Transorbital Approach to Sphenoid Wing Meningiomas

TRANSORBITAL APPROACH TO SPHENOID WING MENINGIOMAS

Darlene E. LUBBE, Hamzah MUSTAK and Kris S. MOE

TRANSORBITAL APPROACH TO SPHENOID WING MENINGIOMAS

Darlene E. LUBBE1, Hamzah MUSTAK2, Kris S. MOE3

1| Associate Professor, FCORL(SA) Division of Otolaryngology, University of Cape Town, South Africa 2| Doctor, Consultant, FCOphth(SA) Division of Ophthalmology, University of Cape Town, South Africa 3| Professor, Departments of Otolaryngology, Head and Neck Surgery, and Neurological Surgery Chief of Division of Facial Plastic and Reconstructive Surgery University of Washington, Seattle, WA, USA 4 Transorbital Approach to Sphenoid Wing Meningiomas

Correspondence address of the ﬁ rst author: Professor Darlene Lubbe Division of Otolaryngology H-53 Old Main Building Groote Schuur Hospital, Observatory Cape Town, South Africa, 7925 E-mail: d@proﬂ ubbe.co.za

Important notes: Transorbital Approach to Sphenoid Medical knowledge is ever changing. As new research and clinical Wing Meningiomas experience broaden our knowledge, changes in treatment and therapy Darlene E. Lubbe1, Hamzah Mustak2, Kris S. Moe3 may be required. The authors and editors of the material herein have 1 consulted sources believed to be reliable in their efforts to provide | Associate Professor, FCORL(SA) information that is complete and in accord with the standards Division of Otolaryngology, University of Cape Town, accept ed at the time of publication. However, in view of the possibili ty South Africa of human error by the authors, editors, or publisher, or changes 2 in medical knowledge, neither the authors, editors, publisher, nor | Doctor, Consultant, FCOphth(SA) any other party who has been involved in the preparation of this Division of Ophthalmology, University of Cape Town, booklet, warrants that the information contained herein is in every South Africa respect accurate or complete, and they are not responsible for 3 any errors or omissions or for the results obtained from use of | Professor, Departments of Otolaryngology, such information. The information contained within this booklet is Head and Neck Surgery, and Neurological Surgery intended for use by doctors and other health care professionals. This Chief of Division of Facial Plastic and Reconstructive material is not intended for use as a basis for treatment decisions, Surgery, University of Washington, Seattle, WA, USA and is not a substitute for professional consultation and/or use of peer-reviewed medical literature. All rights reserved. Some of the product names, patents, and registered designs 1st edition 2017 referred to in this booklet are in fact registered trademarks or © 2017 ® GmbH proprietary names even though speciﬁ c reference to this fact is P.O. Box, 78503 Tuttlingen, Germany not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a Phone: +49 (0) 74 61/1 45 90 representation by the publisher that it is in the public domain. Fax: +49 (0) 74 61/708-529 E-mail: [email protected] The use of this booklet as well as any implementation of the information contained within explicitly takes place at the reader’s No part of this publication may be translated, reprinted own risk. No liability shall be accepted and no guarantee is given or reproduced, transmitted in any form or by any means, for the work neither from the publisher or the editor nor from the electronic or mechanical, now known or hereafter invented, author or any other party who has been involved in the preparation including photocopying and recording, or utilized in any of this work. This particularly applies to the content, the timeliness, the correctness, the completeness as well as to the quality. information storage or retrieval system without the prior Printing errors and omissions cannot be completely excluded. The written permission of the copyright holder. publisher as well as the author or other copyright holders of this work disclaim any liability, particularly for any damages arising out Editions in languages other than English and German are of or associated with the use of the medical procedures mentioned in preparation. For up-to-date information, please contact within this booklet. ® GmbH at the address shown above.

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Table of Contents

1 Introduction ...... 7

2 Transorbital Management of Sphenoid Wing Meningiomas ...... 8 2.1. Background ...... 8 2.2. Traditional Approaches ...... 8 2.3. Reasoning Behind Minimally Invasive Approach ...... 8 2.4. Regional Anatomy ...... 9 2.4.1. Optic Canal ...... 9 2.4.2. Medial Canthus ...... 10 2.4.3. Lateral Canthus ...... 10 2.4.4. Lateral Orbital Wall ...... 11

3 Sphenoid Wing Meningioma Surgery – A Four-Step Endoscopic Transorbital Approach ...... 12 3.1.1. Step 1 ...... 12 3.1.2. Step 2 ...... 14 3.1.3. Step 3 ...... 17 3.1.4. Step 4 ...... 17

4 Postoperative Care ...... 18

5 Results ...... 18

6 Complications ...... 18

7 Conclusions ...... 19

8 Clinical Cases ...... 20

9 References ...... 21 6 Transorbital Approach to Sphenoid Wing Meningiomas 7 1 Introduction

Combined open and endoscopic techniques have medial decompression is performed from the optic successfully been utilized to treat lesions outside protuberance for a distance of at least 1cm along the the reach of the traditional transnasal endoscopic optic canal. We feel that by fi rst performing an optic nerve pathway. Using the transorbital approach and utilizing decompression there is less risk of pressure on the optic the four surgical pathways described by surgeons at nerve during removal of the lateral and superior orbital the University of Washington, certain tumors involving hyperostotic bone. The main symptoms of patients the orbit, sinonasal cavity, anterior and middle cranial with sphenoid wing meningiomas are proptosis, visual fossae can be addressed with minimal morbidity. In loss and orbital pain. Our approach addresses these 3 our experience, better surgical access is obtained, problems with the lateral orbital pathway giving wide visualization is superior and success rates with regards surgical access for removal of the intracranial and orbital to visual outcomes are improved, especially in patients components of the tumor. with hyperostotic sphenoid wing meningiomas with optic nerve compression. The following endoscopic procedures will be demon- strated in this booklet: Sphenoid wing meningiomas are notoriously diffi cult tumors to manage due to their location and proximity Transorbital management of sphenoid wing to vital structures – the optic nerve, superior orbital meningiomas. fi ssure, internal carotid artery and cavernous sinus. The Endoscopic transnasal medial optic nerve gold standard approach for the majority of tumors is the decompression. pterional approach or craniotomy with resultant extensive Endoscopic precaruncular optic nerve tissue dissection. Patients often have severe morbidity decompression. – pain and discomfort – with residual proptosis, visual – Lateral transorbital approach. defi cits and pain post surgery. We describe a technique – Removal of hyperostotic bone. whereby the optic nerve is fi rst decompressed through an endonasal or precaruncular approach. A 180-degree – Removal of intracranial component. 8 Transorbital Approach to Sphenoid Wing Meningiomas 2 Transorbital Management of Sphenoid Wing Meningiomas

2.1. Background Sphenoorbital meningiomas are complex tumors involvement varying degrees of ophthalmoplegia that arise in the dura of the sphenoid wing. They may arise owing to compression of cranial nerves are characterized by hyperostosis of the sphenoid (III, IV, V1, VI) entering the orbit. Surgical treatment of bone. The primary tumor enters the orbit through sphenoorbital meningiomas may be associated with the optic canal or superior orbital fi ssure. The most signifi cant morbidity due to the location of the tumor, common clinical manifestations of sphenoorbital and complete surgical resection is often not feasible meningiomas are proptosis and visual loss due to because of the risk of new or worsening neurological progressive invasion of the orbit and compression of defi cits. the optic nerve. In cases of superior orbital fi ssure

