A concise seminar on access osteotomy to head and neck spaces and skull base.

1. Seminar on Access
Osteotomy
Presented by
Cathrine diana PG III

2. Content
• Introduction
• History
• Advantages and dis advantages
• classification
• Access to cranial base
• Access to infra temporal region
• Access to naso pharynx
• Access to base of tongue and oropharynx
• Access to parapharyngeal spaces
• Post op care
• Complications

3. Introduction
• A plethora of various pathologies occur in the skull base and deep spaces
of the neck.
• The surgical resection of these hidden lesions often poses a great surgical
challenge owing to the anatomical complexity, difficulty in accessibility and
proximity of vital structures.
• A multidisciplinary approach is often required in these situations
• Various approaches have been devised for their better exposure to provide
surgical access by transmaxillary, transzygomatic and transmandibular
approaches

4. Introduction
• The choice and type of access osteotomy to these hidden lesions of the
cranial base like Infratemporal fossa/ Sphenopalatine fossa and /or deep
spaces of neck is most often based on
• the anatomic extent of the lesion,
• vascularity of the lesion and
• involvement of neurovascular structures in and around it.

5. History
• Access osteotomy was first introduced in 1836 by Roux to improve access
in floor of mouth and base of tongue
• Spiro et al proposed the translabial access with mandibulotomy.
• In 1984, Attia et al described translabial access with mandibular osteotomy
anterior to mental foramen, thus preserving the ipsilateral lip sensation.
• The splitting of zygoma to access the infratemporal region has been
previously described by Hamyln et al.,
• the maxilla and the zygomatic bone can be removed in one piece as
described by McGurk and Lello.
• Salins PC introduced the trans naso-orbito-maxillary approach to
the anterior and middle skull base in 1998

6. Classification
• A variety of transfacial surgical approaches to midline skull base lesions
can be organized in a simple classification scheme of six techniques or
levels.
• Three intracranial approaches use a subfrontal trajectory and variable
amounts of transfacial exposure through the nasal and orbital bones.
• supraorbial bar (level 1),
• supraorbitonasal bar (level II), and
• orbitonasal bar (level III)
The transfacial approaches to midline skull base lesions: A classification scheme. Operative Techniques in
Neurosurgery Volume 2, Issue 4, December 1999, Pages 201–217

7. • Three extracranial approaches use a more inferior trajectory and variable
amounts of transfacial exposure through the maxilla.
• The transnasomaxillary approach (level IV) requires a Le Fort II osteotomy
with splitting of the maxillary fragment.
• The transmaxillary approach (level V) requires a Le Fort l osteotomy with
splitting of the palate. The transpalatal approach (level VI) requires
circumferential osteotomy and removal of the hard palate

8. classification
• Mini facial translocation-central is designed
to reach the medial orbit, sphenoid and
ethmoid sinus, and the inferior clivus.
• Mini facial translocation-lateral
• Standard facial translocation achieves
surgical access to the anterolateral skull
base.
• Extended facial translocation--medial
Classification of facial translocation approach to the skull base IVO
P. JANECKA, MD, FACS, [OTOLARYNGOL HEAD NECK SURG 1995;I
12:579-85.

9. classification
• Extended facial translocation-
medial and inferior
• Extended facial translocation-
posterior incorporates the ear,
temporal bone, and posterior
fossa into its surgical access
• Bilateral facial translocation

10. Advantages
1.Presenting optimal lines of "separation" of facial units for a surgical
approach, permitting the least traumatic displacement.
2. The primary blood supply to the "facial units" is through the external
carotid system, which also has a lateral-to-medial direction of flow, thus
ensuring viability of displaced surgical units.
3. The midface contains multiple "hollow" anatomic spaces facilitate the
relative ease of surgical access to the central skull base.
Classification of facial translocation approach to the skull base IVO P. JANECKA, MD, FACS, [OTOLARYNGOL
HEAD NECK SURG 1995;I 12:579-85.

11. 4. Displacement of facial units for an approach to the cranial base offers much
greater tolerance to postoperative surgical swelling, as opposed to similar
displacement of the content of the neurocranium.
5. Reestablishment of the normal anatomy, after repositioning of the facial
units during the reconstructive phase of surgery, provides a high degree of
functional and esthetic achievement.

