Endoscopic management of facial fractures

Transoral Endoscopic-Assisted Reduction and Internal Fixation of Mandibular Condylar Fractures in Children

PURPOSE

Extraoral approaches for open reduction and fixation of condylar fractures in children are associated with serious risks of complications, including facial nerve injury, facial scarring, parotid fistula, and auriculotemporal nerve injury. The purpose of this study was to retrospectively evaluate the outcomes of transoral endoscopic-assisted open reduction and internal fixation of condylar fractures and hardware removal in pediatric patients.

MATERIAL AND METHODS

This study was designed as a retrospective case series. The study included pediatric patients admitted with condylar fractures that were indicated for treatment with open reduction and internal fixation. The patients were clinically and radiographically evaluated with regard to occlusion, mouth opening, lateral and protrusive movement of the mandible, pain, chewing and speech difficulties, and bone healing at the fracture site. Computed tomography images were used to assess the reduction of the fractured segment, the stability of fixation and progress of healing of the condylar fracture at follow-up visits. The same surgical treatment approach was applied to all patients. The data from the study were analyzed for a single group without any comparison to other groups.

RESULTS

The technique was used for the treatment of 14 condylar fractures in 12 patients between the ages of 3 to 11 years. A total of 28 transoral endoscopic-assisted approaches to the condylar region either for reduction and internal fixation or hardware removal were applied. The mean operating time was 53.1 (±11.3) minutes for the fracture repair and 20 (±2.6) minutes for hardware removal, respectively. The mean follow-up time of the patients was 17.8 (±2.7) months (median: 18) months. All patients regained stable occlusion, satisfactory mandibular motion, stable fixation, and complete bone healing at the fracture site at the end of their follow-up period. There was no transient of permanent facial nerve or trigeminal nerve injury in any of the patients.

CONCLUSIONS

Endoscopically assisted transoral approach is a reliable technique for reduction and internal fixation of condylar fracture and hardware removal in pediatric patients. The serious risks of extraoral approaches including facial nerve injury, facial scar, and parotid fistula can be eliminated by using this technique.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit

Introduction  Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods  Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results  EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion  EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Approach for naso-orbito-ethmoidal fracture

The purpose of this study is to discuss several approaches to addressing naso-orbito-ethmoidal (NOE) fracture. Orbital fracture, especially infraorbital fracture, can be treated through the transconjunctival approach easily. However, in more severe cases, for example, fracture extending to the medial orbital wall or zygomatico-frontal suture line, only transconjunctival incision is insufficient to secure good surgical field. And, it also has risk of tearing the conjunctiva, which could injure the lacrimal duct. Also, in most complex types of facial fracture such as NOE fracture or panfacial fracture, destruction of the structure often occurs, for example, trap-door deformity; a fracture of orbital floor where the inferiorly displaced blowout facture recoils to its original position, or vertical folding deformity; fractured fragments are displaced under the other fragments, causing multiple-packed layers of bone.

Endoscopic-Assisted Zygomatic Arch Fracture Repair With a Preauricular Approach

Introduction

Because of numerous negative sequelae with open techniques, endoscopic techniques are beginning to be widely used for maxillofacial fractures. Many endoscopic approaches for this area have been described according to several dissection plans and incisions. The aim of the present study was to report a new surgical incision and dissection method for zygomatic arch fracture that aims at reducing the complication rate of previously defined techniques.

Material and Methods

The authors operated on 8 patients with a new endoscopic-assisted surgical technique. This study focused on evaluating the complication rate and surgical comfort of these patients.

Results

Of the 8 patients, the plate was palpable in the zygomatic arch in one. No complications occurred due to this technique during the 1-year follow-up. Symmetrical facial contour and inconspicuous scars were obtained in all patients. Average operative time was 3 hours; hospitalization time was 1.6 days.

Conclusion

This study demonstrates that an endoscopic-assisted surgical approach with a preauricular mini-incision can be safely performed in isolated multifragment zygomatic arch fractures. Using individually designed plates improved our results. This technique is easy to apply, its cosmetic results are good, and its complication rate is low.

