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. 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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