12. Disadvantages
1. Contamination of the surgical wound with oropharyngeal bacterial flora.
2. The need for facial incisions with subsequent scar development.
3. Emotional considerations for the patient related to "surgical facial
disassembly."
4. The potential need for supplementary airway management (postoperative
endotracheal intubation,temporary tracheostomy).

13. Skull baseapproachanteriorlyand laterally
• Anterior skull base approaches include: Fronto- naso – orbital osteotomy,
Trans nasal, orbitozygomatic osteotomy, naso frontal osteotomy.
• These osteotomies are done to have a straight line access to remove
intracranial lesions.
• S.M. Raza et al reported that Frontal–nasal– orbital craniotomy provides
access to the floor of the anterior and middle cranial fossa while avoiding
excessive brain retraction and oedema.
• A lower incidence of postoperative complications, such as Cerebrospinal
Fluid leak and infection.

14. Fronto nasal/fronto-naso – orbital
osteotomy:
• Anterior access to the orbital and
sphenoethmoidal planes as well as to the nasal
and paranasal cavities The improved
visualization of the anterior skull base and
clival—sphenoidal region facilitates en
bloc tumor removal, optic nerve decompression,
exposure of the medial aspect of the cavernous
sinus, and watertight realignment of the
anterior cranial base dura.

15. • A bicoronal flap is elevated in the
subperiosteal plane
• The flap is dissected down to the FZ suture
lines bilaterally and piriform apertures in
the midline
• The periorbita is dissected from the
superior, medial, and lateral walls of the
orbit back to the apex on either side
• the outline of the nasofrontal segment is
planned
• Titanium micro- or miniplates for
subsequent bone fixation are adapted and
drilled.

16. • osteotomies are made across the
frontal bone, down to and along the
orbital roofs, down the medial orbital
wall and along the nasomaxillary
grooves just anterior to the lacrimal
crest
• A vertical osteotomy performed from
the side just anterior to the crista galli
allows detachment of the frontonasal
segment and exposure of the anterior
skull base

17. Fronto-orbitozygomaticosteotomy
• Usually performed after the modified frontopterional craniotomy, the frontal
and temporal dura are separated from the roof and lateral wall of the orbit.
• the periorbita is gently separated from the lateral wall and the roof of the
orbit for at least 3 cm posteriorly from the orbital rim. Care is exerted not to
enter the periorbita in the region of the lacrimal gland.

18. • The saw blade used for the
osteotomy must be as thin as
possible to prevent an excessive loss
of bone that would compromise a
good reconstruction.
• Modification:
• Osteotomy including maxilla
• One and half approach

19. The trans naso-orbitomaxillaryapproach
to the anteriorand middle skull base
• A modified Weber-Ferguson incision is used.
The lip splitting and lateral nasal component
of the incision are placed opposite the side to
which the nose is to be transposed .
• Osteotomy cuts are made so that the
piriform aperture margins are included as a
rigid base for the transposed nose, which
also widens the area of exposure for the
transnasal exploration. The lateral nasal
osteotomy cuts are made at right angles to
the bone surface

20. • Further osteotomy cuts, to permit the
mobilization of the anterior wall of the
maxillary sinus and part of the inferior
orbital rim
• A Le Fort I level horizontal cut, which
communicates with both the lateral nasal
and zygoma
• The orbital floor osteotomy is joined
medially to the lateral nasal osteotomy
• The entire segment is mobilized, pedicled
on the cheek and hinged on the zygomatic
bone.
• Modification: associated with lefort 1 /
mandibulotomy
Int. ,L Oral Maxillofac. Surg. 1998; 27:53 57

21. Middle cranial baseapproaches
• Include Le Fort I maxillary downfracture osteotomy, sometimes combined
with median or paramedian mandibulotomy and Fronto-Naso-Orbital
osteotomy.
• When compared with other popular approaches, Lefort I osteotomy
provides excellent exposure for angiofibromas, clivus tumors, and the
tumors of the nasopharynx, nasal septum, and nasal cavity.
• In 1988 Belmont et al performed a midsagittal osteotomy and divided the
inferior segment in two halves so as to obtain better access to the pituitary
gland in middle cranial fossa.

