lnfratemporal fossa and lateral skull base dissection: Long-term results BARRY N. ROSENBLUM, MD, FACS, GEORGE P. KATSANTONIS, MD. FACS, MARGARET H. COOPER, PhD, and WILLIAM H. FRIEDMAN,MD. FACS, St. Louis, Missouri
in 1981, we described a new surgical technique featuring en bloc removal of infratemporai fossa malignancies. This approach offered a systematic resection of cancers in this region and was designated “stylohamular dissection”because the medial boundary of the bloc is surgical plane between the styloid process and the hamulus of the pterygoid.All structures lateral to this plane are removed, sparing the internal carotid artery. Since 1977, twenty infratemporal fossa and lateral skull base dissectlons have been performed for palliation of metastatic or recurrent disease in the infratemporal fossa. Most patients obtained palliation of trismus, facial pain, or relief from an unmanageable ulcerating lesion. This technique offers improved average disease-free Intervals, as well as enhanced survival rates compared to non-en bloc resections. A summary of the case presentations, survival statistics, and surgical technique with detailed cadaver dissections are presented. [OTOLARYNGOL HEAD NECKSURG 199o;102:106,]
Despite several offered approaches to the infratemporal fossa for the treatment of malignant disease, many patients with recurrent, metastatic, or direct extension of primary cancers into this region are considered inoperable. The majority of such patients underwent unsuccessful radiation and/or surgery or both for recurrent cancer of the parotid gland. The complicted anatomy and unfamiliarity with systematized approaches to this region are partially responsible. In the last decade, however, dramatically enhanced diagnostic and topognostic capabilities, provided by computed tomography and magnetic resonance imaging, have stimulated interest in this region.* Malignancies in this region are characterized by trismus and pain in the distribution of the mandibular division of the trigeminal nerve. Involvement of the infraorbital nerve and facial nerve occurs in advanced
~
~
~~~
From the Park Central Institute (Drs. Rosenblum, Katsantonis, and Friedman), and the Department of Otolaryngology-Head and Neck Surgery, St. Louis University School of Medicine (Dr. Cooper). Presented at the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Palm Beach, Fla., May 9, 1986. Submitted for publication Aug. 1 , 1985; revision received Jan. 26, 1989; accepted Sept. 26, 1989. Reprint requests: Barry Rosenblum, MD, Park Central Institute, 6125 Clayton Ave., Suite 430, St. Louis, MO 63139. 2311117348
tumors. Bulging of the lateral nasopharyngeal wall may also be seen.3 Most of these tumors have their origin in the parotid gland, but preauricular skin squamous cell carcinomas, buccal mucosa squamous cell carcinomas, tonsil carcinomas, and soft palate carcinomas have been primary sites in our series. The primary site was the infratemporal fossa in one patient who had malignant synovial cell sarcoma. In 1961, Fairbanks-Barbosa3described dissection of the infratemporal fossa in continuity with resection of advanced cancer of the paranasal sinuses. While this resection was not en bloc, it did provide access and a means to exenterate the infratemporal fossa. Terez et al.4 applied the Fairbanks-Barbosa approach in their series of eight patients with infratemporal fossa cancers invading the middle cranial fossa. While two patients died in the immediate postoperative period, local control of disease was achieved in six. Eilber and Zarem4 reported a systematic approach to the infratemporal fossa in fourteen patients in 1976. Their approach was truly en bloc and local control was achieved in ten of the fourteen patients. There were no operative deaths and their postoperative morbidity was acceptable. In 1981, Biller et a1.6 reported on the median labiomandibular glossotomy approach to nasopharynx and skull base malignancies with successful results. In 1981, Friedman et a1.’ described a method for en bloc resection of malignancies of the infratemporal fossa termed the “stylohamular dissection.” This term
106
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Volume 102 Number 2 February 1990
lnfratemporal fossa and lateral skull base dissection 107
Foramen Ovi Foramen Spinosum
Mandibular Nerve Pterygcmaxillary Fissure
Medial Meningeal Auriculotemporai
Pterygoid
bewlllary Artery
lnfe Alveolar Nerve Mylohyoid Nerve
Fig. 2. Contents of the surgical block in stylohamulur dissection.
