Endoscopic Orbital and Periorbital Approaches in Minimally Disruptive Skull Base Surgery

Miller, Craig; Bly, Randall A.; Moe, Kris S.

doi:10.1055/s-0040-1713900

Cited by 18 publications

(18 citation statements)

References 33 publications

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“…The transorbital endoscopic approach is increasingly used for middle and anterior cranial fossa pathology and can provide excellent access to orbital and medial sphenoid wing tumors and the lateral parasellar and cavernous sinus regions; however, we have limited experience with this approach. [31][32][33][34] Many of the tumors that we approached with an MP approach in this series, and some that were approached with an SO route, could likely have been removed through a transorbital route.…”

Section: Specific Tumor Types and The Optimal Surgical Approachmentioning

confidence: 99%

Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases

Avery

Mallari

Barkhoudarian

et al. 2022

Journal of Neurosurgery

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OBJECTIVE The authors’ objective was to compare the indications, outcomes, and anatomical limits of supraorbital (SO) and mini-pterional (MP) craniotomies in patients with intra- and extraaxial brain tumors, and to assess approach selection, utility of endoscopy, and surgical field overlap. METHODS A retrospective analysis was conducted of all brain tumor patients who underwent an SO or MP approach. The analyzed characteristics included pathology, endoscopy use, extent of resection, length of stay (LOS), and complications. On the basis of preoperative MRI data, tumor heatmaps were constructed to compare surgical access provided by both routes, including coronal projection heatmaps for parasellar tumors. RESULTS From 2007 to 2020, 158 patients underwent 173 (84.8%) SO craniotomies and 30 patients underwent 31 (15.2%) MP craniotomies; 71 (34.8%) procedures were reoperations. Of these 204 operations, 110 (63.6%) SO and 21 (67.7%) MP approaches were for extraaxial tumors (meningiomas in 65% and 76.2%, respectively). Gliomas and metastases together represented 84.1% and 70% of intraaxial tumors accessed with SO and MP approaches, respectively. Overall, 56.1% of tumors accessed with the SO approach and 41.9% of those accessed with the MP approach were in the parasellar region. Axial projection heatmaps showed that SO access extended along the entire ipsilateral and medial contralateral anterior cranial fossa, parasellar region, ipsilateral sylvian fissure, medial middle cranial fossa, and anterior midbrain, whereas MP access was limited to the ipsilateral middle cranial fossa, sylvian fissure, lateral parasellar region, and posterior aspect of anterior cranial fossa. Coronal projection heatmaps showed that parasellar access extended further superiorly with the SO approach compared with that of the MP approach. Endoscopy was utilized in 98 (56.6%) SO craniotomies and 7 (22.6%) MP craniotomies, with further tumor resection in 48 (49%) and 5 (71.4%) cases, respectively. Endoscope-assisted tumor removal was clustered in areas that were generally at farther distances from the craniotomy or in angled locations such as the cribriform plate region where microscopic visualization is limited. Gross-total or near-total resection was achieved in 120/173 (69%) SO approaches and 21/31 (68%) MP approaches. Major complications occurred in 11 (6.4%) SO approaches and 1 (3.2%) MP approach (p = 0.49). The median LOS decreased to 2 days in the last 2 years of the study. CONCLUSIONS This clinical experience suggests the SO and MP craniotomies are versatile, safe, and complementary approaches for tumors located in the anterior and middle cranial fossae and perisylvian and parasellar regions. The SO route, used in 85% of cases, achieved greater overall reach than the MP route. Both approaches may benefit from expanded visualization with endoscopy.

