transorbital approach to sphenoid wing · pdf filepterional approach or craniotomy with...

Darlene E. LUBBE, Hamzah MUSTAK and Kris S. MOE

TRANSORBITAL APPROACH TO SPHENOID WING MENINGIOMAS

TRANSORBITAL APPROACH TO SPHENOID WING MENINGIOMAS

Darlene E. LUBBE1, Hamzah MUSTAK2, Kris S. MOE3

1| Associate Professor, FCORL(SA)Division of Otolaryngology, University of Cape Town, South Africa

2| Doctor, Consultant, FCOphth(SA)Division of Ophthalmology, University of Cape Town, South Africa

3| Professor, Departments of Otolaryngology, Head and Neck Surgery, and Neurological Surgery

Chief of Division of Facial Plastic and Reconstructive SurgeryUniversity of Washington, Seattle, WA, USA

Transorbital Approach to Sphenoid Wing Meningiomas4

Transorbital Approach to Sphenoid Wing Meningiomas

Darlene E. Lubbe1, Hamzah Mustak2, Kris S. Moe3

1| Associate Professor, FCORL(SA)Division of Otolaryngology, University of Cape Town, South Africa

2| Doctor, Consultant, FCOphth(SA)Division of Ophthalmology, University of Cape Town, South Africa

3| Professor, Departments of Otolaryngology,Head and Neck Surgery, and Neurological SurgeryChief of Division of Facial Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, USA

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Correspondence address of the fi rst author: Professor Darlene LubbeDivision of OtolaryngologyH-53 Old Main BuildingGroote Schuur Hospital, ObservatoryCape Town, South Africa, 7925E-mail: d@profl ubbe.co.za

Transorbital Approach to Sphenoid Wing Meningiomas 5

Table of Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2 Transorbital Management of Sphenoid Wing Meningiomas . . . . . . . . . . . . . . . . . . . . . . 8

2.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.2. Traditional Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.3. Reasoning Behind Minimally Invasive Approach . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.4. Regional Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.4.1. Optic Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.4.2. Medial Canthus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.4.3. Lateral Canthus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.4.4. Lateral Orbital Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3 Sphenoid Wing Meningioma Surgery – A Four-Step Endoscopic Transorbital Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3.1.1. Step 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.1.2. Step 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.1.3. Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173.1.4. Step 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

4 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

7 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

8 Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

7Transorbital Approach to Sphenoid Wing Meningiomas

1 Introduction

Combined open and endoscopic techniques have successfully been utilized to treat lesions outside the reach of the traditional transnasal endoscopic pathway. Using the transorbital approach and utilizing the four surgical pathways described by surgeons at the University of Washington, certain tumors involving the orbit, sinonasal cavity, anterior and middle cranial fossae can be addressed with minimal morbidity. In our experience, better surgical access is obtained, visualization is superior and success rates with regards to visual outcomes are improved, especially in patients with hyperostotic sphenoid wing meningiomas with optic nerve compression.

Sphenoid wing meningiomas are notoriously diffi cult tumors to manage due to their location and proximity to vital structures – the optic nerve, superior orbital fi ssure, internal carotid artery and cavernous sinus. The gold standard approach for the majority of tumors is the pterional approach or craniotomy with resultant extensive tissue dissection. Patients often have severe morbidity – pain and discomfort – with residual proptosis, visual defi cits and pain post surgery. We describe a technique whereby the optic nerve is fi rst decompressed through an endonasal or precaruncular approach. A 180-degree

medial decompression is performed from the optic protuberance for a distance of at least 1cm along the optic canal. We feel that by fi rst performing an optic nerve decompression there is less risk of pressure on the optic nerve during removal of the lateral and superior orbital hyperostotic bone. The main symptoms of patients with sphenoid wing meningiomas are proptosis, visual loss and orbital pain. Our approach addresses these 3 problems with the lateral orbital pathway giving wide surgical access for removal of the intracranial and orbital components of the tumor.

The following endoscopic procedures will be demon-strated in this booklet:

Transorbital management of sphenoid wingmeningiomas.

� Endoscopic transnasal medial optic nervedecompression.

� Endoscopic precaruncular optic nervedecompression.

– Lateral transorbital approach. – Removal of hyperostotic bone. – Removal of intracranial component.

8 Transorbital Approach to Sphenoid Wing Meningiomas

2 Transorbital Management of Sphenoid Wing Meningiomas

2.1. Background

Sphenoorbital meningiomas are complex tumors that arise in the dura of the sphenoid wing. They are characterized by hyperostosis of the sphenoid bone. The primary tumor enters the orbit through the optic canal or superior orbital fi ssure. The most common clinical manifestations of sphenoorbital meningiomas are proptosis and visual loss due to progressive invasion of the orbit and compression of the optic nerve. In cases of superior orbital fi ssure

involvement varying degrees of ophthalmoplegia may arise owing to compression of cranial nerves (III, IV, V1, VI) entering the orbit. Surgical treatment of sphenoorbital meningiomas may be associated with signifi cant morbidity due to the location of the tumor, and complete surgical resection is often not feasible because of the risk of new or worsening neurological defi cits.

2.2. Traditional Approaches

The gold standard surgical approach to resect sphenoorbital meningiomas includes the pterional approach or variations thereof, and lateral orbitotomy. Surgery is aimed at preserving residual visual function and although there are reports of vision improving

post surgery, between 14–24% of patients have unpredictable deterioration. Studies report up to 20% incidence of new cranial nerve defi cits (mostly CN III palsy), especially for medial-third sphenoid wing meningiomas.3

2.3. Reasoning Behind Minimally Invasive Approach

The combined endoscopic transnasal and lateral transorbital approach is aimed at preserving/ improving residual visual function, resolving the proptosis, improving pain, removing the intracranial and where possible, the orbital components of the tumor after resection of the hyperostotic bone. The technique described here is an endoscopic assisted, minimally invasive approach that provides a wide surgical pathway to the intracranial component of the tumor. The more lateral hyperostotic bone present, the wider the lateral surgical pathway. Visual loss post surgery is the most feared complication

of sphenoid wing meningioma surgery and the technique described here seems to minimize the risk of this dreaded complication. Patients with residual visual function often have a dramatic improvement in their vision within 2 weeks of surgery. Using the technique described here, none of our patients had worsening vision post surgery. The most likely reason for visual preservation/improvement is the fact that the optic nerve is decompressed prior to tumor resection, minimizing the risk of pressure on the optic nerve during dissection.


2.4. Regional Anatomy

2.4.1. Optic Canal

The optic canal is an approximately 10-mm bony corridor, the entrance of which is located in the superomedial orbital apex (optic foramen). The optic nerve, ophthalmic artery and accompanying sympathetic plexus course through this canal as they pass into the orbit from the intracranial space. The walls are formed by the bone of the sphenoid (medially) and its lesser wing (laterally). A fi brous ring, the annulus of Zinn, is attached to the upper, medial and lower aspects of the optic foramen and forms the attachment point for the origin of the rectus muscles. The optic canal courses posteromedially – its medial wall projecting into the upper lateral wall of the sphenoid sinus (Figs. 2.1, 2.2a–c).