2.2. Traditional Approaches The gold standard surgical approach to resect post surgery, between 14–24% of patients have sphenoorbital meningiomas includes the pterional unpredictable deterioration. Studies report up to approach or variations thereof, and lateral orbitotomy. 20% incidence of new cranial nerve de ﬁ cits (mostly Surgery is aimed at preserving residual visual function CN III palsy), especially for medial-third sphenoid and although there are reports of vision improving wing meningiomas.3

2.3. Reasoning Behind Minimally Invasive Approach The combined endoscopic transnasal and lateral of sphenoid wing meningioma surgery and the transorbital approach is aimed at preserving/ technique described here seems to minimize the risk improving residual visual function, resolving the of this dreaded complication. Patients with residual proptosis, improving pain, removing the intracranial visual function often have a dramatic improvement and where possible, the orbital components of the in their vision within 2 weeks of surgery. Using the tumor after resection of the hyperostotic bone. The technique described here, none of our patients technique described here is an endoscopic assisted, had worsening vision post surgery. The most likely minimally invasive approach that provides a wide reason for visual preservation/improvement is the surgical pathway to the intracranial component fact that the optic nerve is decompressed prior to of the tumor. The more lateral hyperostotic bone tumor resection, minimizing the risk of pressure on present, the wider the lateral surgical pathway. Visual the optic nerve during dissection. loss post surgery is the most feared complication Transorbital Approach to Sphenoid Wing Meningiomas 9

2.4. Regional Anatomy

2.4.1. Optic Canal The optic canal is an approximately 10-mm bony corridor, the entrance of which is located in the superomedial orbital apex (optic foramen). The optic nerve, ophthalmic artery and accompanying PEA sympathetic plexus course through this canal as they pass into the orbit from the intracranial space.

The walls are formed by the bone of the sphenoid Annulus of Zinn (medially) and its lesser wing (laterally). A ﬁ brous ring, the annulus of Zinn, is attached to the upper, medial and lower aspects of the optic foramen and forms the attachment point for the origin of the rectus OCR muscles. The optic canal courses posteromedially – ICA its medial wall projecting into the upper lateral wall of the sphenoid sinus (Figs. 2.1, 2.2a–c).

The internal carotid artery passes through the lateral wall of the sphenoid sinus en route to the cavernous Fig.|2.1 A Right optic nerve ( ) endonasally visualized. Optic sinus. The junction between the carotid prominence protuberance ( ); Annulus of Zinn ( ); Posterior ethmoidal and the ﬂ oor of the optic canal forms the lateral artery (PEA); Opticocarotid recess (OCR); Internal carotid artery (ICA). opticocarotid recess, which is found approximately 10 mm from the optic protuberance (Fig. 2.1). Great carotid just above the cavernous sinus. It enters the care must be taken when drilling over the bony canal optic nerve sheath inferomedially and runs below the to avoid carotid artery injury. The lateral opticocarotid optic nerve, within the optic canal. There is some recess is the landmark for the posterior limit of the anatomical variation in the position of the ophthalmic optic canal decompression. The ophthalmic artery artery within the canal but it tends to lie most branches from the medial aspect of the internal commonly in the inferomedial segment.

a b c Fig.|2.2 Superior view of internal surface of skull base (a). Axial CT scan (b). Osteological specimen (c). Optic canal formed by lesser wing of sphenoid ( ) and sphenoid sinus ( ), superior orbital ﬁ ssure ( ). 10 Transorbital Approach to Sphenoid Wing Meningiomas

a b Fig.|2.3 The caruncle of the right eye and the precaruncular approach in a cadaver (a) and in a patient (b).

2.4.2. Medial Canthus The medial canthus forms the medial border of the intubated in order to avoid injury to the canalicular system. palpebral ﬁ ssure. The surface anatomy includes a The incision is then extended superiorly and inferiorly into triangular soft tissue density known as the caruncle the conjunctiva. Blunt-tipped dissection scissors are then that is bordered laterally by the crescent-shaped plica used to dissect a plane directed at the medial orbital wall semilunaris. The lacrimal puncta are located in the medial just behind the posterior lacrimal crest in order to avoid upper and lower lids. The tarsal plates of the upper and injury to the medial palpebral ligament. The periosteum lower lids are attached to the medial bony orbit by the is then incised and elevated with a Freer elevator and a medial palpebral ligament, which comprises an anterior subperiosteal dissection is carried out. The anterior eth- limb (attaches to the anterior lacrimal crest), a posterior moidal artery is identiﬁ ed and cauterized or ligated and limb and a superior limb. The precaruncular approach dissection carried out posteriorly to expose the posterior involves an incision at the border between the skin and ethmoidal artery followed by the optic protuberance and caruncle (Fig. 2.3). The upper and lower canaliculi can be the optic canal.

2.4.3. Lateral Canthus The lateral canthal tendons are lateral condensations lid margin and is formed by attachment of the levator to of the upper and lower tarsi that attach to a bony the tarsus and overlying skin. A skin incision is made in promontory on the zygomatic bone known as Whitnall’s the upper lid crease and extended to the lateral canthal tubercle. A lateral canthotomy involves incising the skin area, into the natural crease lines above the lateral canthal over the lateral canthal area starting in the canthal angle angle, and over the lateral rim (Figs. 3.7a–c). The skin edges and extending over the orbital rim. Blunt dissection is are then elevated under tension and an incision is made then carried out through the underlying orbicularis down through the underlying orbicularis into the pre-aponeurotic to the orbital rim. An incision is made in the periosteum space. This suborbicularis pocket is then extended with overlying the lateral rim and subperiosteal dissection blunt dissection up to the superior orbital rim. Care must carried out medially over the rim to expose Whitnall’s be taken not to breach the orbital septum and cause tubercle. The canthal tendon can then be divided to allow herniation of orbital fat. The periosteum of the superior adequate space for a subperiosteal dissection before the orbital rim is exposed and incised approximately 10 mm bony orbitotomy is performed. above the arcus marginalis. A subperiosteal dissection is then carried out inferiorly past the rim and extended An alternate incision that affords wider access and is posteriorly. Careful dissection should be carried out better served for tumors extending to the superior orbit, is medially to avoid injury to the supra-orbital neurovascular the extended upper lid skin crease incision. The upper lid bundle. crease is found approximately 8–10 mm above the upper Transorbital Approach to Sphenoid Wing Meningiomas 11

2.4.4. Lateral Orbital Wall The lateral wall of the orbit is formed mainly by the greater The superior orbital fi ssure is a linear notch at the orbital wing of the sphenoid with contributions from the zygoma apex between the greater and lesser wings of the and zygomatic process of frontal bone anteriorly (Fig. 2.4). sphenoid. The superior portion of the fi ssure is narrower The recurrent meningeal branch of the middle meningeal and here the lacrimal, frontal and trochlear nerves pass artery may be seen coursing through a foramen in the through outside the annulus of Zinn (Fig. 2.5b). The suture line between the frontal and sphenoid bones oculomotor, abducens and nasociliary branch of the (Figs. 2.4, 2.5a). This artery forms an anastomosis between trigeminal nerve and the superior ophthalmic vein pass the external and internal carotid arterial systems. through the superior orbital fi ssure within the annulus of Zinn (Fig. 2.5c). Too much traction on the orbit during The contributions of the zygomatic and frontal bones to retraction of the orbital contents medially may lead to a the anterolateral wall are thick and serve to protect the superior orbital fi ssure syndrome with resultant CN III, IV, globe from lateral trauma. The posterior zygomatic bone V1 and VI palsies. Great care must be taken to avoid this and the orbital plate of the greater wing of sphenoid are complication by releasing pressure on the orbit every few thinner. The zygomatico-facial and zygomatico-temporal minutes during removal of the lateral hyperostotic bone, nerves and vessels pass through the lateral wall of the by observing the pupil for any change in size or shape orbit to reach the cheek and temporal regions. Posteriorly and by asking the anesthetist to inform the surgical team the lateral wall thickens and meets the temporal bone in the event the patient develops a sudden bradycardia that forms the lateral wall of the cranium. due to pressure on the ocular muscles or nerves.

