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Transorbital Approach to Sphenoid Wing Meningiomas

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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. Any legal claims or claims for damages are excluded. Design and Composing: In case any references are made in this booklet to any 3rd party ® GmbH, Germany publication(s) or links to any 3rd party websites are mentioned, it is made clear that neither the publisher nor the author or other Printing and Binding: copyright holders of this booklet/book endorse in any way the Straub Druck+Medien AG content of said publication(s) and/or web sites referred to or linked Max-Planck-Straße 17, 78713 Schramberg, Germany from this booklet and do not assume any form of liability for any factual inaccuracies or breaches of law which may occur therein. Thus, no liability shall be accepted for content within the 3rd party 05.17–0.5 publication(s) or 3rd party websites and no guarantee is given for any other work or any other websites at all. ISBN 978-3-89756-043-7 Transorbital Approach to Sphenoid Wing Meningiomas 5 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 defi 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
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