Transorbital Endoscopic Eyelid Approach for Resection of Spheno-Orbital Meningiomas with Predominant Hyperostosis: Report of Two Cases and Review of the Literature

Introduction: Spheno-orbital meningiomas (SOM) are slow growing tumors originating from the sphenoidal wing, associated with visual deterioration, extrinsic ocular movement disorders and proptosis caused by hyperostosis of the lateral wall of the orbit. In some cases, the intracranial component is quite small or “en plaque” and the majority of the symptoms arise from adjacent hyperostosis. Craniotomy has traditionally been the standard of care but new minimally invasive multiportal endoscopic approaches offers an alternative. In the current study we aim to present our experience with the transorbital endoscopic eyelid approach for the treatment of two patients with spheno-orbital meningiomas and sphenoid wing hyperostosis.

Methods: A transorbital endoscopic approach was used to remove the lateral and superior orbital walls to relive proptosis in two patients with spheno-orbital meningiomas. An endonasal removal of the lamina papyracea was performed to create room for orbital mobilization. A PubMed search using the terms “transorbital endoscopic approach,” “multiportal endoscopic approach” and “transorbital endonasal approach” was done to identify reports of patients submitted to the multiportal endoscopic approach for spheno-orbital meningiomas.

Results: We report two patients with spheno-orbital meningiomas and proptosis from sphenoid wing hyperostosis. One had prior craniotomy to debulk the intracranial portion of the tumor and the other had minimal intracranial component. Both patient were discharged 2 days after surgery. MRI and CT scans demonstrated significant debulking of the hyperostotic bone and resolution of proptosis. Review of the literature revealed one publication with 3 reports of transorbital eyelid approach for spheno-orbital meningiomas. No measure of relief of proptosis after this surgery has been reported.

Conclusion: The transorbital endoscopic approach, combined with endonasal decompression of the medial orbit, may be a useful minimally invasive alternative to craniotomy in a subset of spheno-orbital meningiomas with predominantly hyperostosis of the orbital wall and minimal intracranial bulky or merely “en plaque” disease. In these cases, relief of proptosis and optic nerve compression are the primary goals of surgery, rather than gross total resection, which may carry too high a morbidity or be unachievable through any approach.