Optic foramen Greater wing SOF of sphenoid Tumor bone through SOF IOF

Lateral rectus muscle

Fig.|2.4 Lateral orbital wall (left eye). Superior Fig.|2.6 Left lateral surgical pathway showing orbital fi ssure (SOF); inferior orbital fi ssure (IOF); tumor entering the orbit through the superior greater wing of sphenoid bone ( ); orbital fi ssure (SOF). zygomatic bone ( ); foramen for recurrent meningeal branch of the middle meningeal artery ( ).

Fig.|2.5a Recurrent meningeal branch of the Fig.|2.5b Left eye lateral pathway showing Fig.|2.5c Left eye lateral pathway showing the middle meningeal artery passing through the superior orbital fi ssure ( ) and the superior orbital fi ssure ( ) with superior foramen in left lateral orbital wall (in suture line optic nerve ( ) at the orbital apex. ophthalmic vein, CNs III, IV, V1 and VI exiting between frontal and sphenoid bones). foramen. The recurrent meningeal branch of the middle meningeal artery may be seen coursing through a foramen in the suture line ( ) just anterior to the superior orbital fi ssure. 12 Transorbital Approach to Sphenoid Wing Meningiomas Sphenoid Wing Meningioma Surgery – 3 A Four-Step Endoscopic Transorbital Approach

The order in which surgical steps are performed is with the 3rd step or intracranial resection, similar to the thought to be of importance. The procedure consists 4-handed approach used in endoscopic transsphenoidal of 4 surgical steps, most of which are performed by pituitary surgery. Without special orbital retractors, 5 the otolaryngologist. An ophthalmologist can assist or hands are often required to retract the orbit and maintain perform part of the procedure and a neurosurgeon assists visualization during drilling of the surgical pathway.

3.1.1. Step 1 I. Endoscopic Transnasal Medial Optic Nerve Decompression A medial optic nerve decompression prevents compres- The spheno-ethmoidectomy is completed and the sion on the optic nerve during the lateral transorbital lamina papyracea is exposed in its posterior third. approach. Most patients present with visual loss and a It is important to remove the face of the sphenoid medial optic nerve decompression has in the authors’ so that the lateral wall of the sphenoid sinus, the experience resulted in improved visual outcome. Two inferomedial recess and optic nerve can be visualised pathways are available (transnasal and precaruncular) to ensure complete decompression of the optic nerve and the choice of procedure depends on the availability in its canal. Navigation is helpful to ensure complete and skills of the otolaryngologist and ophthalmologist. decompression of the optic canal, especially where meningioma invades the sphenoid sinus (Figs. 3.1–3.4). Endoscopic Transnasal Medial Optic The optic protuberance can be identifi ed by the hard Nerve Decompression bone reached when the posterior third of the lamina A standard sphenoethmoidectomy is performed and papyracea has been removed (Fig. 2.2). An endonasal the posterior 1/3 of the lamina papyracea is removed. drill with a 2 or 3-mm diamond burr is required to To assist with multiple instruments working at the gently thin the bone overlying the optic canal. Great target point (the optic nerve), a posterior septectomy care must be taken to ensure the optic nerve is not can be performed, similar to transsphenoidal pituitary traumatized. This is achieved by continuous irrigation surgery. This allows 2 surgeons and 4 hands to work on the optic canal and by achieving good hemostasis. together. The otolaryngologist uses the endoscope Once the bone overlying the optic nerve is suffi ciently and endonasal drill through one nostril, while the thinned, an elevator or small dissector can be used to assistant provides a clear endoscopic view with remove the overlying bone by gently fl icking the bone irrigation and suction through the other nostril. away from the optic nerve (Fig. 3.3). The optic canal is decompressed from the optic protuberance for a The patient is placed in a supine position with the head distance of approximately 10 mm; the opticocarotid slightly fl exed as for standard FESS surgery. Total recess (OCR) forms the posterior margin of the intravenous anesthesia (TIVA) is used to optimize the decompression. A 180°-medial decompression of the surgical fi eld. Although an otolaryngologist performs optic canal is performed, taking care not to injure the the procedure, it is helpful to have the input from an ophthalmic artery which most commonly lies inferior to ophthalmologist during the optic nerve decompression the optic nerve. The artery can however lie in a more to determine the length of canal decompression required. medial position and great care must be taken when The nasal cavity is prepared as for a standard FESS removing the bone over the canal. procedure with 2 ml of topical adrenaline or decongestant A medial orbital decompression may also be required on surgical patties, placed within the middle meatus. for patients with severe proptosis. The periorbital fascia is only incised at the end of the procedure since The technique involves a standard endoscopic allowing fat to prolapse into the nasal cavity will make sphenoethmoidectomy, removal of the posterior 1/3 further decompression of the optic nerve impossible of the lamina papyracea and a 180 degree medial and future surgery diffi cult. decompression of the optic nerve in its canal from the optic protuberance for a distance of approximately 10 mm (Fig. 2.2). Navigation is helpful but by no means essential. A microdebrider or standard FESS instruments can be used to perform the sphenoethmoidectomy. A 0°-HOPKINS® endoscope (diameter 3 mm or 4 mm) and endonasal drill with diamond burrs (size 2 to 4), are used to decompress the canal. Transorbital Approach to Sphenoid Wing Meningiomas 13

Periorbita of right eye

Optic nerve canal

Optic nerve protuberance

Fig.|3.1 Right sphenoethmoidectomy completed with the maxillary sinus Fig.|3.2 Right eye. Decompression of the optic nerve from the optic and sphenoid sinus visualized. The posterior 1/3 of the lamina papyracea protuberance, along the optic canal for 10 mm. has been removed.

Optic canal Right eye lamina papyracea removed OCR

Fig.|3.3 Right eye. Optic canal is decompressed from the optic Fig.|3.4 Navigation is useful to ensure adequate optic canal protuberance for 10 mm along the optic canal using a small dissector. decompression. The navigation cross-hair is seen on the medial Note the opticocarotid recess (OCR). aspect of the optic nerve.

