Combined Endoscopic Endonasal and Transorbital Multiportal Approach for Complex Skull Base Lesions Involving Multiple Compartments

Objective: This study defined the specific areas that connect the surgical corridors of the endoscopic endonasal (EEA) and transorbital approach (TOA) to identify adequate clinical applications and perspectives of this combined multiportal approach. Methods: Consecutive patients who underwent combined EEA and TOA procedures for various pathologies involving multiple compartments of the skull base were enrolled. The different visualizations provided by each approach to the common target connecting the surgical window of the EEA and TOA procedures are highlighted. Results: Eight patients were included between August 2016 and April 2021. The cavernous sinus (CS) was targeted as the common path of the combined approach in four patients with tumors infiltrating the middle cranial fossa (MCF) and central skull base through the CS. The EEA procedure reached the CS from a medial-to-lateral direction. These tumors located in the MCF and lateral compartment of CS were accessed through the TOA corridor; hence, a complete inspection of the CS was achieved using the combined approach. For two patients with MCF tumors extending into the infratemporal fossa (ITF), the horizontal portion of the greater sphenoid wing (hGSW), and the foramen ovale were utilized as the connection area. The TOA procedure accessed the MCF, and the transmaxillary modules of the EEA approached the ITF. Drilling of the base of the hGSW facilitated communication between the MCF and ITF. In the remaining two patients, connection was achieved through the optic canal (OC). Circumferential removal of bone composing the OC was performed in one patient with traumatic compressive optic neuropathy; the EEA procedure accessed the inferomedial part of the OC, while the TOA procedure accessed the superolateral part of the OC. In the other patient, the intracranial compartment of the optic pathway glioma was removed via the EEA procedure, and the intraconal compartment was removed using the TOA procedure. Communication between the intracranial space and orbit was achieved through the OC. Postoperative complications included one cardiac arrest due to underlying cardiovascular disease and one case of oculomotor nerve palsy. Conclusion: The combined EEA and TOA procedure is a useful strategy for complex lesions involving multiple compartments of the skull base. Herein, we identified the specific areas connecting the two surgical approaches, allowing a common path for EEA and TOA procedures to achieve better visualization of pathology with improved surgical accessibility. Publication History Article published online: 15 February 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany