Anterolateral keyhole transorbital routes to the skull base: a comparative anatomical study.

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.

Ophthalmology and oculoplastics for the rhinologist.

PURPOSE OF REVIEW: As the management of ophthalmic and sinus disease advances, it is important to stay abreast of all current management options. This involves knowledge of adjacent anatomy and disease processes, and collaboration between multiple specialties. The authors provide a review of relevant ophthalmic and oculoplastic topics for the rhinologist. RECENT FINDINGS: The scope and surgical skills of oculoplastic and rhinologist specialists have grown in conjunction with medical and technological advancements. Familiarity with the presentations of sinus disease in the orbit can decrease the time to disease recognition, and improve morbidity and mortality. Collaborative approaches provide improved access to areas of interest throughout the orbit and sinuses. Multiportal, transorbital, and endoscopic techniques can improve patient morbidity and mortality compared to conventional open approaches. Familiarity with all medical and surgical treatment options can help tailor treatments to patients' needs. SUMMARY: Multidisciplinary approaches to sinus and orbit disease and the incorporation of new surgical technologies can improve patient options and outcomes.

The Transcaruncular Corridor of the Medial Transorbital Approach to the Frontal Lobe: Technical Nuances and Applications.

BACKGROUND AND IMPORTANCE: Medial orbital access through a transcaruncular corridor has yet to be fully characterized as a potential approach to intradural lesions within the skull base. Transorbital approaches present unique potential in the management of complex neurological pathologies and require subspecialty collaboration across multiple disciplines. CLINICAL PRESENTATION: A 62-year-old man presented with progressive confusion and mild left-sided weakness. He was found to have a right frontal lobe mass with significant vasogenic edema. A comprehensive systemic workup was otherwise unremarkable. A multidisciplinary skull base tumor board conference recommended a medial transorbital approach through transcaruncular corridor, which was performed by neurosurgery and oculoplastics services. Postoperative imaging demonstrated gross total resection of the right frontal lobe mass. Histopathologic evaluation was consistent with amelanotic melanoma with BRAF (V600E) mutation. At his last follow-up visit, 3 months after surgery, the patient did not experience any visual symptoms and had an excellent cosmetic outcome after surgery. CONCLUSION: The transcaruncular corridor through a medial transorbital approach provides a safe and reliable access to the anterior cranial fossa.

Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery?

OBJECTIVES: While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS: Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS: Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS: The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE: IV Laryngoscope, 131:513-517, 2021.

Reduced Tearing With Stable Quality of Life After Vidian Neurectomy: A Prospective Controlled Trial.

OBJECTIVES/HYPOTHESIS: Although vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality-of-life is not well-defined. Endoscopic endonasal transpterygoid approaches (EETA) may require vidian nerve sacrifice. STUDY DESIGN: A prospective cohort trial. METHODS: A prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five-item Dry Eye Questionnaire (DEQ-5) was performed. Preservation of the contralateral vidian nerve allowed comparison between the eye subjected to VN and the control eye postoperatively. RESULTS: Twenty-one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre- and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ-5 score for dry eye severity between the pre- and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ-5 scores when compared to patients with normal tearing (P < .0056). CONCLUSIONS: VN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:1487-1491, 2021.

Gamma knife radiosurgery for uveal melanomas and metastases: a systematic review and meta-analysis.

BACKGROUND: Gamma knife radiosurgery is regarded as the gold-standard stereotactic radiosurgery modality for the treatment of intracranial tumours, and its use has been expanded for the treatment of intraocular malignancies. The aim of this study was to systematically evaluate the efficacy, outcomes, and complications of gamma knife radiosurgery for uveal melanomas and metastases. METHODS: We did a systematic review and meta-analysis to aggregate the clinical outcomes of patients with uveal melanomas or intraocular metastases treated primarily with gamma knife radiosurgery. We searched MEDLINE and Embase for studies published between Sept 1, 1960, and Feb 1, 2020, reporting the use of gamma knife radiosurgery as primary treatment for uveal melanoma or uveal metastases. The search was restricted to clinical studies and relevant grey literature published in English. Studies reporting treatment of benign tumours, extraocular tumours, or other forms of stereotactic radiosurgery were excluded to reduce heterogeneity. No restrictions were placed on participant criteria. Local tumour control and tumour regression were extracted as the primary outcomes and analysed via a random-effects meta-analysis of proportions using the DerSimonian and Laird method with a Freeman-Tukey double arcsine transformation. This study is registered with PROSPERO, CRD42019148165. FINDINGS: Our search returned 454 studies, of which 109 were assessed for full-text eligibility. 52 studies, reporting on 1010 patients with uveal melanoma and 34 intraocular metastases, were eligible for systematic review. 28 studies were included in the meta-analysis. 840 of 898 patients (0·96, 95% CI 0·94-0·97; I2=16%) from 19 studies had local control, and 378 of 478 patients (0·81, 0·70-0·90; I2=83%) from 16 studies experienced tumour regression. INTERPRETATION: Gamma knife radiosurgery is an efficacious primary method of treating uveal melanomas and intraocular metastases, with reliable tumour control rates. Randomised controlled trials should further evaluate the safety and efficacy of gamma knife radiosurgery in this setting. FUNDING: The Rhodes Trust and the Howard Brain Sciences Foundation.

