Endoscopic transnasal cryo-assisted removal of an orbital cavernous hemangioma: a technical note

Resection of orbital apex tumours in the medial orbit via four-handed endonasal and transcaruncular approaches

PURPOSE

To report the surgical outcomes of 4-handed endoscopic and transcaruncular approaches for orbital apex tumours located in the medial orbit.

METHODS

This retrospective, observational study included 6 patients (2 males and 4 females; 3 right and 3 left; mean age, 49.5 years; age range, 38-60 years) who underwent excision of an orbital apex tumour in the medial orbit via 4-handed endonasal and transcaruncular approaches. Data on age, sex, affected side, surgical record and complications, and results of pathological examinations, imaging studies, and ophthalmologic examinations were collected.

RESULTS

Tumours pathologically corresponded to a cavernous haemangioma in 5 cases and a schwannoma in 1 case. The cavernous haemangioma was completely removed in all cases, while the schwannoma was only debulked because the tumour attached to the surrounding tissues. The medial orbital wall was reconstructed simultaneously in 1 case and 8 days after tumour resection in 1 case. Postoperatively, the visual acuity improved or was maintained in all patients. One patient without medial orbital wall reconstruction showed significant enophthalmos on the affected side after surgery. Another patient without medial orbital wall reconstruction did not obtain binocular single vision field in any direction of gaze after surgery due to severe esotropia.

CONCLUSIONS

This report indicates that 4-handed endoscopic and transcaruncular approaches are useful for removal of an orbital apex tumour located in the medial orbit. Medial orbital wall reconstruction after tumour resection may be a better option for reducing the risk of postoperative enophthalmos and esotropia.

Combined Endonasal and Orbital Approach for Resection of Orbital Apical Tumors

PURPOSE

Tumors of the medial orbital apex can be challenging to resect. Primary endonasal resection can be limited by requirements for fat retraction and poor angulation for lateral orbital dissection. Orbital resection alone can have space limitations and a limited view for dissection of the posterior aspect of the tumor. The combined transorbital transnasal approach integrates the retraction and instrumentation advantages of the transorbital approach with the optical and space advantages of the transnasal approach.

METHODS

In this cross-sectional cohort study, patients who underwent surgical resection of an apical orbital tumor via a combined endoscopic and orbital approach from 2014 to 2019 were identified. Clinical history, examination findings, imaging, surgical technique, histopathology, and complications were reviewed.

RESULTS

Six patients were included. Patients presented with proptosis (5), optic neuropathy (3), and motility restriction (2). Surgery involved a medial orbitotomy and endoscopic ethmoidectomy ± sphenoidotomy, medial wall removal, and periosteum opening. The lesion was prolapsed into the sinus, dissected at the apex via the orbital approach, and removed through the nasal cavity. Pathologic diagnoses were cavernous venous malformation (4), venolymphatic malformation (1), and metastatic carcinoid (1). Improvement in pain (2/2), optic neuropathy (2/3), and proptosis (5/5) were noted. Complications included ethmoid mucocele and nasal polyps.

CONCLUSIONS

The combined endonasal and orbital approach involves prolapsing the lesion into the nasal cavity to aid in dissection on the lateral and posterior aspects, maximizing visibility of the tight intraconal space. This technique can be performed by a team of orbital surgeons experienced in both orbital and endonasal surgery.

Clinical Outcome and Technical Nuances After Resection of Orbital Cavernous Venous Malformations-A Single-Center Experience

BACKGROUND

Cavernous venous malformations (CVMs) represent the most common benign intraorbital lesions. Enlarging or symptomatic CVMs (progressive proptosis or visual disturbances) are treated by surgical resection. For this, a variety of different surgical approaches have been described. The aim of this study was to present a contemporary series of orbital CVMs treated via open microsurgical approaches.

METHODS

In this study, patients who underwent resection of orbital CVMs between 2002 and 2019 were included. Presenting symptoms were noted and neuro-ophthalmologic examinations performed pre- and postoperatively. For surgical resection, the location of the orbital CVM and its relation to the orbital anatomy led to decision-making for appropriate approaches. A comparison between anatomical location and surgical outcome was performed.

RESULTS

Overall, 35 patients with orbital CVMs were included. Most common presenting symptoms were progressive proptosis (43%) and visual disturbances (34%). Most common location was the lateral quadrant (37%) followed by the superior quadrant (20%). A subfrontal craniotomy was performed in 40% of cases followed by a supraorbital craniotomy including the orbital rim in 34% of cases. For surgical excision, a cryo-probe was used in 30 patients, and complete resection was feasible in all cases. Location of a CVM within the superior quadrant was associated with improved postoperative recovery of visual acuity. No differences for clinical outcomes were observed depending on the surgical approach.