Fig. 1. View of skull base demonstrates the limits of surgical dissection. Note the line from the styloid process to the pterygoid hamulus corresponds to the medial limits of the dissection.
describes an operation that was designed to remove en bloc those structures in the infratemporal fossa lateral to an imaginary line drawn from the tip of the styloid process to the hamulus of the pterygoid process corresponding to the buccophatyngeal fascia (Fig. I). The contents within this bloc include the medial and lateral pterygoid plate, the medial and lateral pterygoid muscles, the pterygoid venous plexus, the mandibular nerve, lingual nerve, mylohyoid nerve, inferior alveolar nerve, auriculotemporal nerve, otic ganglion, lesser petrosal nerve, chorda tympani nerve, internal maxillary artery, and medial meningeal artery, as well as lymph nodes and infratemproal fossa adnexa (Fig. 2). Patient Selectlon From January 1977 to January 1986, twenty patients underwent infratemporal fossa dissections for primary,
metastatic, or recurrent disease of this region. However, only eighteen have been followed for at least 1 year and theirs are the only results that will be included in this analysis. Eight patients had a variety of parotid cancers, including adenocarcinoma, mucoepidermoid carcinoma, melanoma, fibrosarcoma, and squamous cell carcinoma. Four patients were treated for tonsil carcinoma, including two direct invasions and two recurrences. Two patients had palate cancers; two had preauricular cancers and one each were treated for buccal carcinoma, nasopharynx cancer, malignant synovial cell sarcoma, and tongue cancer. The ages ranged from 26 to 83 years. There were 13 men and 7 women. However, only 12 men and 6 women will be analyzed. Of the previously mentioned patients, there were 11 surgical or radiation failures or both. Technique Before the procedure, a tracheostorny is performed on all patients. The planning of the incision is determined in part by the previous surgical incision on patients in whom an earlier resection had been performed. After a radical neck dissection, a facial flap exposing
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
OtolaryngologyHead and Neck Surgery
108 ROSENBLUM et 01.
Fig. 3. A, After a radical neck dissection, a facial flap exposing the zygomatic arch, parotid gland, and mandible is raised. B, The sphenomandibular, temporomandibular, and stylomandibular ligaments are cut and the mandibular condyle is disarticulated.C, The pterygoid plates are identified and cut from the maxilla. D, The maxillary artery is divided as it enters the pterygomaxillary fissure.
the zygomatic arch, parotid gland, and mandible is raised (Fig. 3, A). Next, osteotomies are created through the body of the mandible. Osteotomies may be placed in the zygoma if necessary to encompass a tumor. The temporalis muscle is cut from the coronoid process. At this point the facial nerve is identified. In most cases, it is necessary to divide the facial nerve trunk. The sphenomandibular, temporomandibular, and stylomandibular ligaments are cut and the mandible condyle is disarticulated from the glenoid fossa (Fig. 3, B). The pterygoid plates are then identified and an osteotome is used to divide them from maxilla (Fig. 3, C). The maxillary artery is identified as it enters the pterygomaxillary fissure and divided. Next the mandibular nerve is divided as it exits from the foramen ovale (Fig. 3, D).
As the pterygoid musculature and contents of the infratemporal fossa are dissected, brisk venous bleeding may be encountered as a result of the interruption of the pterygoid venous plexus. This is controlled initially by pressure and definitively with multiple suture ligations. Finally, the middle meningeal artery is seen entering the foramen spinosum and is divided. The specimen can now be removed. Medial to the boundary of the dissection, the superior pharyngeal constrictor, the tensor veli palatini, the levator palatini, and a cartilaginous eustachian tube are seen. The wound can be closed primarily, but we prefer closure with a myocutaneous flap because skin removal is frequently necessary and flap bulk aids in cosmesis. The average operating time with neck dissection was 4% hours. The average blood loss was approximately 1000 cc.
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Volume 102 Number 2 February 1990
lnfratemporal fossa and lateral skull base dissection 109
Table 1. Operation / location
Patient no.
