A Review of the Lateral Orbitotomy Approach to Resect Tumors Within the Cavernous Sinus and Temporal Lobe

Introduction: Skull base tumors may invade the orbit, orbital apex, and/or cavernous sinus (CS). Common approaches to remove these invasions include invasive orbitozygomatic or fronto-orbital craniotomies. Recently, different types of orbital approaches have been described as minimally invasive techniques for the treatment of this subset of skull base tumors. Due to these tumors' close proximity to the internal carotid artery and cranial nerves (CNs) II–VI, these vital structures may be at risk. With this systematic review we aimed at analyzing the typology of intracranial tumors treated through trans orbital approaches, the complication rates, and outcomes.

Methods: A PubMed/Medline search was performed. We included all studies published, using the key words, “orbital,” “lateral orbitotomy,” “transorbital” in combination with “cavernous sinus,” “temporal lobe” and “intracranial.” All reports of orbital approaches being used for removal of skull base tumors in these regions were included in our analysis. Papers describing endoscopic approaches or intraorbital tumors indications were excluded. From these reports, we collected diagnoses, lesion sizes, lesion locations, approaches used, outcomes (total, near-total, subtotal resection), aesthetic outcomes, postoperative ptosis, postoperative CN palsies, length of CN deficits postoperatively, overall complications, and follow-up length.

Results: A total of 19 papers matched our inclusion criteria totaling 29 patients. 5 (17.2%) of these patients were treated for meningiomas, 13 (44.8%) for cavernous hemangiomas, and 13 (44.8%) for other pathological indications, such as non-meningioma or hemangioma tumors (n = 9; 31.0%), venolymphatic malformation, trauma, dermoid cyst, or infection (n = 1 for all; 3.4%). The approaches included Lateral Orbital approach (n = 14; 4.3%), deep transorbital (n = 4; 13.8%), posterior inferior orbitotomy through Caldwell-Luc incision (n = 4; 13.8%), right lateral orbitotomy by a bicoronal approach (n = 1; 3.4%), frontotemporal craniotomy combined with a posterolateral orbitotomy and anterior clinoidectomy (n = 1; 3.4%), and a frontotemporal craniotomy combined with a lateral superior orbitotomy (n = 1; 3.4%), and transcaruncular (n = 4; 13.8%). While not all cases reported excision success, all LO approaches achieved total (n = 6; 66.7%), near total (n = 2; 22.2%), or subtotal (n = 1, 11.1%) resections. Of the reported complications, one patient who underwent the LO approach had enophthalmos and another had ptosis and diplopia which resolved by the 9-month postoperative checkup. One patient who underwent the deep transorbital approach suffered from oculomotor nerve fragmentation. The posterior inferior approach resulted in decreased eye movements in one patient which improved over time and a posterior orbital floor defect in another patient. A patient who underwent a frontotemporal craniotomy with a lateral superior orbitotomy developed an asymptomatic and time-limited carotid-cavernous fistula, but they presented for a traumatic ocular injury. The transcaruncular approach resulted in diplopia for one patient and an ethmoid mucocele and polyps for another patient.

Conclusions: Orbital approaches to resect tumors located in the cavernous sinus and temporal lobe are less frequently reported compared with compared with the more standard routes. However, those approaches, especially in the era of radiosurgery, may become a more frequent treatment modality for these tumors, which normally require more extensive and invasive approaches. Further research is warranted to optimize these novel neurosurgical approaches.

Publication History

Article published online:
01 February 2023