Orbital Trauma

The orbit is contained within a complex bony architecture with overlying soft tissue that involves many important anatomical structures. Orbital trauma is a frequent cause of damage to these structures. The authors review the literature on reconstructive techniques focusing on fractures of the orbital rim, orbital roof, orbital floor, medial orbital wall, and naso-orbito-ethmoid complex. A thorough literature review was conducted using PubMed analyzing articles relevant to the subject matter. Various search terms were used to identify articles regarding orbital trauma presentation, diagnosis, management, as well as postoperative complications. Articles were examined by all authors and pertinent information was gleaned for the purpose of generating this review. Orbital trauma can result in a wide variety of complications in form and function. Not all orbital fractures require operative repair. However, bony disruption can cause enophthalmos, hypophthalmos, telecanthus, epiphora, cerebrospinal fluid leaks, orbital hematoma, and even blindness to name a few. Timing of operative repair as well as reconstructive method is dictated by the patient's individual presentation. Successful fracture management requires a detailed understanding of the anatomy and pathophysiology to ensure restoration of the patients' preoperative state. Orbital trauma encompasses a wide variety of mechanisms of injury and resulting fracture patterns. A variety of surgical approaches to the orbit exist as has been discussed allowing the surgeon access to all area of interest. Regardless of the fracture complexity, the principles of atraumatic technique, anatomic reduction, and stable fixation apply in all cases.

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.

Evaluation of a Minimally Disruptive Treatment Protocol for Frontal Sinus Fractures

Importance

Despite common goals of frontal sinus fracture treatment (restoring forehead contour and creating a safe sinus), there remains significant variability in evaluation and treatment.

Objective

To describe our experience with a minimally disruptive treatment protocol for the treatment of frontal sinus fractures.

Design, Setting, and Participants

Analysis of prospectively collected data from 2010 through 2015 at a level 1 trauma center. All patients with frontal sinus fractures treated with our protocol from January 2010 to December 2015. Patients with poor follow-up and/or incomplete medical records were excluded from analysis.

Main Outcomes and Measures

Presence of an aerated frontal sinus and aesthetically acceptable forehead contour. Secondary outcome measures were complications related to frontal sinus fractures.

Results

A total of 39 patients were treated under our minimally disruptive protocol, and 25 patients were included in the study; 18 (72%) were male and 7 (28%) were female. Their ages ranged from 6 to 62 years. After review, 22 patients had both clinical and radiographic follow-up. No patients underwent immediate frontal sinus repair. Five of 22 patients underwent surgery for indications other than their frontal sinus fracture: 1 of 5 patients underwent immediate surgical repair due to bilateral LeFort fractures, and 4 of 5 underwent delayed surgery due to nasal polyps (1 patient), scar revision (1 patient), and concomitant LeFort fractures (2 patients). Two of 22 patients (9%) underwent frontal sinus repair after outpatient surveillance due to persistent cerebrospinal fluid leak (1 patient) and orbital roof fracture (1 patient). The remaining 20 patients were treated nonoperatively, and 19 of 20 (95%) had spontaneous improvement in opacification and/or contour deformity. Twelve of 20 patients (60%) had improvement or resolution in both. One patient had ongoing partial opacification and deformity at the 3-month follow-up but was asymptomatic and had bony contour that was aesthetically acceptable to the patient. There were no complications. The median of all follow-up was 3 months.

Conclusions and Relevance

Frontal sinus fractures treated nonoperatively had a high rate of spontaneous ventilation and bony autoreduction with aesthetically acceptable frontal bone remodeling. There were no complications in the nonoperative group. The initial results of this study support further study of the safety and efficacy of a minimally disruptive protocol for frontal sinus fractures.

Level of Evidence

4.

Reconstruction of orbital floor defects assisted by transantral endoscopy

PURPOSE

The goal of orbital reconstruction is to restore anatomy, volume, and function. In extensive orbital floor defects, the visualization of the posterior area is limited through inferior eyelid incisions. The use of endoscope may improve the treatment; however, it is a high-sensitivity technique. The aim of this case series is to describe the combination of inferior eyelid incision with transantral endoscopy for treatment of extensive orbital floor defects.

