Transorbital Craniotomy via Extended Lateral Orbitotomy via Transpalpebral Incision: Case Report and Anatomical Study

Introduction: The transpalpebral approach has become increasingly utilized for anterior skull base tumors and has demonstrated similar efficacy compared with the transcilliary supraorbital approach. Its cosmetic outcomes are more than acceptable with a decreased risk of supraorbital nerve hypesthesia and frontotemporal nerve injury.

Methods: We introduce a variation on the transpalpebral approach to access medial middle fossa structures (e.g., cavernous sinus or Meckel’s cave lesions) by posterior extension of a standard lateral orbitotomy. This approach was studied in cadaver specimen and applied to patients with lateral orbital apex and or medial middle fossa tumors.

Technique: The transpalpebral approach variation herein described utilizes the standard transpalpebral incision extended above and 1 cm lateral to the lateral canthal angle. Periosteum of the lateral orbital rim is incised and elevated from the lateral orbital wall and orbital roof. The temporalis muscle is also dissected in a subperiosteal fashion off the lateral orbital wall and temporal fossa. The lateral orbital osteotomies are performed at the level of the zygoma inferiorly and the frontozygomatic suture superiorly. The lateral orbital rim is outfractured and the posterior wall is rongeured and drilled to the superior orbital fissure, exposing dura. This allows access to the lateral orbital apex and middle cranial fossa. Once exposed, subdural dissection allows for exposure of Meckel’s cave via a modified Dolenc approach with subsequent exposure of the cavernous sinus. Satisfactory range of motion and degree of freedom exists in this large potential space.

Index Case: A 66-year-old woman presented with progressive diplopia and an enhancing 1.5cm lateral orbital tumor extending into the middle fossa, suspicious for schwannoma. She underwent an extended lateral orbitotomy alone and gross total resection of the tumor. There was no immediate postoperative complications and the patient’s vision was stable after surgery.

Conclusion: The extended lateral orbitotomy approach to intracranial tumors is a novel variation of an existing technique and demonstrates versatility to access lesions that would otherwise require approaches with more significant soft-tissue disruption. This approach is ideal for some orbital apex, middle cranial fossa, cavernous sinus and Meckel’s cave lesions.