Multiportal Combined Transorbital Transnasal Endoscopic Approach for the Management of Selected Skull Base Lesions: Preliminary Experience

doi:10.1016/j.wneu.2015.02.034

World Neurosurgery

Volume 84, Issue 1, July 2015, Pages 97-107

https://doi.org/10.1016/j.wneu.2015.02.034 Get rights and content

Background

Skull base lesions are challenging to treat and may be managed using several approaches each with its own advantages and limitations. In selected cases, a modular, combined, multiportal approach could overcome the limits of a single approach and respond well to the needs of the patient.

Methods

We report a preclinical study on 5 cadaveric specimens and 4 preliminary clinical experiences with the combined multiportal transnasal transorbital endoscopic approach for the management of selected complex skull base pathologies. The technical feasibility and safety of this combined approach were evaluated in the preclinical study. The applicability in vivo of such an approach, together with early and late complications, specific morbidity, and hospitalization time were analyzed in the preliminary clinical experiences.

Results

The transnasal endoscopic extended approach combined with the transorbital endoscopic approach offered greater visualization and tissue handling than a single approach alone could. The multiportal combined transorbital transnasal endoscopic approach was used effectively in vivo to resect 1 case of malignant schwannoma arising from the second branch of the trigeminal nerve and 3 cases of spheno-orbital meningioma without significant complications and with minimal morbidity for the patients.

Conclusions

The multiportal combined transorbital transnasal endoscopic approach is a safe and effective procedure for management of selected complex skull base lesions that is able to capitalize on the advantages and overcome the limitations of each single approach. This combined approach offers a multiperspective view of the spaces and allows for a more synergized procedure, especially when dealing with multicompartmental lesions.

Introduction

Skull base lesions are challenging and may be managed via various approaches. The increasing experience of several skull base teams has enabled treatment of many more complex cases using different surgical approaches each with its own advantages and limitations. It is understood that no single surgical corridor offers optimal exposure in every case. Traditional extensive skull base approaches are now used less than in the past, although they remain an important option in certain selected cases and should always be considered by surgical teams in treating such patients.

Endoscopic transnasal approaches enable the treatment of various pathologies located not only in the ventral skull base but also extended laterally and within certain areas of the orbit such as the inferomedial regions. Despite these impressive developments, there are limitations to endoscopic transnasal procedures, mainly related to cases of major lateral extension of lesions. In these cases, the endonasal trajectory seems to be inadequate for optimal control of the lesions. In such cases, an alternative or complementary route is mandatory. In selected cases, a modular, combined, multiportal approach could overcome the limits of a single approach and respond well to the needs of the patient.

Based on our long-standing experience in orbital decompression for Graves disease, with >1500 orbits treated over 20 years (22), we began using the superior eyelid approach in addressing the lateral and superolateral walls of the orbit and, through this window, anterior and middle cranial fossa lesions.

In this article, we report our preclinical experience with 5 cadavers and preliminary clinical experience using the combined multiportal transnasal transorbital approach to manage selected complex skull base pathologies, outlining our preliminary impressions and proposing our critical considerations. Our ultimate goal is to evaluate the practical feasibility of such a combined approach in vivo and to share our very preliminary experience.

Section snippets

Materials and Methods

This study has been performed in compliance with the Helsinki Declaration and with policies approved by the local ethical committee.

Preclinical Evaluation

Full dissection of 5 cadaveric heads (10 sides) was performed. The transnasal endoscopic extended approach combined with the transorbital endoscopic approach enabled greater visualization and tissue handling than a single approach could. The combined approach provided the surgeon with almost 360° visualization and control of the optic nerve, orbital apex, cavernous sinus, and supraclinoid internal carotid artery. The biportal intracranial and infratemporal cooperative dissection performed

Discussion

The indications for extended endonasal approaches have expanded rapidly to include a broad spectrum of central skull base pathology. Although there are undoubted benefits in these approaches, they have limitations, particularly in addressing lesions that cross neurovascular structures or are situated in the far lateral areas. In such cases, diminished visualization may lead either to inadequate surgery or to devastating complications.

