Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients

Neurosurgery ◽  
2017 ◽  
Vol 80 (2) ◽  
pp. 309-322 ◽  
Author(s):  
Joseph D. Chabot ◽  
Paul A. Gardner ◽  
S. Tonya Stefko ◽  
Nathan T. Zwagerman ◽  
Juan Carlos Fernandez- Miranda
Keyword(s):  
Visual Acuity ◽  
Cavernous Sinus ◽  
Middle Cranial Fossa ◽  
Symptomatic Improvement ◽  
Middle Fossa ◽  
Total Resection ◽  
Patients Âgés ◽  
Lateral Orbitotomy ◽  
Patient Reported ◽  
Cranial Fossa

Abstract BACKGROUND: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa. OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa. METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed. RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1). CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

scholarly journals Middle cranial fossa approach for acoustic neuroma

2021 ◽  
Vol 5 (2) ◽  
pp. V12
Author(s):  
Paul W. Gidley ◽  
Joel Z. Passer ◽  
Joshua C. Page ◽  
Franco DeMonte
Keyword(s):  
Acoustic Neuroma ◽  
Hearing Preservation ◽  
Middle Cranial Fossa ◽  
Middle Fossa ◽  
Surgical Indications ◽  
Total Resection ◽  
Technical Aspects ◽  
Middle Fossa Approach ◽  
Acoustic Neuromas ◽  
Cranial Fossa

The middle fossa approach for the resection of small acoustic neuromas is a viable, but underutilized treatment modality with the goal of hearing preservation. The authors aim to demonstrate this approach and its nuances through this video presentation. A 38-year-old man presented with an incidentally discovered small, intracanalicular acoustic neuroma that was initially observed, but growth was noted. The patient had good hearing, and therefore a hearing preservation approach was offered. A gross-total resection was achieved, and the patient maintained good hearing postoperatively. This video demonstrates relevant anatomy, surgical indications, technical aspects of resection, including reconstruction, and postoperative outcomes. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21124

Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application

2018 ◽  
Vol 130 (1) ◽  
pp. 227-237 ◽  
Author(s):  
Huy Q. Truong ◽  
Xicai Sun ◽  
Emrah Celtikci ◽  
Hamid Borghei-Razavi ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Maxillary Sinus ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Middle Cranial Fossa ◽  
Anatomical Landmarks ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Cranial Fossa ◽  
Greater Wing

OBJECTIVEMultiple approaches have been designed to reach the medial middle fossa (for lesions in Meckel’s cave, in particular), but an anterior approach through the greater wing of the sphenoid (transalisphenoid) has not been explored. In this study, the authors sought to assess the feasibility of and define the anatomical landmarks for an endoscopic anterior transmaxillary transalisphenoid (EATT) approach to Meckel’s cave and the middle cranial fossa.METHODSEndoscopic dissection was performed on 5 cadaver heads injected intravascularly with colored silicone bilaterally to develop the approach and define surgical landmarks. The authors then used this approach in 2 patients with tumors that involved Meckel’s cave and provide their illustrative clinical case reports.RESULTSThe EATT approach is divided into the following 4 stages: 1) entry into the maxillary sinus, 2) exposure of the greater wing of the sphenoid, 3) exposure of the medial middle fossa, and 4) exposure of Meckel’s cave and lateral wall of the cavernous sinus. The approach provided excellent surgical access to the anterior and lateral portions of Meckel’s cave and offered the possibility of expanding into the infratemporal fossa and lateral middle fossa and, in combination with an endonasal transpterygoid approach, accessing the anteromedial aspect of Meckel’s cave.CONCLUSIONSThe EATT approach to Meckel’s cave and the middle cranial fossa is technically feasible and confers certain advantages in specific clinical situations. The approach might complement current surgical approaches for lesions of Meckel’s cave and could be ideal for lesions that are lateral to the trigeminal ganglion in Meckel’s cave or extend from the maxillary sinus, infratemporal fossa, or pterygopalatine fossa into the middle cranial fossa, Meckel’s cave, and cavernous sinus, such as schwannomas, meningiomas, and sinonasal tumors and perineural spread of cutaneous malignancy.

scholarly journals Pure Endoscopic Lateral Orbitotomy Approach to the Cavernous Sinus, Posterior, and Infratemporal Fossae: Anatomic Study

2018 ◽  
Vol 80 (03) ◽  
pp. 295-305 ◽  
Author(s):  
Lili Laleva ◽  
Toma Spiriev ◽  
Iacopo Dallan ◽  
Alberto Prats-Galino ◽  
Giuseppe Catapano ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Direct Access ◽  
Petrous Apex ◽  
Anatomic Study ◽  
Anterior Clinoid Process ◽  
Lateral Orbitotomy ◽  
Before And After ◽  
Cranial Fossa

Objective The aim of this anatomic study is to describe a fully endoscopic lateral orbitotomy extradural approach to the cavernous sinus, posterior, and infratemporal fossae. Material and Methods Three prefixed latex-injected head specimens (six orbital exposures) were used in the study. Before and after dissection, a computed tomography scan was performed on each cadaver head and a neuronavigation system was used to guide the approach. The extent of bone removal and the area of exposure of the targeted corridor were evaluated with the aid of OsiriX software (Pixmeo, Bernex, Switzerland). Results The lateral orbital approach offers four main endoscopic extradural routes: the anteromedial, posteromedial, posterior, and inferior. The anteromedial route allows a direct route to the optic canal by removal of the anterior clinoid process, whereas the posteromedial route allows for exposure of the lateral wall of the cavernous sinus. The posterior route is targeted to Meckel's cave and provides access to the posterior cranial fossa by exposure and drilling of the petrous apex, whereas the inferior route gives access to the pterygopalatine and infratemporal fossae by drilling the floor of the middle cranial fossa and the bone between the second and third branches of the trigeminal nerve. Conclusion The lateral orbitotomy endoscopic approach provides direct access to the cavernous sinus, posterior, and infratemporal fossae. Advantages of the approach include a favorable angle of attack, minimal brain retraction, and the possibility of dissection within the two dural layers of the cavernous sinus without entering its neurovascular compartment.

