Greater Wing Research Articles

Biportal Endoscopic TransOrbital and transMaxillary Approach to the Cranio-Orbital Region and Middle Cranial Fossa: A Preliminary Analysis of Maneuverability.

Traditional and well-established transcranial approaches to the spheno-orbital region and middle cranial fossa guarantee optimal intracranial exposure, and additional orbital and zygomatic osteotomies provide further control over extracranial components to be resected; however, these techniques come at the cost of additional morbidity. The introduction of minimally invasive endoscopic approaches and the conceptualization of the so-called "multiportal" paradigm might provide an alternative route. This preliminary study investigates the feasibility of the combined Biportal Endoscopic TransOrbital and transMaxillary Approach (bETOMA) approach to the spheno-orbital and middle cranial fossa regions. Using 4 silicon-injected adult cadaver heads (8 sides; 16 approaches), we systematically dissected through superior eyelid ETOA and endoscopic TMA approaches. The analysis focused on pterygopalatine, infratemporal, anterior and middle cranial fossae, Meckel cave, and cavernous sinus access. We evaluated the feasibility of bETOMA using linear distances, angles of attack, and exposure areas. We also introduced volume of operative maneuverability, its standardized derivative (sVOM), target distance, visuo-operative angle, and working zone volume as novel metrics. The analysis revealed comparable angles of attack between approaches. ETOA and TMA exposure areas were 918.38 ± 223.93 mm2 and 257.07 ± 86.07 mm2, respectively. TMA showed a larger VOM in the greater sphenoid wing, but ETOA offered superior distal maneuverability (sVOM: 5.39 ± 1.94 vs 2.54 ± 0.79 cm3) and closer intracranial space access (27.45 vs 50.83 mm). The combined approaches yielded a mean working zone volume of 13.75 ± 3.73 cm3 in the spheno-orbital interface. The bETOMA approach provides adequate neurovascular exposure and maneuverability to the spheno-orbital region, infratemporal, and anterior and middle cranial fossae, addressing significant limitations of previously investigated monoportal techniques (ie, optic nerve decompression, hyperostotic bone resection, and infratemporal exposure). This combined minimally invasive approach might help manage lesions harbored within the cranio-orbital interface region invading the extracranial space.

The Endoscopic Transorbital Approach for Vascular Surgery: An Anterior Circulation Anatomic Study, 2-Dimensional Operative Video.

Minimally invasive endoscopic approaches in cranial base surgery have been developing in the past decades. The transorbital (TO) route is one promising alternative, yet its adequacy for intracranial vascular lesions remains unclear. The present anatomic work aimed to test the feasibility and to provide a qualitative description of the endoscopic TO approach for the anterior circulation, namely the internal carotid artery and the middle cerebral artery. Seven embalmed adult cadaveric specimens (12 sides) were used in the study. Each side was approached in 3 successive steps: (1) Superior-eyelid TO approach, with great and lesser sphenoid wing removal. (2) Removal of anterior clinoid process (ACP). (3) Removal of the lateral orbital rim. All the procedures were performed under endoscopic view. The TO approach without removing the ACP allowed to dissect the sphenoidal and lateral segments of the Sylvian fissure with an adequate identification of the middle cerebral artery bifurcation in all specimens. The removal of the ACP allowed further dissection toward the opticocarotid cistern, with the identification of the ophthalmic, posterior communicating, and the anterior choroidal arteries. The internal carotid artery bifurcation and A1 segment were also readily identified. Finally, removal of the lateral orbital rim provided a wider and more comfortable access to the above-mentioned vascular structures. According to our anatomic data, the TO approach can be used to reach the main vascular components of the anterior circulation. This opens the field for exploring its application in the treatment of vascular pathology, particularly aneurysms.

Lateral Rectus Muscle Entrapment in Complex Orbital Fracture in a Child.

