J Neurosurg 67:488-499, 1987

Subtemporal-preauricular infratemporal fossa approach

to large lateral and posterior cranial base neoplasms
LALIGAM N. SEr,rIAR, M.D., VICTOR L.
NV.IL F. JONES, M.D.

SCHRAMM,JR., M.D., ANO

Departments of Neurological Surgery, Otolaryngology, and Plastic Surgery, University of Pittsburgh

School of Medicine, Pittsburgh, Pennsylvania
v" A subtemporal-preauricular infratemporal fossa approach to remove 22 large neoplasms involving the
lateral and posterior cranial base is detailed. The areas from which a neoplasm could be removed by this
approach included the sphenoid and clival bone; the medial half of the petrous temporal bone; the infratemporal fossa; the nasopharynx; the retro- and parapharyngeal area; the ethmoid, sphenoid, and maxillary sinuses;
and the intradural clivus-foramen magnum area. The pathology of the neoplasms included benign tumors
such as meningioma, malignant cartilaginous neoplasms such as chordoma, and other malignant lesions such
as nasopharyngeal carcinoma. This approach offers many advantages over other anterior and lateral approaches
to the lateral and posterior cranial base: these include minimal brain retraction; direct access to the ipsilateral
petrous and upper cervical internal carotid artery; reconstruction of extensive cranial base defects, often with
the use of a vascularized rectus abdominis flap; preservation of the hearing conduction mechanism when it is
not involved by tumor; and the maintenance of excellent facial nerve function postoperatively.
The use of an anterior extradural approach (transethmoidal) and of an intradural approach (frontotemporal
or retromastoid), either concurrently or separately, is necessary"in some patients to effect total tumor removal.
The most serious complication in this series was the death of a patient due to postoperative infection and
bilateral carotid artery rupture, which may have been avoided by the use of a rectus abdominis muscle flap
for reconstruction. Among the 21 surviving patients, 18 had a good outcome, two had a fair outcome, and
one with preexisting neurological deficits had a poor outcome. One of the surviving patients with a chordoma
died of pulmonary metastases l year later, without evidence of local recurrence. The length of postoperative
follow-up evaluation in these patients is insufficient to make any judgment about the effectiveness of this
surgical approach in achieving a cure or long-term control of the tumors described.
KEY WORDS
cranial b a s e n e o p l a s m
9 meningioma
nasopharyngeal carcinoma
9 internal carotid artery
9

VeN though m a n y neoplasms involving the cranial base are benign or locally confined malignant lesions, radical resection of extensive lesions remains difficult. Reasons for this include the
location of these tumors below the base of the brain
with the possibility of retraction-related cerebral injury;
the involvement by the t u m o r of basal blood vessels,
injury to which may lead to stroke and/or death; the
involvement of cranial nerves, injury to which results
in significant functional deficits; and the potential for a
postoperative cerebrospinal fluid (CSF) fistula through
the skin, paranasal sinuses, or nasopharynx which may
be followed by meningitis and death. However, several
advances have occurred during the past decade that
permit a total or near total resection of m a n y such
488

9 neurilemoma

9 chordoma

neoplasms with a low morbidity. These advances include an improved understanding of cranial base anatomy, resulting in the introduction of new operative
approaches; the improved management of the petrous
and cavernous internal carotid artery (ICA); the preservation or reconstruction of cranial nerves involved
by the tumor; and improved cranial base reconstruction
techniques.
The cranial base is conveniently classified into anterior, middle, and posterior parts that correspond to the
respective cranial fossae. This classification system is
followed by us in this publication. Jackson and Hide ~2
have divided the middle and posterior cranial base into
three compartments: the sphenoid base, the petrous
temporal base, and the clivus. However, conceptually

J, Neurosurg. / Volume 67/October, 1987

Subtemporal-infratemporal approach to cranial base neoplasms

TABLE 1

TABLE 2

Type of neoplasms operated on via a subtemporalinfratemporal fossa approach

Location of tumors operated on via a subtemporalinfratemporal fossa approach

Tumor Pathology

No. of
Cases

benign neoplasms
angiofibroma,juvenile*
1
epidermoid cyst
2
glomus vagaletumor
1
meningiomat
5
neurilemoma, ninth cranial nervet
1
malignant cartilaginous neoplasms
chordoma*t
2
chondrosarcoma*t
1
other malignant neoplasms
adenoid cysticcarcinomat
2
basal cell carcinoma
l
squamous cell carcinomat
3
undifferentiated carcinoma(recurrent)
3
total cases
22
* In these cases an anterior extradural approach, either transbasal
or transethmoidal, was also used simultaneouslyor in a different stage
for tumor removal.
t In these cases an intradural approach, either retromastoid or
frontotemporal, was used in the same or a different stage for tumor
removal.

it is easier to consider the operative approaches to the

middle and posterior cranial base together since the
surgical problems are similar.
In this paper we describe a combined subtemporal
and preauricular infratemporal fossa approach to the
middle and posterior skull base. This approach has been
found useful for the removal of neoplasms involving
the clivus, sphenoidal area, petrous apex, orbit, cavernous sinus, middle fossa, infratemporal fossa, and the
retro- and parapharyngeal areas. It is a modification of
previously described approaches, but has some advantages over the other techniques. The management of
the petrous and upper cervical ICA and the reconstruction of extensive postoperative cranial base defects are
discussed briefly. We also indicate the limitations of
this approach.

Clinical Material and Methods

Patient Population
Between July, 1983, and August, 1986, 22 patients
with large neoplasms involving the middle and posterior
skull base were operated on using a subtemporal and
preauricular infratemporal fossa approach as the only
approach or as a part of the overall plan. Tables 1 and
2 indicate the pathology and location of the neoplasms.

Preoperative Evaluation
All the patients underwent a neurological, otolaryngological, and general physical examination. Computerized tomography (CT) scanning was performed in the
axial and coronal planes using both soft-tissue and bone
algorithms. Magnetic resonance imaging (MRI) was
performed on all recent patients and was especially

J. Neurosurg. / Volume 6 7 / October, 198 7

Tumor Location
intracranial
middle cranial fossa
cavernous sinus
posterior fossa-cerebeUopontineangle
clivus
foramen magnum
cranial (bone involvement)
clivus (excludingbody of sphenoid)
sphenoid bone
petrous bone, medial region
petrous bone, lateral region
extracranial
orbit
ethmoid sinus
sphenoid sinus
maxillary sinus
infratemporal fossa
retropharyngeal space
parapharyngeal space
upper cervical area
nasopharynx

No. of
Cases
3
11
6
5
1
12
11
17
0
6
4
10
6
18
9
7
1
5

useful in delineating the relationship of blood vessels to

the tumor and identifying the presence of residual
neoplasm on follow-up examination.
Cervical and cerebral arteriography was carried out.
A balloon-occlusion test of the ipsilateral ICA, and
occasionally of both ICA's in sequence, was performed.
The test included a 15-minute trial occlusion period
with monitoring of the patient's neurological status,
and a subsequent stable xenon CT examination. 28 This
test was used to estimate the risk of temporary or
permanent ICA occlusion during the operation.

