Combined Endonasal and Orbital Approach for Resection of Orbital Apical Tumors

Do Minimally Invasive Approaches to Pediatric Orbital Tumors Provide an Advantage on Outcome and Efficiency?

OBJECTIVE

The present study evaluated whether minimally invasive approaches to orbital lesions could improve surgical, clinical, and aesthetic outcomes compared with more invasive ones. This is the first study specifically addressing this topic in children.

METHODS

Children consecutively operated on from January 2010 to January 2020 were analyzed. Thirty patients matched the inclusion criteria and were divided into group A: 14 cases treated with traditional surgical approaches; and group B: 16 cases managed by minimally invasive approaches.

RESULTS

There were no significant differences between the 2 groups in terms of demographic data and extent of tumor resection. Mean surgical time for the approach (40 minutes vs. 70 minutes, P < 0.0001), surgical complication such as periorbital edema (37% vs. 78%, P = 0.02) and dural tear (0 vs. 21%, P = 0.05), and procedures cost (P < 0.0001) were significantly reduced in group B. Regarding clinical outcomes, group B showed a significant reduction both in terms of postoperative pain (mean score based on visual pain scale was 2.9 vs. 4.1 P = 0.003) and mean hospitalization time (4.5 days vs. 5.5 days, P = 0.0004). The cosmetic outcome according to the Sloan classification was significantly better in group B as well (81% vs. 36% class I patients, P = 0.005).

CONCLUSIONS

The use of mini-invasive approaches to orbital tumor has clear advantages in terms of surgical, clinical, and cosmetic outcomes in comparable patients; therefore, they should be preferred whenever feasible. Craniotomic approaches remain necessary for very large tumors.

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.

Adjunctive transseptal corridor: Technique for endoscopic resection of orbital tumor

The transnasal endoscopic approach is increasingly used for resection of tumors that are located inferiorly and medially within the orbit. However, this usually requires multiple-handed manipulations, which demand a second corridor for an assistant. Here, we introduce a simple transseptal corridor from the contra-nare, to facilitate assistant instrument maneuverability. This simple, minimally invasive skill greatly improves operation efficiency and deserves greater attention in endoscopic orbital surgery.

Reconstruction of Medial Orbital Wall Using Autologous Perpendicular Plate of Ethmoid

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion.

Endonasal Endoscopic Removal of Orbital Cavernous Venous Malformation With Optic Neuropathy

Several surgical methods have been employed, but the management of orbital cavernous venous malformations at the orbital apex remains challenging. The authors present an endonasal endoscopy-assisted removal of an orbital apex cavernous venous malformation compressing the optic nerve with the addition of an inferomedial conjunctival approach. A 43-year-old Asian man presented with an orbital cavernous venous malformation incidentally found radiographically with a history of decreased vision of 20/50 oculus dexter (OD). The patient's visual field index was 22%, with signs of optic neuropathy. An endonasal endoscopic procedure combining transconjunctival and caruncular orbitotomies was adopted because of its deep posterior placement inside the orbit. The cavernous venous malformation was removed without complications, and the visual function of the patients recovered. For these challenging lesions, an endonasal endoscopic technique with an anterior orbitotomy may be a promising alternative. Simple packing material may adequately repair the medial orbital wall; there were no complications during the 12-month follow-up period.