1
2
3 4
5
6 7
8 9 10 11 12
13
14
Pathology
Survival
2 months-Died,
Parotid adenocarcinoma Stylohamular dissection/radical neck dissection/ temporal bone resection Parotid squamous cell carcinoma Stylohamular dissection/radical neck dissection Parotid adenocarcinoma Stylohamular dissection/radical neck dissection Pre-auricular skin squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ temporal bone resection Buccal mucosa squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ composite resection of tongue and jaws Tonsil squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ composite resection of tongue and jaws Parotid melanoma Stylohamular dissectioniradical neck dissection Parotid fibrosarcoma Stylohamular dissectioniradical neck dissection Palate squamous cell carcinoma Stylohamular dissectioniradical neck dissection Pre-auricular skin squamous cell carcinoma Stylohamular dissection/ radical neck dissection Tonsil-squamous cell carcinoma Stylohamular dissection/ radical neck dissection Parotid rnucoepidermoid carcinoma Stylohamular dissectioniradical neck dissection Tonsil carcinoma Stylohamular dissection/composite resection of tongue and jaw Parotid mucoepidermoid carcinoma/high grade Stylohamular dissection/radical neck dissection
myocardial infarction
8 years-Alive
and well
2 years-Died,
natural causes
4 years-Died,
local disease
18 months-Died,
2 years-Died,
local disease
18 months-Died, 6 years-Alive, 1 year-Alive,
distant metastasis
with local disease no evidence of disease
16 months-Died,
3 months-Died, 5 days-Died,
CVA
uncontrolled disease distant metastasis
perioperative complications
2 years-Alive,
2 months-Alive,
no evidence of disease
no evidence of disease
~~
CVA.Cerebrovascular accident
DISCUSSION
Table 2. Survival of stylohamular dissection
Malignant neoplasms that occur in the infratemporal fossa are usually recurrent or metastatic disease from a head and neck primary. The most common primary site is the parotid gland, although tumors of the tonsil, palate, preauricular skin, external auditory canal, and middle ear have been known to invade this Of greatest concern in the management of these patients is the relief of pain and trismus. While a surgical cure may be hoped for, it is not expected. Several authors have performed ablative procedures in this region, but with long-term survival interpreted as greater than 2 years of less than five percent, and with a 95% incidence of recurrence within 2 years of initial treatment .4.9.'0 In our series of eighteen patients, eight patients who underwent stylohamular resection were alive at 2 years.
(N = 14) ~
Years of survival
No. of patients
0-1
5
1-3 3-5 5+
6 1 2 14
TOTAL
Palliation was obtained in all except one case (Tables 1 and 2). Stylohamular dissection allows the surgeon to perform an en bloc resection of the contents of the infratemporal fossa in a systematic fashion. This is possible by using facial planes that keep vital vascular structures out of the surgical bloc. The medial border
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
OtolaryngologyHead and Neck Surgery
110 ROSENBLUM et 01.
of the bloc is an imaginary line between the hamulus and the styloid process that corresponds with the buccopharyngeal fascia lying between the internal pterygoid muscle and the superior pharyngeal constrictor muscle. The styloid process is the posterior boundary, unless the tip of the mastoid or part of the temporal bone is included in the dissection. This procedure allows a mandibulectomy to be performed without violation of the surgical bloc. Postoperatively the patients are left with a characteristic step-in deformity, particularly when the zygomatic arch is included in the bloc. Reconstruction of the surgical defect is necessary if skin is included in the resection and is best accomplished with a myocutaneous flap. Over the past 9 years, the stylohamular dissection has offered a relatively safe and dependable means by which to palliate and control local disease in advanced head and neck cancers that invade the infratemporal fossa.
2. Shaheen OH. Swelling of the infratemporal fossa. J Laryngol Rhinol Otol 1982;96:817-38. 3. Fairbanks-BarbosaJ. Surgery of extrinsic cancer of the paranasal sinuses: presentation of a new technique. Arch Otolaryngol 1961;73:129. 4. Fenez JJ, Alksne FJ, Lawrence W. Craniofacial resection for tumors invading the pterygoid fossa. Am J Surg 1969;118:73240. 5. Eilber FR, Zarem HA. Pterygoid dissection for extensive cancer: an old concept revisited. Plast Reconstr Surg 1977;59:545-50. 6. Biller HF, Sugar JN, Krespi YP. A new technique for wide field exposure of the base of the skull. Arch Otolaryngol 1981;107:698-702. 7. Friedman WH, Katsantonis GP, Cooper MH, Lee JM, Strelzow VV. Stylohamular dissection: a new method for en bloc resection of malignancies of the infratemporal fossa. Latyngoscope 1981;9l:1869-79. 8. Shapshay SM, Ebler E, Strong MS. Occult tumors of the infratemporal fossa. Arch Otolaryngol 1976;102:535-8. 9. Frazell EL, Lewis JS. Cancer of the nasal cavity and paranasal sinus. Cancer 1963;161293. 10. Sission GD, Johnson NE, Amen CS. Cancer of the maxillary sinus: clinical classification and management. Ann Otol Rhinol Laryngol 1963;72:1050.
