Transorbital endoscopic eyelid approach for resection of sphenoorbital meningiomas with predominant hyperostosis: report of 2 cases

Abstract

Sphenoorbital meningiomas (SOMs) are slow-growing tumors that originate from the sphenoidal wing and are associated with visual deterioration, extrinsic ocular movement disorders, and proptosis caused by hyperostosis of the lateral wall of the orbit. In some cases, the intracranial component is quite small or "en plaque," and the majority of the symptoms arise from adjacent hyperostosis. Craniotomy has traditionally been the standard of care, but new minimally invasive multiportal endoscopic approaches offer an alternative. In the current study, the authors to present their experience with the transorbital endoscopic eyelid approach for the treatment of 2 patients with SOMs and sphenoid wing hyperostosis. Clinical and radiological data for patients with SOMs who underwent a transorbital endoscopic eyelid approach were retrospectively reviewed. Surgical technique and clinical and radiographic outcomes were analyzed. The authors report the cases of 2 patients with SOMs and proptosis due to sphenoid wing hyperostosis. One patient underwent prior craniotomy to debulk the intracranial portion of the tumor, and the other had a minimal intracranial component. Both patients were discharged 2 days after surgery. MR images and CT scans demonstrated a large debulking of the hyperostotic bone. Postoperative measurement of the proptosis with the aid of an exophthalmometer demonstrated significant reduction of the proptosis in one of the cases. Persistence of intraconal tumor in the orbital apex limited the efficacy of the procedure in the other case. A review of the literature revealed 1 publication with 3 reports of the transorbital eyelid approach for SOMs. No measure of relief of proptosis after this surgery had been previously reported. The transorbital endoscopic approach, combined with endonasal decompression of the medial orbit, may be a useful minimally invasive alternative to craniotomy in a subset of SOMs with a predominantly hyperostotic orbital wall and minimal intracranial bulky or merely en plaque disease. In these cases, relief of proptosis and optic nerve compression are the primary goals of surgery, rather than gross-total resection, which may have high morbidity or be unachievable. In cases with significant residual intraconal tumor, orbital bone removal alone may not be sufficient to reduce proptosis.

Clinical and ophthalmological outcome of endoscopic transorbital surgery for cranioorbital tumors

“…5,6,16,19 To our knowledge, while there have been a few papers on the TOA for orbital lesions, 3,6,19 the literature describing a purely TOA for cranioorbital tumors via a superior eyelid crease incision, with specific ophthalmic outcome measurement, is limited. 1 Our study demonstrates that, via a superior lid crease incision (either the lateral half or full length of the crease), we can successfully remove cranioorbital tumors with minimal postoperative morbidity and excellent improvement in ophthalmological outcome. In particular, the locally invasive nature of en plaque sphenoid wing meningiomas requires a wide exposure to remove all involved structures, which usually include the greater and lesser wings of the sphenoid bone, orbit, and infratemporal fossa.…”

“…3,6,19 In addition, there is limited literature describing a TOA to cranioorbital tumors via a superior eyelid crease incision, with specific ophthalmic outcome measures. 1 The purpose of this study was to describe the clinical and ophthalmological outcomes of patients who underwent an endoscopic TOA in the management of cranioorbital tumors involving the deep orbit and intracranial compartment.…”

Transorbital Endoscopic Surgery for Sphenoid Wing Meningioma: Long-Term Outcomes and Surgical Technique

“…20 Almeida et al reported two cases using a endoscopic transorbital technique via superior eyelid approach for sphenoid wing meningioma and showed an improvement in visual acuity and proptosis at 1 month postoperatively. 30 Dallan et al reported 14 cases of sphenoorbital meningioma treated via transorbital endoscopic and superior eyelid approach and demonstrated that the approach was feasible and safe. In three (21.4%) patients, complete tumor resection was achieved.…”

Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

“…Furthermore, this approach does not injure the temporalis muscle, resulting in no risk of temporalis atrophy. 3,8 Second, as with an endoscopic endonasal procedure, eTOA obviates the need for temporal lobe retraction and avoids the potential risk of injury to the vein of Labbé, thus decreasing the risk of postoperative brain swelling. This, in turn, contributes to rapid postoperative recovery and reduces the length of hospital stay.…”

“…In the era of neuroendoscopic surgery, an endoscopic transorbital approach (eTOA) through the superior eyelid crease has been proposed as a viable way to access anterior and middle cranial fossa lesions such as spheno-orbital meningioma. 3,5,13,22,26,28,41,43 In addition to the visualization of cranio-orbital tumors, a surgical corridor through this approach allows excellent visualization of the lateral cavernous sinus while avoiding the need for brain retraction. 9-13, 15, 26, 28, 34,35 Recent cadaveric studies have suggested that this approach allows direct access to Meckel's cave without disruption of the temporalis muscle, and craniotomy and has been emerging as a complementary route for accessing Meckel's cave.…”