Transfacial approaches to the skull base: The early contributions of Harvey Cushing

In this report, we review Dr. Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his early use of craniofacial approaches for malignant pathology of the skull base. Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912, which included three patients who underwent surgical treatment of lesions involving the skull base through craniofacial approaches: two adults and one child (range 3 to 43 years). The main outcome measures were length of stay and condition recorded at the time of discharge. The indications for surgery included osteochondroma of the sphenoid sinus, sarcoma of the maxillary sinus and middle fossa, and osteoma of the frontal sinus. The mean length of stay was 24.5 days (range 7 to 45 days). Cushing employed craniofacial approaches for malignant pathology nearly 40 years before such techniques became widely used. He practiced the fundamentals of skull base surgery, including preferential removal of bone to achieving adequate exposure for resection. In addition, Cushing clearly understood the importance of proximal vascular control in approaching lesions with complex vascular involvement.