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Section: Specific Tumor Types and The Optimal Surgical Approachmentioning

confidence: 99%

Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases

Avery

Mallari

Barkhoudarian

et al. 2022

Journal of Neurosurgery

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“…Probably the two most important are: 1) the frequent need of angled endoscope and cross-planar technique and instruments to visualize and manage the surgical target; 2) the nasal corridor to the skull base becomes progressively constricted as the target is reached, especially in its lateral aspect. Furthermore, transnasal endoscopic approaches necessitate placement of the endoscope and instruments in a similar vector with minimal offset angle 1 . Based on these grounds, it came naturally to think of the orbit not only as a possible site of pathology but also as a corridor to deeper areas.…”

Section: Introductionmentioning

confidence: 99%

“…We will, therefore, highlight the characteristics that may be useful to clinician in the choice of the best approach for the patient, in a personalized view of the surgical practice. In this respect, although several incisions and approaches have been described and proposed 1,3 , in this chapter we will focus mainly on the superior eyelid endoscopic-assisted approach exploring the following items: • anatomical background and surgical considerations; • surgical instrumentation and setting (multidisciplinary management); • current indications and contraindications; • possible alternatives; • complications;…”

Section: Introductionmentioning

confidence: 99%

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base

Dallan

Cristofani‐Mencacci

Fiacchini

et al. 2021

Acta Otorhinolaryngol Ital

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“…Characteristics of an ideal surgical pathway include those that are direct, short, minimize risk to critical neurovascular structures, risk minimal collateral damage, have a reduced requirement for angled endoscopy and instrumentation, and create an ample optical cavity for target manipulation with minimal instrument–instrument or instrument–endoscope contact. 8 With this in mind, we developed an endoscopic approach to the ITF, PS, and adjacent regions, the “paramaxillary approach.” 1 This transoral pathway employs a small mucosal incision that heals rapidly, and provides a direct, rapid, and safe approach to pathology in this challenging region.…”

Section: Introductionmentioning

confidence: 99%

“…The paramaxillary zone is described as the region which includes the infratemporal fossa (ITF), pterygomaxillary space (PS), parapharyngeal space, and mandibular ramus. 1 The ITF extends medially from the lateral pterygoid plate to the zygomatic arch laterally. 2 The PS (also referred to as the pterygopalatine fossa) extends posteriorly from the dorsal maxillary wall to pterygoid process and connects to the ITF laterally via the pterygomaxillary fissure.…”

Section: Introductionmentioning

confidence: 99%

Endoscopic Paramaxillary Approach to the Infratemporal Fossa and Pterygomaxillary Space: Computer Modeling Analysis and Clinical Series

Konuthula

Abuzeid

Humphreys

et al. 2021

J Neurol Surg B Skull Base

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Objective Several different open and endoscopic approaches for the pterygomaxillary space and infratemporal fossa have been described. Limitations to these approaches include restricted exposure of the infratemporal fossa and difficult surgical manipulation. Study Design Consecutive clinical cases utilizing a novel approach to access lesions in the infratemporal fossa and pterygomaxillary space were reviewed. Data was collected on pathology, lesion location, and surgical approach(es) performed. Computer modeling was performed to analyze the full extent of surgical access provided by the paramaxillary approach to the range of target locations. Results Ten consecutive cases met inclusion criteria. Surgical access to the target lesion was achieved in all cases. Computer modeling of the approach derived the anatomical boundaries of the paramaxillary approach. Wide access to the posterior maxilla, and lateral or medial to the mandibular condyle allows for variability in endoscopic angles and access to more medial pterygomaxillary space lesions. The lateral extent is limited proximally only by the extent of cheek/soft tissue retraction and by the zygomatic arch more superiorly. The superior limit of dissection is at the temporal line. Conclusion The endoscopic paramaxillary approach is a transoral minimally disruptive approach to the ITF and PS that provides excellent surgical exposure for resection of lesions involving these areas. Compared with previously described endoscopic approaches, there are no external incisions; tumor manipulation is straightforward without angled endoscopy, and all areas of the infratemporal fossa and pterygomaxillary space can be accessed.

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Endoscopic Orbital and Periorbital Approaches in Minimally Disruptive Skull Base Surgery

Cited by 18 publications

References 33 publications

Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases

Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base

Endoscopic Paramaxillary Approach to the Infratemporal Fossa and Pterygomaxillary Space: Computer Modeling Analysis and Clinical Series

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