A 6-year-old boy presented with a lateral rectus muscle entrapment in a complex orbital fracture sustained during bicycle riding. He was diagnosed with a skull-base fracture with pneumocephalus and zygomatic and inferior orbital wall fractures at another hospital. The zygomatic fracture and pneumocephalus were treated conservatively. Although a detailed ocular motility examination could not be performed due to pain and inability to open the eyelid, the inferior wall fracture was surgically repaired. Postoperatively, persistent extraocular movement limitation prompted a referral to our clinic. Orbital CT imaging demonstrated a fracture at the greater wing of the sphenoid with a hypoattenuated area in the adjacent middle cranial fossa. Orbital MRI taken thereafter revealed lateral rectus and orbital fat prolapse into the middle cranial fossa, indicating entrapment of these structures through the lateral wall fracture. The incarcerated lateral rectus was released using an endoscopic transorbital approach via an upper lid crease, resulting in the recovery of extraocular movement.

Analyzing Foramen Ovale Morphometrically in Adult Dry Skulls of Nigerian-Based Population

Introduction: The foramen ovale is one of the major foramina on the greater wing of the sphenoid that is used for advanced surgical therapeutic and diagnostic procedures pertaining to the middle cranial fossa. The study was aimed at determining the length and width of foramen ovale in a Nigerian population. Materials and Methods: Seven dehydrated adult skulls, all the same gender, were acquired from the anatomy departments of Achievers University in Owo and Delta State University in Abraka, Nigeria. The length and the width of the foramen ovale were measured using digital sliding calipers. The paired sample t-test was used for the analysis. Results: The mean length of the foramen ovale was 0.611±0.21cm on the right side, and 0.42±0.12cm on the left side. The mean width was 0.5±0.15cm on the right side, and 0.43±0.12cm on the left side. Conclusion: Understanding the dimensions of the foramen ovale vary is crucial for neurosurgery during invasive surgical procedures like percutaneous trigeminal rhizotomy, as well as for biopsying Meckel cave lesions and cavernous sinus tumors.

A study on the morphology and morphometry of foramen ovale in dry human skulls

An oval shape foramen is present in the greater wing of sphenoid through which passes the many vital structures. It is located at the transitional area between intracranial and extracranial structures. It is important for diagnostic and surgical procedures. A total 100 skulls were used for the study. 82 skulls were studied and 18 skulls were excluded from the study. The skulls were collected from Phase I MBBS students from different medical colleges in south India. Skulls in poor conditions or skulls with partly damaged surroundings of the foramen ovale were not considered. Maximum length and width of foramen ovale was measured using digital Vernier calliper. Also, the distance from the anterior root of zygoma and the distance from the articular tubercle on zygomatic arch to foramen ovale were measured. Variation in right and left side were calculated, the variations in shape also recorded. The mean length of foramen ovale was 6.8 ±1 and the mean breath of foramen ovale was 3.65±1. Two-sample independent t test showed significant difference between the right and left breadths of foramen ovale (p 0.0126), while the right and left lengths of foramen ovale were not significant (p 0.245). The mean distance of foramen ovale from articular tubercle on Zygomatic arch was 33±2 mm. The mean distance from anterior root of Zygomatic arch was 21.5 ± 2.1 mm. The present study concludes that there is significant difference between sizes of right and left side foramen ovale. Foramen ovale has practical significance to both neurosurgical and functional cranial neuroanatomy as it provides transcutaneous approaches to the skull base especially in cases of trigeminal neuralgia, as the Gasserion ganglion can be approached through it.

SAT558 Papillary Thyroid Carcinoma With Anaplastic Transformation in a Filipino Male Treated With Radioactive Iodine and Radiotherapy: A Case Report

