Modified Lateral Orbitotomy Approach to Lesions of the Orbital Apex, Superior Orbital Fissure, Cavernous Sinus, and Middle Cranial Fossa

BACKGROUND: The lateral orbitotomy approach (LOA) provides minimally invasive access to the orbit, cavernous sinus region, and middle cranial fossa. Orbital retraction with this approach can nonetheless injure orbital structures, causing unnecessary morbidity. OBJECTIVE: To describe our clinical experience with the modified LOA (mLOA), wherein the medial aspect of the lateral orbital wall posterior to the orbital rim is preserved. METHODS: This is a retrospective, single-institution case series of patients undergoing a mLOA for lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The dimensions and variance of selected anatomic parameters relevant to this approach (orbital rim-superior orbital fossa depth, lateral orbital wall angle) were also analyzed using computed tomography scans from 30 adult patients. RESULTS: Eight patients underwent a mLOA (mean age 54.0 ± 19.6 years; 3 males). Surgical targets included the superior orbital fissure (2; cavernoma and meningioma), sphenoid wing with or without the orbital apex (2; meningioma), cavernous sinus (2; rule out carcinoma and smooth muscle tumor), and anterior/mesial temporal lobe (2; cavernoma). Visual acuity/fields and diplopia was stable or improved in all patients postoperatively. One patient experienced a cerebrospinal fluid leak. On computed tomography analysis, the relevant bony anatomy displayed limited variability, with a mean orbital fossa depth of 42.7 ± 2.8 mm and a lateral orbital wall angle of 44.4° ± 2.7°. CONCLUSION: The mLOA can provide safe, minimally invasive access to select lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The operative corridor has relatively consistent bony anatomy.