II. Endoscopic Precaruncular Medial Optic Nerve Decompression The precaruncular approach is used to remove the utilized as an extra corridor for another 2 instruments lamina papyracea and perform a 180-degree medial (Fig. 3.5c). This obviates the need for a posterior decompression of the optic canal (Figs. 3.5a, b) Wide septectomy and the endoscope gets less blood on the access is achieved with a slightly different angulation to lens, making visualization easier. If a posterior septectomy the optic nerve than with the transnasal route. The nostril is performed, 5–6 instruments can be used at the target on the same side as the precaruncular incision can be point.

a b c Fig.|3.5 Precaruncular approach to the right optic nerve (a, b) and multiportal approach (c) utilizing the right precaruncular and right nasal pathways. 14 Transorbital Approach to Sphenoid Wing Meningiomas

3.1.2. Step 2 The Lateral Transorbital Approach to Sphenoid Wing Meningiomas This is a novel approach to address the hyperostotic The periosteum is elevated, fi rstly off the lateral orbital lateral orbital wall, superior orbital fi ssure, intracranial rim to expose at least 2 cm of the outer lateral orbital and orbital components of the meningioma. This rim. Elevating the periosteum and the temporalis surgery requires two assistants in the absence of special muscle allows for an extra porthole to be made in the orbital retractors. With the use of an orbital retractor, lateral orbital wall for instrumentation (Fig. 3.10). two-surgeon surgery is possible. An ENT-Ophthalmology The periosteum is then stripped off the medial aspect team is involved in removing the lateral orbital wall and of the lateral orbital wall using a Freer elevator. hyperostotic bone involving the orbit and greater wing of Ribbon retractors are used to protect the orbit, retract the sphenoid. The surgery can be performed by either the eye medially in order to expose the lateral orbital an otorhinolaryngologist or ophthalmologist trained in surgical corridor and to ensure a safe corridor for endoscopy. Detailed knowledge of the anatomy of the instrumentation and the endonasal drill (Fig. 3.10). orbit is essential before embarking on the surgery. A burr hole or porthole can be drilled just behind the Three incisions are possible depending on the amount orbital rim (keeping the orbital rim intact for cosmetic of space needed for dissection: purposes) if an extra instrument is required in a narrow corridor. A 6–7mm burr hole gives suffi cient extra space – Retrocanthal incision – useful for biopsies of the to manipulate a suction device during the dissection of lateral orbit (Fig. 3.6a, b). the hyperostotic lateral orbital bone (Figs. 3.8–3.11). – Lateral canthotomy – gives adequate space, espe- Incisions for the Lateral Orbital Approach cially if no superior wall involvement (Fig. 3.8). Retrocanthal incision (no external incision) – useful for – Superior eyelid incision with extension lateral to biopsy (Figs. 3.6a, b). the lateral canthus (Figs. 3.7a, b) (sparing the lateral canthus). This is our standard approach since it Lateral eyelid crease with lateral extension (preserving provides the best access to the superior and lateral the lateral canthus) (Figs. 3.7a–b). orbital walls. Lateral canthotomy approach (Fig. 3.8). A 0°-endoscope (length 18 cm, diameter 3 mm or 4 mm) The lateral canthus of the eye is injected with a 2% is used to help manipulate two to three instruments lidocaine and 1:80 000 adrenaline mixture. through the lateral orbital surgical pathway. A 3 mm An 8-mm lateral canthal incision is made (Fig. 3.8). endoscope allows for more working room within the Blunt dissection with an iris scissors is used to dissect surgical pathway. A Freer dissector is used to develop through the orbicularis oculi muscle onto the orbital rim, a subperiosteal plane in order to lateralize the orbital dividing the upper and lower canthal ligaments (Fig. 3.9). contents (Fig. 3.11).

a b Fig.|3.6 Retrocanthal incision (no external incision); left eye. Transorbital Approach to Sphenoid Wing Meningiomas 15

a b c Fig.|3.7 Superior eyelid incision with extension laterally (a). Superior eyelid crease incision, preserving the lateral canthus (b). Suture through superior eyelid to protect cornea (c).

Fig.|3.8 Right eye. Lateral canthotomy. Fig.|3.9 An iris scissors is used to dissect through the orbicularis muscle onto the orbital rim.

Fig.|3.10 A burr hole is made through the lateral orbital wall, keeping the Fig.|3.11 Subperiosteal dissection with retraction of the right eye orbital rim intact and allowing for extra instrumentation. medially to expose the hyperostotic bone of the lateral orbital wall (Freer suction tip on hyperostotic bone). 16 Transorbital Approach to Sphenoid Wing Meningiomas

Adequate space needs to be created early in the All hyperostotic bone and intraosseous meningioma is dissection to allow for instrument manipulation. This is drilled away, to expose the temporalis muscle antero- achieved by drilling away the lateral orbital wall until the laterally, the dura of the temporal lobe posterolaterally, temporalis muscle is visualized (Fig. 3.12). the anterior cranial fossa superiorly and the periorbita Passage through the surgical pathway is easily accom- medially (Fig. 3.14). plished by using 4- and 5-mm cutting and diamond The superior orbital fi ssure can be identifi ed if the burrs that are attached to a medium and extra-long dissection is carried far enough posteriorly (Figs. 2.5b, c). angled hand piece (KARL STORZ Tuttlingen, Germany). Care should be taken near the superior orbital fi ssure Great care must be taken to ensure that orbital fat and (SOF) and excessive manipulation in this area should temporalis muscle do not get caught up in the shaft of be avoided. Excessive retraction on the orbit medially the burrs during drilling. should also be avoided to prevent a superior orbital Once the cancellous portion of the greater wing of the fi ssure syndrome or damage to cranial nerves III, IV, V1 sphenoid is reached, a bony tunnel is drilled, with a thin and VI. wall of bone on either side, protecting the temporalis The last phase of the surgery involves removing the muscle laterally and the periorbita medially (Fig. 3.13). intracranial and intraorbital components of the tumor.

Bony tunnel

Temporalis Right eye muscle Periorbita of the right retracted eye under retractor medially

Fig.|3.12 Temporalis muscle is exposed ( ) by drilling away the Fig.|3.13 Right eye. Lateral orbital corridor with bony tunnel drilled lateral orbital wall, keeping the orbital rim intact. The suction cannula can between the temporalis muscle and the periorbita of the eye. be visualized though the lateral burr hole.

Anterior cranial fossa dura

Intracranial tumor

Temporalis muscle

Fig.|3.14 Right eye. View of the lateral orbital pathway. Note the temporalis muscle laterally, periorbita medially (under retractor), dura superiorly, and the site of the intracranial tumor. Transorbital Approach to Sphenoid Wing Meningiomas 17

3.1.3. Step 3 Intracranial Tumor Resection It is important to have a neurosurgeon perform/assist with this part of the procedure. The dissection is similar to the standard pterional approach with the neurosurgeon dissecting tumor off the important neurovascular structures. The neurosurgeon uses both hands for dissection while the assistant manipulates the camera. Complete resection depends on tumor encasement of vital structures – the internal carotid artery, the middle cerebral artery (Fig. 3.15), cavernous sinus involvement and tumor spread through the superior orbital ﬁ ssure and optic canal. Complete resection is often not possible and may lead to cranial nerve deﬁ cits and increased morbidity. Tumor debulking in this area is often performed with radiotherapy as a post-operative treatment option. Fig.|3.15 Middle cerebral artery ( ) visible after intracranial tumor The dural defect and CSF leak is repaired using resection. abdominal fat.

