• Journal of Korean Neurosurgical Society
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• 제30권4호
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• pp.479-485
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• 2001

Objective : Several conservative treatments have been tried in peripheral facial nerve paralysis, because 80% of patients recover spontaneously. Surgical decompression may be helpful to the residual, medically intractable patients. We present here our experiences of facial nerve decompression via middle fossa approach, which seems to be one of good surgical therapeutic options for medically refractory peripheral facial nerve paralysis. Method : Three cases of medically intractable peripheral type facial paralysis were microscopically operated via middle cranial fossa approach to decompress the labyrinthine segment of the facial nerve and geniculate ganglion by searching landmarks of middle meningeal artery, greater superficial petrosal nerve and facial hiatus. Results : After operation, two cases of Bell's palsy improved substantially and one case of post-traumatic facial paralysis improved partially. Conclusion : This report is presented to describe the surgical facial nerve decompression via middle fossa for early control of peripheral type facial paralysis. Surgical decompression of edematous peripherally paralysed facial nerve could be preferred to conservative treatment in some patients although more surgical experience should be required.

• Journal of Korean Neurosurgical Society
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• 제30권9호
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• pp.1079-1085
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• 2001

Objective : We analysed various surgical approaches and surgical results of 28 middle cranial base tumors for the purpose of selecting optimal surgical approach to the middle cranial base tumor. Methods : In this retrospective review, 28 patients, including 16 meningioma, 6 trigeminal neurinoma, 2 pituitary adenoma, 2 craniopharyngioma, 1 facial neurinoma, and 1 metastatic tumor, underwent surgical treatment using skull base technique. Of theses, 16 tumors were mainly confined to middle cranial fossae, 5 tumors with extension into both anterior and middle fossa, and 7 tumors with extension into both middle and posterior fossa. Tumors that confined to the middle cranial fossa or extended into the anterior cranial fossa were operated with modified pterional, orbitozygomatic or Dolen'c approach, and tumors that extended into the posterior cranial fossa were operated with anterior, posterior or combined transpetrosal approach. Completeness of tumor resection, surgical outcome, postoperative complication, and follow up result were studied. Results : Total tumor removal was achieved in 9 tumors of 10 tumors that did not extended to the cavernous sinus, and was achieved in 7 tumors of 8 tumors that extended to the lateral wall of the cavernous sinus. Of 10 tumors that extended to the venous channel of the cavernous sinus, only 2 were removed totally. Surgical outcome was excellent in 14 patients, good in 10, fair in 2 and poor in 2. There were no death in this series. Dumbell type tumor which extended into both middle and posterior fossae showed tendency of poor prognosis as compared with tumors that confined middle cranial fossa and extended into both anterior and middle cranial fossa. Postoperative dysfunctions were trieminal hypesthesia in 3, oculomotor nerve palsy in 2, abducens nerve palsy in 2, hemiparesis in 2, cerebellar sign in 1, facial palsy in 1 and hearing impairment in 1. Conclusion : Based on our findings and a review of the literature, we conclude that, when selecting the surgical approach to the middle cranial fossa tumors, the most important factors to be considered were exact location of the tumor mass and existence of the cavernous sinus invasion by tumor mass. We recommend modified pterional or orbitozygomatic approach in cases with tumors located anterior and middle cranial base, without cavernous sinus invasion. In cases with tumors invading into cavernous sinus, we recommend Dolen'c or orbitozygomatic approach. And in lateral wall mass and the cavernous sinus, it is preferred to approach the tumor extradurally. For the tumor involing with middle fossa and posterior fossa(dumbell type) a combined petrosal approach is necessary. In cases with cavernous sinus invasion and internal carotid artery encasement, we recommend subtotal resection of the tumor and radiation therapy to prevent permanent postoperative sequele.