METHODS

Three patients were submitted to orbital reconstruction, and the postoperative CT scans were evaluated to analyze the orbital volume and anteroposterior globe position. Surgical treatment was performed using subciliary inferior palpebral approach to explore the orbital floor and placement of the titanium mesh and an intraoral antrostomy for endoscopy to magnification of the surgical field and adaptation of the mesh.

RESULTS

Postoperative CT scan analysis shows that all treatments restored orbital volume and globe position without compression or damage of the optical nerve.

CONCLUSION

The use of endoscope allowed the precise visualization of the posterior region of the orbit and adaptation of the titanium mesh.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

BACKGROUND

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

METHODS

Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up.

RESULTS

Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes.

CONCLUSION

Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches.

An aesthetic approach in the repair of anterior frontal sinus fractures

The management of upper facial trauma is a common responsibility of surgeons taking care of maxillofacial injuries. Historically, the most commonly used surgical approach has been the bi-temporal (coronal) incision. As is well known, the coronal incision carries some inherent complications such as hair loss, long scars, and increased length of hospital stay. The purpose of this article is to describe an aesthetic approach, similar to an endoscopic brow lift, for the repair of anterior wall fractures of the frontal sinus without the need for long incisions or fixation devices.

Endoscopic surgery of the orbital apex: Outcomes and emerging techniques

OBJECTIVES/HYPOTHESIS

To review our experience with endoscopic orbital apex surgery.

STUDY DESIGN

Retrospective review.

METHODS

All cases with Current Procedural Terminology codes for endoscopic orbital decompression between 2002 and 2011 at two institutions were reviewed. Patients with a diagnosis of Graves orbitopathy or an orbital complication of sinusitis were excluded. Presenting symptoms, lesion location, pathology, surgical outcomes, and complications were examined.

RESULTS

A total of 27 patients were identified. Seventeen (63%) of the patients were men, and the average age was 56 (range = 14-82) years. Eighteen patients had primary orbital apex lesions, and nine patients had sinonasal lesions that predominantly involved the medial orbital apex. The lesions were found to be on the right in 59% of cases. The etiologies include benign (40.7%), malignant (44%), infectious (7.4%), and metastatic (7.4%) lesions. Obtaining a pathologic diagnosis was successful endoscopically in all but two (7.4%) patients, both with lateral lesions. The two-surgeon, four-handed technique and intraoperative image guidance employing fused computed tomography/magnetic resonance imaging were used in the majority of intraconal cases. Complications occurred in three patients (11%) and included myocardial infarction, deep venous thrombosis, and vision loss. There were no cerebrospinal fluid leaks or postoperative hemorrhages. Notably, vision remained stable or improved in all but one patient (3.7% risk of vision decline). Average follow-up was 4 years (range = 1 month-8 years).

CONCLUSIONS

The endoscopic approach to the orbit apex offers significant advantages over traditional external approaches, and should be the preferred approach for all medial and inferior lesions. A two-surgeon multihanded technique can help facilitate difficult cases.

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.

The management of naso-orbital-ethmoid (NOE) fractures

The bony naso-orbital-ethmoid (NOE) complex is a 3-dimensional delicate anatomic structure. Damages to this region may result in severe facial dysfunction and malformation. The management and optimal surgical treatment strategies of NOE fractures remain controversial. For a patient with NOE trauma, doctors should perform comprehensive clinical examination and radiographic analysis to assess the type and extent of fracture. The results of assessment will assist doctors to make a patientspecific program for the sake of reducing post-operation complications and restoring normal appearance and function as much as possible. This review focuses on the advancement of management of NOE fractures including symptoms, classifications, diagnosis, approaches, treatment and new techniques in this field.

