Endoscopic Transorbital Approaches for Surgical Treatment of Middle Fossa Pathology: A Case Series
Bibliographic record
Abstract
Background: In recent years, there has been a shift towards minimally invasive neurosurgery for certain skull base pathologies, focusing on more discrete incisions, smaller craniotomies, and minimal brain retraction. Endoscopic transorbital approaches have been increasingly used to treat lesions of the middle fossae. Lesions such as sphenoid wing meningiomas, trigeminal schwannomas or cavernous sinus disease, which would traditionally require a fronto-temporal craniotomy, can be treated with this minimally invasive approach. Case Presentation: We report four cases of endoscopic transorbital procedures: 3 for removal of sphenoid wing meningiomas, and 1 for a cavernous sinus biopsy. Our surgical approach consists of a superior eyelid approach to the orbital rim and subsequent endoscopy-assisted exposure of the lateral and superior wall of the orbit. Drilling of the sphenoid wing is then pursued to expose the middle fossa dura and meningo-orbital band, and to unroof the superior orbital fissure. Depending on the pathology, the optic canal, anterior clinoid or lateral wall of the cavernous sinus can be reached. The first case is a 63-year-old woman with a left sphenoidal meningioma . Subtotal resection was achieved using a left-sided approach. The patient required reoperation for CSF leak repair on postoperative day 2. The postoperative MRI showed very subtle tumor residue on the anterior clinoid process. She did well on follow-up without any neurological deficit. The second case is a 59-year-old woman with a left spheno-orbital meningioma and predominant hyperostosis diagnosed following progressive loss of vision in her left eye, exophthalmia and constant ocular pressure. Subtotal resection was achieved using a superior eyelid approach. Her surgery involved extensive drilling of the sphenoid wing hyperostosis, decompression of the optic canal and partial anterior clinoidectomy. This was achieved without resection of the orbital rim. Postoperatively, the patient developed transient 3rd, 4th, 5th, and 6th cranial nerve palsies, which had fully recovered on 5-week follow-up. The patient had significant improvement of her vision and the proptosis improved as well. The third case is a 59-year-old woman with a right incidental sphenoid wing meningioma who, underwent subtotal resection with no complications. The last case is an 86-year-old woman who presented with right-sided trigeminal neuralgia and facial hypesthesia. MRI showed an ipsilateral cavernous sinus lesion of unknown etiology. A biopsy was performed using an eyelid approach with interdural dissection for exposure of the lateral wall of cavernous sinus. Pathology findings revealed a nonaggressive lymphoma which was treated with palliative radiotherapy. Her symptoms partially improved after the treatment. Conclusion: Endoscopic transorbital procedures are effective in the treatment of lesion of the middle fossa. They offer a minimally invasive approach with a barely visible scar and minimal brain retraction. These approaches allow access to previously mentioned structures in a more direct trajectory than a pterional or subtemporal approach. Multilayered reconstruction and gentle orbit retraction is necessary to avoid complications. Although the learning curve can be steep, as with all minimally invasive surgeries, we advocate that endoscopic transorbital approaches through the eyelid are an alternative to traditional fronto-temporal craniotomies in the surgical management of middle fossa pathology. Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.004 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.002 |
| Bibliometrics | 0.004 | 0.003 |
| Science and technology studies | 0.004 | 0.003 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.002 | 0.003 |
| Research integrity | 0.006 | 0.004 |
| Insufficient payload (model declined to judge) | 0.003 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".