Staging o f Operations
When the lesion extended into the intradural compartment, surgery was planned to remove the extradural
portion of the tumor first and the remainder at a
subsequent operation (five patients). However, if there
was a considerable intracranial mass, the intradural
portion was removed first (one patient). Occasionally,
an intradural procedure was combined with an extradural procedure (Case 9). In two patients, two extradural approaches were combined.

Anesthesia and Monitoring

For the majority of the patients, anesthesia is induced
with thiopental and a short-acting muscle relaxant, and
is subsequently maintained with an inhalation agent to
permit the monitoring of muscle activity. As needed,
there is monitoring of the electromyographic activity
from the facial muscles, 19 the electromyographic activity from the extraocular muscles, 26 the brain-stem
evoked response, somatosensory evoked response, visual evoked response, and the electroencephalogram. A
489

L. N. Sekhar, et al.

FIG. 1. Diagrams showing the subtemporat-preauricular infratemporal approach to lateral and posterior
cranial base neoplasms. UpperLeft: The solid and dotted lines show the incision used for this approach.
Upper Center: The skin and subcutaneous tissues have been turned forward. The facial nerve (VII) has been
dissected from the stylomastoid foramen to the parotid gland, and its frontalis branch has been exposed beyond
the gland. The internal carotid artery (ICA), the external carotid artery, the internal jugular vein, the digastric
muscle, and the seventh, 10th, and 12th cranial nerves are exposed in the neck. SCM = sternocleidomastoid
muscle. Upper Right: The temporalis muscle has been reflected anteroinferiofly after division of the
zygomatic arch. The lateral and superior orbital rim may also be removed, but this is not shown in these
drawings. The tympanic part of the temporal bone, the bony eustachian tube, and the tensor tympani muscle
are superficial to the petrous ICA. The tumor is closely related to the petrous ICA. The mandibular (V3) and
maxillary (V2) nerves have been exposed after unroofing their bone canals. Lower Left: Early stage in the
exposure of the petrous ICA, starting at its genu and the vertical segment. Note the relationship of the sphenoid
sinus, which lies medial to the V2. Lower Right: The petrous ICA has been mobilized from the carotid canal
and displaced forward. Considerable tumor removal has taken place. The clival bone of the contralateral side
and the clival dura of the ipsilateral side are exposed. The superior orbital fissure and the orbital apex area
have been completely unroofed.

lumbar subarachnoid drain is used for brain relaxation

in all patients, and the use of diuretics such as mannitol
or furosemide is avoided. Intraoperative hypotension is
not used during t u m o r removal. If the ICA has to be
temporarily occluded for repair, the blood pressure is
elevated 20 torr by the anesthesiologist during the period of occlusion. However, this is not necessary if the
patient tolerated the balloon-occlusion test with minimal or no changes in cerebral blood flow (CBF) (see
below).

Operative Technique
Approach to the Tumor. The patient is placed in
the supine position, the head is turned 45* to the
contralateral side, and the neck is extended. The patient
490

is placed either in three-point pin fixation or on a

horseshoe-shaped headrest. If the t u m o r extends toward
the nasopharynx, or if postoperative coughing and swallowing problems are anticipated, a preliminary tracheostomy tube is inserted. The scalp is shaved, and the
head, ipsilateral face, ear, neck (and sometimes the
contralateral neck area), lower abdomen, and ipsilateral
thigh are prepared in a sterile fashion and draped.
The incision is started in the frontal scalp, curved in
front of and below the external auditory canal, and
extended anteriorly on the neck along a skin crease
(Fig. 1 upper left). The cervicofacial skin flap is separated from the temporalis fascia, the fatty tissue of the
face, and the deep fascia in the neck, and is turned
forward. The main trunk of the facial nerve and its

J. Neurosurg. / Volume 67/October, 1987

Subtemporal-infratemporalapproach to cranial base neoplasms

major branches are dissected from the stylomastoid
foramen to the parotid gland, leaving as much tissue
around the nerve as possible. The parotid gland is
separated from the underlying masseteric fascia so as to
avoid traction on the facial nerve when the mandible is
dislocated. The superficial temporal artery and vein are
ligated (Fig. 1 upper center). The temporalis muscle
and fascia are elevated from the temporal fossa. The
zygomatic arch is divided posteriorly and anteriorly,
then removed and preserved. In some cases, the lateral
and superior walls of the orbit are divided along with
the zygomatic arch and are also removed. These maneuvers enable the further anteroinferior reflection of
the temporalis muscle and a flatter approach to the
skull base. The mandibular condyle and the capsule of
the temporomandibular joint are dislocated anteroinferiorly after dividing the attachment of the stylomandibular and sphenomandibular ligaments to the mandible. However, if more space is needed or if free muscle
flap reconstruction is utilized, the condyle of the mandible is excised.
Dissection is performed in the neck to expose the
ICA, the internal jugular vein, and the 10th, 1 lth, and
12th cranial nerves. The digastric muscle is divided.
The styloid process is resected either at this stage or
subsequently, after division of muscles and ligaments
attached to its tip.
A small frontotemporal free bone flap is then elevated, the most anterior burr hole being just superior
to the pterion, and the most posterior one just above
the glenoid fossa. Some CSF is withdrawn through the
lumbar catheter to relax the brain. The dura of the
floor of the middle fossa is separated through the burr
hole superior to the glenoid fossa. Two cuts are then
made with an oscillating saw medial and posterior to
the glenoid fossa, and the entire bone flap is removed
along with the root of the zygomatic arch and the
glenoid fossa (Fig. 1 upper right). Under magnification,
the dura of the middle fossa is then further elevated
from the bone to expose the arcuate eminence, the
greater superficial petrosal nerve, the middle meningeal
artery, and the mandibular nerve (V3). The middle
meningeal artery is coagulated and divided, and the
greater superficial petrosal nerve is divided to avoid
traction on the geniculate ganglion. The greater wing
of the sphenoid bone is then rongeured to unroof the
foramen ovale laterally and anteriorly, the foramen
rotundum laterally, and the superior orbital fissure
inferiorly. The maxillary nerve (V2) will now be well
exposed in the pterygopalatine fossa, and V3 will be
exposed from its origin to its branching in the infratemporal fossa. The superior orbital fissure and the optic
nerve canal may also be completely decompressed by
the removal of the orbital plate of the frontal bone and
the lesser wing of the sphenoid bone.
A self-retaining retractor is placed to protect the
temporal dura, and rongeurs or a high-speed drill are
used to remove bone medial to the glenoid fossa, at the
level of the floor of the middle fossa. The bony eustaJ. Neurosurg. / Volume 6 7 / October, 198 7