The internal carotid artery passes through the lateral wall of the sphenoid sinus en route to the cavernous sinus. The junction between the carotid prominence and the fl oor of the optic canal forms the lateral opticocarotid recess, which is found approximately 10 mm from the optic protuberance (Fig. 2.1). Great care must be taken when drilling over the bony canal to avoid carotid artery injury. The lateral opticocarotid recess is the landmark for the posterior limit of the optic canal decompression. The ophthalmic artery branches from the medial aspect of the internal

Fig. 2.2 Superior view of internal surface of skull base (a). Axial CT scan (b). Osteological specimen (c). Optic canal formed by lesser wing of sphenoid ( ) and sphenoid sinus ( ), superior orbital fi ssure ( ).

a b c

carotid just above the cavernous sinus. It enters the optic nerve sheath inferomedially and runs below the optic nerve, within the optic canal. There is some anatomical variation in the position of the ophthalmic artery within the canal but it tends to lie most commonly in the inferomedial segment.

Fig. 2.1 A Right optic nerve ( ) endonasally visualized. Optic protuberance ( ); Annulus of Zinn ( ); Posterior ethmoidal artery (PEA); Opticocarotid recess (OCR); Internal carotid artery (ICA).

Annulus of Zinn

PEA

OCR

ICA


2.4.2. Medial Canthus

The medial canthus forms the medial border of the palpebral fi ssure. The surface anatomy includes a triangular soft tissue density known as the caruncle that is bordered laterally by the crescent-shaped plica semilunaris. The lacrimal puncta are located in the medial upper and lower lids. The tarsal plates of the upper and lower lids are attached to the medial bony orbit by the medial palpebral ligament, which comprises an anterior limb (attaches to the anterior lacrimal crest), a posterior limb and a superior limb. The precaruncular approach involves an incision at the border between the skin and caruncle (Fig. 2.3). The upper and lower canaliculi can be

intubated in order to avoid injury to the canalicular system. The incision is then extended superiorly and inferiorly into the conjunctiva. Blunt-tipped dissection scissors are then used to dissect a plane directed at the medial orbital wall just behind the posterior lacrimal crest in order to avoid injury to the medial palpebral ligament. The periosteum is then incised and elevated with a Freer elevator and a subperiosteal dissection is carried out. The anterior eth-moidal artery is identifi ed and cauterized or ligated and dissection carried out posteriorly to expose the posterior ethmoidal artery followed by the optic protuberance and the optic canal.

2.4.3. Lateral Canthus

The lateral canthal tendons are lateral condensations of the upper and lower tarsi that attach to a bony promontory on the zygomatic bone known as Whitnall’s tubercle. A lateral canthotomy involves incising the skin over the lateral canthal area starting in the canthal angle and extending over the orbital rim. Blunt dissection is then carried out through the underlying orbicularis down to the orbital rim. An incision is made in the periosteum overlying the lateral rim and subperiosteal dissection carried out medially over the rim to expose Whitnall’s tubercle. The canthal tendon can then be divided to allow adequate space for a subperiosteal dissection before the bony orbitotomy is performed.

An alternate incision that affords wider access and is better served for tumors extending to the superior orbit, is the extended upper lid skin crease incision. The upper lid crease is found approximately 8–10 mm above the upper

lid margin and is formed by attachment of the levator to the tarsus and overlying skin. A skin incision is made in the upper lid crease and extended to the lateral canthal area, into the natural crease lines above the lateral canthal angle, and over the lateral rim (Figs. 3.7a–c). The skin edges are then elevated under tension and an incision is made through the underlying orbicularis into the pre-aponeurotic space. This suborbicularis pocket is then extended with blunt dissection up to the superior orbital rim. Care must be taken not to breach the orbital septum and cause herniation of orbital fat. The periosteum of the superior orbital rim is exposed and incised approximately 10 mm above the arcus marginalis. A subperiosteal dissection is then carried out inferiorly past the rim and extended posteriorly. Careful dissection should be carried out medially to avoid injury to the supra-orbital neurovascular bundle.

Fig. 2.3 The caruncle of the right eye and the precaruncular approach in a cadaver (a) and in a patient (b).

a b


2.4.4. Lateral Orbital Wall

The lateral wall of the orbit is formed mainly by the greater wing of the sphenoid with contributions from the zygoma and zygomatic process of frontal bone anteriorly (Fig. 2.4). The recurrent meningeal branch of the middle meningeal artery may be seen coursing through a foramen in the suture line between the frontal and sphenoid bones(Figs. 2.4, 2.5a). This artery forms an anastomosis between the external and internal carotid arterial systems.

The contributions of the zygomatic and frontal bones to the anterolateral wall are thick and serve to protect the globe from lateral trauma. The posterior zygomatic bone and the orbital plate of the greater wing of sphenoid are thinner. The zygomatico-facial and zygomatico-temporal nerves and vessels pass through the lateral wall of the orbit to reach the cheek and temporal regions. Posteriorly the lateral wall thickens and meets the temporal bone that forms the lateral wall of the cranium.

The superior orbital fi ssure is a linear notch at the orbital apex between the greater and lesser wings of the sphenoid. The superior portion of the fi ssure is narrower and here the lacrimal, frontal and trochlear nerves pass through outside the annulus of Zinn (Fig. 2.5b). The oculomotor, abducens and nasociliary branch of the trigeminal nerve and the superior ophthalmic vein pass through the superior orbital fi ssure within the annulus of Zinn (Fig. 2.5c). Too much traction on the orbit during retraction of the orbital contents medially may lead to a superior orbital fi ssure syndrome with resultant CN III, IV, V1 and VI palsies. Great care must be taken to avoid this complication by releasing pressure on the orbit every few minutes during removal of the lateral hyperostotic bone, by observing the pupil for any change in size or shape and by asking the anesthetist to inform the surgical team in the event the patient develops a sudden bradycardia due to pressure on the ocular muscles or nerves.

Fig. 2.5a Recurrent meningeal branch of the middle meningeal artery passing throughforamen in left lateral orbital wall (in suture line between frontal and sphenoid bones).

Fig. 2.5b Left eye lateral pathway showingthe superior orbital fi ssure ( ) and theoptic nerve ( ) at the orbital apex.

Fig. 2.5c Left eye lateral pathway showing the superior orbital fi ssure ( ) with superior ophthalmic vein, CNs III, IV, V1 and VI exiting foramen. The recurrent meningeal branch of the middle meningeal artery may be seen coursing through a foramen in the suture line ( ) just anterior to the superior orbital fi ssure.