In contrast, traditional external approaches offer wide

Conclusions

The endoscopic combined multiportal transnasal transorbital approach is at its dawn. As with any other minimally invasive approach, the most critical aspect in multiportal endoscopic skull base surgery is achieving adequate exposure of the surgical field, which should be wide enough to permit handling of the anatomic structures. In this context, we agree with Figueiredo et al. (13), who stated that the choice of surgical approach should not be based on the anatomic structures being exposed, but

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Transorbital and supraorbital uniportal multicorridor approach to the orbit, anterior, middle and posterior cranial fossa: Anatomic study
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The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per “extended-transorbital approach” and combined with others ventro-basal approaches featuring the concept of “multiportal surgery”. Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it “Uniportal multicorridor” approach.
The aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study.
Anatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described.
We analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura.
The described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.
Endoscopic Transorbital Approach for Spheno-Orbital Tumors: Case Series and Systematic Review of Literature
2023, World Neurosurgery
Transorbital neuroendoscopic surgery (TONES) comprises a group of approaches with indications expanding from orbital tumors to more complex skull base lesions. We analyzed the role of the endoscopic transorbital approach (eTOA) for spheno-orbital tumors, reporting the results of our clinical series and of a systematic review of the literature.
All patients operated on from 2016 to 2022 at our institution for a spheno-orbital tumor through an eTOA were included in a clinical series, and a systematic review of the literature was performed.
Our series consisted of 22 patients (16 females, mean age 57 ± 13 years). Gross tumor removal was achieved in 8 patients (36.4%) after the eTOA and in 11 (50.0%) after a multistaged strategy combining the eTOA with the endoscopic endonasal approach. Complications included 1 chronic subdural hematoma and 1 permanent extrinsic ocular muscle deficit. Patients were discharged after 2.4 ± 1.3 days. The most common histotype was meningioma (86.4%). Proptosis improved in all cases, visual deficit in 66.6%, and diplopia in 76.9%. These results were confirmed by the review of the 127 cases reported in the literature.
Despite its recent introduction, a significant number of spheno-orbital lesions treated with an eTOA are being reported. Its main advantages are favorable patient outcome and optimal cosmetic results, with minimal morbidity and quick recovery. This approach can be combined with other surgical routes or adjuvant therapies for complex tumors. However, it is a technically demanding procedure, requiring specific skills in endoscopic surgery, that should be reserved to dedicated centers.
Endoscopic Transorbital Approach for the Management of Spheno-Orbital Meningiomas: Literature Review and Preliminary Experience
2023, World Neurosurgery
The endoscopic transorbital approach (ETOA) is a minimally invasive approach that could be particularly appropriate for management of spheno-orbital meningiomas. The aim of this study was to perform a systematic review of the literature on the management of spheno-orbital meningiomas via the minimally invasive ETOA, searching for clinical scenarios in which this approach could be best indicated. A secondary aim was to describe 4 illustrative cases.
A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data including patient demographics, tumor features, and surgical and postoperative outcomes were collected. Cases from our initial experience with ETOA were included in the data.
Data of 58 patients from 9 selected records and from our surgical series were collected. Subtotal, near-total, and gross total resection rates were 44.8%, 10.3%, and 32.7%, respectively. Symptom improvement after surgery was 100% for proptosis, 93% for visual impairment, and 87% for ophthalmoplegia. The most common postoperative complications were transient ophthalmoplegia and maxillary nerve hypoesthesia. Cerebrospinal fluid leak was reported in 2 patients.
Our findings support the use of the ETOA for management of spheno-orbital meningiomas, particularly in at least 3 clinical scenarios: 1) when predominant hyperostotic bone is present; 2) when a globular tumor not showing excessive medial or inferior infiltration is being treated; 3) as part of a multistage treatment for diffuse lesions.
Recent progress in endoscopic skull base surgery: Functional preservation and multiportal approaches
2023, Auris Nasus Larynx