chian tube and the tensor tympani muscles will be

exposed, and are excised. The genu of the petrous ICA
lies medial to the eustachian tube, covered by a thin
layer of bone or no bone at all. It is unroofed here
initially, using fine bone punches, and is followed inferiorly and superiorly. The vertical segment of the petrous ICA will be exposed inferiorly (Fig. 1 lower left).
The periosteal lining of the carotid canal is densely
adherent to a fibrocartilaginous ring at the entrance of
the carotid canal. This ring has to be divided to mobilize
the junction of the petrous and upper cervical ICA. The
upper cervical segment of the ICA usually makes an
anterior loop and a posterior turn prior to entry into
the carotid canal. It is dissected free to the level of the
styloid process.
The horizontal segment of the petrous ICA is then
traced forward. One must be careful not to remove
petrous bone posterosuperior to the genu of the petrous
ICA since the cochlea and the geniculate ganglion of
the facial nerve are located here. In order to trace the
petrous ICA to the cavernous sinus, one has to remove
bone around the artery, working in front of and behind
the V3 and with retraction of the V3. If the V3 is invaded
by neoplasm, it may be excised, and this improves the
exposure. The petrous ICA is surrounded by a periosteal
layer and a venous plexus of variable size. After the
entire petrous ICA has been unroofed, it is separated
from its bone canal and, after mobilizing the upper
cervical ICA, the artery is rotated forward with the aid
of vessel loops.
The petrous bone medial to the carotid canal and the
bone of the petrous apex region posterosuperior to the
horizontal segment of the petrous ICA are removed
with a drill. This exposes the petroclival synchondrosis
and the clival bone. The bone of the clivus may now
be removed with a drill to expose the dura from the
level of the petrous apex to the foramen magnum. Bone
removal near the occipital condyle must be performed
cautiously to avoid injury to the ninth, 10th, 1 lth, and
12th cranial nerves and the jugular bulb. If necessary,
the hypoglossal nerve may be unroofed and followed
into the posterior fossa. The upper part of the anterior
arch of the atlas and the tip of the odontoid process
may also be removed by this approach. Exposure below
this area, however, needs the approach of Stevenson, et
al. 29 This can be performed by working below the facial
nerve (in front of the ICA and the external carotid
artery) during the same operation. Significant venous
bleeding may occur from the basilar venous plexus after
removal of the clival bone but can be controlled by
packing and head elevation (Fig. 1 lower right). If the
clival dura is opened, intradural structures such as the
pons, medulla, and the vertebrobasilar arteries will be
exposed.
Removal of the sphenoid bone at the root of the
pterygoid processes and medial to the V2 exposes the
sphenoid sinus. The lateral walls of the body of the
sphenoid bone can be completely removed by this
approach, but the V2 may have to be divided to improve
491

L. N. Sekhar, et al.
this exposure. The inferior and medial surfaces of the
cavernous ICA will also be exposed in this process, and
one has to be careful not to injure the vessel. If the V2
is divided, it may be resutured together at the end of
the operation.
One may enter the posterior and inferior aspects of
the cavernous sinus by following the petrous ICA upward. Alternatively, the anterior aspect of the cavernous
sinus may be entered by following the V2 backward into
the lateral wall between the leaves of the dura, and then
entering the cavernous sinus between the ophthalmic
division of the trigeminal nerve (V~) and the V2. Entry
into the cavernous sinus is much easier when the tumor
extends from one area into the other, and the surgeon
follows the path taken by the tumor.
Extensions of the neoplasm into the orbit, maxillary
sinus, ethmoid sinus, infratemporal fossa, and retroand parapharyngeal space are easily removed by this
approach. When the tumor extends into the petrous
apex of the opposite side near or around the contralateral petrous ICA, it may also be removed by this
approach. However, this is not recommended unless
proximal control of the contralateral ICA has been
previously obtained in the neck.
Management of the Petrous and Upper Cervical
ICA. The management of the petrous and upper cervical ICA depends in part on the pathology of the
neoplasm, the presence of arterial wall invasion as determined at surgery, and the results of the preoperative
balloon-occlusion test. 28 Based on the balloon-occlusion test, patients may be divided into three categories.
Patients who develop neurological deficits during preoperative test balloon occlusion are considered to be at
high risk for stroke if the artery is permanently occluded
intraoperatively or postoperatively, or if the artery is
temporarily occluded for an extended period intraoperatively. The operative risk is therefore higher for these
patients, and nonoperative therapy should be reconsidered. If an operation is elected, a preoperative extracranial-intracranial bypass should be considered. The second group of patients includes those who tolerate test
balloon occlusion well clinically but develop a CBF
reduction in the middle cerebral artery territory to the
range of 15 to 30 ml/100 mg/min. These patients are
at moderate risk for stroke after permanent ICA occlusion but at minimal risk after prolonged temporary
occlusion. If the ICA has to be resected at operation in
a patient in this group, it should be directly reconstructed by a short saphenous vein graft. The majority
of patients fall into the third group: those without
clinical symptoms or signs during test occlusion and
who have CBF values greater than 30 ml/100 gm/min
in the middle cerebral artery distribution during the
occlusion period. Such patients will probably tolerate
permanent ICA occlusion, provided that occlusion is
performed as close to the ophthalmic artery as possible
(eliminating a stump as an embolic source) and that
careful attention is paid to intraoperative and postoperative blood pressure, blood volume, and rheology.
492