Fig. 2.4 Lateral orbital wall (left eye). Superior orbital fi ssure (SOF); inferior orbital fi ssure (IOF); greater wing of sphenoid bone ( ); zygomatic bone ( ); foramen for recurrent meningeal branch of the middle meningeal artery ( ).

Optic foramenSOF

IOF

Fig. 2.6 Left lateral surgical pathway showing tumor entering the orbit through the superior orbital fi ssure (SOF).

Greater wing Greater wing of sphenoid of sphenoid boneboneTumorTumor

throughthroughSOFSOF

Lateral rectusLateral rectusmusclemuscle


3 Sphenoid Wing Meningioma Surgery – A Four-Step Endoscopic Transorbital Approach

The order in which surgical steps are performed is thought to be of importance. The procedure consists of 4 surgical steps, most of which are performed by the otolaryngologist. An ophthalmologist can assist or perform part of the procedure and a neurosurgeon a ssists

with the 3rd step or intracranial resection, similar to the 4-handed approach used in endoscopic transsphenoidal pituitary surgery. Without special orbital retractors, 5 hands are often required to retract the orbit and maintain visualization during drilling of the surgical pathway.

3.1.1. Step 1I. Endoscopic Transnasal Medial Optic Nerve Decompression

A medial optic nerve decompression prevents compres-sion on the optic nerve during the lateral transorbital approach. Most patients present with visual loss and a medial optic nerve decompression has in the authors’ experience resulted in improved visual outcome. Two pathways are available (transnasal and precaruncular) and the choice of procedure depends on the availability and skills of the otolaryngologist and ophthalmologist.

The patient is placed in a supine position with the head slightly fl exed as for standard FESS surgery. Total intravenous anesthesia (TIVA) is used to optimize the surgical fi eld. Although an otolaryngologist performs the procedure, it is helpful to have the input from an ophthalmologist during the optic nerve decompression to determine the length of canal decompression required. The nasal cavity is prepared as for a standard FESS procedure with 2 ml of topical adrenaline or decongestant on surgical patties, placed within the middle meatus.

The technique involves a standard endoscopic sphenoethmoidectomy, removal of the posterior 1/3 of the lamina papyracea and a 180 degree medial decompression of the optic nerve in its canal from the optic protuberance for a distance of approximately 10 mm (Fig. 2.2). Navigation is helpful but by no means essential. A microdebrider or standard FESS instruments can be used to perform the sphenoethmoidectomy. A 0°-HOPKINS® endoscope (diameter 3 mm or 4 mm) and endonasal drill with diamond burrs (size 2 to 4), are used to decompress the canal.

� The spheno-ethmoidectomy is completed and the lamina papyracea is exposed in its posterior third. It is important to remove the face of the sphenoid so that the lateral wall of the sphenoid sinus, the inferomedial recess and optic nerve can be visualised to ensure complete decompression of the optic nerve in its canal. Navigation is helpful to ensure complete decompression of the optic canal, especially where meningioma invades the sphenoid sinus (Figs. 3.1–3.4).

� The optic protuberance can be identifi ed by the hard bone reached when the posterior third of the lamina papyracea has been removed (Fig. 2.2). An endonasal drill with a 2 or 3-mm diamond burr is required to gently thin the bone overlying the optic canal. Great care must be taken to ensure the optic nerve is not traumatized. This is achieved by continuous irrigation on the optic canal and by achieving good hemostasis. Once the bone overlying the optic nerve is suffi ciently thinned, an elevator or small dissector can be used to remove the overlying bone by gently fl icking the bone away from the optic nerve (Fig. 3.3). The optic canal is decompressed from the optic protuberance for a distance of approximately 10 mm; the opticocarotid recess (OCR) forms the posterior margin of the decompression. A 180°-medial decompression of the optic canal is performed, taking care not to injure the ophthalmic artery which most commonly lies inferior to the optic nerve. The artery can however lie in a more medial position and great care must be taken when removing the bone over the canal.

� A medial orbital decompression may also be required for patients with severe proptosis. The periorbital fascia is only incised at the end of the procedure since allowing fat to prolapse into the nasal cavity will make further decompression of the optic nerve impossible and future surgery diffi cult.

Endoscopic Transnasal Medial OpticNerve Decompression

� A standard sphenoethmoidectomy is performed and the posterior 1/3 of the lamina papyracea is removed.

� To assist with multiple instruments working at the target point (the optic nerve), a posterior septectomy can be performed, similar to transsphenoidal pituitary surgery. This allows 2 surgeons and 4 hands to work together. The otolaryngologist uses the endoscope and endonasal drill through one nostril, while the assistant provides a clear endoscopic view with irrigation and suction through the other nostril.


II. Endoscopic Precaruncular Medial Optic Nerve Decompression

The precaruncular approach is used to remove the lamina papyracea and perform a 180-degree medial decompression of the optic canal (Figs. 3.5a, b) Wide access is achieved with a slightly different angulation to the optic nerve than with the transnasal route. The nostril on the same side as the precaruncular incision can be

utilized as an extra corridor for another 2 instruments(Fig. 3.5c). This obviates the need for a posterior septectomy and the endoscope gets less blood on the lens, making visualization easier. If a posterior septectomy is performed, 5–6 instruments can be used at the target point.

Fig. 3.1 Right sphenoethmoidectomy completed with the maxillary sinus and sphenoid sinus visualized. The posterior 1/3 of the lamina papyracea has been removed.

Fig. 3.2 Right eye. Decompression of the optic nerve from the optic protuberance, along the optic canal for 10 mm.

PeriorbitaPeriorbitaof right eyeof right eye

Optic nerveOptic nervecanalcanal

Optic nerveOptic nerveprotuberanceprotuberance

Fig. 3.3 Right eye. Optic canal is decompressed from the optic protuberance for 10 mm along the optic canal using a small dissector. Note the opticocarotid recess (OCR).

Right eye lamina Right eye lamina papyracea removedpapyracea removed

Optic canalOptic canal

OCROCR

Fig. 3.4 Navigation is useful to ensure adequate optic canal decompression. The navigation cross-hair is seen on the medial aspect of the optic nerve.

Fig. 3.5 Precaruncular approach to the right optic nerve (a, b) and multiportal approach (c) utilizing the right precaruncular and right nasal pathways.

a b c


3.1.2. Step 2The Lateral Transorbital Approach to Sphenoid Wing Meningiomas

This is a novel approach to address the hyperostotic lateral orbital wall, superior orbital fi ssure, intracranial and orbital components of the meningioma. This surgery requires two assistants in the absence of special orbital retractors. With the use of an orbital retractor, two-surgeon surgery is possible. An ENT-Ophthalmology team is involved in removing the lateral orbital wall and hyperostotic bone involving the orbit and greater wing of the sphenoid. The surgery can be performed by either an otorhinolaryngologist or ophthalmologist trained in endoscopy. Detailed knowledge of the anatomy of the orbit is essential before embarking on the surgery.