3.1.4. Step 4 Orbital Tumor Resection Sphenoid wing meningiomas enter the orbit through the superior orbital ﬁ ssure (Fig. 3.16) or optic canal. Resection of this component depends on the patient’s symptoms (visual loss, proptosis and cranial nerve involvement). With the assistance of an ophthalmologist the periorbita is incised laterally and the tumor is carefully dissected / debulked. Care is taken to identify the lateral rectus muscle to prevent injury. In certain instances where the proptosis has been adequately addressed, no obvious intra-orbital meningioma is visible and the patient has no pre-operative cranial nerve III, IV, V1 and VI deﬁ cits, the periorbita may only be incised without exploring the orbit. Fig.|3.16 Left lateral orbital pathway with intra-orbital tumor beneath the intact periorbita ( ). 18 Transorbital Approach to Sphenoid Wing Meningiomas 4 Postoperative Care

Intraoperatively, all patients receive prophylactic anti- An ice pack is placed over the operated eye and the biotics (1 g IVI cefazolin) and a dose of systemic patient is encouraged to ice the eye on a regular basis for corticosteroids (betamethazone or dexamethazone, 8 mg at least one week. The head of the bed is slightly elevated IVI, depending on their weight, age and co-morbid and the patient is asked to not sleep on the side of the factors). surgery. Observations include the following: The precaruncular wound requires no suturing. A Neurological observations (GCS) for 24 hours. corrugated drain is inserted in the lateral orbital pathway Observe for a cerebrospinal ﬂ uid leak. to prevent a post-operative hematoma. Polyglactin 5/0 is Check eye movements (function of cranial nerves III, used to approximate the periosteum in the lateral incision IV, V1, VI), for a RAPD (relative afferent pupillary defect) and the skin (with the orbicularis muscle) is closed with and gross visual assessment to make sure the vision Nylon 6/0. If a CSF-leak was created during the resection has not deteriorated. of the intracranial component, this is ﬁ rst repaired with abdominal fat and / or fascia lata.

5 Results 6 Complications

The results of resection of our fi rst seven sphenoid wing Although no complications were experienced with the meniongiomas were published in Clinical Otolaryngology precaruncular approach in our series, care must be in August 2016.1 Table 5.1 shows the results of the fi rst taken to prevent the following: 12 patients who received a medial optic nerve decom- A CSF leak will occur if dissection is carried above the pression, followed by a lateral orbitotomy. All patients level of the anterior and posterior ethmoidal arteries had a long history of visual loss and / or proptosis. Only during optic nerve decompression. one patient had no improvement in her vision. With the development of new instrumentation and confi dence Bleeding from the anterior or posterior ethmoidal with the procedure, total resection of some sphenoid arteries with potential retraction of the arteries within wing meningiomas is possible. the intraconal space. Dissection is aimed at fi nding the arteries so this would be an unusual complication. Pre-Operative Post-Operative Trauma to the lacrimal system may occur if due care is Case No. not taken to identify the position of the canaliculi. When VA VA gaining experience with this approach, the surgeon can 1 NLP NLP place lacrimal probes during the dissection to protect 2 6/18 6/6 the canaliculi from damage. 3 6/36 6/18 The optic nerve is vulnerable during the drilling phase 4 6/24 6/12 of the optic nerve decompression. It is important to 5 6/36 6/36 drill carefully along the optic canal using cold water 6 6/6 6/6 irrigation and to skeletonize the bone over the canal, removing the last bit of bone with a Cottle elevator 7 HM 6/9 rather than with a drill. 8 CF 6/12 9 6/18 6/18 10 NLP CF 11 CF 6/24 12 HM 6/36 Table 5.1 Key to acronyms: Counting fi ngers at 1 cm (CF); no light perception (NLP); hand movements (HM); visual acuity (VA). Transorbital Approach to Sphenoid Wing Meningiomas 19

Complications that may occur during drilling of the lateral pathway Herniation of fat hinders use of a drill and makes further radiotherapy and a craniotomy for removal of the dissection very diffi cult. The greatest risk during this intracranial part of the tumor. An intraoperative warning part of the procedure is causing damage to the orbit and sign is the development of a bradycardia that recovers temporalis muscle by the shaft of the drill. It is therefore immediately on releasing the ribbon retractor. essential to have only a few millimeters of drill shaft exposed and this part of the drill must be kept in direct Sudden changes in the shape and size of the pupil is view at all times. Using an ultrasonic bone dissector a warning sign of raised intra-ocular pressure, central can prevent any injuries caused by a drill shaft and it retinal artery occlusion or traction on the nerves that has the benefi t of a multifunctional instrument that can regulate pupil size. The pupil should be inspected every be used simultaneously for bone removal, suction and few minutes and retractors removed until the pupil has irrigation. returned to its normal size and shape. Too much medial traction on the eye can cause If the intracranial part of the tumor is resected, a large contusion of the lateral rectus muscle, and lead to a CSF leak will require repair using fat. An inadvertent superior orbital fi ssure syndrome with CN III, IV, V1 and CSF-leak can occur with thinning of the bone VI nerve palsies. In our series we had one patient who overlying the roof of the orbit (anterior cranial fossa) sustained a temporary V1 neuropraxia and one patient or posterolateral orbit (middle fossa CSF leak). This who developed a superior orbital fi ssure syndrome can be avoided using only diamond drill burrs and with temporary neuropraxia that resolved completely ‘egg-shelling’ the bone overlying the dura in these after 3 months. The patient had recently undergone areas.

7 Conclusions

The transorbital approach to sphenoid wing meningio- All bony hyperostotic bone can be removed from the mas provides an excellent minimally invasive alternative lateral orbital wall – up to temporalis muscle and the to the traditional pterional / craniotomy approaches. dura of the anterior and middle cranial fossa. The advantage of performing an endoscopic medial The more hyperostotic bone present, the wider the 180-degree medial optic nerve decompression prior surgical pathway required and the wider the neuro- to addressing the main tumor bulk seems to be an surgical access to the intracranial portion of the tumor. improvement in visual outcomes. Further studies will A surgical team consisting of an ophthalmologist and be required to ascertain whether performing an endo- otolaryngologist can address most of the sphenoid scopic optic nerve decompression prior to a traditional wing meningioma with a neurosurgeon-ENT team approach to the main tumor bulk, may improve visual performing the ﬁ nal stage of the procedure. outcome. The main patient symptoms, visual loss and proptosis, can be adequately addressed through this minimally invasive approach. 20 Transorbital Approach to Sphenoid Wing Meningiomas 8 Clinical Cases

All cases to date of publication (17) have been women. All Surgical approach: An endonasal, 180-degree left except one had an improvement in vision. medial optic nerve decompression was performed and was followed by resection of the lateral hyperostotic The patient below is a 62 year old female patient and bone and orbital component of the tumor (Fig 8.4). The her history, presentation, treatment and post-operative lateral pathway was accessed through an extended results were similar to all the other patients. superior eyelid incision (sparing the lateral canthus) (Fig 8.2). Navigation was used to ensure maximal optic Medical History: The patient presented with progressive canal decompression and removal of hyperostotic bone visual loss in her left eye over a period of one year. She (Fig 8.3). could only count ﬁ ngers at 1 meter at the time of surgery. Her proptosis measured 25 mm pre-operatively (21 mm Results: Ophthalmology assessment at 6 weeks showed on the right). that the proptosis had improved to 22.5 mm (from 25 mm) and visual acuity improved to 20/40 (from Imaging revealed a large left-sided sphenoid wing counting ﬁ ngers) in the affected left eye. She still had a meningioma with compression of the optic nerve, a grade 2 RAPD on the left, as before, and the disc was lateral bony hyperostotic component and intra-orbital still pale, as expected. She had full ocular motility and no component (Figs. 8.1, 8.3). diplopia.

