The Endoscopic Transnasal Approach to Orbital Tumors: A Review

Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section

Introduction

Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery.

Research question

Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection.

Material and methods

A PRISMA based literature search was performed to select the most relevant papers on the topic.

Results

Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery.

Discussion and conclusion

This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Orbital hemangioma extirpation via a transnasal endoscopic surgical approach: A case report

INTRODUCTION

Orbital tumors are heterogeneous lesions originating from various structures in the eyeball, including the extraconal, conal, and intraconal spaces. One orbital tumor type is a vascular tumor, such as a hemangioma. Hemangiomas are most common in women aged 20-64 years. They are painless and slow-growing, leading to proptosis. The diagnosis can generally be established by clinical examination and computed tomography (CT) or magnetic resonance imaging scans. Orbital hemangioma management can involve regular observation of small and asymptomatic tumors or surgery for large symptomatic tumors.

PRESENTATION OF CASE

We report a 20-year-old Asian woman who presented with swelling on the medial side of her right eyelid that had increased over the last three months. A non-contrast head CT scan showed a mass in the right eye's medial wall. The patient underwent a joint operation with an ophthalmologist to remove the median orbital tumor by transnasal endoscopic orbital surgery. Anatomical pathology examination of the tumor tissue identified hemangiomas.

CONCLUSION

An endoscopic transnasal approach is a safe and effective way to access and manage an orbital tumor medial to the optic nerve. It is essential to have a multidisciplinary team with experience in endoscopic procedures. This patient had satisfactory results at their three-month postoperative follow-up. They reported no symptoms, and their CT scan did not show a relapsed mass in the right oculi region.

"Elastic stretch cavity building" system in endoscopic thyroidectomy via the axillary approach: a case series

Background

Patients undergoing conventional endoscopic thyroidectomy via the axillary approach, which is commonly used clinically, suffered from a range of postoperative complications. This study aimed to prevent postoperative complications and evaluate patients' satisfaction with cosmetic outcomes in endoscopic thyroidectomy via the axillary with the use of "Elastic Stretch Cavity Building" System.

Methods

In this retrospective case series study, the clinical data of patients who were admitted to the Thyroid Surgery Department of Ningbo Medical Centre Lihuili Hospital between December 2020 and December 2021 for endoscopic thyroidectomy via the axillary approach under the "Elastic Stretch Cavity Building" System.

Results

A total of 67 patients were included, all surgeries were successfully completed. The operation time was 75.61 ± 13.67 minutes; the postoperative drainage volume was 109.97 ± 37.54 ml; the average postoperative hospital stay was 4 (2-6) days. There was no skin ecchymosis, effusion or infection, hypocalcemia, convulsions, upper extremity dyskinesia, and temporary hoarseness after the surgery. The patients were satisfied with the cosmetic effects, and the cosmetic score was 4 (3-4).

Conclusion

The "Elastic Stretch Cavity Building" System in endoscopic thyroid surgery via the axillary approach might reduce the risks of complications and achieve satisfactory results with the cosmetic outcomes.

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.

Middle cranial fossa trigeminal schwannoma resection through endoscopic transnasal maxillary sinus approach: A case report and literature review

The endoscopic transnasal maxillary sinus approach is usually performed in resecting tumors located in the pterygopalatine fossa and infratemporal fossa, but is rarely used in the resection of lesions in the middle cranial fossa. Because of the complicated anatomical structure of the middle cranial fossa, trigeminal schwannomas (TSs) located in this region are usually dissected through conventional craniotomy surgical approaches; however, the endoscopic transnasal maxillary sinus approach can be used in resection of middle cranial fossa TSs. The current study presented the case of a 59-year-old man who suffered intermittent headaches for 2 years without other notable medical history and neurological abnormalities. The patient was diagnosed with a middle cranial fossa TS. After imaging and assessment of anatomical features, the tumor was totally resected through the transnasal maxillary sinus approach. Following surgery, the symptoms were relieved and the patient returned to a normal life. Light numbness was complained of in the distribution area of the maxillary nerve of the right side of the face, but this was gradually relieved. Combined with a literature review, the present case indicated that the endoscopic transnasal maxillary sinus approach may provide a safer and more direct option for resecting middle cranial fossa lesions, which is worthy of increased clinical application.

Endoscopic Endonasal Removal of Orbital Schwannoma: Focus on Surgical Technique

Orbital schwannomas are a rare disease, representing about 1% of orbital tumors, potentially involving any subsite within the orbit. They usually present with painless, nonpulsatile proptosis, while diplopia and vision impairment due to extrinsic ocular muscles or optic nerve involvement are rarely observed.¹ A wait-and-see policy is advocated in case of small asymptomatic lesions. However, if progressive dimensional increase or symptoms are observed, surgical resection represents the treatment of choice.² Different surgical approaches have been proposed, mainly depending on tumor dimension and location inside the orbit, as well as surgical expertise. With advances in technology,³ knowledge,⁴ and surgical techniques,⁵ transnasal endoscopic approaches have emerged as a valid option in the management of lesions located medially to the optic nerve, with the advantage of improved visualization and overall decreased morbidity as compared with external approaches.⁶ We present the case of a 19-year-old woman, affected by an intraextraconal orbital schwannoma located in the left orbit's inferomedial aspect, with a 1-year history of left proptosis associated with retrobulbar pain exacerbated by the upward gaze. The lesion was completely removed with an endoscopic transnasal approach (Video 1), without evidence of postoperative sequelae or visual impairment. Magnetic resonance imaging performed 3 months after surgery showed good surgical results without evidence of persistence of disease. A multidisciplinary approach, involving different specialists familiar with orbital anatomy and physiology, is required for a proper management of patients affected by orbital pathologies.