� Three incisions are possible depending on the amount of space needed for dissection:

– Retrocanthal incision – useful for biopsies of the lateral orbit (Fig. 3.6a, b).

– Lateral canthotomy – gives adequate space, espe-cially if no superior wall involvement (Fig. 3.8).

– Superior eyelid incision with extension lateral to the lateral canthus (Figs. 3.7a, b) (sparing the lateral canthus). This is our standard approach since it provides the best access to the superior and lateral orbital walls.

� The lateral canthus of the eye is injected with a 2% lidocaine and 1:80 000 adrenaline mixture.

� An 8-mm lateral canthal incision is made (Fig. 3.8). � Blunt dissection with an iris scissors is used to dissect through the orbicularis oculi muscle onto the orbital rim, dividing the upper and lower canthal ligaments (Fig. 3.9).

� The periosteum is elevated, fi rstly off the lateral orbital rim to expose at least 2 cm of the outer lateral orbital rim. Elevating the periosteum and the temporalis muscle allows for an extra porthole to be made in the lateral orbital wall for instrumentation (Fig. 3.10).

� The periosteum is then stripped off the medial aspect of the lateral orbital wall using a Freer elevator.

� Ribbon retractors are used to protect the orbit, retract the eye medially in order to expose the lateral orbital surgical corridor and to ensure a safe corridor for instrumentation and the endonasal drill (Fig. 3.10).

� A burr hole or porthole can be drilled just behind the orbital rim (keeping the orbital rim intact for cosmetic purposes) if an extra instrument is required in a narrow corridor. A 6–7mm burr hole gives suffi cient extra space to manipulate a suction device during the dissection of the hyperostotic lateral orbital bone (Figs. 3.8–3.11).

Incisions for the Lateral Orbital Approach � Retrocanthal incision (no external incision) – useful for biopsy (Figs. 3.6a, b).

� Lateral eyelid crease with lateral extension (preserving the lateral canthus) (Figs. 3.7a–b).

� Lateral canthotomy approach (Fig. 3.8).

A 0°-endoscope (length 18 cm, diameter 3 mm or 4 mm)is used to help manipulate two to three instruments through the lateral orbital surgical pathway. A 3 mm endoscope allows for more working room within the surgical pathway. A Freer dissector is used to develop a subperiosteal plane in order to lateralize the orbital contents (Fig. 3.11).

Fig. 3.6 Retrocanthal incision (no external incision); left eye.

a b


Fig. 3.7 Superior eyelid incision with extension laterally (a). Superior eyelid crease incision, preserving the lateral canthus (b). Suture through superior eyelid to protect cornea (c).

a b c

Fig. 3.8 Right eye. Lateral canthotomy. Fig. 3.9 An iris scissors is used to dissect through the orbicularis muscle onto the orbital rim.

Fig. 3.10 A burr hole is made through the lateral orbital wall, keeping the orbital rim intact and allowing for extra instrumentation.

Fig. 3.11 Subperiosteal dissection with retraction of the right eyemedially to expose the hyperostotic bone of the lateral orbital wall (Freer suction tip on hyperostotic bone).


� Adequate space needs to be created early in the dissection to allow for instrument manipulation. This is achieved by drilling away the lateral orbital wall until the temporalis muscle is visualized (Fig. 3.12).

� Passage through the surgical pathway is easily accom-plished by using 4- and 5-mm cutting and diamond burrs that are attached to a medium and extra-long angled hand piece (KARL STORZ Tuttlingen, Germany). Great care must be taken to ensure that orbital fat and temporalis muscle do not get caught up in the shaft of the burrs during drilling.

� Once the cancellous portion of the greater wing of the sphenoid is reached, a bony tunnel is drilled, with a thin wall of bone on either side, protecting the temporalis muscle laterally and the periorbita medially (Fig. 3.13).

� All hyperostotic bone and intraosseous meningioma is drilled away, to expose the temporalis muscle antero-laterally, the dura of the temporal lobe posterolaterally, the anterior cranial fossa superiorly and the periorbita medially (Fig. 3.14).

� The superior orbital fi ssure can be identifi ed if the dissection is carried far enough posteriorly (Figs. 2.5b, c). Care should be taken near the superior orbital fi ssure (SOF) and excessive manipulation in this area should be avoided. Excessive retraction on the orbit medially should also be avoided to prevent a superior orbital fi ssure syndrome or damage to cranial nerves III, IV, V1 and VI.

The last phase of the surgery involves removing the intracranial and intraorbital components of the tumor.

Fig. 3.14 Right eye. View of the lateral orbital pathway. Note the temporalis muscle laterally, periorbita medially (under retractor), dura superiorly, and the site of the intracranial tumor.

Anterior cranialfossa dura

Intracranial tumor

Temporalismuscle

Fig. 3.13 Right eye. Lateral orbital corridor with bony tunnel drilled between the temporalis muscle and the periorbita of the eye.

Temporalismuscle

Bony tunnel

Periorbita of the righteye under retractor

Fig. 3.12 Temporalis muscle is exposed ( ) by drilling away the lateral orbital wall, keeping the orbital rim intact. The suction cannula can be visualized though the lateral burr hole.

Right eye retracted medially


3.1.3. Step 3Intracranial Tumor Resection

� It is important to have a neurosurgeon perform/ assist with this part of the procedure. The dissection is similar to the standard pterional approach with the neurosurgeon dissecting tumor off the important neurovascular structures. The neurosurgeon uses both hands for dissection while the assistant manipulates the camera.

� Complete resection depends on tumor encasement of vital structures – the internal carotid artery, the middle cerebral artery (Fig. 3.15), cavernous sinus involvement and tumor spread through the superior orbital fi ssure and optic canal. Complete resection is often not possible and may lead to cranial nerve defi cits and increased morbidity. Tumor debulking in this area is often performed with radiotherapy as a post-operative treatment option.

� The dural defect and CSF leak is repaired using abdominal fat.

3.1.4. Step 4Orbital Tumor Resection

Sphenoid wing meningiomas enter the orbit through the superior orbital fi ssure (Fig. 3.16) or optic canal. Resection of this component depends on the patient’s symptoms (visual loss, proptosis and cranial nerve involvement).

� With the assistance of an ophthalmologist the periorbita is incised laterally and the tumor is carefully dissected / debulked. Care is taken to identify the lateral rectus muscle to prevent injury.

� In certain instances where the proptosis has been adequately addressed, no obvious intra-orbital menin-gioma is visible and the patient has no pre-operative cranial nerve III, IV, V1 and VI defi cits, the periorbita may only be incised without exploring the orbit.

Fig. 3.15 Middle cerebral artery ( ) visible after intracranial tumor resection.