• Journal of Korean Neurosurgical Society
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• 제29권1호
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• pp.118-125
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• 2000

Objective : Trigeminal neurinomas are rare tumors that may locate in the middle fossa or posterior fossa and straddled both the middle and posterior fossa, according to their origin in the nerve complex. The aim of this study was to analyze the clinical presentation, operative approaches employed and outcome in 15 patients who were treated surgically, with special emphasis on surgical approach. Method : Between 1994 and 1998, a total of fifteen patients were histopathologically identified as neurinomas originating from the trigeminal nerve complex at the tumor clinic in the neuroscience center of the our university. Results : The surgical approach to these tumors depends on their anatomical location and tumor size. Six patients had tumors confined to the middle fossa, five patients had tumors limited to the posterior fossa, and four patients both in middle and posterior fossa components of their tumors. Nine neurinomas were removed via the conventional approach(pterional, subtemporal, suboccipital) and six were excised using skull base approach(transzygomatic subtemporal, orbitozygomatic, transpetrosal). Total resection of the tumor was possible in 10 cases. Total resection of tumor was accomplished in 83% of patients following skull base approach compared with 56% of patients following conventional approach. The surgical outcome was excellent or good in 13 cases, fair in one and, poor in one. There was no operative death. In the immediate postoperative period, aggravation of preoperative facial hypesthesia and 6th cranial nerve palsy were common. Although, these deficits were generally transient, eight patients remained with some degree of trigeminal hypesthesia, two had facial weakness, one neurotrophic keratitis, one diplopia, and one mastication difficulty. Conclusion : Surgical approach to the trigeminal neurinoma depends on the tumor location and tumor size. Skull base approach provides more complete tumor excision without increased morbidity compared to conventional approach. Surgeons have to be meticulous in order to reduce postoperative complication.

• Journal of Korean Neurosurgical Society
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• 제40권2호
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• pp.125-127
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• 2006

Facial nerve schwannomas are uncommon tumors. A 40-year-old female presented with left-side facial weakness. Computed tomography[CT] imaging showed a $3\;{\times}\;2cm$ lesion on the posterior portion of the left middle cranial fossa. The mass abutted the anterior aspect of the left petrous bone with a wide erosive change involving the area of the left facial nerve ganglion [geniculate ganglion]. A well-circumscribed extra-axial mass was seen on magnetic resonance imaging[MRI]. The tumor was completely removed through subtemporal approach and the patient was discharged without additional neurological deficit. This rare case is discussed and a review of the relevant literature is presented.

• Journal of Korean Neurosurgical Society
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• 제61권3호
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• pp.407-414
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• 2018

Objective : The purpose of the present study was to describe an OrBitoZygomatic (OBZ) surgical variant that implies the drilling of the orbital roof and lateral wall of the orbit without orbitotomy. Methods : Design : cross-sectional study. Between January 2010 and December 2014, 18 patients with middle fossa lesions underwent the previously mentioned OBZ surgical variant. Gender, age, histopathological diagnosis, complications, and percentage of resection were registered. The detailed surgical technique is described. Results : Of the 18 cases listed in the study, nine were males and nine females. Seventeen cases (94.5%) were diagnosed as primary tumoral lesions, one case (5.5%) presented with metastasis of a carcinoma, and an additional one had a fibrous dysplasia. Age ranged between 27 and 73 years. Early complications were developed in four cases, but all of these were completely resolved. None developed enophthalmos. Conclusion : The present study illustrates a novel surgical OBZ approach that allows for the performance of a simpler and faster procedure with fewer complications, and without increasing surgical time or cerebral manipulation, for reaching lesions of the middle fossa. Thorough knowledge of the anatomy and surgical technique is essential for successful completion of the procedure.

• Journal of Korean Neurosurgical Society
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• 제41권5호
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• pp.347-351
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• 2007

The authors present a new technique for surgery of cholesterol granuloma [CG] at the petrous apex. An epidural middle fossa approach is used to expose and remove the cyst, with silicon tube drainage into the sphenoid sinus via the anterolateral cavernous sinus triangle between the first and second divisions of the trigeminal nerve. This novel method is less invasive skull base approach to the petrous apex and very effective for minimizing recurrence of CGs within the petrous apex.