Abstract Disclosure: A.A. Apa-ap: None. P. Abarquez: None. M.B. Sedurante: None. A. Ongbit: None. P. Carlos Miguel: None. F. Acenas: None. J. Gacula: None. V. Lee: None. S. Estreller: None. INTRODUCTION. Papillary thyroid carcinoma (PTC) is an epithelial malignancy showing follicular differentiation and distinctive nuclear features, with a generally excellent prognosis. On the other hand, anaplastic thyroid cancer (ATC) is rare and highly lethal, with an incidence of only 0.7% in the Philippines. CASE DESCRIPTION. This paper describes a 43year old Filipino male with a 3-year history of anterior neck mass with an initial fine needle aspiration biopsy read as probable PTC. He underwent total thyroidectomy and bilateral radical lymph node dissection and histopathology revealed conventional PTC, solid variant with 5% focal anaplastic transformation. Metastatic workup revealed multiple sub-centimeter pulmonary nodules and a tiny hypodense nodule on left adrenal gland on CT scan. Bone scintigraphy showed increased tracer uptake in the posterior 10th rib and the sphenoid's greater wing. While the multidisciplinary team wanted to proceed with Radiation therapy (RT) first to address the more aggressive histology, this was not possible logistically and thus RAI was performed first. This slight deviation from guidelines was deemed acceptable by Nuclear Medicine due to the possible decrease in iodine absorption from post radiation fibrosis. After a dose of 150 mci, 4 weeks after surgery, patient then completed 33 fractions of RT. Surveillance revealed stable pulmonary nodules and adrenal mass but increasing TSH-stimulated thyroglobulin and antithyroglobulin. Patient underwent another cycle RAI and is currently stable on his 16th month from diagnosis, 15th month post initial RAI, and 13th month post-RT. DISCUSSION. In several case series, patients with minor anaplastic component had 1- and 2-year survival rates of 88% and 43%, respectively with a median survival of 17 months. The overall prognosis of patients with PTC with minor ATC component points to the value of active surveillance compared to more aggressive treatment modalities in the setting of conventional ATC. Presentation Date: Saturday, June 17, 2023

The “Hamantaschen” Sign: A Unique Appearance of Lesions Arising from the Sphenoid Greater Wing

The “Hamantaschen” Sign: A Unique Appearance of Lesions Arising from the Sphenoid Greater Wing

Clinical anatomy of the sphenoid bone and its terminology

Abstract The sphenoid bone, an unpaired, irregular, and pneumatic (air-filled) component of the neurocranium, is a clinically important landmark, particularly in surgery and radiology. This bone is often regarded as one of the most complex bones of the skull. This literature review aims to compile peer-reviewed articles concerning the anatomy of the sphenoid bone while briefly exploring its clinical relevance. The sphenoid bone consists of a centrally positioned body containing the sphenoidal sinus, as well as three pairs of processes projecting from the body, namely the greater wings, lesser wings, and pterygoid processes. The sphenoid is closely associated with five cranial nerves (CNs II, III, IV, V1, V2, and VI) and is adjacent to the pituitary gland. The cavernous sinus, housing the internal carotid artery, lies laterally to the body of the sphenoid. Various neurological conditions, such as injury, inflammation, vascular malformations, aneurysms, and tumors, can either directly impact the sphenoid or occur in close proximity to it. A comprehensive understanding of the anatomy of the sphenoid is indispensable for diagnosing and planning the treatment of these conditions. Therefore, a detailed knowledge of the anatomy of the head, including the sphenoid, is essential in clinical practice. It ensures accurate diagnoses, safe surgical procedures, and effective management of diverse conditions affecting the skull, sinuses, brain, and adjacent structures. Inaccuracies or errors in the diagnosis or treatment of such conditions can lead to adverse patient outcomes, including various complications and delayed management of serious neurological conditions.

Proptosis due to Isolated Intra-orbital Meningocele-a case Report

Congenital orbital wall defects are very rare bone abnormalities that can cause protrusion of intracranial contents into the orbit. The protrusion of the meninges, which encompasses cerebrospinal fluid (CSF), result in a condition known as the orbital meningocele, a rare cause of pulsatile proptosis. Here, we present a 4-year-old female with left eye proptosis referred to our clinic. On magnetic resonance imaging (MRI), a cystic structure was present. The patient underwent surgery for cyst removal. CSF leakage was noted during surgery. Computed tomography (CT) scan revealed a bony defect in the sphenoid greater wing and the resulting meningocele. Craniotomy surgery was performed to close and fill the defect

Endoscopic Endonasal Transpterygoid Approach: Technical Lessons.