Fig. 3.16 Left lateral orbital pathway with intra-orbital tumor beneath the intact periorbita ( ).


4 Postoperative Care

Intraoperatively, all patients receive prophylactic anti-biotics (1 g IVI cefazolin) and a dose of systemic corticosteroids (betamethazone or dexamethazone, 8 mgIVI, depending on their weight, age and co-morbid factors).

The precaruncular wound requires no suturing. A corrugated drain is inserted in the lateral orbital pathway to prevent a post-operative hematoma. Polyglactin 5/0 is used to approximate the periosteum in the lateral incision and the skin (with the orbicularis muscle) is closed with Nylon 6/0. If a CSF-leak was created during the resection of the intracranial component, this is fi rst repaired with abdominal fat and / or fascia lata.

An ice pack is placed over the operated eye and the patient is encouraged to ice the eye on a regular basis for at least one week. The head of the bed is slightly elevated and the patient is asked to not sleep on the side of the surgery. Observations include the following:

� Neurological observations (GCS) for 24 hours. � Observe for a cerebrospinal fl uid leak. � Check eye movements (function of cranial nerves III, IV, V1, VI), for a RAPD (relative afferent pupillary defect) and gross visual assessment to make sure the vision has not deteriorated.

5 Results

The results of resection of our fi rst seven sphenoid wing meniongiomas were published in Clinical Otolaryngology in August 2016.1 Table 5.1 shows the results of the fi rst 12 patients who received a medial optic nerve decom-pression, followed by a lateral orbitotomy. All patients had a long history of visual loss and / or proptosis. Only one patient had no improvement in her vision. With the development of new instrumentation and confi dence with the procedure, total resection of some sphenoid wing meningiomas is possible.

6 Complications

Although no complications were experienced with the precaruncular approach in our series, care must be taken to prevent the following:

� A CSF leak will occur if dissection is carried above the level of the anterior and posterior ethmoidal arteries during optic nerve decompression.

� Bleeding from the anterior or posterior ethmoidal arteries with potential retraction of the arteries within the intraconal space. Dissection is aimed at fi nding the arteries so this would be an unusual complication.

� Trauma to the lacrimal system may occur if due care is not taken to identify the position of the canaliculi. When gaining experience with this approach, the surgeon can place lacrimal probes during the dissection to protect the canaliculi from damage.

� The optic nerve is vulnerable during the drilling phase of the optic nerve decompression. It is important to drill carefully along the optic canal using cold water irrigation and to skeletonize the bone over the canal, removing the last bit of bone with a Cottle elevator rather than with a drill.

Table 5.1 Key to acronyms: Counting fi ngers at 1 cm (CF); no light perception (NLP); hand movements (HM); visual acuity (VA).

Case No.Pre-Operative Post-Operative

VA VA1 NLP NLP

2 6/18 6/6

3 6/36 6/18

4 6/24 6/12

5 6/36 6/36

6 6/6 6/6

7 HM 6/9

8 CF 6/12

9 6/18 6/18

10 NLP CF

11 CF 6/24

12 HM 6/36


Complications that may occur during drilling of the lateral pathway � Herniation of fat hinders use of a drill and makes further dissection very diffi cult. The greatest risk during this part of the procedure is causing damage to the orbit and temporalis muscle by the shaft of the drill. It is therefore essential to have only a few millimeters of drill shaft exposed and this part of the drill must be kept in direct view at all times. Using an ultrasonic bone dissector can prevent any injuries caused by a drill shaft and it has the benefi t of a multifunctional instrument that can be used simultaneously for bone removal, suction and irrigation.

� Too much medial traction on the eye can cause contusion of the lateral rectus muscle, and lead to a superior orbital fi ssure syndrome with CN III, IV, V1 and VI nerve palsies. In our series we had one patient who sustained a temporary V1 neuropraxia and one patient who developed a superior orbital fi ssure syndrome with temporary neuropraxia that resolved completely after 3 months. The patient had recently undergone

radiotherapy and a craniotomy for removal of the intracranial part of the tumor. An intraoperative warning sign is the development of a bradycardia that recovers immediately on releasing the ribbon retractor.

� Sudden changes in the shape and size of the pupil is a warning sign of raised intra-ocular pressure, central retinal artery occlusion or traction on the nerves that regulate pupil size. The pupil should be inspected every few minutes and retractors removed until the pupil has returned to its normal size and shape.

� If the intracranial part of the tumor is resected, a large CSF leak will require repair using fat. An inadvertent CSF-leak can occur with thinning of the bone overlying the roof of the orbit (anterior cranial fossa) or posterolateral orbit (middle fossa CSF leak). This can be avoided using only diamond drill burrs and ‘egg-shelling’ the bone overlying the dura in these areas.

7 Conclusions

� The transorbital approach to sphenoid wing meningio-mas provides an excellent minimally invasive alternative to the traditional pterional / craniotomy approaches.

� The advantage of performing an endoscopic medial 180-degree medial optic nerve decompression prior to addressing the main tumor bulk seems to be an improvement in visual outcomes. Further studies will be required to ascertain whether performing an endo-scopic optic nerve decompression prior to a traditional approach to the main tumor bulk, may improve visual outcome.

� The main patient symptoms, visual loss and proptosis, can be adequately addressed through this minimally invasive approach.

� All bony hyperostotic bone can be removed from the lateral orbital wall – up to temporalis muscle and the dura of the anterior and middle cranial fossa.

� The more hyperostotic bone present, the wider the surgical pathway required and the wider the neuro-surgical access to the intracranial portion of the tumor.

� A surgical team consisting of an ophthalmologist and otolaryngologist can address most of the sphenoid wing meningioma with a neurosurgeon-ENT team performing the fi nal stage of the procedure.


8 Clinical Cases

All cases to date of publication (17) have been women. All except one had an improvement in vision.

The patient below is a 62 year old female patient and her history, presentation, treatment and post-operative results were similar to all the other patients.

Medical History: The patient presented with progressive visual loss in her left eye over a period of one year. She could only count fi ngers at 1 meter at the time of surgery. Her proptosis measured 25 mm pre-operatively (21 mm on the right).

Imaging revealed a large left-sided sphenoid wing meningioma with compression of the optic nerve, a lateral bony hyperostotic component and intra-orbital component (Figs. 8.1, 8.3).

Surgical approach: An endonasal, 180-degree left medial optic nerve decompression was performed and was followed by resection of the lateral hyperostotic bone and orbital component of the tumor (Fig 8.4). The lateral pathway was accessed through an extended superior eyelid incision (sparing the lateral canthus)(Fig 8.2). Navigation was used to ensure maximal optic canal decompression and removal of hyperostotic bone (Fig 8.3).