CONCLUSIONS

Resection of orbital CVMs is indicated in patients with visual disturbances or progressive proptosis. In these, microsurgical approaches can be used with minimal morbidity for complete removal of these well-circumscribed lesions.

The Endoscopic Transnasal Approach to Orbital Tumors: A Review

Historically, surgical access to orbital tumors has required a transcutaneous, transconjunctival or transcranial approach. Resection of orbital tumors is notoriously challenging due to the surrounding dense network of critical structures in a confined bony cavity. Advances in endoscopic endonasal surgery, initially used for sinonasal and skull base conditions, have allowed for expansion of its applications beyond the sinorbital interface. In the past decade, the evolution of techniques has enabled a purely endoscopic, minimally invasive approach to medially located orbital pathology with good outcomes. With experience and multidisciplinary collaboration between orbit and rhinologic surgeons, this has expanded to allow for a safe and effective transnasal approach to nearly all regions of the orbit with or without assistance from the orbital side. This review summarizes the relevant anatomy, variations of surgical approaches, and literature regarding outcomes of the endoscopic endonasal approach to orbital tumors.

Surgical Approaches to the Orbit: A Neurosurgical Perspective

Orbital pathologies can be complex to manage surgically. In this article, we describe some of the most common and relevant approaches to orbital tumours. For each approach we describe the appropriate indications, surgical technique, potential complications, and illustrate a case example.

Management of Orbital Masses: Outcomes of Endoscopic and Combined Approaches With No Orbital Reconstruction

Introduction

The endoscopic endonasal approach to management of orbital pathology has expanded. Due to the rarity of these conditions, most reports in the literature consist of small case reports. We report a series from a single institution with a focus on outcomes.

Methods

A retrospective chart review was carried out between 2010 and 2018.

Results

Twenty-four patients were identified (average age 58 years, 15 males, 9 females). Average follow-up was 14.9 months. Most common etiologies included cavernous hemangioma (7), metastases (6), idiopathic orbital inflammatory syndrome (6), orbital hematoma/clot (2), and schwannoma (1). Most common presenting symptoms were decreased visual acuity (8), proptosis (8), diplopia (7), and incidental findings (2). All patients underwent endoscopic medial wall orbital decompressions. Sixteen involved a combined open approach by an ophthalmologist. Pathology was either biopsied (15), resected (6), or could not be identified (3). No intraoperative complications were noted. No patients underwent orbital reconstruction of the medial wall. Six patients developed postoperative sinusitis successfully managed with antibiotics. One patient developed epistaxis managed conservatively. In 5 patients, Sino-Nasal Outcome Test-22 scores increased immediately postop and then decreased, whereas scores only decreased in 6 patients. Six patients noted reduced proptosis. There were no new cases of diplopia or worsening visual acuity.

Conclusions

A combined endoscopic endonasal and external approach can be useful for managing orbital lesions. Patients tolerated the procedure well with improvement in ocular symptoms and minimal sinonasal complications. Reconstruction of the medial wall may not be warranted to prevent postoperative diplopia.

Trans-septal suture retraction for endoscopic orbital surgery

PURPOSE

We describe a novel technique for endonasal endoscopic orbital surgery. Previously described strategies for minimally invasive orbital surgery include mobilization of the medial rectus muscle and cryosurgical retraction of the pathologic lesion. Herein we describe endoscopic trans-septal suture retraction of an orbital cavernous hemangioma to facilitate intra-orbital dissection from an external approach.

METHODS

A 36-year-old male presented with blurred vision in his left eye for several years, along with several months of progressive left proptosis and decreasing visual acuity. Imaging revealed a 2.5 cm orbital mass consistent with a cavernous hemangioma. The patient underwent a combined transconjunctival and endoscopic approach for resection.

RESULTS

Following left medial orbital wall and floor decompression, endoscopic trans-septal suture retraction facilitated dissection of the lesion from intraorbital structures. A complete extracapsular resection of the lesion was achieved. The inferomedial orbit was reconstructed with a synthetic implant.

CONCLUSION

Trans-septal suture retraction is an effective adjunctive technique for endonasal endoscopic orbital tumor surgery. This technique facilitates safe retraction and dissection of soft tissue lesions from critical intraorbital structures.

Endoscopic Transnasal Cryo-Assisted Removal of Orbital Cavernous Hemangiomas: Case Report and Technical Hints

BACKGROUND

Cryoprobe devices are used by ophthalmic and orbital surgeons for extraction of fluid-filled intraorbital lesions. No series has described cryodissection via an exclusively transnasal approach. We describe 2 cases of purely endoscopic transnasal removal of intraconal orbital hemangiomas with the aid of a dedicated cryoprobe.