Image-guided transorbital procedures with endoscopic video augmentation

PURPOSE

Surgical interventions to the orbital space behind the eyeball are limited to highly invasive procedures due to the confined nature of the region along with the presence of several intricate soft tissue structures. A minimally invasive approach to orbital surgery would enable several therapeutic options, particularly new treatment protocols for optic neuropathies such as glaucoma. The authors have developed an image-guided system for the purpose of navigating a thin flexible endoscope to a specified target region behind the eyeball. Navigation within the orbit is particularly challenging despite its small volume, as the presence of fat tissue occludes the endoscopic visual field while the surgeon must constantly be aware of optic nerve position. This research investigates the impact of endoscopic video augmentation to targeted image-guided navigation in a series of anthropomorphic phantom experiments.

METHODS

A group of 16 surgeons performed a target identification task within the orbits of four skull phantoms. The task consisted of identifying the correct target, indicated by the augmented video and the preoperative imaging frames, out of four possibilities. For each skull, one orbital intervention was performed with video augmentation, while the other was done with the standard image guidance technique, in random order.

RESULTS

The authors measured a target identification accuracy of 95.3% and 85.9% for the augmented and standard cases, respectively, with statistically significant improvement in procedure time (Z=-2.044, p=0.041) and intraoperator mean procedure time (Z=2.456, p=0.014) when augmentation was used.

CONCLUSIONS

Improvements in both target identification accuracy and interventional procedure time suggest that endoscopic video augmentation provides valuable additional orientation and trajectory information in an image-guided procedure. Utilization of video augmentation in transorbital interventions could further minimize complication risk and enhance surgeon comfort and confidence in the procedure.

Transnasal endoscopic repair of posterior table fractures

OBJECTIVES/HYPOTHESIS

Conventional treatment of frontal sinus posterior table fractures has included osteoplastic flap or cranialization procedures despite considerable advances in endoscopic technique and experience. The objective of the current study was to evaluate outcomes of frontal sinus fractures involving the posterior table managed using endoscopic approaches.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary care, academic university hospital.

METHODS

Prospective evaluation of patients with posterior table fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of the skull base defect, complications, and clinical follow-up.

RESULTS

Thirteen patients (average age 37 years) with posterior table fractures were treated using endoscopic techniques from 2008 to 2012. Mean follow-up time was 68 weeks (range, 2-206 weeks). Patients were primarily managed using Draf IIb frontal sinusotomies with 1 individual requiring a concomitant trephine. A Draf III procedure was performed in 1 patient. Average fracture defect (length vs width) was 13 × 4.5 mm, and average length involving the posterior table was 9.7 mm (1-30 mm). Skull base defects were covered with a septal flap and/or free tissue grafts. Although 1 individual required a revision frontal sinusotomy and follow-up was short in several patients, all sinuses remained patent on last clinical examination.

CONCLUSION

Management of frontal sinus posterior table fractures using minimally invasive endoscopic techniques provides excellent outcomes in selected cases. Fractures of up to 30 mm in length were adequately managed in this series and indicate this approach can be a viable alternative in the treatment of these fractures.

Lag screw fixation of fracture of the anterior mandible: a new minimal access technique

OBJECTIVE

Purpose of this study to introduce a new minimal access technique for management of anterior mandible fracture with several advantages over conventional methods.

METHOD

Four cases of undisplaced anterior mandibular fracture were selected. Tension band was achieved either by arch bar fixation to mandible or placement of interdental wire followed by intermaxillary fixation. With a 1 cm vertical incision was placed adjacent to fractured line. Fractured segment was immobilized with lag screw with minimal stripping. All patients were followed for 6 months.

RESULTS

All four cases shown good stable segment after 6 months of post operative follow up. OPG revealed well placed lag screw and there were no surgical complications, for example parasthesia, scarring and odema.

CONCLUSION

Fixation of anterior mandible fracture using this technique can achieve good stability and appropriate compression. The technique is simple and easily performed, reducing the surgical time, reduce the chances of infection due to less exposure and promote the healing process by producing stress in the fracture lines.