• Archives of Plastic Surgery
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• 제45권1호
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• pp.23-28
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• 2018

Background Condylar process fractures account for one-third of all mandibular fractures, and the distal fragment is prone to dislocate to the medial side due to the pulling of the lateral pterygoid muscle. Retromandibular approaches are commonly used, but the intraoperative view becomes limited in medially dislocated fractures. This study summarized a series of cases of retromandibular reduction for medially dislocated condylar process fractures and described our supplementary procedure to realign the dislocated condylar process. Methods Nine patients with medially dislocated condylar process fractures underwent surgical correction from January 2012 to December 2016. In 6 of them, it was possible to realign the fractures with a conventional retromandibular approach, but for 3 cases of severe dislocation to the middle cranial fossa, a supplementary transoral procedure was carried out. The angle difference between the ramus and condyle, ramus height, and maximal mouth opening (MMO) were evaluated. Results All 9 cases were restored to the proper anatomical alignment without any major complications, and postoperative images revealed successful union. The angle difference was $8.94^{\circ}{\pm}4.11^{\circ}$ preoperatively, and $0.99{\pm}0.49^{\circ}$ at the 6-month follow-up. The pretreatment ramus height difference was $6.12{\pm}6.09mm$, and the postoperative difference was $0.18{\pm}0.10mm$. These changes after surgery were statistically significant. The MMO before surgery was $11.44{\pm}3.0mm$, and the postoperative MMO was $37.2{\pm}2.9mm$, reflecting a significant increase after reduction. Conclusions Retromandibular reduction is a useful method in medially dislocated condylar process fractures, and additional transoral assistance should be considered to realign condylar processes that severely dislocate to the middle cranial fossa.

• Journal of Korean Neurosurgical Society
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• 제59권1호
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• pp.17-25
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• 2016

Objective : Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach. Methods : Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images. Results : All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed ${\geq}2$ times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients. Conclusion : Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.

• Journal of Korean Neurosurgical Society
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• 제57권4호
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• pp.298-302
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• 2015

This case report describes the symptoms and clinical course of a 35-year-old female patient who was diagnosed with a temporo-sphenoidal encephalocele. It is characterized by herniation of cerebral tissue of the temporal lobe through a defect of the skull base localized in the middle fossa. At the time of first presentation the patient complained about recurrent nasal discharge of clear fluid which had begun some weeks earlier. She also reported that three months earlier she had for the first time suffered from a generalized seizure. In a first therapeutic attempt an endoscopic endonasal approach to the sphenoid sinus was performed. An attempt to randomly seal the suspicious area failed. After frontotemporal craniotomy, it was possible to localize the encephalocele and the underlying bone defect. The herniated brain tissue was resected and the dural defect was closed with fascia of the temporalis muscle. In summary, the combination of recurrent rhinorrhea and a first-time seizure should alert specialists of otolaryngology, neurology and neurosurgery of a temporo-sphenoidal encephalocele as a possible cause. Treatment is likely to require a neurosurgical approach.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제40권
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• pp.19.1-19.6
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• 2018

Background: Calcium pyrophosphate dihydrate deposition disease (CPDD) is a rare disease in the temporomandibular joint (TMJ) space. It forms a calcified crystal mass and induces a limitation of joint movement. Case presentation: The calcified mass in our case was occupied in the left TMJ area and extended to the infratemporal and middle cranial fossa. For a complete excision of this mass, we performed a vertical ramus osteotomy and resected the mass around the mandibular condyle. The calcified mass in the infratemporal fossa was carefully excised, and the segmented mandible was anatomically repositioned. Scanning electronic microscopy (SEM)/energy-dispersive X-ray spectroscopy (EDS) microanalysis was performed to evaluate the calcified mass. The result of SEM/EDS showed that the crystal mass was completely composed of calcium pyrophosphate dihydrate. This result strongly suggested that the calcified mass was CPDD in the TMJ area. Conclusions: CPDD in the TMJ is a rare disease and is difficult to differentially diagnose from other neoplasms. A histological examination and quantitative microanalysis are required to confirm the diagnosis. In our patient, CPDD in the TMJ was successfully removed via the extracorporeal approach. SEM/EDS microanalysis was used for the differential diagnosis.