METHODS

All transnasal endoscopic intraorbital procedures were collected and analyzed. In cases in which intraorbital dissection was performed with the use of an Optikon Cryo-line probe, clinical features, histology, size and location of the lesion, early and late complications, surgical procedure time, and hospital length of stay were analyzed. Patient follow-up included endoscopic endonasal evaluations performed at 2, 4, and 8 weeks after surgery and ophthalmologic and orthoptic evaluations performed 2 days and 2 months after surgery.

RESULTS

Two transnasal intraorbital endoscopic procedures with the aid of the dedicated Cryo-line probe were collected. Lesions were located in the intraconal space, medial to the optic nerve. In both patients, the histologic evaluation was compatible with cavernous hemangioma, and complete resection was obtained. Mean hospital stay was 5.5 days. Postoperative ophthalmologic and orthoptic evaluations performed 2 months postoperatively revealed complete resolution of preoperative symptoms.

CONCLUSIONS

Cryoprobes represent an adjunctive tool in the orbital surgeon's armamentarium useful in the extraction of fluid-filled intraorbital lesions. This preliminary experience suggests that their use can ease the removal of intraconal hemangiomas with an exclusively transnasal approach. The analysis of further cases is necessary to confirm safety and efficacy.

Tumors of the Orbit: Case Report and Review of Surgical Corridors and Current Options

Tumors that involve the orbit can be classified into two major groups: primary tumors of the orbit and tumors that extend into the orbit from other sites. The most frequent primary orbital lesions in adults include cavernous hemangiomas, lymphoid tumors, and meningiomas. The most common tumors that extend into the orbit are meningiomas, followed by sinonasal carcinomas. In this article, we report a case of intraconal orbital lesion operated at our center and a review of the surgical approaches to the orbit.

Endonasal Approach to Orbital Pathology

PURPOSE

Transnasal endoscopic orbital surgery in an emerging surgical field. The surgical field has expanded from orbital decompression to excision of tumours from the medial orbit and over the last 20 years. As instrumentation has improved, the nature, location and size of tumours being excised has changed.

METHODS

This article discusses the salient surgical considerations when approaching an orbital lesion via a transnasal endoscopic route and reviews the literature.

RESULTS

An endonasal approach offers a potential space surgeons can utilise to access the orbit, possibly providing additional exposure, illumination and magnification to the medial and apical aspects of selected lesions.

CONCLUSIONS

An endonasal approach may be useful as a sole or adjunctive approach in selected cases of orbital tumour excision.

A new surgical technique for excision of orbital cavernous hemangioma: a 15-year experience

PURPOSE

To present a new surgical technique for excision of orbital cavernous hemangiomas (CHs).

METHODS

This retrospective case series study included patients with orbital CH who were operated from 2001 to 2016 at our referral center. Epidemiologic data, symptoms, signs, and images were reviewed from patients' files with at least one year of follow-up. Surgical results and complications were documented. We used the "index finger dissection" technique without grasping the tumor for release of adhesions and its removal.

RESULTS

We included 60 patients with orbital CH consisting of 36 (60%) female and 24 (40%) male patients with mean age of 40 ± 12.1 (range 9-66) years. The main complaint was proptosis with average size of 5.3 ± 2 millimeters. The surgical approach was lateral orbitotomy in 49 (81.7%) patients, medial transcutaneous in seven (11.7%) patients, inferior transconjunctival in three (5%) patients, and simultaneous lateral and medial orbitotomy in one (1.6%) patient. All tumors were removed intact; complications included ptosis in one subject, lower lid retraction in one case, and diplopia in two patients, all of which improved before 2 months. No optic nerve damage occurred.

CONCLUSION

The "index finger dissection" technique without grasping the tumor for excision of orbital CH, via any external approach to the tumor, is a safe technique with minimal complications.

Endoscopic Medial Rectus Sling: A Window Into the Intraconal Orbital Apex

PURPOSE

Surgical approaches to the medial orbit especially within the cone of orbital muscles necessitate great precision and care to avoid damage to surrounding structures-most importantly the optic nerve. The authors present a novel technique in which access to the medial orbital contents was achieved through an entirely endoscopic approach.

METHODS

A 72-year-old Caucasian female presented with loss of vision in the right eye and reduced extraocular movements. Baseline blood tests were within normal limits. Inflammatory markers were slightly elevated. CT scan revealed bilateral medial orbital apex masses. Biopsy of the right orbital apex lesion was performed through an exclusively endoscopic approach in which the medial rectus muscle was retracted infero-medially.