Fig.|8.1 Large left sphenoid wing meningioma with compression of the Fig.|8.2 Lateral orbital incision extending from superior eyelid crease, optic nerve (navigation cross hairs). sparing the lateral canthus.

Fig.|8.3 Navigation cross hairs at posterolateral aspect of lateral surgical Fig.|8.4 Lateral surgical pathway with ribbon retractor retracting the pathway, nearing the superior orbital ﬁ ssure. orbit medially. Transorbital Approach to Sphenoid Wing Meningiomas 21

a b

c d Fig.|8.5 Preoperative (a, b) and postoperative views (c, d) (taken at 3 week follow-up).

9 References

1. LUBBE D, MUSTAK H, TAYLOR A, FAGAN 3. SUGHRUE ME, RUTKOWSKI MJ, CHEN CJ, J. Minimally invasive endo-orbital approach SHANGARI G, KANE AJ, PARSA AT et al. Modern to sphenoid wing meningiomas improves surgical outcomes following surgery for sphenoid visual outcomes - our experience with the ﬁ rst wing meningiomas. J Neurosurg 2013;119(1):86–93. seven cases. Clin Otolaryngol 2016. doi:10.1111/ doi:10.3171/2012.12.JNS11539. coa.12722. 2. MOE KS, BERGERON CM, ELLENBOGEN RG. Transorbital neuroendoscopic surgery. Neurosurgery 2010;67(3 Suppl Operative):ons16-28. doi:10.1227/01.NEU.0000373431.08464.43. 22 Transorbital Approach to Sphenoid Wing Meningiomas

Surgical Handle, Blades, Tissue Forceps and Spatulas

208120 208211 208215

208000 533312 635012– 635112– 635025 635122

208000 Surgical Handle, Fig. 3, length 12.5 cm, 635012 Spatula, malleable, width 12 mm, for Blades 208010 – 15, 208210 – 15 length 20 cm 635017 Same, width 17 mm 208120 Blade, for Handle 208100, Fig. 20, non-sterile, package of 100 635025 Same, width 25 mm

208211 Blade, Fig. 11, sterile, package of 100 635112 Orbital Spatula, with double graduation, width 12 mm, length 20 cm 208215 Same, Fig. 15 635117 Same, width 17 mm 533312 ADSON Tissue Forceps, serrated, 1 x 2 teeth, 635122 Same, width 22 mm length 12 cm

It is recommended to check the suitability of the product for the intended procedure prior to use. Transorbital Approach to Sphenoid Wing Meningiomas 23

Elevators, Retractor and Scissors

474000 479000 28164 DM 505600 791815

474000 FREER Elevator, double-ended, 505600 SENN Retractor, double-ended, blunt, semisharp and blunt, length 20 cm length 15 cm

479000 MASING Elevator, double-ended, graduated, 791815 REYNOLDS Scissors, curved, delicate tips, sharp and blunt, length 22.5 cm length 15 cm

28164 DM Elevator, sharp, straight tip, slightly curved spatula, with round handle, size 3 mm, length 23 cm 24 Transorbital Approach to Sphenoid Wing Meningiomas

UNIDRIVE® S III ENT SCB/UNIDRIVE® S III ECO The multifunctional unit for ENT

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

S III S III

® ®

Special Features: UNIDRIVE UNIDRIVE ENT SCB ECO Touch Screen: Straightforward function selection via touch screen O – Set values of the last session are stored OO Optimized user control due to touch screen O – Choice of user languages O – Operating elements are single and clear to read due to color display O – One unit – multifunctional: – Shaver system for surgery of the paranasal sinuses and anterior skull base – INTRA Drill Handpieces (40,000 rpm and 80,000 rpm) – Sinus Shaver OO – Micro Saw – Dermatome – High-Speed Handpieces (60,000 rpm and 100,000 rpm) O –

Two motor outputs: Two motor outputs enable simultaneous connection of two motors: OO For example, a shaver and micro motor

Soft start function O –

Textual error messages O –

Integrated irrigation and coolant pump: – Absolutely homogeneous, micro-processor controlled irrigation rate throughout OO the entire irrigation range – Quick and easy connection of the tubing set

Easy program selection via automated motor recognition OO Continuously adjustable revolution range OO Maximum number of revolutions and motor torque: Microprocessor-controlled motor rotation OO speed. Therefore the preselected parameters are maintained throughout the drilling procedure Maximum number of revolutions can be preset OO SCB model with connections to the KARL STORZ Communication Bus O – (KARL STORZ-SCB) Irrigator rod included O – Transorbital Approach to Sphenoid Wing Meningiomas 25

Motor Systems Speciﬁ cations

System speciﬁ cations

Mode Order No. rpm

Shaver mode oscillating Operation mode: in conjunction with Handpiece: Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 10,000* DRILLCUT-X® II N Shaver Handpiece 40 7120 55 10,000*

Sinus burr mode rotating Operation mode: in conjunction with Handpiece: Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 12,000 DRILLCUT-X® II N Shaver Handpiece 40 7120 55 12,000

High-speed drilling mode counterclockwise or clockwise Operation mode: in conjunction with: Max. rev. (rpm): High-Speed Micro Motor 20 7120 33 60,000/100,000

Drilling mode counterclockwise or clockwise Operation mode: in conjunction with: Max. rev. (rpm): micro motor 20 7110 33 40,000/80,000 and connecting cable [] 20 7111 73 Micro saw mode in conjunction with: Max. rev. (rpm): micro motor 20 7110 33 15,000/20,000 and connecting cable [] 20 7111 73 Dermatome mode in conjunction with: Max. rev. (rpm): micro motor 20 7110 33 8,000 and connecting cable []20 7111 73 Power supply: 100 – 240|VAC, 50/60|Hz

Dimensions: 300 x 165 x 265 mm (w x h x d)

Two outputs for parallel connection of two motors

Integrated irrigation pump: Flow: adjustable in 9 steps

* Approx. 4,000 rpm is recommended as this is the most efficient suction/performance ratio.