A surprisingly large proportion of neoplasms may be

dissected away from the ICA, occasionally requiring
temporary trapping to repair arterial lacerations. However, when a noncartilaginous malignant neoplasm encases a major artery, we prefer to excise the abnormal
arterial segment, with or without vein graft reconstruction, as determined by the preoperative balloon-occlusion test.
Reconstruction. If the tumor extends into both the
intra- and extradural compartments, we recommend
removal in two stages. The first stage usually consists
ofextradural removal and reconstruction, but the intradural portion may be resected first if there is significant
intracranial mass effect. A single-stage resection may be
performed if the paranasal sinuses or the nasopharynx
will not be open to the surgical cavity at the end of the
tumor resection.
Dural defects resulting from tumor resection are repaired with autologous fascia grafts, such as pericranium, temporalis fascia, or fascia lata. A watertight repair
may not be possible, but even so the graft must cover
the entire defect and must be anchored circumferentially with a few sutures under magnification. In our
experience, the use of a cyanoacrylate adhesive has
been unsatisfactory for the closure of dural fistulae.
If the surgical site communicates with the nasopharynx, paranasal sinuses, or the external surface upon
completion of the tumor resection, it must be reconstructed using vascularized tissue. Such reconstruction
is especially important to protect the exposed dura and
major blood vessels. Small defects may be closed by
transposing the temporalis muscle. However, this muscle is unreliable for the reconstruction of larger defects
because of its small size and arc of rotation and because
of the occlusion of its blood supply that occurs during
such extensive procedures. For larger defects, we prefer
the use of a vascularized rectus abdominis muscle
flap. ~4'~5The lower one-half or two-thirds of one rectus
abdominis muscle is harvested along with the deep
inferior epigastric artery and vein. The vein is first
anastomosed to a suitable recipient neck vein, such as
a tributary of the internal jugular vein or the internal
jugular vein itself. The artery is then anastomosed to
one of the branches of the external carotid artery or to
the external carotid artery itself. Both anastomoses are
performed using standard microsurgical techniques
(Fig. 2). An interposition vein graft may be necessary if
the recipient vessels are at a distance. The vascularized
muscle is then positioned so as to occlude the communication with the nasopharynx and the paranasal
sinuses. The muscle flap is used to reconstruct the
lateral wall of the nasopharynx and cover the dura. The
exposed dura, the bone flap, and the ICA (or graft)
must be completely isolated from the nasopharynx or
sinus cavities. It is not necessary to graft skin to the
muscle that is exposed to the nasopharynx, as it is
rapidly covered by mucosa. The rectus abdominis muscle flap has been used successfully by us for reconstruction of the cranial base in 22 cases. 14A5The advantages

J. Neurosurg. / Volume 67~October, 1987

Subtemporal-infratemporal approach to cranial base neoplasms

of this technique are that a large area may be covered
and the flap is harvested with the patient in the supine
position. A disadvantage is the need for a microvascular
anastomosis.
Other vascularized flaps available for the reconstruction of the cranial base include the galeopericranial flap
fed by the supraorbital vessels, 2 the sternomastoid muscle flap based on the occipital vessels, 13 the pectoralis
major myocutaneous flap,1 the latissimus dorsi myocutaneous flap, 21 and the extended trapezius myocutaneous flap. 18,22

Postoperative Care. Postoperatively, the patient's

head is kept elevated. Drainage of CSF is continued for
3 to 5 days if there was a sizable dural repair and if the
nasopharynx or the paranasal sinuses were exposed.
The hematocrit, platelet count, prothrombin time, and
partial thromboplastin time are carefully followed if
there was significant intraoperative blood loss and the
blood constituents are appropriately replaced. The vascularity of the rectus abdominis flap is monitored by
an external or an implanted Doppler probe for 5 to 7
days. The tracheostomy tube is removed on the 3rd to
5th postoperative day. Unilateral dysfunction of the
ninth and 10th cranial nerves is common and does not
usually restrict careful resumption of oral feeding. However, if aspiration does occur, early postoperative injection of the vocal cord with Teflon or Gelfoam paste is
suggested. Bilateral dysfunction of these nerves, however, warrants prolonged nasogastric or gastrostomy
feeding and tracheostomy.
Computerized tomography scanning and arteriography are performed prior to discharge to make sure that
there are no unrecognized postoperative problems. The
postoperative stay averages 12 days.
Illustrative Cases

Case 13." Clivus, Sphenoidal, and Ethmoidal

Chondrosarcoma
This 24-year-old man developed transient confusion
and dizziness after a minor head injury 2 months prior
to admission. Computerized tomography scanning and
subsequent MRI demonstrated a very large mid and
upper clival, sphenoidal, and ethmoidal tumor, with
extension into both cavernous sinuses. Nasopharyngeal
biopsy revealed the lesion to be a well-differentiated
chondrosarcoma (Fig. 3 upper left and upper right).
Upon examination, his only deficit was a long-standing
amblyopic fight eye with a visual acuity of 20/400.
Sequential balloon-occlusion tests of both ICA's were
well tolerated clinically, with insignificant CBF changes.
The tumor was exposed by a subtemporal and infratemporal fossa approach and also by a transethmoidal
lateral rhinotomy approach. The maxillary nerve was
divided to gain better exposure. Both petrous and cavernous ICA's were found to be displaced and partially
surrounded by tumor. The combination of the two
approaches was very useful to effect a subtotal tumor
resection, including the tumor in the right cavernous
J. Neurosurg. / Volume 67 / October, 1987

FlG. 2. Diagram showing a rectus abdominis vascularized

muscle flap, which has been attached to the extemal carotid
artery and the internal jugular vein by means of microvascular
anastomosis. It can then be placed appropriately to fill the
cavity and to occlude the defect in the nasopharynx and
the paranasal sinuses created by the operative approach (see
Fig. 1).

sinus region. A dural tear in the region of the cribriform

plate was repaired with a small pericranial graft. A small
dural opening was noted at the site of the previous
biopsy but was difficult to suture. A vascularized rectus
abdominis flap was brought into the clival-sphenoidal
area through the infratemporal fossa. It was sutured
inferiorly to the wall of the nasopharynx and superiorly
to the periorbita on both sides. Nasal packing and CSF
drainage were maintained for 5 days. However, upon
removal of the packing, CSF rhinorrhea occurred and
persisted. The patient underwent reoperation via the
bifrontal-transethmoidal route. The leakage was noted
to be from the region of the foramen caecum, which
was not covered by the muscle flap. The muscle flap
was quite adherent to the basal frontal, sphenoidal, and
clival dura. After dural repair, a galeopericranial flap
based on the supraorbital vessels was placed between
the dura and muscle as an additional layer of protection.
Postoperatively, the patient had deficits of the fifth,
sixth, and ninth cranial nerves. Except for V2 numbness,
the function of the remaining nerves has returned.
Follow-up CT and MRI revealed a residual tumor in
the suprasellar and left cavernous sinus regions (Fig. 3
lower left and lower right). This was subsequently
removed by a left frontotemporal intradural approach.
Radiation therapy was administered postoperatively as
an adjuvant.
This case illustrates the use of a combined lateral and
anterior approach for the resection of an extensive
cranial base neoplasm. The reconstruction was extremely important here; without it we would not have
been able to avoid a serious meningeal infection.