22. Lefort I osteotomy
• The down-fracture technique
provides the surgeon with a safe
approach that allows visualization
of the maxillary sinuses, nasal
cavity, naso-pharynx, base of the
skull and upper cervical spine. This
approach can also be combined
with a midline lip split,
mandibulotomy and glossotomy to
give access to retropharyngeal
structures
The Le Fort I osteotomy as a surgical approach for removal of tumours of the
Midface Hermann F. Sailer, Piet E. Haers, Klaus W. GrfitzJournal of Cranio-MaxillofaciaI Surgery (1999) 27, 1~

23. Modificationin lefort 1
• Le Fort I osteotomy is used
for identification of the
tumour margins in
posterior maxilla following
maxillectomy and lateral
swing of the unaffected
maxilla
• to allow for complete
posterior tumour
extirpation.
Le Fort Maxillary Swing Procedure for Posterior Maxilla Tumor Extirpation Deepak
Kademani, DMD, MD*J Oral Maxillofac Surg 65:1055-1058, 2007

24. • Modification: two piece lefort 1
• The Le Fort I osteotomy as a maxillotomy,
with midline split of the hard and soft
palate, can be used safely in certain clinical
situations for lesions of the nasal cavity,
nasopharynx, upper anterior cervical spine
and base of skull, for which direct
visualization is required
• Lefort 2 osteotomy

25. Maxillary SwingProcedure
• This surgical approach is most
suitable for lesions that are
located on the medial aspect of
the infra temporal fossa in the
pterygomaxillary region or in the
lateral wall of the nasopharynx.

26. Maxillary removaland reinsertion
• Favorable surgical technique for the
treatment of anterior cranial base (ACB)
tumors in adults and even in children.
• Improves operative morbidity by
preserving both function and form of the
maxillary region and gives excellent
exposure to ACB.
Maxillary removal and reinsertion: A favorableapproach for extensive
anterior cranial base tumorsOtolaryngology–Head and Neck Surgery
(2010) 142, 322-326

27. • After an extended facial de-gloving to
allow exposure of the midface, titanium
craniofacial plates are planned and
shaped before making the bone cuts.
. After completion of the osteotomies, the
corresponding maxillary bone is removed
and after wide exposure to the ACB is
obtained, the tumour can be removed
Maxillary removal and reinsertion: A favorable approach for extensive anterior cranial base
tumorsOtolaryngology–Head and Neck Surgery (2010) 142, 322-326

28. Approachesto infra temporalregion-
• Zygomatic arch osteotomy:
• It include zygomatic arch osteotomy
with inferior orbital rim extensions,
pedicled or non pedicled and
inverted L Zygomatic bone
osteotomy with or without
involvement of lateral orbital rim.

29. • The osteotomised zygomatic arch with
the masseter muscle was reflected
inferiorly. In these cases, zygomatic
arch osteotomy is pedicled inferiorly on
masseter & was swung laterally &
inferiorly. This permitted stripping
temporalis muscle from temporal bone
& swinging it latero-inferiorly thus
exposing infratemporal fossa & the
lesion

30. • Zygomatic arch osteotomy can be combined with vertical ramus
osteotomy of mandible with median or paramedian mandibulotomy
for better exposure of the inferior extent of the lesion in the
infratemporal space.
• Modification: along with coronoidectomy

31. MandibulotomyApproachto the
Infratemporal Fossa
• Hidden lesions located of
parapharyngeal, lateral pharyngeal
spaces and deep spaces of neck,
posterior oral floor and
retromaxillary region can be
accessed by mandibular
osteotomies. They include median
or paramedian step or vertical
mandibulotomy with mandibular
swing approach.

32. Types of lip splitting
Oral Maxillofac Surg 59:1292-1296, 2001 *

33. • A standard paramedian mandibulotomy
is performed through a lower lip–
splitting midline incision on the lower lip,
chin, and the submental and
submandibular regions. A short cheek
flap is elevated, remaining anterior to
the mental foramen.
• An angled mandibular osteotomy is
placed between the lateral incisor and
the canine teeth. The mylohyoid muscle
is divided to allow lateral retraction of
the mandible

35. Mandibulotomy Approach for a Tumor of the
LateralAspectof theInfratemporalFossa
• Benign and malignant tumors of the infratemporal
fossa located posterolateral to the maxillary antrum
but medial to the ascending ramus of the mandible
are best approached via a mandibulotomy approach.
• As the mandible is swung laterally, further wider
exposure is obtained by division of the lateral
pterygoid muscle inferior to the greater wing of the
sphenoid bone, exposing the lower end of the
tumor.