REFERENCES 1. Doubleday LD, Jing GS, Wallace S. Computed tomography of
infratemporal fossa. Radiology 1981;138:619-24.
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
in 1981, we described a new surgical technique featuring en bloc removal of infratemporai fossa malignancies. This approach offered a systematic resection of cancers in this region and was designated “stylohamular dissection”because the medial boundary of the bloc is surgical plane between the styloid process and the hamulus of the pterygoid.All structures lateral to this plane are removed, sparing the internal carotid artery. Since 1977, twenty infratemporal fossa and lateral skull base dissectlons have been performed for palliation of metastatic or recurrent disease in the infratemporal fossa. Most patients obtained palliation of trismus, facial pain, or relief from an unmanageable ulcerating lesion. This technique offers improved average disease-free Intervals, as well as enhanced survival rates compared to non-en bloc resections. A summary of the case presentations, survival statistics, and surgical technique with detailed cadaver dissections are presented. [OTOLARYNGOL HEAD NECKSURG 199o;102:106,]
Despite several offered approaches to the infratemporal fossa for the treatment of malignant disease, many patients with recurrent, metastatic, or direct extension of primary cancers into this region are considered inoperable. The majority of such patients underwent unsuccessful radiation and/or surgery or both for recurrent cancer of the parotid gland. The complicted anatomy and unfamiliarity with systematized approaches to this region are partially responsible. In the last decade, however, dramatically enhanced diagnostic and topognostic capabilities, provided by computed tomography and magnetic resonance imaging, have stimulated interest in this region.* Malignancies in this region are characterized by trismus and pain in the distribution of the mandibular division of the trigeminal nerve. Involvement of the infraorbital nerve and facial nerve occurs in advanced
~
~
~~~
From the Park Central Institute (Drs. Rosenblum, Katsantonis, and Friedman), and the Department of Otolaryngology-Head and Neck Surgery, St. Louis University School of Medicine (Dr. Cooper). Presented at the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Palm Beach, Fla., May 9, 1986. Submitted for publication Aug. 1 , 1985; revision received Jan. 26, 1989; accepted Sept. 26, 1989. Reprint requests: Barry Rosenblum, MD, Park Central Institute, 6125 Clayton Ave., Suite 430, St. Louis, MO 63139. 2311117348
tumors. Bulging of the lateral nasopharyngeal wall may also be seen.3 Most of these tumors have their origin in the parotid gland, but preauricular skin squamous cell carcinomas, buccal mucosa squamous cell carcinomas, tonsil carcinomas, and soft palate carcinomas have been primary sites in our series. The primary site was the infratemporal fossa in one patient who had malignant synovial cell sarcoma. In 1961, Fairbanks-Barbosa3described dissection of the infratemporal fossa in continuity with resection of advanced cancer of the paranasal sinuses. While this resection was not en bloc, it did provide access and a means to exenterate the infratemporal fossa. Terez et al.4 applied the Fairbanks-Barbosa approach in their series of eight patients with infratemporal fossa cancers invading the middle cranial fossa. While two patients died in the immediate postoperative period, local control of disease was achieved in six. Eilber and Zarem4 reported a systematic approach to the infratemporal fossa in fourteen patients in 1976. Their approach was truly en bloc and local control was achieved in ten of the fourteen patients. There were no operative deaths and their postoperative morbidity was acceptable. In 1981, Biller et a1.6 reported on the median labiomandibular glossotomy approach to nasopharynx and skull base malignancies with successful results. In 1981, Friedman et a1.’ described a method for en bloc resection of malignancies of the infratemporal fossa termed the “stylohamular dissection.” This term
106
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
Volume 102 Number 2 February 1990
lnfratemporal fossa and lateral skull base dissection 107
Foramen Ovi Foramen Spinosum
Mandibular Nerve Pterygcmaxillary Fissure
Medial Meningeal Auriculotemporai
Pterygoid
bewlllary Artery
lnfe Alveolar Nerve Mylohyoid Nerve
Fig. 2. Contents of the surgical block in stylohamulur dissection.