Results: Ophthalmology assessment at 6 weeks showed that the proptosis had improved to 22.5 mm (from25 mm) and visual acuity improved to 20/40 (from counting fi ngers) in the affected left eye. She still had a grade 2 RAPD on the left, as before, and the disc was still pale, as expected. She had full ocular motility and no diplopia.

Fig. 8.1 Large left sphenoid wing meningioma with compression of the optic nerve (navigation cross hairs).

Fig. 8.2 Lateral orbital incision extending from superior eyelid crease, sparing the lateral canthus.

Fig. 8.3 Navigation cross hairs at posterolateral aspect of lateral surgical pathway, nearing the superior orbital fi ssure.

Fig. 8.4 Lateral surgical pathway with ribbon retractor retracting the orbit medially.


9 References

1. LUBBE D, MUSTAK H, TAYLOR A, FAGAN J. Minimally invasive endo-orbital approach to sphenoid wing meningiomas improves visual outcomes - our experience with the fi rst seven cases. Clin Otolaryngol 2016. doi:10.1111/coa.12722.

2. MOE KS, BERGERON CM, ELLENBOGEN RG. Transorbital neuroendoscopic surgery. Neurosurgery 2010;67(3 Suppl Operative):ons16-28. doi:10.1227/01.NEU.0000373431.08464.43.

3. SUGHRUE ME, RUTKOWSKI MJ, CHEN CJ, SHANGARI G, KANE AJ, PARSA AT et al. Modern surgical outcomes following surgery for sphenoid wing meningiomas. J Neurosurg 2013;119(1):86–93. doi:10.3171/2012.12.JNS11539.

Fig. 8.5 Preoperative (a, b) and postoperative views (c, d) (taken at 3 week follow-up).

a b

c d


Surgical Handle, Blades, Tissue Forceps and Spatulas

It is recommended to check the suitability of the product for the intended procedure prior to use.

208000 Surgical Handle, Fig. 3, length 12.5 cm,for Blades 208010 – 15, 208210 – 15

208120 Blade, for Handle 208100, Fig. 20, non-sterile, package of 100

208211 Blade, Fig. 11, sterile, package of 100208215 Same, Fig. 15

533312 ADSON Tissue Forceps, serrated, 1 x 2 teeth, length 12 cm

635012 Spatula, malleable, width 12 mm, length 20 cm

635017 Same, width 17 mm635025 Same, width 25 mm

635112 Orbital Spatula, with double graduation, width 12 mm, length 20 cm

635117 Same, width 17 mm635122 Same, width 22 mm

208000

208211 208215208120

533312 635112–635122

635012–635025


474000 FREER Elevator, double-ended,semisharp and blunt, length 20 cm

479000 MASING Elevator, double-ended, graduated, sharp and blunt, length 22.5 cm

28164 DM Elevator, sharp, straight tip,slightly curved spatula, with round handle,size 3 mm, length 23 cm

505600 SENN Retractor, double-ended, blunt,length 15 cm

791815 REYNOLDS Scissors, curved, delicate tips, length 15 cm

Elevators, Retractor and Scissors

505600474000 479000 79181528164 DM


Touch Screen: Straightforward function selection via touch screen

Optimized user control due to touch screen

Set values of the last session are stored

Choice of user languages

Operating elements are single and clear to read due to color display

One unit – multifunctional:– Shaver system for surgery of the paranasal sinuses and anterior skull base– INTRA Drill Handpieces (40,000 rpm and 80,000 rpm)– Sinus Shaver– Micro Saw– Dermatome– High-Speed Handpieces (60,000 rpm and 100,000 rpm)

Two motor outputs: Two motor outputs enable simultaneous connection of two motors:For example, a shaver and micro motor

Integrated irrigation and coolant pump:– Absolutely homogeneous, micro-processor controlled irrigation rate throughout

the entire irrigation range– Quick and easy connection of the tubing set

Easy program selection via automated motor recognition

Irrigator rod included

Continuously adjustable revolution range

Maximum number of revolutions and motor torque: Microprocessor-controlled motor rotation speed. Therefore the preselected parameters are maintained throughout the drilling procedure

Maximum number of revolutions can be preset

SCB model with connections to the KARL STORZ Communication Bus(KARL STORZ-SCB)

–

–

Special Features:

–

–

–

–

–

–

Soft start function

Textual error messages –

UN

IDR

IVE

® S

III

EC

O

UN

IDR

IVE

® S

III

EN

T S

CB

UNIDRIVE® S III ENT SCB/UNIDRIVE® S III ECOThe multifunctional unit for ENT

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO



Touch Screen: 6.4" / 300 cd/m2

Weight: 5.2 kg 4.7 kg

Certified to: IEC 601-1 CE acc. to MDD IEC 60601-1

Available languages: English, French, German, numerical codesSpanish, Italian, Portuguese,Greek, Turkish, Polish, Russian

Motor SystemsSpecifi cations

System specifi cations

Mode Order No. rpm

Shaver mode oscillatingOperation mode: in conjunction with Handpiece:Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 10,000*

DRILLCUT-X® II N Shaver Handpiece 40 7120 55 10,000*

Sinus burr mode rotatingOperation mode: in conjunction with Handpiece:Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 12,000

DRILLCUT-X® II N Shaver Handpiece 40 7120 55 12,000

High-speed drilling mode counterclockwise or clockwiseOperation mode: in conjunction with: Max. rev. (rpm): High-Speed Micro Motor 20 7120 33 60,000/100,000

Drilling mode counterclockwise or clockwiseOperation mode: in conjunction with: Max. rev. (rpm): micro motor 20 7110 33 40,000/80,000

and connecting cable 20 7111 73

Micro saw mode in conjunction with: Max. rev. (rpm): micro motor 20 7110 33 15,000/20,000

and connecting cable 20 7111 73

Dermatome mode in conjunction with:Max. rev. (rpm): micro motor 20 7110 33 8,000 and connecting cable 20 7111 73

Power supply: 100 – 240 VAC, 50/60 Hz

Dimensions: 300 x 165 x 265 mm(w x h x d)

Two outputs for parallel connection of two motors

Integrated irrigation pump: Flow: adjustable in 9 steps

* Approx. 4,000 rpm is recommended as this is the most efficient suction/performance ratio.