36. Approachfor the nasopharynx
• Surgical access to the nasopharyngeal
and retromaxillary region is dictated by
the size and location of the tumor
• Small, centrally located tumors can be
approached through the palate. Larger
and lateral lesions may require a
medial maxillectomy or maxillary swing
approach

37. Transpalatal approach

38. MedialMaxillectomyApproach
• A modified Weber-Ferguson incision
with a Lynch extension
• Care is taken, however, to prevent
injury to the infra-orbital nerve
• generous anterior wall antrotomy is
made
• The opening in the anterior wall is
extended up to the nasal process of
the maxilla

39. Access to oropharynxand baseof tongue:
• Median Labiomandibular Glossotomy
(Trotter’s Operation):
• Tumors located in the midline of the
oropharynx and the craniocervical
junction can be approached optimally
with a mandibulotomy and median
glossotomy.

40. • Splitting the tongue in the midline
through a relatively avascular
plane permits preservation of the
lateral neurovascular bundles to
both halves of the tongue and
leaves the patient with very little
functional deficit.
• Modification: mandibulotomy
with paralingual extension and
mandibular swing

41. Access to para-pharyngealspaces
• The styloid process, the
stylomandibular ligament and the
mandible impede access to
parapharyngeal region. Division of
the mandible was first proposed by
Ariel et al.
• The most important maneuvers and
osteotomies that have been proposed
to improve surgical access to the
parapharyngeal space

42. Double mandibular osteotomy with coronoidectomy for tumours in the parapharyngeal space N.
Lazaridis, ∗ K. Antoniades † British Journal of Oral and Maxillofacial Surgery (2003) 41, 142–146

44. Stylomandibulartenotomy
Stylomandibular tenotomy in the transcervical removal of large
benign parapharyngeal tumoursBritish Journal of Oral and Maxillofacial Surgery (2002) 40, 313–316
Adequate exposure was achieved by just dividing the stylomandibular
ligament and retracting the mandible anteriorly without the need for
mandibulotomy or superficial parotidectomy

45. Modified attia approach for enormous pleomorphic adenoma of para-pharyngeal space with
all-embracing chondroid calcification Bansal V (2015- Volume 1(5): 141-145)

46. Attia’sAnterolateralapproach
• The Anterolateral approach for better exposure parapharyngeal space,
infratemporal space and pterygomaxillary space
• The approach described here results in a wide-field exposure of both the
pterygomaxillary and parapharyngeal spaces with no sacrifice of either
mandibular function or the sensory supply of the face or oral cavity. The
parapharyngeal space is entered through a transcervical incision

47. Postoperativecare
• Neuromonitoring – intensive care for first few days of surgery
• Airway
• For patients who have experienced disruption of the nasolacrimal drainage
system, appropriate eye care is necessary.
• When the nasolacrimal duct is resected, an indwelling nasolacrimal stent
is placed at the time of surgery to retain a natural draining passage for
tears and to reestablish epithelialization of a neonasolacrimal duct tract

48. • Wound Care: extensive humidification of the air is necessary to reduce
dryness, crusting, and bleeding in case of surgery involved in nasal and
para nasal sinuses.
• Pulmonary care for prevention of pneumonia and routine prophylaxis for
deep vein thrombosis are used while the patient is still confined to bed and
early ambulation is not feasible. Once the patient is able to sit up, gradual
progressive ambulation is encouraged, with the goal of having the patient
fully ambulatory by the fifth to seventh postoperative day.

49. • When the surgical intervention involves the masticator space or TMJ, the
development of trismus is a risk.
• Initially trismus develops because of a spasm of the muscles of mastication
resulting from postoperative pain and discomfort, and later, trismus occurs
as a result of fibrosis around the TMJ and the masticator group of muscles.
• Therefore exercises of the jaw are initiated in the early postoperative
period, and the patient is instructed to self execute jaw exercises during the
recovery phase. Mechanical devices for prevention and/or improvement of
trismus are available and should be used when indicated.

