Indications and Safety of the Zygomatic Osteotomy in Middle Cranial Fossa Surgery: A Retrospective Cohort Review

Indications and Safety of the Zygomatic Osteotomy in Middle Cranial Fossa Surgery: A Retrospective Cohort Review

We read with great interest the paper entitled “Indications and Safety of the Zygomatic Osteotomy in Middle Cranial Fossa Surgery: A Retrospective Cohort Review” by Neal et al.[1] The authors concluded that “zygomatic osteotomy (ZO) was preferentially used because of the increased exposure of the surgical window needed to resect these larger tumors,” “did not increase the risk of surgery as measured by incidence of surgical complications,” and “increase the operative window, facilitate multidirectional access, and decrease temporal lobe retraction.” However, several studies reported no significant differences in terms of surgical exposure.[2] [3] [4] [5]

A “decision-making process for when to use a ZO in middle cranial fossa (MCF) surgery” was presented. It suggests that a ZO should be considered in case of an anterior-posterior (A–P) angle of approach, tumors larger than 30 mm, and located in the anterior half of the MCF.

We agree that both the tumor location and the surgical trajectory need to be strictly considered when evaluating the need for a ZO. However, we do not believe that tumor size plays a relevant role during surgical planning. In their series, Neal et al used the ZO in 15 tumor cases, and 13 out of them were meningiomas. Brain parenchyma is usually displaced by extra-axial tumors, which act as a natural retractor, while vessels can be even attached to the capsule or encased by the lesion. The standard microsurgical technique consists in gradually debulking the lesions by preserving its capsule which represents a safe layer and retracts surrounding structures. Nonetheless, meningiomas can be first extradurally devascularized by coagulating their dural feeding vessels; thus, some retraction or extended surgical exposure may be helpful during this step. However, if the ZO allows better control part of the tumor, it should be considered, regardless of the tumor size.

During the last decades, surgical and functional expectations in elective cases have been progressively increasing. In fact, patients' comfort, functional, and esthetic results need to be carefully considered. Neal et al did not consider the following relevant aspects in their investigation: is there any chewing discomfort when performing a ZO? Is the esthetic result influenced by? Is there any specific discomfort reported by their patients during the clinical follow-up?

In conclusion, we do not believe that the tumor size itself should influence the decision of whether to perform a ZO or not. The tumor location in the anterior half of the MCF and an A–P angle of approach, as reported by Neal et al, should lead the decision process. Furthermore, other factors may influence surgical planning, such as the extension of the tumor in the infratemporal or posterior fossa.[6] Innovations and evolutions in technologies and techniques have been providing even better surgical and functional outcomes; nowadays, patient-oriented results, such as esthetic and comfort, need to be strictly pursued. Accordingly, more invasive procedures should be limited to carefully selected cases.

Publication History

Received: 11 October 2019

Accepted: 22 January 2020

Article published online:
09 March 2020

• References

• 1 Neal E, Pressman E, Athienitis A. et al. Indications and safety of the zygomatic osteotomy in middle cranial fossa surgery: a retrospective cohort review. J Neurol Surg B Skull Base 2019; 80 (03) 225-231
• 2 Melamed I, Tubbs RS, Payner TD, Cohen-Gadol AA. Trans-zygomatic middle cranial fossa approach to access lesions around the cavernous sinus and anterior parahippocampus: a minimally invasive skull base approach. Acta Neurochir (Wien) 2009; 151 (08) 977-982
• 3 Schwartz MS, Anderson GJ, Horgan MA, Kellogg JX, McMenomey SO, Delashaw Jr JB. Quantification of increased exposure resulting from orbital rim and orbitozygomatic osteotomy via the frontotemporal transsylvian approach. J Neurosurg 1999; 91 (06) 1020-1026
• 4 Ercan S, Scerrati A, Wu P, Zhang J, Ammirati M. Is less always better? Keyhole and standard subtemporal approaches: evaluation of temporal lobe retraction and surgical volume with and without zygomatic osteotomy in a cadaveric model. J Neurosurg 2017; 127 (01) 157-164
• 5 Lee JS, Scerrati A, Zhang J, Ammirati M. Quantitative analysis of surgical exposure and surgical freedom to the anterosuperior pons: comparison of pterional transtentorial, orbitozygomatic, and anterior petrosal approaches. Neurosurg Rev 2016; 39 (04) 599-605
• 6 Jeong SK, Lee EJ, Hue YH, Cho YH, Kim JH, Kim CJ. A suggestion of modified classification of trigeminal schwannomas according to location, shape, and extension. Brain Tumor Res Treat 2014; 2 (02) 62-68