J Korean Neurosurg Soc.  2018 May;61(3):407-414. 10.3340/jkns.2017.0208.

Modified Orbitozygomatic Approach without Orbital Roof Removal for Middle Fossa Lesions

• López-Elizalde R
• Robledo-Moreno E
• O´Shea-Cuevas G
• Matute-Villaseñor E
• Campero A
• Godínez-Rubí M

• KMID: 2417366
• DOI: http://doi.org/10.3340/jkns.2017.0208

Abstract

OBJECTIVE
The purpose of the present study was to describe an OrBitoZygomatic (OBZ) surgical variant that implies the drilling of the orbital roof and lateral wall of the orbit without orbitotomy.
METHODS
Design : cross-sectional study. Between January 2010 and December 2014, 18 patients with middle fossa lesions underwent the previously mentioned OBZ surgical variant. Gender, age, histopathological diagnosis, complications, and percentage of resection were registered. The detailed surgical technique is described.
RESULTS
Of the 18 cases listed in the study, nine were males and nine females. Seventeen cases (94.5%) were diagnosed as primary tumoral lesions, one case (5.5%) presented with metastasis of a carcinoma, and an additional one had a fibrous dysplasia. Age ranged between 27 and 73 years. Early complications were developed in four cases, but all of these were completely resolved. None developed enophthalmos.
CONCLUSION
The present study illustrates a novel surgical OBZ approach that allows for the performance of a simpler and faster procedure with fewer complications, and without increasing surgical time or cerebral manipulation, for reaching lesions of the middle fossa. Thorough knowledge of the anatomy and surgical technique is essential for successful completion of the procedure.

Keyword

Skull base; Orbit; Zygoma; Neurosurgery; Craniotomy; Cranial fossa, Middle

MeSH Terms

Cranial Fossa, Middle
Craniotomy
Cross-Sectional Studies
Diagnosis
Enophthalmos
Female
Humans
Male
Neoplasm Metastasis
Neurosurgery
Operative Time
Orbit*
Skull Base
Zygoma

Figure

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  Fig. 1. A : The location of the skin incision is strategic. Thus, it respects the main trunk of the superficial temporal artery, the auriculotemporal nerve, and the main trunk of the VII cranial nerve and its frontotemporal and supraorbital branches. B : Main artery trunk of the superficial temporal artery is displaced forward along with the cutaneous flap. Later, the deep fascia of the temporal muscle is dissected retrogradedly to preserve the aponeurotic blade and the neurovascular supply. C : Once the cutaneous flap is elevated, the temporal muscle is dissected for disinsertion and rejection toward the malar eminence, leaving a muscle and fascia eyebrow of approximately 3×1 cm at the level of the superior temporal line, as well as at the location of the primary trepan. D : frontotemporo-sphenoidal (pterional) craniotomy model in the variant of the proposed surgical technique.

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  Fig. 2. A : The bony surfaces of the orbital roof and the lateral wall are observed after the pterional craniotomy, rendering it difficult to access the cranial vault. It is necessary to retract the brain to a greater degree in order to achieve better visualization of the skull base when the orbital roof is not drilled. B : In this image, the proposed technique is shown: an OBZ approach without orbitotomy but with the drilling of orbital roof and lateral wall. It can be observed that that drilling of all roof bony protrusions enlarges the access field to the cranial fossa. C : The same procedure as in (B) was performed. The dashed lines indicate the site where the osteotomy would be performed in a conventional OBZ approach. D : conventional OBZ approach after orbitotomy with exposure of periorbital soft tissues. When comparing (B) and (C) with (D), it may be observed that, with sufficient drilling, there is no need to remove the orbital roof and wall, unless the pathology involves the orbit itself. Arrowheads in (C) and (D) shows that the space gained in both procedures is comparable. E : The orbital drilling in the model proposed provides an opportunity to obtain a broad corridor, thus avoiding retraction and cerebral contusion. F : Access to the cranial fossa after removing the orbit in the conventional OBZ approach. In (E) and (F), it can be observed that the surgical field in the proposed and the conventional approaches is similar. OBZ : OrBitoZygomatic.

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  Fig. 3. Model of a complementary transzygomatic approach. A : It can be observed that by removing 3 cm from the zygomatic arch, the access to the infratemporal fossa is widened, which allows to increase the depth of the surgical field, the angle of vision, and reduces cerebral retraction when approaching injuries in the infratemporal fossa or the cavernous sinus. B : A tranzygomatic approach is combined with peeling of the middle fossa and a Kawase approach to access the middle fossa, with no need to remove the orbit.

Reference

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