50. Complication
• Complications related to the branches of internal carotid artery can be of
sudden onset and are most serious. They include vasospasm, thrombosis,
and hemorrhage.
• Alterations in cerebrospinal fluid dynamics may lead to postoperative
leakage of cerebrospinal fluid, pseudomeningocele, and hydrocephalus.
Acute hydrocephalus that develops postoperatively is usually obstructive
because of mass effect (edema, hemorrhage). In contrast, delayed
hydrocephalus is typically communicating and related to poor absorption
of the cerebrospinal fluid or scarring of the basal cisterns.

51. • The substantial risk of injury to the cranial nerves, facial nerve weakness
• tongue dysfunction
• TMJ dysfunction
• Mal alignment of dentition
• Malunion
• Scaring , lower eye lid retraction
• epiphora
• Infection , oral contamination
• Problems with swallowing and loss of sensation in the palate
• Need for tracheostomy to maintain airway post operatively

52. Summary
• Many craniofacial techniques have been in use to improve access to the skull
base, infra temporal , para/ lateral pharyngeal region
• varying degrees of mobilisation have been described in literatures however, the
primary objectives are similar.
• Improved access to the pathology should be achieved with minimal brain
retraction.
• The procedure should facilitate protection of the brain and adjacent
neurovascular structure
• The surgery of access should have minimal morbidity and introduce minimal
additional operating time.
• Patient specific osteotomy approach need to be carried out based on the site,
size, type of tumour, adjacent anatomical structure, anticipated complication

53. references
• 1.Head and neck oncology Jatin P Shah
• 2. Operative oral and maxillofacial surgery- Langdon patel
• 3.. The transfacial approaches to midline skull base lesions: A classification
scheme. Operative Techniques in Neurosurgery Volume 2, Issue 4,
December 1999, Pages 201–217
• 4. The Le Fort I osteotomy as a surgical approach for removal of tumours
of the Midface Hermann F. Sailer, Piet E. Haers, Klaus W. Grfitz Journal of
Cranio-MaxillofaciaI Surgery (1999) 27, 1~
• 5. Oral Maxillofac Surg 59:1292-1296, 2001 Functional and Aesthetic
Results of Various Lip-Splitting Incisions: A Clinical Analysis of 60 Cases
Alexander D. Rapidis, MD, DDS, Dr Dent, Oral Maxillofac Surg 59:1292-
1296, 2001 *
• 6. CRANIOFACIAL OSTEOTOMIES FOR HIDDEN HEAD & NECK LESIONS
• Mohammad Akheel, Suryapratap Singh Tomar2 Craniofacial osteotomies
for hidden head & neck lesions, Journal of Head & Neck physicians and
surgeons, 2013;1(1):1-3
•

54. • 7. Classification of facial translocation approach to the skull base IVO P.
JANECKA, MD, FACS, Pittsburgh, Pennsylvania OTOLARYNGOL HEAD NECK
SURG 1995;I 12:579-85.
• 8. Journal of Cranio-Maxillofacial Surgetlv (1997) 25, 285-293 Craniofacial
access to the anterior and middle cranial fossae and skull base G. Lello 1, R
Statham 2, J. Steers 2, M. McGurk 3 . Journal of Cranio-Maxillofacial
Surgetlv (1997) 25, 285-293
• 9. G. K. B. Sandor, D. A. Charles, V. G. Lawson, C. H. Tator: Trans oral
approach to the nasopharynx and clivus using the Le Fort I osteotomy with
midpalatal split. Int. J. Oral MaxiIlofac. Surg. 1990; 19:352 355.
• 10. A new external approach to the pterygomaxillary fossa and
parapharyngeal space. Attia EL, Bentley KC, Head T, Mulder D. Head Neck
Surg. 1984 Mar-Apr;6(4):884-91.
• 11. Maxillary-fronto-temporal approach for removal of recurrent
malignant infratemporal fossa tumors: Anatomical and clinical study
Yuxing Guo, Chuanbin Guo* Journal of Cranio-Maxillo-Facial Surgery 42
(2014) 206e212
• 12. Double mandibular osteotomy with coronoidectomy for tumours in
the parapharyngeal space N. Lazaridis, ∗ K. AntoniadesBritish Journal of
Oral and Maxillofacial Surgery (2003) 41, 142–146

55. Thank you…