Case 6. Meningioma
This 4 1-year-old woman had undergone two previous
partial resections and radiation therapy for an extensive
493

L. N. Sekhar, et al.

FIG. 3. Magnetic resonance images in Case 13. Upper Left: Preoperative Tl-weighted sagittal image
revealing a tumor involving the ethmoid and sphenoid sinuses and the upper and mid clivus. A small lesion
created by nasopharyngeal biopsy can be seen in the ports. UpperRight: Preoperative Trweighted coronal
image showing a tumor inside both cavernous sinuses and in the supraseUar region. Lower Left: The T2weighted sagittal image after the first operation demonstrating the muscle flap (M) and no residual tumor in
this plane. Lower Right: Postoperative Tl-weighted coronal image showing blood clot within the right
cavernous sinus and residual tumor in the suprasellar region and the left cavernous sinus.

medial sphenoid wing meningioma involving the cavernous sinus and the middle cranial fossa. The tumor
continued to grow despite the radiation therapy, and
involved the orbital apex, cavernous sinus, middle fossa,
sphenoid, maxillary and clival bones, the sphenoid and
ethmoid sinuses, and the infratemporal fossa (Fig. 4
upper pair). The ICA had been occluded during a
previous operation, and the second and third cranial
nerves were nonfunctional when she presented to us. A
5-mm proptosis was present.
At the first operation the entire extradural tumor was
removed by a subtemporal extradural-preauricular infratemporal fossa approach. A rectus abdominis flap
was placed to occlude the space occupied by the tumor
and to seal off the sphenoid, ethmoid, and maxillary
494

sinuses. However, the flap failed in the postoperative

period, apparently because the tip of a long intravenous
catheter had been placed in the outflow vein to which
the flap was attached. Upon reexploration, much of the
muscle was found to be already adherent to the tissues
and was therefore left in place. The small temporalis
muscle flap was transposed to occlude the maxillary
sinus. Fortunately, the patient recovered without any
infection, and the muscle healed by fibrosis.
Three months later the remainder of the tumor
within the cavernous sinus, the middle fossa, and the
orbital apex was removed by an intradural and extradural frontotemporal approach. Since the patient had
no vision or function of the third cranial nerve on that
side, the abducens and trochlear nerves were removed
J. Neurosurg. / Volume 67/October, 1987

Subtemporal-infratemporal approach to cranial base neoplasms

FIG. 4. Computerized tomography scans in Case 6. Upper Pair." Preoperative contrast-enhanced axial
images, using a soft-tissue algorithm (left) and a bone algorithm (right), demonstrating a meningioma involving
the cavernous sinus, middle fossa, orbital apex, sphenoid bone, sphenoid sinus, and ethmoid sinus. Extension
of tumor into the infratemporal fossa and maxillary bone is not shown. Lower Pair." Postoperative axial
images at a higher (left) and lower (right) level illustrating the absence of tumor and the occlusion of the dead
space with temporalis muscle. The rectus abdominis muscle flap, which is now devascularized, is also shown.

along with the tumor. Following the second operation,

she apparently has no residual tumor (Fig. 4 lower
pair). She has been followed for only 1 year postoperatively.
Operative Results
The operative results and outcome are given in Table
3. Of the 10 patients with benign neoplasms, total
tumor excision was performed in eight patients and
subtotal excision in two, as judged by postoperative CT
scans and MRI. The follow-up period ranged from 9
months to 3 years in this group, and no patient has
shown evidence of recurrence or regrowth to date. One
of these 10 patients also underwent radiation therapy.
In the group of three patients with malignant cartilaginous neoplasms, total resection was achieved in two
patients and a subtotal resection in one patient. All
three patients received postoperative radiation therapy.
Two have no evidence of tumor on the most recent

J. Neurosurg. / Volume 67~October, 1987

scans. One patient (Case 12) died 1 year postoperatively

of pulmonary metastases, but had no evidence of local
recurrence. The follow-up time in this group is also
short, ranging from 9 months to 11 years. In the last
group of nine patients with "other malignant neoplasms," total excision was achieved in seven patients,
subtotal excision in one, and partial excision in one. Of
the eight surviving patients, one developed local recurrence at the margin of previous tumor resection and
another cervical lymph node metastases without local
recurrence. Both have undergone further operations for
tumor removal.
Among the total group of 22 patients there was one
postoperative death. Eighteen patients are independent
and have returned to their previous occupation (good
outcome), two have some deficits (either preexistent or
new postoperatively) but are able to care for themselves
(fair outcome), and one requires assistance for personal
care because of preoperative neurological deficits (poor
495

L. N. Sekhar, et al.
TABLE 3

Extent of tumor resection and outcome

Case
No.

Tumor

benign neoplasms
1 juvenile angiofibroma

Operative Approach*

Extent of
Resection

Irradiation

subtemporal-infratemporal, transethmoidal

total

no

2
3
4

epidermoid cyst
epidermoid cyst
glomus vagale tumor

subtemporal-infratemporal
subtemporal-infratemporal
subtemporal-infratcmporal

total
total
total

no

meningioma

1: subtemporal-infratemporal; 2: frontotemporal;

total

yes

6
7

meningioma
meningioma

1: subtemporal-infratemporal; 2: frontotemporal
subtemporal-infratemporal, frontotemporal
approach

total
total

no

8
9

meningioma
meningioma

1: subtemporal-infratemporal; 2: frontotemporal
1: retromastoid; 2: suboccipital-Cl laminectomy;
3: subtemporal-infratemporal

subtotal
subtotal

no

total

no

total

proton
beam
external
beam

3: facial nerve reconstruction

10

neurilemoma, ninth
1: retromastoid; 2: subtemporal-infratemporal
cranial nerve
malignant cartilaginous neoplasms
11
chordoma
subtemporal-infratemporal

no
no

no

no

Follow-Up Period
& Outcomet
9 mos: good, 3rd, 4th, 6th, 7th
cranial nerve paresis resolving, no recurrence
2 89yrs: good, no recurrence
1 yr: good, no recurrence
1 yr: fair, swallowing & speech
problems, no recurrence
3 yrs: good, 7th cranial nerve
palsy resolving, no recurrence
1 yr: good, no recurrence
1 yr: good, persistent loss of
2nd cranial nerve function,
no recurrence
9 mos: good, residual tumor
9 mos: good, 9th, 10th cranial
nerve paresis, residual tumor
1 89
yrs: good, no recurrence
1 89
yrs: good, no recurrence