[ ]

[ ]

[ ]


Motor SystemsHigh-speed micro motor

Brushless high-speed micro motor Smallest possible dimensions Autoclavable Reprocessable in a cleaning machine Maximum torque 6 Ncm

� Maximum torque 6 Ncm � Number of revolutions can be continuously adjusted up to 60.000 rpm

� Provided a suitable handle is used, the number of revolutions can be continuously adjusted up to 100,000 rpm

Special Features of the high-speed micro motor:

20 7120 33

20 7120 33 High-Speed Micro-Motor, max. speed 60,000 rpm,including connecting cable, for use with UNIDRIVE® S III ENT/NEURO

Optional Accessoriesfor UNIDRIVE® S III ENT SCB and UNIDRIVE® S III ECO

031131-10* Tubing Set, for irrigation, for single use, sterile, package of 10

280053 C Spray Nozzle, for the reprocessing of INTRA burr handpieces, for use with Universal Spray 280053 B

280053 Universal Spray, 6x 500 ml bottles – HAZARDOUS GOODS – UN 1950 including: Spray Nozzle

* mtp medical technical promotion gmbh,take-off GewerbePark 46, 78579 Neuhausen ob Eck/Germany,Phone: +49 (0) 74 67 9 45 04-0, Fax: +49 (0) 74 67 9 45 04-99,E-Mail: [email protected], www.mtp-tut.com


High-Speed Diamond Burrs, 60,000 rpm, for single use , sterile, package of 5

Diameter in mm

2

extra long

320220 EL

super long

320220 SL

3 320230 EL 320230 SL

4 320240 EL 320240 SL

High-Speed Coarse Diamond Burrs, 60,000 rpm, for single use , sterile, package of 5

Diameter in mm

2

extra long

320320 EL

super long

320320 SL

3 320330 EL 320330 SL

4 320340 EL 320340 SL

UNIDRIVE® S III ENT SCBHigh-Speed Handpieces, malleable, slim, angled, 60,000 rpm

252671 High-Speed Handpiece, extra long, malleable, slim, angled,60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33

252672 High-Speed Handpiece, super long, malleable, slim, angled,60,000 rpm, for use with High-Speed Micro-Motor 20 7120 33

For use with High-Speed Drills, shaft diameter 1 mmand with High-Speed Micro Motor 20 7120 33

252672

128 mm

60,000 rpm

diameter 4.7 mm

malleable

The handpieces have malleable shafts that can bebent up to 20° according to user requirements.

252671

108 mm

4.7 mm

4.7 mm


UNIDRIVE® S III ENT SCBUNIDRIVE® S III ECORecommended System Confi guration

40 7016 20-1 40 7014 20

40 7016 01-1 UNIDRIVE® S III ENT SCB, motor control unit with color display,touch screen, two motor outputs, integrated irrigation pump andSCB module, power supply 100 – 240 VAC, 50/60 Hz

including: Mains Cord Irrigator Rod Two-Pedal Footswitch, two-stage, with proportional function Clip Set, for use with silicone tubing set SCB Connecting Cable, length 100 cm Single Use Tubing Set*, sterile, package of 3


Specifications:

Touch Screen

Flow

Power supply

UNIDRIVE® S III ENT SCB: 6.4"/300 cd/m2

9 steps

100 – 240 VAC, 50/60 Hz

Dimensions w x h x d

Weight

Certifi ed to

300 x 165 x 265 mm

5.2 kg

EC 601-1, CE acc. to MDD

40 7014 01 UNIDRIVE® S III ECO, motor control unit with two motor outputs andintegrated irrigation pump, power supply 100 – 240 VAC, 50/60 Hz

including: Mains Cord Two-Pedal Footswitch, two-stage, with proportional function Clip Set, for use with silicone tubing set Single Use Tubing Set*, sterile, package of 3

* mtp medical technical promotion gmbh,take-off GewerbePark 46, 78579 Neuhausen ob Eck/Germany,Phone: +49 (0) 74 67 9 45 04-0, Fax: +49 (0) 74 67 9 45 04-99,E-Mail: [email protected], www.mtp-tut.com


UNIDRIVE® S III ENT SCBUNIDRIVE® S III ECOSystem Components

DRILLCUT-X® II N Shaver Handpiece,optional adaptability toShaver Tracker, for use with UNIDRIVE® S III ECO/ENT/NEURO

40 7120 55

031131-10

Single Use Tubing Set

U N I T S I D E

P A T I E N T S I D E

Shaver Blade

41305 DN

Shaver Blade, curved

41201KN

41302KN

Sinus Burr

Two-Pedal Footswitch

20 0166 30

DRILLCUT-X® II Shaver Handpiece, for use with UNIDRIVE® S IIIECO/ENT/NEURO

40 7120 50

252660 – 252692

High-Speed Handpiece

High-Speed Micro-Motor

20 7120 33

High-Performance EC Micro Motor II

20 7110 3320 7111 73

252575 – 252590

INTRA Drill Handpiece


Max. 10,000 rpm for shaver blades, max. 12,000 rpm for sinus shaver

Straight suction channel

Integrated irrigation channel

Powerful motor, also suitable for harder materials

Absolutely silent running, no vibration

Completely immersible and machine-washable

LOCK allows fixation of shaver blades and sinus shavers

Extremely lightweight design

Optional, ergonomic handle, detachable

Can be adapted to navigation tracker

Special Features:

–

DR

ILLC

UT-

X®

II

4071

2050

DR

ILLC

UT-

X®

IIN

40

7120

55

DRILLCUT-X® Shaver HandpiecesSpecial Features

40 7120 50 DRILLCUT-X® II Shaver Handpiece,for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 50

40 7120 55 DRILLCUT-X® II N Shaver Handpiece,optional adaptability to Shaver Tracker 40 8001 22,for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

40 7120 55


DRILLCUT-X® II Shaver Handpiece

Special Features: � Powerful motor � Absolutely silent running � Enhanced ergonomics � Lighweight design � Oscillation mode for shaver blades, max. 10,000 rpm

� Rotation mode for sinus shavers, max. 12,000 rpm � Straight suction channel andintegrated irrigation

40 7120 50 DRILLCUT-X® II Shaver Handpiece,for use with UNIDRIVE® S III ECO/ENT/NEURO/OMFS

� The versatile DRILLCUT-X® II Shaver Handpiece can be adapted to individual needs of the user

� Easy hygienic processing, suitable for use in washer and autoclavable at 134° C

� Quick coupling mechanism facilitates morerapid exchange of work inserts

� Proven DRILLCUT-X® blade portfolios can be used

40 7120 90

40 7120 90 Handle, adjustable, for use with DRILLCUT-X® II 40 7120 50and DRILLCUT-X® II N 40 7120 55

41250 RA

41250 RA Cleaning Adaptor, LUER-Lock,for cleaning DRILLCUT-X® shaver handpieces

Optional Accessory:

40 7120 50


Handle for DRILLCUT-X® II Shaver Handpiecefor use with DRILLCUT-X® II 40 7120 50 and DRILLCUT-X® II N 40 7120 55

Special Features: � Ergonomic design � Ultralight construction � Easy handle control allows individual adjustment

40 7120 90

� The adjustable handle can be mounted toDRILLCUT-X® II or -X II N Shaver Handpiece

� Easy fi xation via rotary lock � Sterilizable

40 7120 90 Handle, adjustable, for use with DRILLCUT-X® II 40 7120 50and DRILLCUT-X® II N 40 7120 55