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

Touch Screen: 6.4" / 300 cd/m2

Weight: 5.2 kg 4.7 kg

Certified to: IEC 601-1 CE acc. to MDD IEC 60601-1

Available languages: English, French, German, numerical codes Spanish, Italian, Portuguese,| Greek, Turkish, Polish, Russian 26 Transorbital Approach to Sphenoid Wing Meningiomas

Motor Systems High-speed micro motor

Special Features of the high-speed micro motor: O Brushless high-speed micro motor Maximum torque 6 Ncm O Smallest possible dimensions Number of revolutions can be continuously O Autoclavable adjusted up to 60.000 rpm O Reprocessable in a cleaning machine Provided a suitable handle is used, the number of revolutions can be continuously adjusted up O Maximum torque 6 Ncm to 100,000 rpm

20 7120 33

20 7120 33 High-Speed Micro-Motor, max. speed 60,000 rpm, including connecting cable, for use with UNIDRIVE® S III ENT/NEURO

Optional Accessories for UNIDRIVE® S III ENT SCB and UNIDRIVE® S III ECO

280053 Universal Spray, 6x 500 ml bottles – HAZARDOUS GOODS – UN 1950 including: Spray Nozzle

280053 C Spray Nozzle, for the reprocessing of INTRA burr handpieces, for use with Universal Spray 280053 B

031131-10* Tubing Set, for irrigation, for single use, sterile, package of 10

* mtp medical technical promotion gmbh, take-off GewerbePark 46, 78579 Neuhausen ob Eck/Germany, Phone: +49 (0) 74 67 9 45 04-0, Fax: +49 (0) 74 67 9 45 04-99, E-Mail: [email protected], www.mtp-tut.com Transorbital Approach to Sphenoid Wing Meningiomas 27

UNIDRIVE® S III ENT SCB High-Speed Handpieces, malleable, slim, angled, 60,000 rpm

For use with High-Speed Drills, shaft diameter 1 mm 60,000 rpm and|with High-Speed Micro Motor 20 7120 33 diameter 4.7 mm

The handpieces have malleable shafts that can be bent up to 20° according to user requirements.

malleable

108 mm

4.7 mm 252671

128 mm

252672 4.7 mm

252671 High-Speed Handpiece, extra long, malleable, slim, angled, 60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33 252672 High-Speed Handpiece, super long, malleable, slim, angled, 60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33

High-Speed Diamond Burrs, 60,000 rpm, for single use , sterile, package of 5

Diameter in mm extra long super long

2 320220 EL 320220 SL

3 320230 EL 320230 SL

4 320240 EL 320240 SL

High-Speed Coarse Diamond Burrs, 60,000 rpm, for single use , sterile, package of 5

Diameter in mm extra long super long

2 320320 EL 320320 SL

3 320330 EL 320330 SL

4 320340 EL 320340 SL 28 Transorbital Approach to Sphenoid Wing Meningiomas

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO Recommended System Conﬁ guration

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

40 7016 20-1 40 7014 20

40 7016 01-1 UNIDRIVE® S III ENT SCB, motor control unit with color display, touch screen, two motor outputs, integrated irrigation pump and SCB module, power supply 100 – 240 VAC, 50/60 Hz including: Mains Cord Irrigator Rod Two-Pedal Footswitch, two-stage, with proportional function Clip Set, for use with silicone tubing set SCB Connecting Cable, length 100 cm Single Use Tubing Set*, sterile, package of 3

40 7014 01 UNIDRIVE® S III ECO, motor control unit with two motor outputs and integrated irrigation pump, power supply 100 – 240 VAC, 50/60 Hz including: Mains Cord Two-Pedal Footswitch, two-stage, with proportional function Clip Set, for use with silicone tubing set Single Use Tubing Set*, sterile, package of 3

Specifications: Touch Screen UNIDRIVE® S III ENT SCB: 6.4"/300 cd/m2 Dimensions w x h x d 300 x 165 x 265 mm Flow 9 steps Weight 5.2 kg Power supply 100 – 240 VAC, 50/60 Hz Certiﬁ ed to EC 601-1, CE acc. to MDD

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO System Components

Two-Pedal Footswitch Single Use Tubing Set

20 0166 30 031131-10

UNIT SIDE

PATIENT SIDE

High-Speed Micro-Motor High-Performance EC Micro Motor II DRILLCUT-X® II Shaver Handpiece, DRILLCUT-X® II N Shaver Handpiece, for|use with UNIDRIVE® S III optional adaptability to ECO/ENT/NEURO Shaver|Tracker, for use with UNIDRIVE®|S|III|ECO/ENT/NEURO

20 7110 33 20 7120 33 20 7111 73 40 7120 50 40 7120 55

High-Speed Handpiece INTRA Drill Handpiece Shaver Blade

41201KN 252660 – 252692 252575 – 252590 Shaver Blade, curved

41302KN

Sinus Burr

41305 DN 30 Transorbital Approach to Sphenoid Wing Meningiomas

DRILLCUT-X® Shaver Handpieces Special Features

II II

® ®

7120 55 Special Features: 7120 50 DRILLCUT-X DRILLCUT-X 40 N 40 Max. 10,000 rpm for shaver blades, max. 12,000 rpm for sinus shaver O O Straight suction channel OO Integrated irrigation channel O O Powerful motor, also suitable for harder materials O O Absolutely silent running, no vibration O O Completely immersible and machine-washable O O LOCK allows fixation of shaver blades and sinus shavers O O Extremely lightweight design O O Optional, ergonomic handle, detachable O O Can be adapted to navigation tracker – O

40 7120 50

40 7120 50 DRILLCUT-X® II Shaver Handpiece, for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 55

40 7120 55 DRILLCUT-X® II N Shaver Handpiece, optional adaptability to Shaver Tracker 40 8001 22, for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS Transorbital Approach to Sphenoid Wing Meningiomas 31

DRILLCUT-X® II Shaver Handpiece

Special Features: Powerful motor The versatile DRILLCUT-X® II Shaver Handpiece Absolutely silent running can be adapted to individual needs of the user Enhanced ergonomics Easy hygienic processing, suitable for use in washer and autoclavable at 134° C Lighweight design Quick coupling mechanism facilitates more Oscillation mode for shaver blades, rapid|exchange of work inserts max.|10,000|rpm Proven DRILLCUT-X® blade portfolios can be used Rotation mode for sinus shavers, max.|12,000|rpm Straight suction channel and integrated irrigation

40 7120 50

40 7120 50 DRILLCUT-X® II Shaver Handpiece, for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 90

40 7120 90 Handle, adjustable, for use with DRILLCUT-X® II 40 7120 50 and DRILLCUT-X® II N 40 7120 55

Optional Accessory:

41250 RA

41250 RA Cleaning Adaptor, LUER-Lock, for cleaning DRILLCUT-X® shaver handpieces 32 Transorbital Approach to Sphenoid Wing Meningiomas

Handle for DRILLCUT-X® II Shaver Handpiece for use with DRILLCUT-X® II 40 7120 50 and DRILLCUT-X® II N 40 7120 55

Special Features: Ergonomic design The adjustable handle can be mounted to ® Ultralight construction DRILLCUT-X II or -X II N Shaver Handpiece Easy handle control allows individual adjustment Easy ﬁ xation via rotary lock Sterilizable

40 7120 90

40 7120 90 Handle, adjustable, for use with DRILLCUT-X® II 40 7120 50 and DRILLCUT-X® II N 40 7120 55 Transorbital Approach to Sphenoid Wing Meningiomas 33

Shaver Blades, straight for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41201 GN

Shaver Blades, straight, sterilizable for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

serrated cutting edge, 41201 KN diameter|4|mm, color code: blue-red

double serrated cutting edge, 41201 KK diameter 4|mm, color code: blue-yellow

concave cutting edge, 41201 GN oval cutting window, diameter|4|mm, color code: blue-green

concave cutting edge, oblique 41201 LN cutting window, diameter|4|mm, color code: blue-black

straight cutting edge, 41201 SN diameter|4|mm, color code: blue-blue

serrated cutting edge, 41201 KSA diameter|3|mm, color code: blue-red

double serrated cutting edge, 41201 KKSA diameter|3|mm, color code: blue-yellow

double serrated cutting edge, 41201 KKSB diameter|2|mm, color code: blue-yellow

concave cutting edge, oblique 41201 LSA cutting window, diameter|3|mm, color code: blue-black

