Sphenoid Wing Meningioma Treatment & Management

Updated: Nov 11, 2016
  • Author: Bhupendra C K Patel, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Surgical Care

Total microsurgical resection of sphenoid wing meningioma is usually curative. A recurrence risk approaching 30% has been reported when incomplete removal is attempted. [58, 84] Depending on the bony involvement and the soft tissue component of the tumor, the principles of resecting a sphenoid wing en plaque meningioma are complete removal of all the involved bone, including the sphenoid wing, orbital roof, and orbital lateral wall. Decompression of optic nerve, superior orbital fissure, and maxillary branch of the trigeminal nerve posteriorly to foramen rotundum should be accomplished.

The skin incision is made 0.5-1 cm anterior to the tragus at the level of the zygomatic arch and extended behind the hairline toward the widow peak. It can be curved back across the midline toward the contralateral superior temporal line, if needed. Care must be taken not to injure the temporal branch to the frontalis muscle or the facial nerve that passes anterior to it. The temporalis muscle, along with the superficial and the deep fascial layers, are incised in similar fashion from the skin down to the bone. The musculocutaneous flap is reflected anteriorly using a periosteal elevator. Avoid cauterizing the blood supply and innervation to the temporalis muscle to prevent future muscle atrophy.

Once the muscle is elevated and reflected anteriorly, lateral sphenoid wing hyperostosis is usually apparent, and any noticed during elevation of the temporal muscle is excised.

Multiple bur holes are then made around the invaded or hyperostotic bone to prevent excessive bleeding and dural tear. The drill is then used to connect the bur holes and to remove the invaded bone. This process continues until all hyperostotic tissue is removed from the sphenoid wing down to the meningo-orbital band.

The meningo-orbital band is then coagulated and cut sharply, followed by dural stripping from the superior orbital fissure and the anterior part of the lateral wall of the cavernous sinus, exposing the middle fossa floor laterally to the foramen spinosum and posteriorly to the foramen rotundum. Hyperostotic tissue is then removed in a similar manner from the orbital roof and lateral walls of the orbit.

The superior orbital fissure is completely decompressed. The optic nerve in the canal is unroofed, and anterior clinoidectomy is performed.

Once the bone removal is complete, attention is focused on resecting the intradural portion of the tumor, and the dura is resected beyond the enhanced dural tail. The intraorbital extension with involvement of the periorbita and extraocular muscles should also be removed.

Abdominal fat or temporalis fascia with or without pericranial flap can be used to repair the frontal, maxillary, and ethmoid sinuses if they have been opened to prevent postoperative development of a CSF leak and rhinorrhea. A duraplasty is performed using a dural substitute.

There is no clear consensus in the literature regarding whether to reconstruct the orbit. Orbital wall reconstruction has been recommended whenever the orbital floor or more than one wall has been resected or the periorbita was resected to prevent occurrence of pulsatile enophthalmos postoperatively. [85] However, studies have concluded that this complication is uncommon and that orbital reconstruction is unnecessary except in rare occasions when the orbital rim is resected. [9, 86, 87]

When orbital reconstruction is needed, the area can be reconstructed using mesh, dural substitute, or split bone if only the superior and lateral walls of the orbit have been removed. The cranial flap is placed back if it was not involved by the tumor, or a piece of Medpor can be used to cover the cranial defect, making sure to cover the keyhole area. The temporal muscle is then reattached, and the skin is closed in two layers. 

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Medical Care

Anecdotal reports have described using antihormonal agents in the treatment of meningiomas. Medical treatment is reserved for atypical and malignant meningiomas as an adjunct to surgery.

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