Fig. 1. View of skull base demonstrates the limits of surgical dissection. Note the line from the styloid process to the pterygoid hamulus corresponds to the medial limits of the dissection.
describes an operation that was designed to remove en bloc those structures in the infratemporal fossa lateral to an imaginary line drawn from the tip of the styloid process to the hamulus of the pterygoid process corresponding to the buccophatyngeal fascia (Fig. I). The contents within this bloc include the medial and lateral pterygoid plate, the medial and lateral pterygoid muscles, the pterygoid venous plexus, the mandibular nerve, lingual nerve, mylohyoid nerve, inferior alveolar nerve, auriculotemporal nerve, otic ganglion, lesser petrosal nerve, chorda tympani nerve, internal maxillary artery, and medial meningeal artery, as well as lymph nodes and infratemproal fossa adnexa (Fig. 2). Patient Selectlon From January 1977 to January 1986, twenty patients underwent infratemporal fossa dissections for primary,
metastatic, or recurrent disease of this region. However, only eighteen have been followed for at least 1 year and theirs are the only results that will be included in this analysis. Eight patients had a variety of parotid cancers, including adenocarcinoma, mucoepidermoid carcinoma, melanoma, fibrosarcoma, and squamous cell carcinoma. Four patients were treated for tonsil carcinoma, including two direct invasions and two recurrences. Two patients had palate cancers; two had preauricular cancers and one each were treated for buccal carcinoma, nasopharynx cancer, malignant synovial cell sarcoma, and tongue cancer. The ages ranged from 26 to 83 years. There were 13 men and 7 women. However, only 12 men and 6 women will be analyzed. Of the previously mentioned patients, there were 11 surgical or radiation failures or both. Technique Before the procedure, a tracheostorny is performed on all patients. The planning of the incision is determined in part by the previous surgical incision on patients in whom an earlier resection had been performed. After a radical neck dissection, a facial flap exposing
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
OtolaryngologyHead and Neck Surgery
108 ROSENBLUM et 01.
Fig. 3. A, After a radical neck dissection, a facial flap exposing the zygomatic arch, parotid gland, and mandible is raised. B, The sphenomandibular, temporomandibular, and stylomandibular ligaments are cut and the mandibular condyle is disarticulated.C, The pterygoid plates are identified and cut from the maxilla. D, The maxillary artery is divided as it enters the pterygomaxillary fissure.
the zygomatic arch, parotid gland, and mandible is raised (Fig. 3, A). Next, osteotomies are created through the body of the mandible. Osteotomies may be placed in the zygoma if necessary to encompass a tumor. The temporalis muscle is cut from the coronoid process. At this point the facial nerve is identified. In most cases, it is necessary to divide the facial nerve trunk. The sphenomandibular, temporomandibular, and stylomandibular ligaments are cut and the mandible condyle is disarticulated from the glenoid fossa (Fig. 3, B). The pterygoid plates are then identified and an osteotome is used to divide them from maxilla (Fig. 3, C). The maxillary artery is identified as it enters the pterygomaxillary fissure and divided. Next the mandibular nerve is divided as it exits from the foramen ovale (Fig. 3, D).
As the pterygoid musculature and contents of the infratemporal fossa are dissected, brisk venous bleeding may be encountered as a result of the interruption of the pterygoid venous plexus. This is controlled initially by pressure and definitively with multiple suture ligations. Finally, the middle meningeal artery is seen entering the foramen spinosum and is divided. The specimen can now be removed. Medial to the boundary of the dissection, the superior pharyngeal constrictor, the tensor veli palatini, the levator palatini, and a cartilaginous eustachian tube are seen. The wound can be closed primarily, but we prefer closure with a myocutaneous flap because skin removal is frequently necessary and flap bulk aids in cosmesis. The average operating time with neck dissection was 4% hours. The average blood loss was approximately 1000 cc.
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
Volume 102 Number 2 February 1990
lnfratemporal fossa and lateral skull base dissection 109
Table 1. Operation / location
Patient no.