Over the past couple of decades, endoscopic skull base surgery (ESBS) has significantly evolved and is applied to a broad range of skull base pathologies, including sinonasal malignancies. Recent studies have demonstrated remarkable progress of ESBS in complete resection with low morbidity and extension of its application to larger and more complex lesions. In this review, we focus on the evolution of functional preservation and multiportal approaches. Progress in preoperative assessments and surgical techniques improved the preservation of olfactory function after ESBS. The technical feasibility of olfaction preservation even after resection of olfactory groove lesions has been reported. To overcome the limitations of extending use of the endoscopic endonasal approach in surgical fields, various types of multiportal approaches, including combinations of the endoscopic endonasal and transorbital, transmaxillary, or transoral approach, have been reported, as they are useful for complete resection of extensive pathologies while limiting morbidity. These innovative techniques are still in the process of maturation. Hence, an ongoing critical evaluation is essential to ensure efficacy.
Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section
2023, Brain and Spine
Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery.
Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection.
A PRISMA based literature search was performed to select the most relevant papers on the topic.
Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery.
This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.
A Frontal Route to Middle and Posterior Cranial Fossa: Quantitative Study for the Lateral Transorbital Endoscopic Approach and Comparison with the Subtemporal Approach
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Citation Excerpt :
On the one hand, TOEAs overcome the lateral anatomic limitations of endoscopic endonasal approaches (EEAs) while achieving equal endoscopic visibility. On the other hand, the TOEAs decrease the invasiveness and complications associated with open skull base surgery.14,15 Of major interest, the anterior surgical pathway provided by the TOEAs allows the avoidance of brain retraction, and thus preventing brain injury.
Skull base lesions within the middle cranial fossa (MCF) remain challenging. Recent reports suggest that transorbital endoscopic approaches (TOEAs) might be particularly suitable to access the MCF and expose the lateral wall of the cavernous sinus and the Meckel's cave.
The present study was developed to compare the nuances of the subtemporal approach (STA) with those of the lateral TOEA (LTOEA) to the MCF and posterior cranial fossa (PCF) in cadaveric specimens. After orbital craniectomy, interdural opening of the cavernous sinus lateral wall (CSlw), exposure of the Gasserian ganglion, and extradural elevation of the temporal lobe was performed. Next, anterior endoscopic petrosectomy was performed and the PCF was accessed. We quantitatively analyzed and compared the angles of attack and distances between LTOEA and STA to different structures at the CSlw, petrous apex (PA), and PCF.
Cadaveric dissection through the LTOEA completely exposed the CSlw and PA. LTOA exhibited larger distances than the STA to all targets. Importantly, these differences were greater at the PA and its surrounding key anatomic landmarks. The horizontal and vertical angles of attack allowed by the LTOA were smaller both for the CSlw and PA. However, these differences were not significant for the vertical angle of attack at the CSlw.
LTOEA provides a direct ventral route to the medial aspect of MCF, PA, and PCF. Although TOEAs are versatile approaches, the unfamiliar surgical anatomy and limited instrument maneuverability demand extensive cadaveric dissection before moving to the clinical setting.

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleMultiportal Combined Transorbital Transnasal Endoscopic Approach for the Management of Selected Skull Base Lesions: Preliminary Experience

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Preclinical Evaluation

Discussion

Conclusions

J Craniomaxillofac Surg

Oper Tech Otolaryngol Head Neck Surg

World Neurosurg

Minimally invasive transpalpebral “eyelid” approach to the anterior cranial base

Neurosurgery

Supraorbital-pterional approach to skull base lesions

Neurosurgery

Lateral orbital wall approach to the cavernous sinus

J Neurosurg

Eyelid approach to the anterior cranial base

J Neurosurg

Applications and outcomes of orbital and transorbital endoscopic surgery

Otolaryngol Head Neck Surg

Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors

Otolaryngol Head Neck Surg

Lateral transorbital neuroendoscopic approach to the lateral cavernous sinus

J Neurol Surg B Skull Base

Tension pneumocephalus after endoscopic sinus surgery: a technical report of multiportal endoscopic skull base repair

Otolaryngol Head Neck Surg

Quality of life following endoscopic endonasal resection of anterior skull base cancers

J Neurosurg

Original Article
Multiportal Combined Transorbital Transnasal Endoscopic Approach for the Management of Selected Skull Base Lesions: Preliminary Experience