Combined Transfrontal Basal Craniotomy and Lateral Rhinotomy in a Patient with Nasopharyngeal Carcinoma Involving the Anterior Skull Base and Right Orbit

Introduction: The literature stresses the advantages of aggressive multimodality treatment for advanced nasopharyngeal carcinoma. A selection of operative approaches depends on the size of the anterior skull base defects and extent of intracranial invasion. This paper reports a case of a 63-year-old female patient diagnosed with nasopharyngeal carcinoma with anterior skull base invasion and right orbital spread.

Material and Methods: A 63-year-old female patient suffered headache, epistaxis, anosmia, proptosis, ophtalmoplegia, amaurosis, and right orbital pain. Brain MR showed a large tumor in the anterior skull base involving the frontal sinuses, ethmoidal bone, right sphenoidal sinus, right orbital and optical nerves, nasal cavities, and right maxillary sinus. A total body CT scan revealed no distant metastases. After neoadjuvant radiotherapy, the authors decided to perform a combined transfrontal basal craniotomy and lateral rhinotomy in order to achieve both the intracranial and the facial part removal of the tumor. Via the transfrontal basal approach a gross resection of the skull base part of the lesion was obtained. Furthermore, through the right orbital roof, a partial decompression of the right orbitand optical nerve was possible. Lateral rhinotomy allowedthe removal of the intranasal and maxillary parts of the tumor. The patient underwent fractioned radiotherapy (median dose: 6600 cGy) and chemotherapy (cisplatin plus 5-fluorouracil).

Results: No postoperative CSF fistula was observed. On histological examination, the tumor proved to be squamous cell nasopharyngeal carcinoma. Immunohistochemical staining for K.i.67/Mib1 revealed a percentage of 75%. On 6-month follow-up the patient presented with amaurosis in the right eye.

Conclusions: Following Roh, the nasopharyngeal carcinoma with skull base invasion should be divided into the following groups: simple skull base erosion; minimal involvement of either anterior or posterior cranial nerves; multiple involvements of both cranial nerves; and intracranial extension. Salvage surgery is often the only curative chance for patients newly diagnosed with nasopharyngeal carcinoma with intracranial involvement. The reported case confirms the validity of combined transfrontal basal craniotomy and lateral rhinotomy in the treatment of those forms with anterior skull base and facial extension. The cisplatin-based chemotherapy, used in the reported case, is considered helpful even if limited by cumulative toxicities. Newer drugs such gemcitabine and vinorelbine have been shown to be active in salvage therapy when cisplatin-containing combinations have failed. Orbital invasion in nasopharyngeal carcinoma is rare. Hsu reported an observational case series of 406 patients affected by nasopharyngeal carcinoma with orbital invasion, finding that orbital invasion confers a particularly poor prognosis on these patients.