The endoscopic endonasal transpterygoid approach (EETPA) provides direct access to the petrous apex, lateral clivus, inferior cavernous sinus compartment, jugular foramen, and infratemporal fossa. 1,2 In the coronal plane, it provides exposure far beyond a traditional sphenoidotomy. The pterygoid process of the sphenoid bone forms the junction between the body and greater sphenoid wing before bifurcating because it descends into medial and lateral plates. The key to this exposure lies in the region's bony foramina: the palatovaginal canal, vidian canal, and foramen rotundum. 3. After performing a maxillary antrostomy, stepwise exposure of these foramina leads to the pterygopalatine fossa. The sphenopalatine artery is cauterized as it becomes the posterior septal artery at the sphenopalatine foramen, and the maxillary sinus' posterior wall is opened to expose the pterygopalatine fossa. After mobilizing and retracting the contents of the pterygopalatine fossa, the pterygoid process is removed, improving access in the coronal plane. 4. Vidian neurectomy causes decreased or absent lacrimation. Injury to the maxillary nerve or its branches results in facial, palatal, or odontogenic anesthesia or neuralgia. In addition, the EEPTA precludes the ability to raise an ipsilateral nasal septal flap, making it crucial to plan reconstruction preoperatively. 4,5. There are 5 variants of the EEPTA: extended pterygopalatine fossa, lateral recess of the sphenoid sinus, petrous apex, infratemporal fossa and petrous carotid artery, and middle and posterior skull base. 5The patient consented to the procedure.Images in the video used with permission as follows: images at 0:33 and 1:15 reused from Bozkurt et al, 3 © Georg Thieme Verlag KG; image at 0:39 from Prosser et al, 5 © John Wiley and Sons; images at 0:54, 9:03, and 9:38 from Kasemsiri et al, 1 © John Wiley and Sons; images at 1:07 and 9:44 from Falcon et al, 2 © John Wiley and Sons; image at 1:15 from Sandu et al, 4 © Springer Nature.

Prevalence of Anatomical Variations of Sphenoid Sinus and Its Adjacent Structures Pneumatization and Its Significance: A CT Scan Study.

The purpose of our study was to assess the prevalence of variations and type of sphenoid sinus and its adjacent structures pneumatization and its significance. This prospective study included 114 patients who underwent CT of the paranasal sinuses. The CT scan in axial, coronal and mid sagital section were analysed to assess the type of pneumatization of the sphenoid sinus and its adjacent structures like; anterior clinoid process, greater wing of sphenoid and pterygoid process. The sphenoid sinus pneumatization was classified into Conchal, Presellar, and Sellar types, later comprised of sellar and post-sellar types. Out of 114 cases of pneumatized sphenoid sinus, 5.2% cases were conchal type, 26.3% cases Presellar type and 68.4% cases sellar type. The one or more adjacent structures was pneumatized in 71 (62.2%) of cases. The adjacent structures which found to be pneumatized are anterior clinoid process in 26.3%, Pterygoid process in 23.6%, and greater wing of sphenoid in 12.3% cases. The pneumatization of adjacent structures was more prevalent in sellar type of sphenoid sinus, followed by pre-sellar type and no pneumatization in conchal type. The anterior clinoid process pneumatization was present in 26.1% of cases, in which 3 (2.6%) cases in pre-sellar type and 27 (23.5%) cases in sellar type. It was unilaterally pneumatized in 13 (11.4%) and bilaterally in (17 (14.9%) cases. The pterygoid process pneumatization was present in 27 (23.6%) of cases, unilateral in 16 (14%) cases and bilateral in 11 (9.6%) cases. The Greater wing of sphenoid pneumatization was found in 14 (12.3%) cases, no cases in conchal types, 2 (1.8%) in pre-sellar type, and 12 (10.4%) in sellar type There was no statistically difference found in between right and left side of sphenoid sinus and its structure pneumatization. The extent of pneumatization of the sphenoid sinus has clinical and surgical implications in sinus diseases, sellar and central skull base lesions.