12

chordoma

l: transbasal-ethmoidal; 2: subtemporal-infratemporal; 3: frontotemporal

subtotal

13

chondrosarcoma

l: subtemporal-infratemporal, transethmoidal;
2: subfrontal (CSF leak); 3: frontotemporal

total

external
beam

1: subtemporal-infratemporal; 2: frontotemporal

total

yes

1 yr: good, no recurrence

l: subtemporal-infratemporal; 2: frontotemporal

total

no

1 yr: good, recurrent tumor

l: subtemporal-infratemporal; 2: frontotemporal

total

yes

l 89yrs: good, no recurrence

l: subtemporal-infratemporal; 2: carotid repair;

3: abscess drainage; 4: CSF shunt
subtemporal-infratemporal

partial

no

2 mos: died

total

yes

1 88
yr: good, no recurrence

subtemporal-infratemporal
l: subtemporal-infratemporal; 2: abscess drainage,
rectus abdominis flap
subtemporal-infratemporal

total
subtotal

yes

l yr: good, no recurrence

1 yr: poor, no recurrence

total

subtemporal-infratemporal

total

external
beam
external
beam

other malignant neoplasms

14
adenoid cystic carcinoma
15
adenoid cystic carcinoma, recurrent
16
squamous cell carcinoma
17
squamous cell carcinoma
18
squamous cell carcinoma
19
basal cell carcinoma
20
undifferentiated carcinoma, recurrent
21
undifferentiated carcinoma, recurrent
22
undifferentiated carcinoma, recurrent

no

1 yr: fair, pulmonary metastases, no local tumor; died

of disease
9 mos: good, no recurrence

1 yr: good, no recurrence

1 yr: good, lymph node metastases, no local tumor

* CSF = cerebrospinal fluid.

t For a description of outcome categories see text.

outcome) (Table 3). One patient (Case 12) with a fair

postoperative outcome died of his disease 1 year later.
The incidence of postoperative complications in this
series is given in Table 4. One patient (Case 17) died 2
months postoperatively. This patient had a squamous
cell carcinoma of the nasopharynx and tumor invasion
of the clivus, sphenoid, and retro- and parapharyngeal
areas, and encasement of both petrous and upper cervical ICA's. She did well initially following a subtotal
tumor resection. Temporalis muscle rather than a vascularized rectus abdominis flap was used for reconstruc496

tion, but the ICA apparently remained exposed to the

nasopharynx. The patient suffered ipsilateral ICA rupture, wound infection, and subsequently contralateral
ICA rupture. Despite carotid reconstruction and subs e q u e n t r e c t u s a b d o m i n i s flap r e c o n s t r u c t i o n , s h e e v e n tually died of infection.
O n e p a t i e n t ( C a s e 12) w h o u n d e r w e n t t h r e e - s t a g e
e x c i s i o n o f a clival, s p h e n o i d a l , a n d e t h m o i d a l c h o r doma suffered a stroke 3 weeks after the second operation due to petrous ICA thrombosis and embolic occlusion of the middle cerebral artery. This occurred shortly

J. Neurosurg. / Volume 67 / October, 1987

Subtemporal-infratemporalapproach to cranial base neoplasms

TABLE 4
Postoperative complications
Complication
death (carotid rupture & infection)
stroke (moderate recovery)
wound infection
cerebrospinal fluid leak*
rectus abdominis flap failure (uneventful)
cranial nerve palsy
II: permanent deficit
lII, IV, VI: temporary palsy
Ill, IV: temporary,palsy
ophthalmic division of the trigeminal nerve
maxillary nerve
mandibular nerve
VI: permanent palsy
VI: temporarypalsy
VII: permanent palsy (graftreconstruction)
VII: temporary palsy
IX, X: permanent deficit
* One reexploration.

No. of
Cases
1
1
3
4
1
1
1
1
1
2
7
1
3
I
2
5

after an intradural frontotemporal operation on the

contralateral side. Endothelial injury tp the ICA upon
dissection from tumor during the second operation,
kinking of the ICA due to excessive head turning, and
perioperative hypercoagulability may all have contributed to the middle cerebral artery occlusion. This patient made a fair recovery from the stroke and subsequently underwent radiation therapy. One year later,
he developed pulmonary metastases and died without
evidence of local recurrence.
Two other patients suffered wound infections, one
due to the inadequate exclusion of the nasopharynx by
a temporalis flap and the other due to inadequate
exclusion of an open sphenoid sinus by a rectus abdominis flap. The first infection was resolved by the application of a rectus abdominis flap and antibiotics and
the second with antibiotics. Four patients had CSF
leakage postoperatively. One required reexploration
and the others responded to CSF drainage via a lumbar
catheter. Of the 12 rectus abdominis flaps that were
used for reconstruction in this series of 22 patients, one
failed postoperatively as previously discussed.
Among the cranial nerve complications, permanent
visual deterioration in one patient and temporary paralysis of the third, fourth, and sixth cranial nerves were
related to operations within the cavernous sinus. In one
patient with a malignant tumor within the cavernous
sinus, the abducens nerve was sacrificed along with the
neoplasm during a subsequent intracavernous operation. One patient sustained a permanent postoperative
facial paralysis, but has made a good recovery with graft
reconstruction. In some patients temporary facial palsies recovered completely within 3 months except for
persistent frontalis muscle weakness. Permanent deficits
of the ninth and 10th cranial nerves were always due
to tumor invasion. Four of five patients with deficits
J. Neurosurg. / Volume 6 7 / October, 198 7

received a Teflon injection of the vocal cord and recovered a good voice and swallowing function. One
patient who has bilateral vocal cord paralysis because
of bilateral glomus vagale tumors that occurred 10 years
apart remains disabled with regard to both swallowing
and speaking.
Although 10 patients had unilateral resection of the
mandibular condyle, these patients had only temporary
problems of malocclusion and chewing, lasting 3 to 6
months postoperatively.
Discussion