Combined Surgical Approaches In and Around the Orbit.

Orbital pathology requiring surgery can be planned based on the nature of the disease and the position of this relative to the globe and optic nerve complex. Multidisciplinary treatment is now common, and this sometimes includes multiple surgical corridors employed for approach. The orbit is also now frequently used as a corridor to intracranial pathology, and these same processes may be applied. Combined surgical approaches, whether at the same time or staged, allow for minimization of manipulation of critical neurovascular structures in complex skull base pathology.

Craniofacial Cleft: A Case of Tessier 10 Cleft With a Novel Method to Repair Large Bilateral Colobomas.

OBJECTIVE: To describe a reliable method utilizing large, rotation flaps to reconstruct a number 10 Tessier cleft. DESIGN: This is a descriptive clinical case report. SETTING: Pediatric teaching hospital affiliated with a university. PATIENTS, PARTICIPANTS: One participant in this clinical case report. INTERVENTIONS: Full-thickness excision of the clefted eyelid, brow, and forehead tissue was performed bilaterally to develop medial and lateral eyebrow and forehead flaps. Right: the forehead/brow flap was rotated caudally to reapproximate the eyebrow and an eyelid rotation flap was also used to reapproximate the lid margin. Left: forehead/brow rotation flap allowed realignment of the eyebrow and a series of Z-plasties were used in the eyelid to reapproximate the lid margin and to lengthen the eyelid. MAIN OUTCOME MEASURE(S): Develop and construct a reliable reconstruction with full-eyelid closure and minimal donor site morbidity. RESULTS: Complete eyelid closure bilaterally was achieved intraoperatively, and was maintained at 6-month follow-up with no evidence of ocular pathology. CONCLUSIONS: Large, bilateral upper eyelid colobomas require repair to prevent blindness. Although free tarsomarginal grafts and lid-sharing procedures have been described, we demonstrate that large rotation flaps designed along the cleft margin can provide a reliable reconstruction and minimize donor-site morbidity.

Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system.

BACKGROUND: Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed. METHODS: An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. RESULTS: Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. CONCLUSION: Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.

Lateral Transorbital Versus Endonasal Transpterygoid Approach to the Lateral Recess of the Sphenoid Sinus-A Comparative Anatomic Study.

BACKGROUND: The treatment of cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus (LRSS) faces difficulties due to the deep location of the osseous defect. When treated with craniotomies, brain retraction is a concern. The endoscopic endonasal transpterygoid approach (EETA) is a direct and less invasive procedure; however, it may require transection of the vidian nerve (VN). OBJECTIVE: To investigate the feasibility of a lateral transorbital approach (LTOA) as an alternative pathway to the LRSS that avoids VN sacrifice. METHODS: Six embalmed heads with well-pneumatized LRSS were preselected by inspecting their computed tomography scans. One LTOA and one EETA were performed on 1 side of each specimen. The approaches were compared regarding working distance and neurovascular structures being sacrificed. The working area of the LTOA was also measured. RESULTS: The average working distances were 59.9 (±2.94) mm for the LTOA and 76.4 (±3.99) mm for the EETA (P < .001). The LTOA generated a working area with a diameter of 9 to 14 mm. The EETA demanded the sacrifice of VN and the sphenopalatine artery in all specimens to expose the LRSS. No neurovascular structures were found in the trajectory of the LTOA. CONCLUSION: The LTOA to the LRSS is feasible, with minimal risk of injuring neurovascular structures. It offers a shorter pathway when compared to the EETA. Although the LTOA provides no options for vascularized flap reconstruction, it allows immediate access to muscle grafts. The LTOA may serve as an alternative to treating cerebrospinal fluid leaks of the LRSS.

Nonhealing orbital floor fracture in a pediatric patient: A unique presentation of pseudo-silent sinus syndrome.

Silent sinus syndrome was first described as spontaneous enophthalmos and hypoglobus associated with subclinical maxillary sinusitis without prior trauma or surgery. This clinical entity has later been described after trauma in which damage to the ostiomeatal complex leads to atelectasis of the maxillary sinus. We report a case of a 14-year-old boy who presented 4 years after sustaining a non-operative orbital floor fracture with enophthalmos and transient diplopia. Computed tomography (CT) demonstrated enlargement in size of the original orbital floor fracture and bilateral maxillary sinus disease. Bilateral chronic sinusitis suggested an anatomical predisposition to sinusitis unrelated to the prior trauma. The authors propose that, in this case, negative pressure in the maxillary sinus and chronic inflammation led to bone resorption and failure of the orbital fracture to heal. This differs from prior reports of silent sinus syndrome in that there was complete resorption of bone of the orbital floor and no decrease in volume of the maxillary sinus given the open communication of the sinus and the orbit, making this a unique presentation of pseudo-silent sinus syndrome in a pediatric patient.

