The Combined Subtemporal - Transfacial Approach
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Supplemental Results
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Case 1 (Fig 3a)
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An eighteen-year-old male patient presented with a history of nasal obstruction and allergy-like
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symptoms, progressing during the past four years, and with right hearing loss and headaches
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during the past one year. He had jaw numbness. The pre-operative MRI showed a massive
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JNA of the involving the paranasal sinuses and nasopharynx, with intracranial extension
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through the skull base to adjoin the right cavernous sinus, Meckel's cave, and medial temporal
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lobe. There was compression of the right orbit as well as erosion of the clivus. Angiography
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revealed that the tumor derived blood supply from both the right internal and external carotid
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arteries. Resection was performed using two procedures staged two days apart. The day after
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embolization, a subtemporal approach was performed to separate the tumor from the
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intracranial cavity and vascular supply. This approach allowed resection of the portion of the
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tumor that was compressing the right temporal lobe, and divorced the tumor from its right
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internal carotid artery blood supply. In the second stage, an endoscopic transnasal resection
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was employed to successfully remove the remainder of the tumor. Post-operative MRI
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revealed only a slight amount of residual disease within the cavernous sinus, which has
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remained stable for 16 months.
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Case 2 (Fig 3b)
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An 11 year old boy presented with recurrent, severe epistaxis, left facial numbness along the
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jaw, and a left serous middle ear effusion. MRI revealed a JNA that eroded through the skull
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base through the foramen ovale. It also extended inferiorly into the parapharyngeal space (not
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shown in included image). After embolization, a subtemporal approach was performed and the
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tumor was separated from the intracranial cavity. An endoscopic transfacial approach was then
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attempted to resect the rest of the disease. However, bleeding remained extensive, particularly
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from the inferior aspect of the tumor, and only ~50% of the tumor could be removed. Four days
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later, a midface degloving procedure was performed to complete a subtotal resection. In
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contrast to all of the other procedures, where the only residual disease was within the
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The Combined Subtemporal - Transfacial Approach
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cavernous sinus, this tumor was based too inferiorly in the neck to be completely resected.
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Thus, two foci of residual tumor were left behind in this sub-total resection, at the cavernous
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sinus and near the carotid bifurcation.
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Both areas recurred eight months postoperatively and a repeat midface degloving was
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performed. Again, only a subtotal resection could be performed, with both foci of residual
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disease remaining. The residual in the neck regrew rapidly and at 18 months post-operatively
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a transcervical approach was performed to ligate the external carotid artery and completely
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resect the lower focus of residual tumor. With only one focus of residual disease remaining, the
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ongoing plan is to manage the expected recurrences in the central sinonasal cavity solely with
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endoscopic debridement (in this now 13 year old patient).
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Case 3 (Fig 3c)
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A 13 year old boy presented with recurrent epistaxis and left middle ear effusion. He was found
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to also have facial numbness in the V2 and V3 distributions. A large JNA with cavernous sinus
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invasion was found. After embolization, a combined subtemporal approach and open
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transfacial resection using a lateral rhinotomy approach was performed. A near total resection
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was achieved, with only minimal residual at the cavernous sinus. This recurred on an annual
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basis and was managed with annual endoscopic debridements as an outpatient. Once the
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child reached 19 years old, growth of the tumor remnant spontaneously arrested as shown by
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MRI. He is now undergoing interval surveillance imaging and observation.
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Case 4 (Fig 3d)
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A 21 year old male was diagnosed with a Stage IVb JNA at an outside facility, and underwent
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1 past craniotomy by neurosurgery and later, 5 partial endoscopic resections by
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otolaryngology. The patient presented to our center after experiencing a life threatening
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nosebleed while driving, to a Hgb of 5 on admission. We then performed a staged cranio-
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orbito-zygomatic lateral approach followed by an open transfacial approach 6 days apart. A
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near total resection was again achieved without any concerning long term sequelae. He had
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one episode of severe epistaxis 15 months postoperatively, and recurrent JNA was found in
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The Combined Subtemporal - Transfacial Approach
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the region of the left pterygopalatine fossa that was managed endoscopically with minimal
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blood loss.
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