In: Wilkins RH, Rengachary SS (eds) Neurosurgery, vol 1. McGraw-Hill, New York, pp 927–929Google Scholar
  45. 45.
    List CF (1941) Neurologic syndromes accompanying developemental anomolies of occipital bone, atlas and axis. J Arch Neurol Psychiatry 45: 577–618Google Scholar
  46. 46.
    Malis LI (1985) Surgical resection of tumours of the skull base. In: Wilkins RH, Rengachary SS (eds) Neurosurgery, vol 1. McGraw-Hill, New York, pp 1011–1020Google Scholar
  47. 47.
    Marks JS, Sharp J (1981) Rheumatoid cervical myelopathy. Q J Med 199: 307–319Google Scholar
  48. 48.
    Mayberg MR, Symon LD (1986) Meningiomas of the clivus and apical petrous bone. Report of 35 cases. J Neurosurg 65: 160–167PubMedCrossRefGoogle Scholar
  49. 49.
    McAfee PC, Bohlman HH, Riley LH, Robinson RA, Southwick WO, Nachles NE (1987) The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am 69: 1371–1383PubMedGoogle Scholar
  50. 50.
    Meijers KA, Cats A, Kramer HP, Lyuendijk W, Onvlee GJ, Thomeer RTW (1984) Cervical myelopathy in rheumatoid arthritis. Clin Exp Rheumatol 2: 239–245PubMedGoogle Scholar
  51. 51.
    Menezes AH, VanGilder JC (1988) Transoral-transpharyngeal approach to the anterior craniocervical junction. J Neurosurg 69: 895–903PubMedCrossRefGoogle Scholar
  52. 52.
    Mullen S, Naunton R, Hekmat-Panah J, Vialati G (1966) The use of the anterior approach to ventrally placed tumours in the foramen magnum and vertebral column. J Neurosurg 24: 536–543CrossRefGoogle Scholar
  53. 53.
    Neil-Dwyer G, Sharr M, Haskell R, Currie D, Hosseini M (1988) Zygomatico-temporal approach to the basis cranii and basilar artery. Neurosurgery 23: 20–22PubMedCrossRefGoogle Scholar
  54. 54.
    Price JC (1986) The midfacial degloving approach to the central skull base. Ear Nose Throat J 65: 174–180PubMedGoogle Scholar
  55. 55.
    Price JC, Holliday MJ, Kennedy DW, Johns ME, Richtmeier WJ, Mattox DE (1988) The versatile midface degloving approach. Laryngoscope 98: 291–295PubMedGoogle Scholar
  56. 56.
    Redlund-Johnell I (1984) Dislocations of the cervical spine in rheumatoid arthritis. Thesis. Malmo University, pp 69–89Google Scholar
  57. 57.
    Rock JP, Tomecek FJ, Ross L (1993) Transoral surgery: an anatomic study. Skull Base Surg 3: 109–116PubMedCrossRefGoogle Scholar
  58. 58.
    Rosegay H (1981) Cushings legacy to transsphenoidal surgery. J Neursurg 54: 448–454CrossRefGoogle Scholar
  59. 59.
    Samii M, Ammirati MD, Mahran A, Bini W, Sepehrnia A (1989) Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 24: 12–17PubMedCrossRefGoogle Scholar
  60. 60.
    Schloffer H (1907) Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin Wochenschr 20: 621–624Google Scholar
  61. 61.
    Scoville WB, Sherman IJ (1951) Platybasia. Report of ten cases with comments on familial tendencies, a special diagnostic sign, and the end results of operation. Ann Surg 133: 469–502Google Scholar
  62. 62.
    Sekhar LN, Nanda A, Sen C, Snyderman CN, Janecka IP (1992) The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg 76: 198–206PubMedCrossRefGoogle Scholar
  63. 63.
    Sen CN, Sekhar LN (1990) The subtemporal and preauricular infratemporal approach to intradural structures ventral to the brainstem. J Neurosurg 7: 345–354Google Scholar
  64. 64.
    Spillane JD, Pallis C, Jones AM (1957) Developemental abnormalities in the region of the foramen magnum. Brain 80: 11–53PubMedCrossRefGoogle Scholar
  65. 65.
    Stapleton SR, Wilkins PR, Archer DJ, Uttley D (1993) Chondrosarcoma of the skull base: a series of eight cases. Neurosurgery 32: 348–356PubMedCrossRefGoogle Scholar
  66. 66.
    Stevenson GC, Stoney RJ, Perkins RK, Adams JE (1966). A transcervical transclivai approach to the vertebral surface of the brain stem for removal of a clivus chordoma. J Neurosurg 24: 544–551PubMedCrossRefGoogle Scholar
  67. 67.
    Svien HJ, Litzow TJ (1965) Removal of certain hypophyseal tumors by the transantralsphenoid route. J Neurosurg 23: 603–611PubMedCrossRefGoogle Scholar
  68. 68.
    Uttley D (1993) In: Lynn J, Bloom SR (eds) Surgical endocrinology. Butter-worths Heinemann, London pp 171–192Google Scholar
  69. 69.
    Uttley D, Archer DJ, Marsh HT, Bell BA (1991) Improved access to lesions of the central skull base by mobilisation of the zygoma: experience with 54 cases. Neurosurgery 28: 99–104PubMedCrossRefGoogle Scholar
  70. 70.
    Uttley D, Archer DJ, Taylor WAS, Bell BA (1993) Midline aneurysms of the vertebrobasilar junction: an effective anterior approach. Br J Neurosurg 7: 389–394PubMedCrossRefGoogle Scholar
  71. 71.
    Uttley D, Moore AJ, Archer DJ (1989) Surgical management of mid-line skull base tumors: a new approach. J Neurosurg 71: 705–710PubMedCrossRefGoogle Scholar
  72. 72.
    Watkins LD, Uttley D, Archer DJ, Wilkins PR, Plowman N (1992) Giant-cell tumours of the sphenoid bone. Neurosurgery 30: 576–581PubMedCrossRefGoogle Scholar
  73. 73.
    Wellbourn RB (1986) The evolution of transsphenoidal pituitary microsurgery. Surgery 100: 1185–1190Google Scholar
  74. 74.
    Wilson CB (1984) A decade of pituitary microsurgery. J Neurosurg 61: 814–833PubMedCrossRefGoogle Scholar
  75. 75.
    Wissinger JP, Danoff D, Wisiol ES, French LA (1967) Repair of an aneurysm of the basilar artery by a transclivai approach. Case report. J Neurosurg 26: 417–419Google Scholar
  76. 76.
    Yasargil MG, Mortara RW, Curcic M (1980) Meningiomas of the basal posterior cranial fossa. Adv Tech Stand Neurosurg 7: 3–115CrossRefGoogle Scholar
  77. 77.
    Yasargil MG, Smith RD, Gosser JR (1978) Microsurgery of the internal carotid artery and its branches. Prog Neurol Surg 9: 58–121Google Scholar

Copyright information

© Springer-Verlag Wien 1997

Authors and Affiliations

  • D. Uttley
    • 1
  1. 1.Department of NeurosurgeryAtkinson Morley’s HospitalWimbledon LondonUK

Personalised recommendations