Nasomaxillary osteotomy in lesions of the central compartment of the middle cranial base.

The pituitary fossa, sphenoid rostrum, sphenoid sinus, nasopharynx, pterygopalatine fossa and clivus are the components of the central compartment of the middle cranial base. It is a surgical challenge to gain access to this region. This fact has led to the development of a number of surgical procedures reported in the literature. However, none of these techniques can provide a wide and direct exposure to the middle cranial fossa without morbidity on its own. In this report, nasomaxillary osteotomy is described as a satisfactory alternative to reach the middle cranial fossa. With the nasomaxillary osteotomy technique, a wide access can be obtained to the central compartment of the skull base, caudally till the inferior clivus and upper cervical vertebrae (C1, C2). Since bilateral, internal carotid arteries are in sight laterally, the technique provides a secure resection of tumors with marked lateral extensions. Repositioning the translocated bone segment, surrounding the apertura piriformis, results in satisfactory cosmesis postoperatively. The technique is discussed on the basis of eight cases with the histopathological diagnosis of squamous cell carcinoma (1 case), olfactory neuroblastoma (2 cases), chordoma (2 cases) and juvenile nasopharyngeal angiofibroma (3 cases). No vascular complication has been encountered. One chordoma patient died of the disease in the follow-up period. All other cases, including one squamous cell carcinoma patient, are alive and disease-free without cosmetic deformity. In conclusion, nasomaxillary osteotomy provides a wide and direct exposure to the central compartment of the skull base in a relatively short period of time, securing the vascular and neural structures. Besides, it offers the advantage that it can be combined with other techniques in extensive tumors, while cosmesis and nasal functions are preserved.