Anterior Transcranial (Craniofacial) Resection of Tumors of the Paranasal Sinuses: Surgical Technique and Results

To the Editor: I was interested in the article by McCutcheon et al.(3) regarding transcranial resection of paranasal sinus tumors and, in particular, in the comment by Haines (2) regarding the apparent disregard of the oncological surgical principle of theen bloc resection of tumors. A craniofacial resection is necessary to achieve an en bloc resection, which cannot be performed by a craniotomy alone. The authors have reported a disappointing median survival of 20 months for squamous cell carcinoma and 26 months for adenocarcinoma in this series. In our reported series of 46 cases (1) of paranasal sinus cancer treated by craniofacial resection, the 5-year survival rate was 73% for squamous cell carcinoma and 83% for adenocarcinoma. This has further improved to 75% for squamous cell carcinoma and 85% for adenocarcinoma in 67 patients. This cannot be explained purely by patient selection, as there was macroscopic infiltration of the dura in 32 of our 46 patients and there was no correlation between outcome and dural involvement in our series. Neurosurgeons are used to removing intracranial tumors in a "piecemeal" fashion and may forget that the biology of essentially extracranial tumors requires an en bloc resection for satisfactory tumor control. The high incidence of epidural hematomas in the series presented by McCutcheon et al. (2) may reflect the inability to obtain satisfactory hemostasis through craniotomy alone. Among our 67 patients, there were no postoperative epidural hematomas or symptomatic pneumocephalus. We attribute this to meticulous hemostasis through both the cranial and facial wounds and suturing the pericranium firmly to the bone defect to exclude blood and air from the intracranial cavity. Andrew H.