In order to justify extensive operative procedures to

remove cranial base neoplasms, one must show that the
procedure can be performed safely and that the outcome is better than it would be if the disease progressed
naturally or if other treatment modalities such as irradiation or chemotherapy were used. In this small series,
we have shown the safety of the operation and are
making further efforts to reduce the morbidity. Whether
the outcome is better than with existing treatment
modalities will only be known after longer follow-up
evaluation of a larger number of patients. A discussion
of the various operative approaches to the cranial base
follows. The current treatment outlook for different
neoplasms of the skull base, the management of the
petrous and upper cervical ICA, and the methods of
cranial base reconstruction have been discussed in detail
elsewhere. ~4.~5,27,28
The operative approaches available to the lateral and
posterior cranial base may be divided into primarily
intradural and primarily extradural approaches. We
exclude from this discussion primarily intradural approaches such as the retromastoid paracerebellar, frontotemporal, and subtemporal approaches since the use
and limitations of these are well known. 24'25Such intradural approaches may also be used for the removal of
extradural lesions when the lesion is small and does not
extend into the paranasal sinuses or the nasopharynx
(for instance, for a trigeminal neurinoma in the cavernous sinus).
The primarily extradural approaches may be classified into anterior and lateral. Some of these may also
be used for intradural lesions, provided that a CSF
fistula into a paranasal sinus or nasopharynx does not
result following operation.
The anterior extradural approaches include the transbasal approach of Derome, and the transethmoidal, the
transsphenoidal, and the transoral techniques. 2 In general, the anterior approaches provide a more direct view
of the midline structures, but are limited craniocaudally
and also laterally by the petrous ICA's. In the event of
intraoperative injury to the pertrous ICA, control of
the hemorrhage is very difficult, and reconstruction is
impossible. It may be possible to repair dural tears with
microsurgical technique, but with the exception of the
transbasal approach, it is not possible to provide an
additional layer of vascularized tissue protection be497

L. N. Sekhar, et al.
tween the dura and the nasopharynx. The transbasal
approach does allow an extensive galeopericranial flap
reconstruction. The latter approach is primarily extramucosal and extradural, but if a dural tear should occur,
CSF leakage problems are similar to these associated
with the other anterior approaches unless adequate
reconstruction and CSF drainage are provided. The
transbasal approach allows an extensive exposure of the
ethmoid and sphenoid sinuses and the mid and lower
clivus. The exposure provided by the transethmoidal
approach is similar, but the optic nerves and orbital
apex are not quite as well exposed. The transsphenoidal
approach provides a less extensive exposure of the
sphenoid sinus and of the mid clivus than do the
previous two exposures. However, the upper clivus
(hidden behind the sella turcica) may be best exposed
by this approach. The transoral transpalatal approach
provides a shorter route to the mid and lower clivus
and the foramen magnum region than do the other
anterior approaches. However, should CSF leakage occur, the potential for grave meningeal infection is greatest with this approach.
A variety of lateral extradural approaches have been
developed to overcome some of the problems of the
anterior approaches. With the exception of the infratemporal fossa approach of Fisch and our subtemporal-infratemporal fossa approach, they all share the
disadvantage of limited exposure. The translabyrinthine approach is popularly used for the removal of
small and medium-sized acoustic neuromas, and may
also be used in combination with the retromastoid
intradural approach. 5'6 The transcochlear approach is a
further extension of the translabryrinthine technique,
but with the removal of the cochlea. Such an approach
can provide a restricted exposure of the mid clivus, and
has been used for the removal of intradural lesions such
as meningiomas.9'~~With both of these approaches the
patient's hearing is destroyed, and with the transcochlear approach a prolonged facial paralysis always results,
often with incomplete recovery and synkinesis. The
infratemporal approach of Fisch has been divided into
Types A, B, and C. 3-5 The Type A and B approaches
involve a retroauricular incision with transection of the
external ear canal, removal of the middle ear structures,
and displacement of the facial nerve from the fallopian
canal. These two approaches have been used for lesions
involving jugular bulb, facial recess, hypotympanic and
apical areas of the petrous temporal bone, and the lower
clivus. Examples of tumors removable by these approaches include glomus jugulare tumors, jugular foramen neurilemomas, and petrous apex epidermoid tumors. A permanent conductive hearing loss always
results, and a prolonged temporary facial paralysis generally occurs, followed usually by incomplete recovery
and synkinesis of facial movements. The Type C infratemporal fossa approach utilizes a retroauricular incision but does not involve facial nerve displacement; a
conductive hearing loss always follows. This technique
has been used by Fisch for lesions in the nasopharyn498

geal, parasellar, retromaxillary, and paratubal regions

(such as juvenile angiofibromas), and for nasopharyngeal carcinomas. Our approach differs from the Type C
approach of Fisch in that the incision is preauricular,
which avoids conductive hearing loss, and a temporal
craniotomy is utilized to gain additional exposure. We
have also used it for more extensive lesions, with improved reconstruction techniques.
The middle fossa approach for trigeminal nerve section and the middle fossa approach to the internal
auditory canal were early subtemporal extradural approaches to the middle and posterior cranial base. 7,8
Recent reports have described the exposure of the cerebellopontine angle and the intradural clival structures
by the removal of the petrous apex bone superior to
the horizontal segment of the petrous ICA.11,16'23
In an effort to achieve a low approach to the floor of
the middle fossa and the petrous bone from an anterolateral direction, some surgeons have used a technique
that involves the temporary excision of the lateral and
superior walls of the orbit and the zygomatic arch (the
orbitozygomatic infratemporal approach)J 7'2~176This
technique has been incorporated in our approach.
Stevenson, et al., 29 described an anterolateral approach to the clivus and foramen magnum area between
the ICA and the pharyngeal wall. This has the advantage
of not opening the nasopharynx to the CSF spaces, so
that the possibility of infection is minimized.
It will be noted that our subtemporal-preauricular
infratemporal fossa approach provides a more extensive
exposure than most of the approaches described above,
but incorporates elements of many of them. The limitations of this approach are as follows. When the neoplasm extends into the facial recess and hypotympanic
area and conductive hearing is already lost, postauricular incision and a transtemporal approach with displacement of the facial nerve as described by Fisch
(Type A) is necessary. For extensive clival lesions, it
would be advantageous to combine our lateral approach
with an anterior approach such as the transbasal or
transethmoidal technique. Our approach does not provide control of the contralateral ICA. For lesions involving both ICA's, control of the contralateral ICA in
the neck is preferable. After removal of a clival neoplasm from the ipsilateral side, the opposite ICA may
be exposed either in the petrous apex region (petrous
ICA) or in the sphenoid sinus (cavernous ICA) but the
surgeon must be careful to avoid injury since repair is
difficult. Finally, our experience with the use of this
approach for intradural lesions is limited and needs
further definition.
Conclusions

We have described the resection of some extensive

cranial base neoplasms by means of a subtemporal and
preauricular infratemporal fossa approach, with simultaneous reconstruction. The management of bilateral
ICA encasement, the reduction of cranial nerve morJ. Neurosurg. / Volume 67 / October, 1987

Subtemporal-infratemporalapproach to cranial base neoplasms

bidity, and the prevention of infection are problems
that require continued study and resolution. The length
of follow-up evaluation in our patients is too short to
make any j u d g m e n t about the efficacy o f this surgical
approach in effecting a cure or a long-term control of
such neoplasms.