Orbital fractures: a review

This review of orbital fractures has three goals: 1) to understand the clinically relevant orbital anatomy with regard to periorbital trauma and orbital fractures, 2) to explain how to assess and examine a patient after periorbital trauma, and 3) to understand the medical and surgical management of orbital fractures. The article aims to summarize the evaluation and management of commonly encountered orbital fractures from the ophthalmologic perspective and to provide an overview for all practicing ophthalmologists and ophthalmologists in training.

Endoscopic approach to maxillofacial trauma

Endoscopic approaches to maxillofacial trauma have included their use in temporomandibular joint arthroscopy, zygomatic arch repair, repair after orbital trauma, repair of frontal sinus fractures, and finally in the repair of subcondylar mandibular fractures. These techniques provide exciting new options for the management of facial fractures. Many of the techniques provide a steep learning curve and require specialized equipment. The approach to an orbital blowout fracture allows the use of a Caldwell-Luc approach and the use of a naturally occurring body space (the maxillary sinus) for the visualization and maneuvering of the endoscope, tools, and implants. The use of the endoscope in the management of fractures for facial structures such as mandibular subcondylar fractures, which do not have a naturally occurring body cavity, may present greater challenges when trying to obtain visualization, reduction, and fixation. When used for the treatment of subcondylar fractures, wide exposure and the use of right-angled drills and screw drivers may significantly help with this procedure. This may be considered by some surgeons as an endoscopically "assisted" procedure that can possibly be accomplished with direct visualization and the use of dental mirrors. It remains to be seen as to whether some of these diverse endoscopic applications will represent the standard of care in the future or remain a specialized technique practiced by a minority of surgeons in a few specialized centers. This article reviews various endoscopic applications to maxillofacial trauma and discusses some of the controversies of these techniques.

Endoscopically assisted reduction of anterior table frontal sinus fractures

AIMS

To present a retrospective series of six patients with endoscopically assisted reduction of anterior table frontal sinus fractures.

MATERIALS AND METHODS

The patients with isolated anterior table fractures were treated between April 2005 and June 2006 in the Leiden University Medical Centre. In two of the six patients the procedure was performed under local anaesthesia. The endoscope was introduced via existing lacerations, an incision in a natural skin crease or just above the hairline. The fracture was reduced and if necessary fixed.

RESULTS

In all patients restoration of the cosmetic deformity was achieved clinically.

CONCLUSION

The use of endoscopes makes minimally invasive reduction of outer table fractures of the frontal sinus possible, even under local anaesthesia.

State of the art in craniomaxillofacial trauma: frontal sinus

PURPOSE OF REVIEW

Many of the successes and controversies in endoscopic management of craniofacial trauma are exemplified in the management of frontal sinus trauma.

RECENT FINDINGS

The effort to reduce surgical morbidity and to optimize reconstruction of craniomaxillofacial injuries has resulted in the development of less invasive surgical approaches and in the use of computer image guidance in surgical planning and execution. Minimally invasive management of frontal sinus inflammatory disease has gained wide acceptance. The technology and techniques applied to surgery of the floor of the frontal sinus is now being applied to the management of frontal sinus trauma. A paradigm shift in the treatment of frontal sinus trauma may be underway.

SUMMARY

An increasing scope of less severe injuries is being managed expectantly with endoscopic frontal sinus surgery available for salvage. There may be an overall decrease in the most severe frontal sinus injuries owing to enforcement of seatbelt and airbag usage. And the most severe injuries are often best managed through cranialization with anterior skull base reconstruction. Thus, the role for frontal sinus obliteration purely to obviate fractures of the frontal sinus outflow tract may be vanishing.

Orbital endoscopic surgery

Minimally invasive ″keyhole″ surgery performed using endoscopic visualization is increasing in popularity and is being used by almost all surgical subspecialties. Within ophthalmology, however, endoscopic surgery is not commonly performed and there is little literature on the use of the endoscope in orbital surgery. Transorbital use of the endoscope can greatly aid in visualizing orbital roof lesions and minimizing the need for bone removal. The endoscope is also useful during decompression procedures and as a teaching aid to train orbital surgeons.

In this article, we review the history of endoscopic orbital surgery and provide an overview of the technique and describe situations where the endoscope can act as a useful adjunct to orbital surgery.