A childhood secondary headache case associated with Langerhans cell histiocytosis

Neurological involvement is very rare in patients with a diagnosis of Langerhans Cell Histiocytosis (LCH). During the course of the disease, headache can also be seen in addition to systemic effects. A 6 years old girl was admitted to the hospital with only a headache without any systemic symptoms and was diagnosed with LCH. Magnetic resonance imaging showed a solid mass extending from the sphenoid bone corpus to the left great wing of the sphenoid, left orbital apex, left posterior ethmoid cells, left cavernous sinus, and dural space. The correct decision for neuroimaging in patients with headaches is very important in terms of mortality and morbidity. We wanted to share our patient’s case who was diagnosed with LCH by presenting only with headache without any other systemic finding, to remind that LCH may be a secondary cause of headache.

Transorbital drillout to the cavernous sinus: an approach for squamous cell carcinoma with perineural spread. Illustrative cases

This study describes a transorbital apical approach to the cavernous sinus, where the greater wing of sphenoid (GWS) and superior orbital fissure (SOF) are drilled out to access the interdural incision zone and lateral wall of the cavernous sinus. This was a retrospective series of 3 patients with periocular squamous cell carcinoma (SCC) and radiological evidence of perineural spread to the cavernous sinus. Following an orbital exenteration, the GWS was drilled to reach the lateral border of the SOF. The meningo-orbital band, a periosteal transition between the frontotemporal basal dura and periorbita, was incised to enter the lateral wall of the cavernous sinus. The relevant cranial nerves were biopsied to provide an accurate zonal classification of disease. The transorbital apical approach via the SOF provides a corridor of access to the cranial nerves within the lateral wall of the cavernous sinus. This technique was successfully performed on 3 patients with periocular SCC. One case had radiological evidence of intracavernous oculomotor nerve involvement, 1 patient demonstrated nasociliary nerve enlargement at the SOF, and another had frontal nerve involvement extending into the cavernous sinus. Cerebrospinal fluid leak occurred in 1 case addressed with fat packing and fascial closure.

A Comprehensive Computed Tomographic Analysis of Pneumatization Pattern of Sphenoid Sinus and Their Association with Protrusion/Dehiscence of Vital Neurovascular Structure in a Pakistani Subgroup.

To determine the clinically significant association between pneumatization types of the sphenoid sinus (SS) and protrusion/ dehiscence of the optic nerve (ON) and the internal carotid artery (ICA). This prospective cross-sectional study was conducted between November 2020 and April 2021 at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi. This study examined 300 computed tomography (CT) PNS patients aged 18-60 years. The forms of SS pneumatization, extent of pneumatization to the greater wing (GW), anterior clinoid process (ACP), and pterygoid process (PP), as well as the protrusion/dehiscence of the ON and ICA were examined. A statistical relationship was identified between pneumatization type and protrusion/dehiscence of the ON and ICA. The study included 171 men and 129 women with an average age of 39.28 ± 10.9 years. The most commonly encountered pneumatization type was postsellar (63.3%), followed by sellar (27.3%), presellar (8.7%), and conchal (0.75%). The most frequent extended pneumatization was observed up to PP (44%), followed by ACP (31.33%), and GW (16.67%). The rate of dehiscence of the ON and ICA was less than that of protrusion of the same structures. The association between postsellar and sellar pneumatization types and protrusion of the ON and ICA was statistically significant (p < 0.001), with the postsellar type showing more protrusions of the ON and ICA than the sellar type. The pneumatization type of SS has a significant impact on the protrusion/dehiscence of adjacent vital neurovascular structures and should be mentioned in CT reports to alert surgeons for any disastrous intraoperative complications and outcomes.