17.

18.

Acknowledgments

The authors wish to acknowledge the encouragement and

support of Drs. P. J. Jannetta, E. Myers, W. Futrell, and other
colleagues in the performance of this work. Drs. Chandra Sen,
Kenneth Shestak, and David Eibling participated in the operative management of a few of these patients. Jon Coulter
made the illustrations and Judy Campbell prepared the manuscript.
References

1. Ariyan S, Cuono CB: Use of the pectoralis major myocutaneous flap for the reconstruction of large cervical,
facial or cranial defects. Am J Surg 140:503-506, 1980
2. Derome PJ: Management of cranial chordomas, in Sekhar
LN, Schramm VL Jr (eds): Tumors of the Cranial Base:
Diagnosis and Treatment. Mt Kisco, NY: Futura (In press,
1987)
3. Farrior JB: Infratemporal approach to skull base for glomus tumors: anatomic considerations. Ann Otol Rhinol
Laryngol 93:616-622, 1984
4. Fisch U, Kumar A: Infratemporal surgery of the skull
base, in Rand RW (ed): Microneurosurgery, ed 3. St
Louis: CV Mosby, 1985, pp 398-420
5. Glasscock ME, Miller GW, Drake FD, et al: Surgery of
the skull base. Laryngoscope 88:905-923, 1978
6. Glasscock ME III, Pensak ML, Gulya AJ: Surgery of the
skull base, in Rand RW (ed): Mieroneurosurgery, ed 3. St
Louis: CV Mosby, 1985, pp 421-454
7. Hartley F: lntracranial neurectomy of the second and
third divisions of the fifth nerve. A new method. NY Med
J 55:317-319, 1892
8. House WF: Middle cranial fossa approach to the petrous pyramid. Report of 50 cases. Arch Otolaryngol 78:
460-469, 1963
9. House WF, De La Cruz A, Hitselberger WE: Surgery of
the skull base: transcochlear approach to the petrous apex
and clivus. Otolaryngology 86:770-779, 1978
10. House WF, Hitselberger WE: The transcochlear approach
to the skull base. Arch Otolaryngoi 102:334-342, 1976
11. House WF, Hitselberger WE, Horn KL: The middle fossa
transpetrous approach to the anterior-superior cerebellopontine angle. Am J Otol 7:1-4, 1986
12. Jackson IT, Hide TH: A systematic approach to tumours
of the base of the skull. J Maxillofac Surg 10:92-98,
1982
13. Jackson IT, Laws ER Jr, Martin RD: A craniofacial
approach to advanced recurrent cancer of the central face.
Head Neck Surg 5:474-488, 1983
14. Jones NF, Schramm VL, Sekhar LN: Reconstruction of
the cranial base following tumor resection. Br J Plast
Surg 40:155-162, 1987
15. Jones NF, Sekhar LN, Schramm VL: Free rectus abdominis muscle flap reconstruction following radical resection
of tumors of the middle and posterior cranial base. Plast
Reconstr Surg 78:471-477, 1986
16. Kawase T, Toya S, Shiobara R, et al: Transpetrosal ap-

J. Neurosurg. / Volume 6 7 / October, 198 7

19.

20.

21.
22.

23.

24.
25.

26.
27.

28.

29.

30.

proach for aneurysms of the lower basilar artery. J Neurosurg 63:857-861, 1985
Lesoin F, Authficque A, Villette L, et al: Anteroexternal
approach to the internal carotid artery at the base of the
skull and intrapetrously, in: Proceedings of the International Symposium on Cavernous Sinus. Ljubljana, Yugoslavia: University Medical Centre, 1986, pp 265-274
McCraw JB, Magee WP, Kalwai CH: Uses of the trapezius and sternomastoid myocutaneous flaps in head
and neck reconstruction. Plast Reconstr Surg 63:49-57,
1979
Moller AR, Jannetta P J: Preservation of facial function
during removal of acoustic neuromas. Use of monopolar
constant-voltage stimulation and EMG. J Neurosurg 61:
757-760, 1984
Pellerin P, Lesoin F, Dhellemmes P, et al: Usefulness of
the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas.
Neurosurgery 15:715-718, 1984
Quillen CG: Latissimum dorsi myocutaneous flaps in
head and neck reconstruction. Piast Reconstr Surg 63:
664-670, 1979
Rosen HM: The extended trapezius musculocutaneous
flap for cranio-orbital facial reconstruction. Plast Reconstr Surg 75:318-324, 1985
Sekhar LN, Burgess J, Akin O: An anatomical study of
the cavernous sinus emphasizing operative approaches
and the related vascular and neural reconstruction. Neurosurgery (In press, 1987)
Sekhar LN, Jannetta PJ: Cerebellopontine angle meningiomas. Microsurgical excision and follow-up results. J
Neurosurg 60:500-505, 1984
Sekhar LN, Jannetta P J: Petroclival and medial tentorial
meningiomas, in Sekhar LN, Schramm V Jr (eds): Tumors
of the Cranial Base: Diagnosis and Treatment. Mt Kisco,
NY: Futura (In press, 1987)
Sekhar LN, MOller A: Operative management of tumors
involving the cavernous sinus. J Neurosurg 64:879-889,
1986
Sekhar LN, Schramm VL Jr, Jones NF: Operative management of large neoplasms of the lateral and posterior
cranial base, in Sekhar LN, Schramm VL Jr (eds): Tumors
of the Cranial Base: Diagnosis and Treatment. Mt Kisco,
New York: Futura (In press, 1987)
Sekhar LN, Schramm VL Jr, Jones NF, et al: Operative
exposure and surgical management of the petrous and
upper cervical internal carotid artery. Neurosurgery 19:
967-982, 1986
Stevenson GC, Stoney RJ, Perkins RK, et al: A transcervical transclival approach to the ventral surface of the
brain stem for removal of a clivus chordoma. J Neurosurg
24:544-551, 1966
Suzuki T, Tokuno H, Hakuba A: The orbito-zygomatic
infratemporal approach (a new surgical technique), in:
Proceedings of the International Symposium on Cavernous Sinus. Ljubljana, Yugoslavia: University Medical
Centre, 1986, pp 390-398

Manuscript received November 6, 1986.

Accepted in final form April 4, 1987.
Address for Dr. Schramm: Center for Cranio-facial-Skull
Base Surgery, St. Luke's Plaza, 501 East 19th Avenue, Denver,
Colorado 80264.
Address reprint requests to: Laligam N. Sekhar, M.D.,
Department of Neurosurgery, 9402 Presbyterian-University
Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.

499