Orbitozygomatic Approach to Parasellar Lesions

Abstract

Objective: To study the orbitozygomatic approach for parasellar region. Its applicability, extent of exposure and feasibility in a series of sixteen patients with different parasellar lesions operated on during the period between 2000 and 2009.

Patients and methods: the study included sixteen patints (nine females and seven males) with different parasellar lesions operated on through the orbitozygomatic approach. The age of the patients ranged from twenty one to sixty five (mean 47.6). The lesions included ten parasellar meningiomas, ( five sphenoid ridge meningioma, three clinoidal meningioma and two cavernous sinus meningioma), five of them with intraorbital extension, three trigeminal neurinomas, one cavernous sinus cavernoma, one aneurismal bone cyst and one retrochiasmatic craniopharyngioma

Results: The main presenting symptoms were headache, diplopia, visual disturbance, and epilepsy. Total removal was done in thirteen patients and subtotal in three (two cavernous sinus meningiomas and one cavernous sinus cavernoma). Extraocular muscle palsy occurred in three patients, one of them had permanent deficit and two improved, one patient with third nerve palsy was subjected to operation for elevation of the upper eyelid by an ophthalmologist. CSF rhinorhea occurred in one patient and was complicated with bacterial meningitis. It was treated by repeated lumber puncture and antibiotics but it was not responding for a long period and yielded poor patient outcome. Outcome was classified into: excellent, if the patient has no neurological deficit; good if the patient has normal daily activity with minor neurological dysfunction; fair, if the patient is moderately disabled but independent with major neurologic deficit; poor if the patient has sever neurologic disability and totally dependent. In this study outcome was excellent in nine patients, good in five patients, fair in one patient and poor in one patient. The fair result was due to contralaterl hemiplegia as a result of occlusion of the sylvian vein on the left side and subsequent venous infarction. The poor result was due to post operative meningitis as a result of CSF rhinorrhea.

Conclusion: Orbitozygomatic approach provides better exposure to the parasellar region than conventional pterional and subtemporal approaches. The exposure is wider, the working distance is shorter, and the anatomic verifications of vital structures is better. This approach, however, is technically more demanding because the familiarity with the topographic anatomy and the microsurgical techniques are essential to its execution.