RESUMO
OBJECTIVE: Although keyhole transorbital approaches are gaining traction, their indications have not been adequately studied comparatively. In this study the authors have defined them also as transwing approaches-meaning that they use the different facies of the sphenoid wing for cranial entry-and sought to compare the four major ones: 1) lateral orbitocraniotomy through a lateral canthal incision (LatOrb); 2) modified orbitozygomatic approach through a palpebral incision (ModOzPalp); 3) modified orbitozygomatic approach through an eyebrow incision (ModOzEyB); and 4) supraorbital craniotomy through an eyebrow incision (SupraOrb), coupled with its expanded version (SupraTransOrb). METHODS: Cadaveric dissections were performed at the neuroanatomy lab. To delineate the skull base exposure, four formalin-fixed heads were used, with two sides dedicated to each approach. The outer limits were assessed via image guidance and were mapped and illustrated accordingly. A fifth head was dissected purely endoscopically, just to facilitate an overview of the transwing concept. Qualitative features were also rigorously examined. RESULTS: The LatOrb proves to be more versatile in the middle cranial fossa (MCF), whereas the anterior cranial fossa (ACF) exposure is limited to a small area above the sphenoid ridge. An anterior clinoidectomy is possible; however, the exposure of the roof of the optic canal is suboptimal. The ModOzPalp adequately exposes both the ACF and MCF. Its lateral trajectory allows the inferior to superior view, yet there is restricted access to the medial anterior skull base (olfactory groove). The ModOzEyB also provides extensive exposure of the ACF and MCF, but has a more superior to inferior trajectory compared to the ModOzPalp, making it more appropriate for pathology reaching the medial anterior skull base or even the contralateral side. The anterior clinoidectomy is performed with improved visualization of the optic canal. The SupraOrb provides mainly anterior cranial base exposure, with minimal middle fossa. An anterior clinoidectomy can be performed, but without any direct observation of the superior orbital fissure. Some MCF access can be accomplished if the lateral sphenoid wing is drilled inferiorly, leading to its highly versatile variant, the SupraTransOrb. CONCLUSIONS: All the aforementioned approaches use the sphenoid wing as skull base corridor from a specific orientation point; hence these are designated as transwing approaches. Their peculiarities mandate careful case selection for the effective and safe completion of the surgical goals.
Assuntos
Craniotomia , Base do Crânio , Humanos , Base do Crânio/cirurgia , Base do Crânio/anatomia & histologia , Craniotomia/métodos , Fossa Craniana Média/cirurgia , Fossa Craniana Anterior/cirurgia , Órbita/cirurgia , CadáverRESUMO
A 79-year-old female presented to the emergency department for sudden-onset ocular pain, edema, and erythema around her left eye. She also had a left-sided migraine and frontal fullness for 2 weeks. She had attentive care for the diagnosis of orbital cellulitis and prompt recognition of necrotizing fasciitis. Wound cultures were positive for over 5 strains of bacteria in addition to Aspergillus. In a combined effort by our institution's Ophthalmology and Otolaryngology departments, the patient was successfully treated with debridement, porcine bladder matrix, antibiotics, and antifungals. The authors describe the first reported case of eyelid and periorbital necrotizing fasciitis, caused by mixed flora and Aspergillus fumigatus, that showed promising wound healing with the outlined treatment paradigm.