1
2
3 4
5
6 7
8 9 10 11 12
13
14
Pathology
Survival
2 months-Died,
Parotid adenocarcinoma Stylohamular dissection/radical neck dissection/ temporal bone resection Parotid squamous cell carcinoma Stylohamular dissection/radical neck dissection Parotid adenocarcinoma Stylohamular dissection/radical neck dissection Pre-auricular skin squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ temporal bone resection Buccal mucosa squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ composite resection of tongue and jaws Tonsil squamous cell carcinoma Stylohamular dissection/ radical neck dissection/ composite resection of tongue and jaws Parotid melanoma Stylohamular dissectioniradical neck dissection Parotid fibrosarcoma Stylohamular dissectioniradical neck dissection Palate squamous cell carcinoma Stylohamular dissectioniradical neck dissection Pre-auricular skin squamous cell carcinoma Stylohamular dissection/ radical neck dissection Tonsil-squamous cell carcinoma Stylohamular dissection/ radical neck dissection Parotid rnucoepidermoid carcinoma Stylohamular dissectioniradical neck dissection Tonsil carcinoma Stylohamular dissection/composite resection of tongue and jaw Parotid mucoepidermoid carcinoma/high grade Stylohamular dissection/radical neck dissection
myocardial infarction
8 years-Alive
and well
2 years-Died,
natural causes
4 years-Died,
local disease
18 months-Died,
2 years-Died,
local disease
18 months-Died, 6 years-Alive, 1 year-Alive,
distant metastasis
with local disease no evidence of disease
16 months-Died,
3 months-Died, 5 days-Died,
CVA
uncontrolled disease distant metastasis
perioperative complications
2 years-Alive,
2 months-Alive,
no evidence of disease
no evidence of disease
~~
CVA.Cerebrovascular accident
DISCUSSION
Table 2. Survival of stylohamular dissection
Malignant neoplasms that occur in the infratemporal fossa are usually recurrent or metastatic disease from a head and neck primary. The most common primary site is the parotid gland, although tumors of the tonsil, palate, preauricular skin, external auditory canal, and middle ear have been known to invade this Of greatest concern in the management of these patients is the relief of pain and trismus. While a surgical cure may be hoped for, it is not expected. Several authors have performed ablative procedures in this region, but with long-term survival interpreted as greater than 2 years of less than five percent, and with a 95% incidence of recurrence within 2 years of initial treatment .4.9.'0 In our series of eighteen patients, eight patients who underwent stylohamular resection were alive at 2 years.
(N = 14) ~
Years of survival
No. of patients
0-1
5
1-3 3-5 5+
6 1 2 14
TOTAL
Palliation was obtained in all except one case (Tables 1 and 2). Stylohamular dissection allows the surgeon to perform an en bloc resection of the contents of the infratemporal fossa in a systematic fashion. This is possible by using facial planes that keep vital vascular structures out of the surgical bloc. The medial border
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
OtolaryngologyHead and Neck Surgery
110 ROSENBLUM et 01.
of the bloc is an imaginary line between the hamulus and the styloid process that corresponds with the buccopharyngeal fascia lying between the internal pterygoid muscle and the superior pharyngeal constrictor muscle. The styloid process is the posterior boundary, unless the tip of the mastoid or part of the temporal bone is included in the dissection. This procedure allows a mandibulectomy to be performed without violation of the surgical bloc. Postoperatively the patients are left with a characteristic step-in deformity, particularly when the zygomatic arch is included in the bloc. Reconstruction of the surgical defect is necessary if skin is included in the resection and is best accomplished with a myocutaneous flap. Over the past 9 years, the stylohamular dissection has offered a relatively safe and dependable means by which to palliate and control local disease in advanced head and neck cancers that invade the infratemporal fossa.
2. Shaheen OH. Swelling of the infratemporal fossa. J Laryngol Rhinol Otol 1982;96:817-38. 3. Fairbanks-BarbosaJ. Surgery of extrinsic cancer of the paranasal sinuses: presentation of a new technique. Arch Otolaryngol 1961;73:129. 4. Fenez JJ, Alksne FJ, Lawrence W. Craniofacial resection for tumors invading the pterygoid fossa. Am J Surg 1969;118:73240. 5. Eilber FR, Zarem HA. Pterygoid dissection for extensive cancer: an old concept revisited. Plast Reconstr Surg 1977;59:545-50. 6. Biller HF, Sugar JN, Krespi YP. A new technique for wide field exposure of the base of the skull. Arch Otolaryngol 1981;107:698-702. 7. Friedman WH, Katsantonis GP, Cooper MH, Lee JM, Strelzow VV. Stylohamular dissection: a new method for en bloc resection of malignancies of the infratemporal fossa. Latyngoscope 1981;9l:1869-79. 8. Shapshay SM, Ebler E, Strong MS. Occult tumors of the infratemporal fossa. Arch Otolaryngol 1976;102:535-8. 9. Frazell EL, Lewis JS. Cancer of the nasal cavity and paranasal sinus. Cancer 1963;161293. 10. Sission GD, Johnson NE, Amen CS. Cancer of the maxillary sinus: clinical classification and management. Ann Otol Rhinol Laryngol 1963;72:1050.
REFERENCES 1. Doubleday LD, Jing GS, Wallace S. Computed tomography of
infratemporal fossa. Radiology 1981;138:619-24.
Downloaded from oto.sagepub.com at Oakland University on June 5, 2016
