Sequelae and Rehabilitation

The morbidity of surgical resection of tumors of the middle cranial fossa, irrespective of the surgical approach that is chosen, relate to paralysis or paresis of the lower cranial nerves as well as the facial mimetic musculature.52 If vagus nerve injury or sacrifice occur, paralysis of the pharynx, palate, and the vocal cord will ensue. In many instances, the initial breathiness and aspiration of liquids that can occur will gradually resolve as there is compensatory movement of the contralateral vocal cord. However, if this compensation is inadequate, complete glottic closure can be reestablished by surgically medializ-ing the paralyzed vocal cord (Figure 12-10).52,53

Additionally, velopharyngeal insufficiency may result from paralysis of the palatal branch of the vagus nerve. To decrease the degree of nasal regurgitation that occurs, Netterville52 has successfully employed unilateral palatal adhesion in which the nasopharyngeal surface of the palate is sutured to the posterior pharyngeal wall.

When the spinal accessory nerve is injured and the sternomastoid and trapezius muscles subsequently paralyzed, shoulder pain and restricted range of motion may occur. In these situations, aggressive postoperative physical therapy can prevent the development of adhesive capsulitis and scapular "winging," although normal shoulder range of motion and strength are not possible.54 Isolated glossopharyngeal or hypoglossal nerve paralysis is not usually associated with significant morbidity, although speech and swallowing therapy may assist with any resultant dysphagia or articulatory difficulties. However, combinations of nerve paralyses such as a simultaneous

Figure 12-10. A, Arytenoid adduction sutures placed prior to placement of silastic implant. B, Placement of silastic implant. C and D, Gradual tightening of arytenoid adduction suture with medialization closure of the posterior commissure. Reprinted with permission from Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis. Kraus DH, Orlikoff RF, Rizk SS, Rosenberg DB. Head Neck 1999;21:52-29. Copyright © 1999 John Wiley & Sons Inc.

Figure 12-10. A, Arytenoid adduction sutures placed prior to placement of silastic implant. B, Placement of silastic implant. C and D, Gradual tightening of arytenoid adduction suture with medialization closure of the posterior commissure. Reprinted with permission from Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis. Kraus DH, Orlikoff RF, Rizk SS, Rosenberg DB. Head Neck 1999;21:52-29. Copyright © 1999 John Wiley & Sons Inc.

hypoglossal and vagal injury may result in significant aspiration necessitating gastrostomy.

Surgical interruption of the facial nerve, such as during a middle cranial fossa approach, can result in either partial or total paralysis of the facial musculature. The resulting corneal exposure, oral incompetence, and cosmetic deformity are formidable rehabilitation challenges. While a variety of surgical procedures are available for providing either static or dynamic facial reanimation including nerve crossovers, muscle transfers, and skin tightening procedures (brow/face lifts), immediate attention should be focused on the reestablishment of complete eye closure and the prevention of exposure keratopathy. This can be effectively performed by the subcutaneous placement of a gold weight in the upper eye lid (Figure 12-11).55 Such measures may be quite helpful as return of facial function, in instances where the anatomic integrity of the nerve has been maintained, may take 6 to 12 months.

Results

In light of the wide variety of benign and malignant histologies whose resection requires exposure of the middle cranial base, an objective assessment of the results of treatment is difficult to determine. However, data regarding the results of treatment for advanced parotid neoplasms is one area in which clinical series may be compared. Leonetti and colleagues described their experience in the surgical management of advanced (stage IV) parotid neo-plasms.56 In this series of 27 patients, they identified three categories of disease: tumors adjacent to either the bony or cartilaginous external auditory canal (EAC) and tumor extending into the EAC (both of which could be treated with the resection of the involved segment of the EAC), and tumor invading the middle ear and/or jugular bulb necessitating sacrifice of both the jugular foramen and the cochlea. With a mean follow-up period of 31.8 months, the resection of these advanced tumors resulted in 60 percent of the patients being alive without disease. A few, small series of extensive adenoid cystic carcinomas of the sinonasal cavity requiring anterior/ middle fossa resections have also been published. Shotton and colleagues57 reported 11 of 13 patients tumor-free at 1 to 15 years after infratemporal fossa dissection for T2 to T4 adenoid cystic carcinoma. More recently, Pitman and colleagues58 reported a 41 percent overall survival at 36 months and a 36 percent rate of local recurrence in a series of 35 patients whose sinonasal adenoid cystic carcinoma required either an anterior or anterolateral craniofa-cial resection. With respect to extensive adenoid cystic carcinoma involving the skull base, neutron radiotherapy has also been employed with a 53 percent reported locoregional control rate at 5 years.59 Additionally a small series of middle cranial fossa resections reported by Fisch60 demonstrated good success in achieving either subtotal or total tumor removal in patients with very extensive juvenile nasopharyngeal angiofibromas extending to or invading the cavernous sinus.

Another area in which some uniformity with respect to tumor histology allows for the critical assessment of the results of surgical therapy is in the case of temporal bone resection for squamous cell carcinoma of the external ear canal. Temporal bone resection for tumors arising from the ear/EAC or impinging upon it has evolved greatly, with improvements in radiographic imaging. Consequently, the bony erosion associated with a tumor, extension of the tumor into the middle ear, and an assessment of the ipsilateral parotid are all evaluable and highlight the critical importance of obtaining a deep resection

Gold Eyelid Weights And Mri
Figure 12-11. Placement of gold weight in upper eyelid for paralysis of the upper division of the facial nerve.

margin as well as the need to identify the facial nerve and carotid artery.61 In a review of a series of 26 studies on this topic, Prasad and Janecka61 determined that when a squamous carcinoma of the external auditory canal extends to the middle ear cleft, patients who undergo a subtotal temporal bone resection (whose medial margin is the internal carotid artery) had a 41.7 percent 5-year survival as compared to only a 28.7 percent 5-year survival for any less extensive resection. These results, as well as the fact that nearly 90 percent of those patients who died of their tumors in this series experienced local tumor recurrence, strongly suggest that when surgery is performed, an appropriately aggressive approach and resection of the middle cranial base is mandatory.

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