The So-Called Cavernous Sinus: A Review of the Controversy and Its Implications for Neurosurgeons

Neurosurgery ◽  
1982 ◽  
Vol 11 (5) ◽  
pp. 712-717 ◽  
Author(s):  
John N. Taptas
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Cranial Nerves ◽  
Sella Turcica ◽  
Middle Cranial Fossa ◽  
Cranial Fossa ◽  
Base Of The Skull ◽  
Extradural Space

Abstract The so-called cavernous sinus is a venous pathway, an irregular network of veins that is part of the extradural venous network of the base of the skull, not a trabeculated venous channel. This venous pathway, the internal carotid artery, and the oculomotor cranial nerves cross the medial portion of the middle cranial fossa in an extradural space formed on each side of the sella turcica by the diverging aspects of a dural fold. In this space the venous pathway has only neighborhood relations with the internal carotid artery and the cranial nerves. The space itself must be distinguished from the vascular and nervous elements that it contains. The revision of the anatomy of this region has not only theoretical interest but also important clinical implications.

scholarly journals Clinical, surgical and postoperative outcome analysis of tumors occupying both posterior and middle cranial fossa

2021 ◽  
Vol 18 (2) ◽  
pp. 36-44
Author(s):  
Rahul Singh ◽  
Ravi Shankar Prasad ◽  
Ramit Chandra Singh ◽  
Kulwant Singh ◽  
Anurag Sahu
Keyword(s):  
Postoperative Outcome ◽  
Middle Cranial Fossa ◽  
Posterior Cranial Fossa ◽  
Gross Total Resection ◽  
Outcome Analysis ◽  
Subtotal Resection ◽  
Combined Approach ◽  
Total Resection ◽  
Trigeminal Schwannoma ◽  
Cranial Fossa

Objectives: To analyse clinical, surgical and postoperative outcome perspectives of tumors occupying both middle and posterior cranial fossa. Materials and Methods: This retrospective cohort study includes 23 patients operated for tumors involving both middle and posterior cranial fossa in our department between August 2016 and August 2020. Each patient was evaluated for age, sex, co morbidities, tumour histopathology, clinical presentation, radiological characteristics, surgical and outcome characteristics. Unpaired t- test and chi-square test was used for statistical analysis. P < 0.05 was considered statistically significant. Results: The mean age was 46 years (range 40–57 years), with the majority of patients being female (56.5%). Most tumors (65.3%) were trigeminal schwannoma, with the remaining being vestibular schwannoma (21.7%), facial schwannoma (8.7%) and epidermoid (4.3%). The most commonly used surgical approach was the retrosigmoid approach (30.4%) and combined approach (30.4%).  Gross total resection (GTR) was done in 14 patients while subtotal resection (STR) was done in 9 patients. STR was significantly associated (p<0.05) with persisting cranial nerve deficit and tumour progression.  Midbrain compression, internal carotid artery and cavernous sinus involvement were significantly (p<0.05) associated with STR. Conclusions: Trigeminal schwannoma is the most common tumour involving both middle and posterior cranial fossa. Combined approach for such tumours is required in tumours having significant size in both middle cranial fossa and posterior cranial fossa. The intent of surgery is to achieve a gross total resection (GTR) but adhesions and involvement of critical brain structures results in STR.

Endoscopic supraorbital extradural approach to the cavernous sinus: a cadaver study

2011 ◽  
Vol 114 (5) ◽  
pp. 1331-1337 ◽  
Author(s):  
Fuminari Komatsu ◽  
Mika Komatsu ◽  
Tooru Inoue ◽  
Manfred Tschabitscher
Keyword(s):  
Cavernous Sinus ◽  
Complex Structure ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Cadaver Study ◽  
Minimal Invasiveness ◽  
Small Complex ◽  
Transcranial Approach ◽  
Cranial Fossa ◽  
Extradural Approach

Object The cavernous sinus is a small complex structure located at the central base of the skull. Recent extensive use of endoscopy has provided less invasive approaches to the cavernous sinus via endonasal routes, although transcranial routes play an important role in the approach to the cavernous sinus. The aims of this study were to evaluate the feasibility of the purely endoscopic transcranial approach to the cavernous sinus through the supraorbital keyhole and to better understand the distorted anatomy of the cavernous sinus via endoscopy. Methods Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks. Results The endoscopic supraorbital extradural approach was divided into 4 stages: entry into the extradural anterior cranial fossa, exposure of the middle cranial fossa and the periorbita, exposure of the superior cavernous sinus, and exposure of the lateral cavernous sinus. This approach provided superb views of the cavernous sinus structures, especially through the clinoidal (Dolenc) triangle. The lateral wall of the cavernous sinus, including the infratrochlear (Parkinson) triangle and anteromedial (Mullan) triangle, was also clearly demonstrated. Conclusions An endoscopic supraorbital extradural approach offers excellent exposure of the superior and lateral walls of the cavernous sinus with minimal invasiveness via the transcranial route. This approach could be an alternative to the conventional transcranial approach.

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