Scarless Brain Surgery Removes Tumors via Natural Skull Opening

A novel endoscopic transvestibular paramandibular approach uses the infratemporal fossa (ITF) and parapharyngeal space (PPS) to gain access to the middle cranial base.

Researchers at the Johns Hopkins University (JHU) School of Medicine (Baltimore, MD, USA) developed the transvestibular endoscopic approach using a vertical oral mucosal incision along the ascending ramus of the mandible, opening an optical corridor to the ITF and PPS, which was maintained patent with the aid of a Hardy speculum. The contents of the ITF and PPS were then explored with the aid of a 0-degree 4-mm rigid endoscope. The approach was thus able to provide exposure and access to the middle cranial base at the level of the foramen ovale, accessing the mid-PPS.

The new approach was applied to four patients with lesions involving the ITF and PPS, allowing branches of the trigeminal nerve in the ITF to be safely explored and preserved. Exposure and visualization of the internal maxillary artery and branches were also achieved. Of the four patients, two underwent resection of a primary and a recurrent pleomorphic adenoma, one had chronic pain relief from a large synovial chondromatosis, and one had debulking of a recurrent mucoepidermoid carcinoma. The only complications were self-limiting hypoesthesia of the lip in one patient and transient dysphagia in another patient. The study was published in the October 2011 issue of Laryngoscope.

“I looked at the ‘window’ that already exists in the skull, above the jawbone and below the cheekbone and realized this was an access route not previously recognized for this kind of surgery,” said lead author assistant professor of facial plastic and reconstructive surgery Kofi Boahene, MD. “We plan to try the new procedure using a surgical robot, which could provide even better visualization for surgeons and further reduce chances of complications for patients.”

Traditional surgeries to remove skull base tumors require incisions through the face and bone removal, which can sometimes be disfiguring. Additionally, these operations can harm facial nerves, leading to paralysis that affects facial expressions and days or weeks of hospitalization and recovery.

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Johns Hopkins University (JHU) School of Medicine