Faculty Bibliography

OBJECTIVE:To determine the morbidity and mortality associated with a large series of patients undergoing craniofacial resection at one institution. The series is also analyzed with respect to pathology, disease recurrence, and role of adjuvant therapy. DESIGN/METHODS:Retrospective review with a mean follow-up of 3 years (range, 6 months to 8 years). SETTING/METHODS:Tertiary care, urban referral center. PATIENTS/METHODS:The study included 73 consecutive patients (39 male and 34 female). Ages ranged from 13 to 78 years with a mean of 53.1 years. All patients had benign or malignant tumors of the paranasal sinuses. MAIN OUTCOME MEASURES/METHODS:Morbidity associated with craniofacial resection was categorized as follows: early (within 30 days of surgery) or late (> 30 days); neurologic, ocular, or infectious. RESULTS:Overall morbidity rate was 63%, and the mortality rate was 2.7%. Of the patients who had complications develop, 26 had development of major morbidities and there were two mortalities. The most common complications were transient alteration in mental status (15 patients), diplopia (11 patients), cerebrospinal fluid leak (10 patients), and osteomyelitis of the frontal bone flap (eight patients). CONCLUSIONS:Craniofacial resection is an effective surgical treatment for paranasal sinus tumors. The mortality rate is acceptable and morbidity appears directly related to experience with the procedure. Infectious complications were the most devastating.

Wire breakage after a cervical occiput to C2 wire fixation and fusion resulted in the transdural and intramedullary migration of a wire fragment in a patient who remained neurologically intact. The risks of sublaminar wiring fixation are discussed, along with newer techniques for posterior cervical stabilization.

Treatment of some tumors and aneurysms of the skull base may require internal carotid artery (ICA) sacrifice. Preoperatively to determine the dependence of the cerebral blood flow on a particular vessel, we perform a balloon test occlusion (BTO) by temporarily occluding the vessel in an awake patient. During occlusion, clinical evaluations and cerebral blood flow measurements are assessed. We have performed 300 BTOs. Eleven patients (3.7%) have had complications. Six (2%) were asymptomatic dissections. Five (1.7%) had neurologic deficits that persisted beyond the test period. Of these five, one was back to baseline in less than 24 hours, one recovered completely in a week, and one (0.33%) had a minimal but persistent dysphasia. These latter three cases are unexplained but might have resulted from unrecognized dissections or embolic events. Finally, one patient with a persistent deficit required energency surgery for reasons unrelated to the BTO and was therefore difficult to assess, and one required emergency middle cerebral artery embolectomy and repair of the dissection. The preoperative knowledge of carotid dependence in cases in which the ICA is at risk is essential, since vascular grafts or alternative surgical approaches are necessary in patients unable to tolerate carotid sacrifice. Since approximately 15 to 20% of the population falls into this category, a preoperative BTO appears justified