Zygomatic transmandibular approach

The biologic behavior of clival chordomas is often unexpected. Sometimes they invade the middle cranial fossa, infratemporal fossa, and parapharyngeal space. Lesions growing in these areas tend to remain clinically silent for long periods so that when the diagnosis is made, the tumors already have grown considerably. The clinical course in these cases is dominated by obstruction of the upper airways and digestive tract, deficit of the lower cranial nerves, diplopia, and facial hypesthesia. Surgical management of these kinds of masses is difficult because sometimes exposure is not enough for their resection, but the zygomatic-transmandibular approach offers a good option, even when clival chordomas are large or giant. The main advantages of this procedure are wide and safe exposure of the tumor, complete control of neurovascular structures, facilitation of the dural closure, minimal manipulation of the facial nerve, and the easy combination of this technique with other skull base approaches. The morbidity index is low and characterized by minimal problems in chewing, which can be avoided with an adequate physiotherapy program. Limitations of the resection are related to the infiltration pattern of the tumor more than to the approach itself.