Macroscopic Analysis of the Insertion Points of the Lateral Pterygoid Muscle in Adult Individuals

The lateral pterygoid muscle (LPM) is intimately related with the temporomandibular joint (TMJ), playing an important role in its physiology. This makes it of interest to researchers who investigate temporomandibular disorders. The literature indicates that anatomical variations exist in the insertion of the superior fascicle of the LPM. Imaging and cadaver studies have revealed that the LPM may present an accessory fascicle. The study object was to carry out macroscopic analysis of the LPM, examining the origin and insertion of its superior and inferior fascicles. The study used 38 half-heads of adult individuals fixed in formaldehyde 10 %. To carry out macroscopic analysis of the LPM, an initial incision was made along the lower margin of the zygomatic arch; the origin of the masseter muscle was then dissected, separating its insertion on the lateral face of the mandibular ramus and retracting the muscle to posteroinferior. Two incisions were made on the zygomatic arch and the insertion of the temporal muscle on the coronoid process was identified with dissection pincers; it was dissected to gain access to the infratemporal fossa and the two fascicles of the LPM. The superior fascicle (SF) originated on the infratemporal face of the greater wing of the sphenoid, and on the superior third of the lateral face of the lateral lamina of the pterygoid process of the sphenoid in 26 samples. In 12 samples, it originated on the greater wing of the sphenoid and the infratemporal crest of the sphenoid. Type I insertion was found in 20 samples, Type II in 6 samples and Type III in 12 samples. In all the samples analysed, the inferior fascicle (IF) originated on the inferior two thirds of the lateral face of the lateral lamina of the pterygoid process and on the lateral face of the pyramidal process of the palatine, with insertion on the pterygoid fovea. The accessory fascicle (AF) of the LPM was present in 6 samples. The AF originated on the greater wing of the sphenoid in 2 cases and inferior to the superior fascicle in 4 cases; its insertion was on the capsular disc complex in all cases. The results obtained in our study contribute anatomical data on the LPM in Brazilian adult individuals, with evaluation of its insertion points.

Orbital metastasis from breast carcinoma presenting as an osteoblastic lesion

A 66-year-old female presented with a swollen and itchy eyelid for 4 weeks. A computed tomography (CT) scan revealed a lesion epicentered in the greater wing of the sphenoid and anterior lateral and superior orbital walls, predominantly showing osteoblastic features. Magnetic resonance imaging (MRI) demonstrated further calvarial and pachymeningeal involvement. Biopsy of the lesion demonstrated a poorly differentiated carcinoma. A distant history of breast cancer (20 years) prompted specific immunochemistry that confirmed breast carcinoma metastases. Staging positron emission tomography-computed tomography (PET) revealed multisystem spread. This report highlights the fact that breast carcinoma metastasis may rarely present with a predominantly osteoblastic lesion in the orbit.

Inner ear modifications in Dar-es-Soltane II H5 (Morocco): A case of labyrinthitis ossificans

ObjectiveThis paper presents the inner ear modifications in Dar-es-Soltane II H5, an Aterian fossil possibly dated to 100 ka. MaterialThe remains consist of a large portion of the cranium including the face, the left frontal and temporal bones, part of the left parietal bone and greater wing of the sphenoid. MethodsThe bony labyrinth anatomy was investigated on existing micro-CT data acquired by the MPI-EVA. ResultsThe observation of micro-CT sections revealed a partial filling of the semi-circular canals that raises question about its origin. A careful examination of the micro-CT sections shows that the elements present in the semicircular canals were denser than the sediments observed in other regions and cavities of the temporal bone. ConclusionsThe current evidence suggests a pathological origin of this condition with partial ossification of the membranous labyrinth. The differential diagnosis indicates a case of labyrinthitis ossificans in its early stages. SignificanceThis pathological condition can be responsible for permanent hearing loss and is associated with dizziness and vertigo. Along with the Singa skull, Dar-es-Soltane II H5 represents one of the oldest known cases of labyrinthitis ossificans. LimitationsThe early stage of disease and the absence of the right temporal bone limit conclusions about the degree of disability of the individual and their dependence on the rest of the group. Suggestions for further researchTo carry out a paleopathological study of all the fossils from Dar-es-Soltane II.