Minimally Invasive Approaches for Anterior Skull Base Meningiomas: Supraorbital Eyebrow, Endoscopic Endonasal, or a Combination of Both? Anatomic Study, Limitations, and Surgical Application.

BACKGROUND: Minimally invasive accesses to the anterior skull base include the endoscopic endonasal approach (EEA) and the supraorbital eyebrow approach. These 2 are often seen as competing approaches, not alternative or combinatory approaches. In this study, we evaluated the anatomic limitations of each approach and the combined approach for accessing the anterior skull base. METHODS: Ten neurovascular injected cadaver heads were used for the study. The supraorbital approach to the anterior skull base was performed on 5 heads, and EEA was done on the other 5 heads. Then, the supraorbital approach was added to the 5 heads receiving EEA. Visualization and surgical limitations were recorded by the ability to perform resection of the crista galli, anterior clinoid, cribriform plate, and planum sellae. RESULTS: The maximal lateral extension of EEA for anterior skull base was the midorbit line anteriorly but narrowing down toward the orbital apex. The limitation of the supraorbital approach was found mostly medial and anterior. Drilling of anterior skull base was impossible medially between the sphenoethmoidal suture and the posterior aspect of the crista galli. The combined approach showed complementary areas of visualization and surgical maneuverability. Three clinical cases were presented to illustrate the indications for the stand-alone supraorbital approach, EEA, and combined approach. CONCLUSION: The limitations of the EEA when dealing with lateral extension of anterior skull base meningiomas, and the limitations of the supraorbital eyebrow approach for medial skull base drilling and reconstruction, can be overcome by a judicious, anatomically based combination of both approaches.

Endoscopic Endonasal Optic Nerve Decompression for Fibrous Dysplasia.

Objective To evaluate visual outcomes and potential complications for optic nerve decompression using an endoscopic endonasal approach (EEA) for fibrous dysplasia. Design Retrospective chart review of patients with fibrous dysplasia causing extrinsic compression of the canalicular segment of the optic nerve that underwent an endoscopic endonasal optic nerve decompression at the University of Pittsburgh Medical Center from 2010 to 2013. Main Outcome Measures The primary outcome measure assessed was best-corrected visual acuity (BCVA) with secondary outcomes, including visual field testing, color vision, and complications associated with the intervention. Results A total of four patients and five optic nerves were decompressed via an EEA. All patients were symptomatic preoperatively and had objective findings compatible with compressive optic neuropathy: decreased visual acuity was noted preoperatively in three patients while the remaining patient demonstrated an afferent pupillary defect. BCVA improved in all patients postoperatively. No major complications were identified. Conclusion EEA for optic nerve decompression appears to be a safe and effective treatment for patients with compressive optic neuropathy secondary to fibrous dysplasia. Further studies are required to identify selection criteria for an open versus an endoscopic approach.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients.

Background: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa. Objective: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa. Metuods: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients' clinical and radiographic records were retrospectively reviewed. Results: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1). Conclusion: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

Congenital entropion and hypotropia secondary to duplication of the inferior rectus muscle.

Congenital anomalies of the extraocular muscles apart from congenital fibrosis are relatively rare. Duplication of extraocular muscles is a particularly rare congenital anomaly that has been rarely reported in the literature. We present a case of unilateral congenital entropion and hypotropia resulting from duplication of the inferior rectus muscle.

INTRAOCULAR SYNOVIAL SARCOMA.

PURPOSE: To describe the first reported case of intraocular synovial sarcoma. METHODS: A 29-year-old man was enucleated for a blind, painful eye. Pathologic examination revealed an unexpected intraocular spindle cell tumor. RESULTS: Immunohistochemical characterization revealed diffuse reactivity of the tumor cells for vimentin and focal positivity for epithelial markers pankeratin and epithelial membrane antigen. Melanoma markers were negative. Fluorescent in situ hybridization studies identified a t(X;18) (p11.2;q11.2) translocation, establishing a final diagnosis of synovial sarcoma. There was no evidence of extraocular extension as the resected margin of the optic nerve was free of tumor. Further imaging studies revealed no extraocular primary site or metastasis. CONCLUSION: The incidental discovery of an intraocular malignancy in this case underscores the importance of routine histopathologic analysis of all enucleated globes. To the authors' knowledge, this is the first reported case of an intraocular synovial sarcoma, either as metastasis or as primary site.

Visual Outcomes after Endoscopic Endonasal Approach for Craniopharyngioma: The Pittsburgh Experience.

This series of patients has been published in the neurosurgical literature earlier this year, detailing multiple aspects of both the surgical technique and postoperative outcomes. Our aim in this series is not to revisit all the aspects of this publication, but rather to analyze more specifically the benefits of this procedure as it pertains to the preservation of neurological structures of vision-specifically the optic chiasm-and provide a more detailed analysis of visual outcomes in these patients.