Access Osteotomies

7/30/2019 Access Osteotomies

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Access osteotomies


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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


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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


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Indications

Central skull base lesions

Tumours situated in or extending into themaxillary sinus, the sphenoid sinus or

nasopharynx

Single access route for exposing the medial

compartment of the inferior skull base.


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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


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The anterior cuts are completedby 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


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The last cut is through theposterior wall of the maxillarysinus.

The palate should be free ofbony attachments, it will remainattached by the tissues of thesoft palate, the periosteum of theposterior wall, and the vessels of

the pterygomaxillary fissue.

Exposure of the tumour site byretraction of the palate in inferior

direction.


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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


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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 themidline.

This incision extends anteriorly to include the

gingival papilla on the palatal aspect of thecentral incisors.

The soft palate incision is a fullthickness incision

through oral mucosa, muscle, and nasal mucosa.


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The standard Le Fort I osteotomy is

then performed

A spatula osteotome is then used to

finish the midline split between thecentral 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.


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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 sinusand pterygoid plates


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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 palateis cut through the contralateral floor of the nose

from posterior to the anterior.


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Septum is detached from the

columela anteriorly

Medial cuts made from pyriformaperture to the orbital rim.

The cut is angled laterally

either to go through the inferiororbital rim or enter into the

maxillary sinus inferior to the

rim


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The orbital cuts are then performed

after elevation of the periosteum oforbital 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.


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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


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Transpalatal approach

Four types of variations-

- retraction of soft palate only

- palatal drop

- palatal split

- palatal split with labiomandibular glossotomy


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Technique

Palatal drop

The incision made through the

mucosa and periosteum down tothe palatal bone upto the palatal

junction.

Muscles of the soft palate dividedfrom hard palate andnasopharyngeal mucosa at the

junction.

The flap is pushed down, exposing


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Palatal split

The incision begins just lateral to the

base of the uvula, curves immediately

back to the midline and then traversesthe midline of the soft palate.

The incision is extended to hard palate

to allow soft palate to retract withouttearing.

The soft palate is retracted vertically

upto the hard palate.


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The muscular attachment of softpalate and nasopharynx is

divided, soft palate is only

attached to the anterior tonsillar

pillar and anteriorly to the hardpalate mucosa.

The posterior aspect of the hard

palate is exposed which can be

removed exposing the posterior

aspect of the septum


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Transpalatal with labiomandibular glossotomy

Involves midline lip incision,

mandibular split, and division ofthe tongue.


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Complications

CSF fistula

Wound complications associated with the

posterior pharyngeal wall Palatal wound problems


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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


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Technique

The lip split incision begins at thevermillion border and continuesalong nasal ala and lateral nose.

It runs horizontally at the innercanthus which it transects.

It continues at the depth of theinferior lid fornix through theconjuctiva to the lateral canthus,where it exits to meet the verticalbicoronal or preauricular incision.


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The cheek flap is reflectedinferiorly to the level of the hardpalate after the elevation of themaxillary periosteum and the

massteric fascia in a downwarddirection.

The frontotemporal scalp flap isreflected towards the midlineafter completion of the bicoronaland transtemporal incisions andappropriate undermining.


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Complications

Scar contracture

Epiphora

Facial paralysis

Non union or malunion at osteotomies


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Transethmoidal approach

Most direct and shortest route to the pituitary

Advantages

- working distance shorter than any pituitaryapproach

- avoids craniotomy

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

fossa


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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 bekept medial to the superior

orbital foramen with the lower

end extending 2-3mm below

the level of inner canthus.


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The elevation of the periosteum includes thetrochlea 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.


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Complications

Orbital hematoma

Diplopia

Blindness


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Transseptal transsphenoidal

approach

Advantage :

Avoids facial incision over a

highly esthetic region

Provides access to middlecranial fossa


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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.


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The quadrangular septal cartilage is disarticulatedfrom its attachment to the vomer inferiorly and to

the ethmoid plate posteriorly, leaving the septal

acrtilage hinged superiorly.

This exposes the ethmoid plate and vomerbetween its blades.


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Complication

CSF leak

Meningitis

Septal deformation

Loss of nasal tip projection

Denervation of the upper incisors


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Access to parapharyngeal space

Approaches to parapharyngeal space:

- transcervical

- trans parotid- trans cervical-transparotid

-transoral

-transoral- external approach

-cervical-transpharyngeal approach


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Trans parotid approach

For deep lobe parotid tumours tosave facial nerve.

A superficial parotidectomy isperformed, at the end of whichthe superficial lobe is left pedicledinferiorly.

Alternatively, the superficial lobecan be excised completely andthe deep lobe removed as aseparate specimen.


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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 theTMJ as well as digastric and the

bony external auditory meatus.


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The retromandibular vein is divided and thesuperficial 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.


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Mandibulotomy

Indications :

For large neoplasms,

Malignancies,

Highly vascular tumours,

Lesion that require proximal and distal control ofICA


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Midline mandibulotomy-

(mandibular swing approach)

Resection of oral cavity andoropharyngeal malignancies

Access to oropharynx, retropharynx,

parapharyngeal space, superior

cervical vertebrae and skull base,and floor of the mouth.


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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 contourof 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 boneand ends at the anterior border of sternomastoid .

- The submandibular part of the incision is deepened through

the platysma and the submandibular gland is removed


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- The midline of the mandible is then

split

- The mucosal incision is then carried

out inside the mandible and

deepened to include the division ofmylohyoid close to its insertion into

the mandible.


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The incision in the mucous

membrane is continued onto the

anterior faucial pillar ending on thesoft palate

The osteoplatic flap containing the

mandible is retracted as far out aspossible and the tumor is separated

from the adjacent structures by

blunt dissection and excised


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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.


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Subcutaneous mandibulotomy

- resection of tumours more than 5cm located insuperior medial PPS,

done by midline mandibulotomy and division ofmylohyoid, anterior belly of digastrics, andgeniohyoid muscle allow mandibule to be rotated

superolaterally;

avoids morbidity of intraoral and lip split incisionsand need for tracheostomy.


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Complication of mandibulotomy-

Malocclusion

Non union Loss of dentition

IAN injury

Need for lip split incision, tracheostomy, NG tube


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Palatopahryngeal approach

for excision of :-

- parapharyngeal tumours which arebenign, medially bulging,

- relatively avascular,

- extra-parotid and

- free from the contents of carotidsheath.

Trans oral approach to superomedialparapharyngeal space .Otolaryngology-

head and neck surgery(2006) 134,466-470


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An incision extending from theposterior 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


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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


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Infratemporal approach

- can be used for malignant tumors involving the skullbase or jugular foramen.

- This approach can be combined with frontotemporalcraniotomy for removal of tumors with significantintracranial extension.

- A parotidectomy incision with cervical extension isextended superiorly into a hemicoronal scalpincision.


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- 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 areexposed.


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Thank

you


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Refrences

Tyler M. Lewark.Le Fort I Osteotomy and Skull BaseTumors.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 : 407-409

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.

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