Shaver Blades, straightfor Nasal Sinuses and Skull Base Surgery

For use with DRILLCUT-X® II and DRILLCUT-X® II N

41201 GN

serrated cutting edge,diameter 4 mm,color code: blue-red

concave cutting edge, obliquecutting window, diameter 4 mm,color code: blue-black

straight cutting edge,diameter 4 mm,color code: blue-blue

serrated cutting edge, diameter 3 mm,color code: blue-red

concave cutting edge, obliquecutting window, diameter 3 mm, color code: blue-black

Shaver Blade length 12 cmDetail 40 7120 50 DRILLCUT-X® II Handpiece

40 7120 55 DRILLCUT-X® II N Handpiece

41201 KN

41201 KK

41201 GN

41201 LN

41201 SN

41201 KSA

double serrated cutting edge, diameter 3 mm, color code: blue-yellow

41201 LSA

double serrated cutting edge,diameter 4 mm,color code: blue-yellow

concave cutting edge, oval cutting window, diameter 4 mm,color code: blue-green


41201 KKSB

Shaver Blades, straight, sterilizable

for use with

41201 KKSA

41200 RA Cleaning Adaptor, LUER-Lock, for cleaning the inner and outer blades of reusable Shaver Blades 412xx

Optional Accessory:


Shaver Blades, curvedfor Nasal Sinuses and Skull Base Surgery


41204 KKB

curved 35°, cutting edge serratedbackwards, diameter 4 mm,color code: blue-red

curved 40°, cutting edge serratedbackwards, double serrated, diameter 4 mm, color code: blue-yellow

41202 KN

curved 40°, cutting edge serratedforwards, double serrated,diameter 4 mm,color code: blue-yellow

41204 KKF

41204 KKB


41204 KKFA

41204 KKBA

curved 40°, cutting edge serrated backwards, double serrated,diameter 3 mm,color code: blue-yellow



Shaver Blades, curved 35°/40°, sterilizable

for use with


Optional Accessory:




41203 KKF

curved 65°, cutting edge serratedforwards, diameter 4 mm,color code: blue-red

curved 65°, cutting edge serratedbackwards, diameter 4 mm,color code: blue-red

41203 KNF


41203 KKF

41203 KNB

curved 65°, cutting edge serratedbackwards, double serrated,diameter 4 mm,color code: blue-yellow

curved 65°, concave cutting edge,oval cutting window, forwardopening, diameter 4 mm,color code: blue-green

curved 65°, concave cutting edge,oval cutting window, backward opening, diameter 4 mm,color code: blue-green

41203 KKB

41203 KKFA

41203 KKBA

41203 GNF

41203 GNB


curved 65°, cutting edge serratedbackwards, double serrated,diameter 3 mm,color code: blue-yellow



Shaver Blades, curved 65°, sterilizable

for use with


Optional Accessory:


Shaver Blades, straightfor Nasal Sinuses and Skull Base Surgery

41301 KK

serrated cutting edge,diameter 4 mm, color code: blue-red


straight cutting edge,diameter 4 mm,color code: blue-blue

serrated cutting edge,diameter 3 mm, color code: blue-red




concave cutting edge, oval cuttingwindow, diameter 4 mm,color code: blue-green

41301 KN

41301 KK

41301 GN

41301 LN

41301 SN

41301 KSA

41301 KKSA

41301 LSA

Shaver Blade length 12 cm Detail 40 7120 50 DRILLCUT-X® II Handpiece



41301 KKSB

for use with

Shaver Blades, straight, for single use , sterile, package of 5





41302 KN

for use withShaver Blade length 12 cmDetail 40 7120 50 DRILLCUT-X® II Handpiece


curved 35°, cutting edgeserrated backwards,diameter 4 mm,color code: blue-red

curved 40°, cutting edgeserrated backwards, double serrated, diameter 4 mm,color code: blue-yellow

curved 40°, cutting edgeserrated forwards, doubleserrated, diameter 4 mm,color code: blue-yellow


curved 40°, cutting edgeserrated backwards, doubleserrated, diameter 3 mm,color code: blue-yellow

Shaver Blades, curved 35°/40°, for single use , sterile, package of 5

41302 KN

41304 KKF

41304 KKB

41304 KKFA

41304 KKBA



41303 KKB


Shaver Blades, curved 65°, for single use , sterile, package of 5

41303 KNF

41303 KKF

41303 KNB

41303 KKB

41303 KKFA

41303 KKBA

41303 GNF

41303 GNB

curved 65°, cuttingedge serrated forwards,diameter 4 mm,color code: blue-red

curved 65°, cutting edge serrated backwards,diameter 4 mm,color code: blue-red


curved 65°, cutting edgeserrated backwards, doubleserrated, diameter 4 mm,color code: blue-yellow

curved 65°, cuttingedge concave forwards,oval cutting window, diameter 4 mm,color code: blue-green

curved 65°, cutting edgeconcave backwards,oval cutting window,diameter 4 mm,color code: blue-green

curved 65°, cutting edge serrated forwards, doubleserrated, diameter 3 mm,color code: blue-yellow

curved 65°, cutting edgeserrated backwards, doubleserrated, diameter 3 mm, color code: blue-yellow

Shaver Blade length 12 cmDetail

for use with

40 7120 50 DRILLCUT-X® II Handpiece40 7120 55 DRILLCUT-X® II N Handpiece


Sinus Burrs, curvedfor Nasal Sinuses and Skull Base Surgery


41305 RN

Sinus Burrs, curved 70°/55°/40°/15°, for single use , sterile, package of 5

41303 WN

41303 DT

41304 W

41305 RN

41305 DN

41305 D

Sinus Burr length 12 cmDetail 40 7120 50 DRILLCUT-X® II Handpiece


for use with

curved 55°, cylindric,drill diameter 3.6 mm,shaft diameter 4 mm, color code: red-blue

curved 15°, bud drill,drill diameter 4 mm,shaft diameter 4 mm, color code: red-black

curved 15°, diamond head,drill diameter 3 mm,shaft diameter 4 mm,color code: red-yellow

curved 70°, diamond head, drill diameter 3.6 mm,shaft diameter 4 mm,color code: red-yellow

curved 40°, cylindric, drill diameter 3 mm,shaft diameter 4 mm,color code: red-blue

curved 15°, diamond head, drill diameter 5 mm,shaft diameter 4 mm, color code: red-yellow

41305 DW

curved 40°, diamond head, drill diameter 5 mm,shaft diameter 4 mm, color code: red-yellow


Accessories for Shaver

39550 A Wire Tray, provides safe storage of accessories for KARL STORZ paranasal sinus shaver systems during cleaning and sterilization

for storage of: – Up to 7 shaver attachments

– Connecting cable

39550 A

Please note: The instruments displayed are not included in the sterilizing and storage tray.


Notes:

with the compliments of

KARL STORZ — ENDOSKOPE

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