Transorbital neuroendoscopic surgery for lateral skull base pathologies: Early institutional experience

Background: Minimally invasive endoscopic approaches to the skull base have expanded the range of surgical options for lesions traditionally resected through transcranial approaches. Transorbital Neuroendoscopic Surgery (TONES) offers a direct lateral corridor to the anterior and middle cranial fossae while minimizing brain retraction and damage. We report two cases utilizing TONES for two distinct lateral skull base pathologies. Case Description: We highlight the clinical outcomes of the TONES approach for two patients. Case 1 involved a 37-year-old male who underwent resection of a lateral sphenoid wing meningioma. Case 2 involved a 38-year-old female who underwent repair of bilateral lateral recess meningoencephaloceles and chronic cerebrospinal fluid (CSF) leak using a staged hybrid approach combining TONES and endoscopic endonasal surgery. In Case 1, a superior eyelid crease incision with lateral orbital rim osteotomy provided a direct transorbital corridor to the lateral sphenoid wing, achieving a Simpson Grade II resection while preserving cranial nerve function and excellent cosmesis. There was no recurrence at 6 months. In Case 2, a hybrid strategy using a left-sided TONES approach with the right-sided endoscopic endonasal transpterygoid repair addressed bilateral skull base defects with no CSF leak at 1 year. Both patients experienced good postoperative recovery without neurological morbidity. Conclusion: TONES represents an appropriate minimally invasive approach for selected lateral skull base pathologies. Strategies integrating transorbital and endonasal corridors create better exposure and minimize excessive dissection and morbidity. With an experienced team of committed oculoplastic surgeons, otorhinolaryngologists, and neurosurgeons, patients with selected lateral skull base pathologies could benefit from this surgical option.