RESULTS

This exclusively endonasal approach to the medial intraconal space provided excellent access to the orbital apex, thus allowing successful biopsy of the medial orbital apex lesion. A video of the surgical technique demonstrates its use in this patient (see Video, Supplemental Digital Content 1, available at http://links.lww.com/IOP/A123).

CONCLUSIONS

Similar reports of endonasal medialization of the medial rectus for accessing intraconal orbital lesions have been previously described in the rhinological literature. The authors describe a modification that allows for a safe and less invasive approach to the medial intraconal space and intraorbital optic nerve. There is minimal trauma to the surrounding tissues and no further damage to the optic nerve along with no associated adverse clinical sequelae. In addition, this negates the need for an adjuvant external or transconjunctival approach.

Endoscopic treatment of orbital tumors

Different orbital and transcranial approaches are performed in order to manage orbital tumors, depending on the location and size of the lesion within the orbit. These approaches provide a satisfactory view of the superior and lateral aspects of the orbit and the optic canal but involve risks associated with their invasiveness because they require significant displacement of orbital structures. In addition, external approaches to intraconal lesions may also require deinsertion of extraocular muscles, with subsequent impact on extraocular mobility. Recently, minimally invasive techniques have been proposed as valid alternative to external approaches for selected orbital lesions. Among them, transnasal endoscopic approaches, “pure” or combined with external approaches, have been reported, especially for intraconal lesions located inferiorly and medially to the optic nerve. The avoidance of muscle detachment and the shortness of the surgical intraorbital trajectory makes endoscopic approach less invasive, thus minimizing tissue damage. Endoscopic surgery decreases the recovery time and improves the cosmetic outcome not requiring skin incisions. The purpose of this study is to review and discuss the current surgical techniques for orbital tumors removal, focusing on endoscopic approaches to the orbit and outlining the key anatomic principles to follow for safe tumor resection.

Endoscopic transethmoidal approach with or without medial rectus detachment for orbital apical cavernous hemangiomas

PURPOSE

To determine the indications for the addition of a transcaruncular approach along with detachment of the medial rectus muscle during the removal of small apical cavernous hemangiomas using an endoscopic transethmoidal approach.

DESIGN

Retrospective, noncomparative case series.

METHODS

Multicenter study of 12 patients with apical orbital tumors removed using an endoscopic transethmoidal approach. The decision to detach the medial rectus muscle with the addition of a transcaruncular approach was made during surgery for tumors largely lateral to the medial rectus muscle. Tumors adjacent to the medial orbital wall were removed via an endoscopic transethmoidal approach alone.

RESULTS

Seven tumors were removed via an endoscopic transethmoidal approach combined with medial rectus muscle detachment, whereas 5 patients underwent removal without detachment of the medial rectus. All patients had visual impairment. Complete excision of the hemangiomas was achieved in all patients and tumor size ranged from 6 × 5 mm to 20 × 12 mm. The mean postoperative follow-up time was 11.8 ± 4.3 months. At final follow-up, the best-corrected visual acuity improved in 11 patients. Three patients had transient horizontal diplopia resulting from partial paralysis of the medial rectus muscle after detachment during surgery.

CONCLUSIONS

The endoscopic transethmoidal approach with or without medial rectus detachment is a promising approach for selected small cavernous hemangiomas located at the deep medial orbital apex. Detachment of the medial rectus muscle can be a useful technique for tumors located largely lateral to the medial rectus muscle. Further studies will be required to demonstrate the safety and efficacy of this technique.

Endoscopic endonasal resection of medial orbital lesions with intraoperative MRI

BACKGROUND

Various approaches have been described and used for operating on lesions in the orbit. The approach selection is based on the pathology in the orbit and its exact location. This study was performed to evaluate the endoscopic endonasal approach (EEA) for orbital lesions and application of intraoperative MRI (iMRI).

METHODS

Since 2006, the present authors have performed 614 endoscopic endonasal procedures. iMRI was used in 409 of these cases. Three orbital lesions approached via the endonasal route with a minimum follow-up of 1 year were analysed.

RESULTS

EEA was used in one case of intraconal cavernoma, one extraconal cavernoma and one solitary fibrous tumour in the orbit. The lesion was located medially to the optic nerve in all cases. Radical resection was achieved and the patient's vision was improved in two cases with a preoperative visual field deficit. iMRI was useful in two cases. In one case intraoperative MRI helped to find an intraconal lesion; in the other case iMRI led to evacuation of haemostatic material and blood, which was causing compression in the orbit.

CONCLUSIONS

The EEA should be considered whenever a lesion in the orbit is located medially to the optic nerve. Excellent results were achieved. iMRI proved useful in selected cases.