Optional Accessory: 41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner and outer blades of reusable Shaver Blades 412xx 34 Transorbital Approach to Sphenoid Wing Meningiomas

Shaver Blades, curved for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41204 KKB

Shaver Blades, curved 35°/40°, sterilizable for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

curved 35°, cutting edge serrated 41202 KN backwards, diameter|4|mm, color code: blue-red

curved 40°, cutting edge serrated forwards, double serrated, 41204 KKF diameter|4|mm, color code: blue-yellow

curved 40°, cutting edge serrated backwards, double serrated, 41204 KKB diameter|4|mm, color code: blue-yellow

curved 40°, cutting edge serrated forwards, double serrated, 41204 KKFA diameter|3|mm, color code: blue-yellow

curved 40°, cutting edge serrated backwards, double serrated, 41204 KKBA diameter|3|mm, color code: blue-yellow

Optional Accessory: 41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner and outer blades of reusable Shaver Blades 412xx Transorbital Approach to Sphenoid Wing Meningiomas 35

Shaver Blades, curved for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41203 KKF

Shaver Blades, curved 65°, sterilizable for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

curved 65°, cutting edge serrated 41203 KNF forwards, diameter|4|mm, color code: blue-red

curved 65°, cutting edge serrated 41203 KNB backwards, diameter|4|mm, color code: blue-red

curved 65°, cutting edge serrated forwards, double serrated, 41203 KKF diameter|4|mm, color code: blue-yellow

curved 65°, cutting edge serrated backwards, double serrated, 41203 KKB diameter|4|mm, color code: blue-yellow

curved 65°, cutting edge serrated forwards, double serrated, 41203 KKFA diameter|3|mm, color code: blue-yellow

curved 65°, cutting edge serrated backwards, double serrated, 41203 KKBA diameter|3|mm, color code: blue-yellow

curved 65°, concave cutting edge, oval cutting window, forward 41203 GNF opening, diameter|4|mm, color code: blue-green

curved 65°, concave cutting edge, oval cutting window, backward 41203 GNB opening, diameter|4|mm, color code: blue-green

Optional Accessory: 41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner and outer blades of reusable Shaver Blades 412xx 36 Transorbital Approach to Sphenoid Wing Meningiomas

Shaver Blades, straight for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41301 KK

Shaver Blades, straight, for single use , sterile, package of 5 for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

serrated cutting edge, 41301 KN diameter|4|mm, color code: blue-red

double serrated cutting edge, 41301 KK diameter 4|mm, color code: blue-yellow

concave cutting edge, oval cutting 41301 GN window, diameter|4|mm, color code: blue-green

concave cutting edge, oblique 41301 LN cutting window, diameter|4|mm, color code: blue-black

straight cutting edge, 41301 SN diameter|4|mm, color code: blue-blue

serrated cutting edge, 41301 KSA diameter|3|mm, color code: blue-red

double serrated cutting edge, 41301 KKSA diameter|3|mm, color code: blue-yellow

double serrated cutting edge, 41301 KKSB diameter|2|mm, color code: blue-yellow

concave cutting edge, oblique 41301 LSA cutting window, diameter|3|mm, color code: blue-black Transorbital Approach to Sphenoid Wing Meningiomas 37

Shaver Blades, curved for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41302 KN

Shaver Blades, curved 35°/40°, for single use , sterile, package of 5 for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

curved 35°, cutting edge serrated backwards, 41302 KN diameter|4|mm, color code: blue-red

curved 40°, cutting edge serrated forwards, double 41304 KKF serrated, diameter 4|mm, color code: blue-yellow

curved 40°, cutting edge serrated backwards, double 41304 KKB serrated, diameter|4|mm, color code: blue-yellow

curved 40°, cutting edge serrated forwards, double 41304 KKFA serrated, diameter|3|mm, color code: blue-yellow

curved 40°, cutting edge serrated backwards, double 41304 KKBA serrated, diameter|3|mm, color code: blue-yellow 38 Transorbital Approach to Sphenoid Wing Meningiomas

Shaver Blades, curved for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41303 KKB

Shaver Blades, curved 65°, for single use , sterile, package of 5 for use with Shaver Blade Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

curved 65°, cutting edge serrated forwards, 41303 KNF diameter|4|mm, color code: blue-red

curved 65°, cutting edge serrated backwards, 41303 KNB diameter|4|mm, color code: blue-red

curved 65°, cutting edge serrated forwards, double 41303 KKF serrated, diameter|4|mm, color code: blue-yellow

curved 65°, cutting edge serrated backwards, double 41303 KKB serrated, diameter|4|mm, color code: blue-yellow

curved 65°, cutting edge serrated forwards, double 41303 KKFA serrated, diameter|3|mm, color code: blue-yellow

curved 65°, cutting edge serrated backwards, double 41303 KKBA serrated, diameter|3|mm, color code: blue-yellow

curved 65°, cutting edge concave forwards, 41303 GNF oval cutting|window, diameter|4|mm, color code: blue-green

curved 65°, cutting edge concave backwards, 41303 GNB oval cutting window, diameter|4|mm, color code: blue-green Transorbital Approach to Sphenoid Wing Meningiomas 39

Sinus Burrs, curved for Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41305 RN

Sinus Burrs, curved 70°/55°/40°/15°, for single use , sterile, package of 5 for use with Sinus Burr Detail ® 40 7120 50 DRILLCUT-X II Handpiece length 12 cm 40 7120 55 DRILLCUT-X® II N Handpiece

curved 40°, cylindric, drill diameter|3|mm, 41304 W shaft diameter 4 mm, color code: red-blue

curved 55°, cylindric, drill diameter|3.6|mm, 41303 WN shaft diameter 4 mm, color code: red-blue

curved 15°, bud drill, drill diameter|4|mm, 41305 RN shaft diameter 4 mm, color code: red-black

curved 15°, diamond head, drill diameter|3|mm, 41305 DN shaft diameter 4 mm, color code: red-yellow

curved 15°, diamond head, drill diameter|5|mm, 41305 D shaft diameter 4 mm, color code: red-yellow

curved 40°, diamond head, drill diameter|5|mm, 41305 DW shaft diameter 4 mm, color code: red-yellow

curved 70°, diamond head, drill diameter|3.6|mm, 41303 DT shaft diameter 4 mm, color code: red-yellow 40 Transorbital Approach to Sphenoid Wing Meningiomas

Accessories for Shaver

39550 A

39550 A Wire Tray, provides safe storage of accessories for KARL STORZ paranasal sinus shaver systems during cleaning and sterilization for storage of: – Up to 7|shaver attachments – Connecting cable

Please note: The instruments displayed are not included in the sterilizing and storage tray. Transorbital Approach to Sphenoid Wing Meningiomas 41

Notes: 42 Transorbital Approach to Sphenoid Wing Meningiomas

Notes: with the compliments of KARL STORZ — ENDOSKOPE