Craniofacial fibrous dysplasia with aneurysmal bone cyst: A rare coexistence

Fibrous dysplasia (FD) is a developmental anomaly in which the normal bone marrow is replaced by fibro-osseous tissue. Fibrous dysplasia can affect either single (monostotic) bone or multiple (polyostotic) bones. Craniofacial FD is a monostotic FD involving the craniofacial bones. However, CFD is one of the rare forms of FD. Aneurysmal bone cyst (ABC) is a rare non-neoplastic bone lesion. ABCs are expansile lytic lesions composed of numerous blood-filled channels and cystic spaces that mostly involve the long bones and vertebrae and occur rarely in the craniofacial bones. ABCs can occur either as a primary bony lesion or secondary to various pre-existing benign and malignant bone tumors like fibrous dysplasia. Concomitant occurrence of FD and ABC is rare with only few cases reported in the literature. Here, we report on a case of ABC in a 24-year-old woman who had presented with right frontal and facial swelling for over 6 years followed by proptosis of right eye. Computed tomography revealed an expansile lytic lesion with peripheral ground glass densities involving the body and greater wing of sphenoid, lateral wall of orbit, squamous part of temporal bone with associated thinning and rarefaction of the bony walls. Further, MRI of the same patient revealed multiple cystic spaces some of them showing fluid-fluid levels within.

CT-Scan Images of The Posterior Orbital, Orbital Apex, Extraocular Muscles Positions and Axes in Craniosynostosis

Craniosynostosis is the premature and pathological fusion, either partial or complete, of one or more cranial sutures. One of the ophthalmological complications is strabismus (in 39–76% of cases), with more severe manifestations in syndromic craniosynostosis. Head-CT with 3D-reconstruction can be used to evaluate the anatomical abnormalities of the orbital aspects to assist clinicians in planning surgery. Materials and Methods: A retrospective descriptive–observational study was conducted for 43 patients in the period from January 2017 to March 2022. The patients had syndromic or non-syndromic craniosynostosis and underwent head CT-scans at Dr. Soetomo General Hospital, Surabaya. The posterior orbital bones, orbital apexes, positions and axes of the extraocular muscles were evaluated by an neuroimaging radiology consultant. Results: 26 male subjects (60.5%) and 17 female subjects (39.5%) were evaluated. 18 patients (41.9%) had normal posterior orbital configurations and extraocular muscles, 4 (9.3%) showed mild abnormalities, 13 (30.2%) had moderate abnormalities, 2 (4.7%) showed moderate–severe abnormalities, and 6 (11.6%) had seesaw pattern abnormalities. 33 patients (76.7%) had normal orbital apex configurations, 3 (7%) showed ballooning ethmoidal sinuses, 2 (4.7%) had protrusions of the lateral orbital wall (greater sphenoid wing), and 5 (11.6%) showed combined ethmoidal sinus ballooning and protrusion of the lateral orbital wall. Conclusion: The smallest excyclorotation was observed for the mild abnormalities of the posterior orbital configuration and extraocular muscles in the right eye (4.5–11.3°) and left eye (3.6–7°). The greatest was noted for the seesaw pattern in the right eye (7.6–21.4°) and left eye (7.4–30°). 3 patients (7%) had an incyclorotated axis and 26 (60.5%) had an excyclorotated axis, with a greater degree of excyclorotation in the seesaw pattern.

Anatomy and Diseases of the Greater Wings of the Sphenoid Bone.

The greater wings of the sphenoid bone (GWS) comprise the components of the sphenoid bone that make up most of the posterior orbital wall and form the anterior and medial parts of the floor of the middle cranial fossa. Many important skull base foramina, which transmit vital neurovascular structures, are present in these paired wings on either side of the central body of the sphenoid bone. A wide variety of diseases can affect the GWS, ranging from benign osseus lesions to malignant primary and secondary bone abnormalities. The complex three-dimensional curved (winged) shape of the GWS and the wide array of pathologic entities that affect this bone can make it challenging for the radiologist to report the imaging findings accurately, especially in relation to the important skull base foramina. The authors describe a systematic approach to understanding the three-dimensional anatomy of the GWS and review important diseases, with the aid of imaging examples. Useful imaging "pearls" that can help in making specific diagnoses are provided throughout the article. ©RSNA, 2022.