Microsurgical Lateral Orbital Approaches to Resect Tumors within the Cavernous Sinus, Middle Fossa, and Temporal Lobe: A Systematic Review.

Common approaches to remove skull base tumors invading the orbital apex, cavernous sinus, middle fossa, or temporal lobe include orbitozygomatic or fronto-orbital craniotomies. Recently, different types of orbital approaches have been described as alternative minimally invasive techniques.  With this systematic review, we analyzed the typology of intracranial tumors treated through transorbital approaches, especially through the lateral orbital (LO) wall, and analyzing the complication rates and outcomes.  A PubMed/Medline search was performed using the criteria: "orbitotomy," "transorbital," "transpalpebral," and "lateral orbitotomy" in combination with "cavernous sinus," "middle fossa," and "temporal lobe."  From these reports, we collected diagnoses, lesion sizes and locations, approaches, outcomes, aesthetic outcomes, postoperative ptosis, postoperative cranial nerve (CN) palsies, length of CN deficits postoperatively, overall complications, and follow-up length.  A total of 13 papers and 3 of our own cases matched our inclusion criteria totaling 160 patients. Most patients were treated for meningiomas (135, 84.4%). The approaches included the LO approach (  = 54; 33.8%), deep transorbital (  = 5; 3.1%), mini-LO (  = 91; 56.9%), and modified LO (  = 10; 6.2%). While not all cases reported excision success, the various LO approaches achieved total (  = 42; 26.25%) resection margins. Postoperative ocular complications (including CN palsies, proptosis, or ocular disturbances) totaled 46 (28.8%) new CN palsies, 23 (14.4%) occurrences of vision loss, 1 (1.7%) with worsened proptosis, 5 (3.9%) with worsened enophthalmos, and 42 (26.3%) other complications.  Microsurgical LO approaches, especially in the era of radiosurgery, may become a suitable alternative to other more established craniotomies.