[Extensive lower clivus chordomas. Removal using the unilateral transmandibular approach].
OBJECTIVE
Clival chordomas are rare skull-base tumors with local malignant behavior. Their control and removal remain difficult because of their anatomical location and because of their extensions. The goal of the treatment is complete surgical removal in a single stage if possible, with minimal deficits, followed by proton therapy. If the tumor remains extradural for a while, it finally progresses through the dura backwards to reach and displace the brain stem and upper cervical cord. Its anterior extension in the retropharyngeal space offers a logical opportunity and many advantages to use an anterior approach.


METHODS
With three consecutive cases, we try to demonstrate that the unilateral transmandibular approach offers a large exposure of the lower clivus, the foramen magnum in its ventral part, the ipsilateral infratemporal fossa and C1 to C3. Surgical complications concern the lower cranial nerves, including the hypoglossal. Serous otitis media is possible in case of opened Eustachian tube. Tracheostomy is needed because of a transient tongue oedema.


RESULTS
The unilateral transmandibular approach enabled to anatomical and physiological nasal preservation, large operative field facilitating dural closure and tumor removal, with acceptable cosmetic results and sequellae considering the natural course and prognosis of the tumor.


CONCLUSIONS
This approach seems to be very useful to reach and removed extensive lower chordomas.
Fournier
H-D
HD
Département de neurochirurgie et service d'ORL et chirurgie cervicofaciale, centre hospitalier universitaire, 4, rue Larrey, 49933 Angers cedex 9, France. HDFournier@chu-angers.fr
Hue
A-S
AS
Laccourreye
L
L
D000293:Adolescent; D000368:Aged; D002817:Chordoma / Q000601:surgery*; D035301:Cranial Fossa, Middle / Q000473:pathology; D020209:Cranial Nerve Injuries / Q000209:etiology / Q000473:pathology; D005064:Eustachian Tube / Q000293:injuries; D005539:Foramen Magnum / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008334:Mandible / Q000033:anatomy & histology / Q000601:surgery*; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D010027:Osteotomy; D010033:Otitis Media / Q000209:etiology; D010614:Pharynx / Q000033:anatomy & histology; D011183:Postoperative Complications / Q000473:pathology; D011379:Prognosis; D019292:Skull Base Neoplasms / Q000601:surgery*; D014057:Tomography, X-Ray Computed