Neuronavigation-Guided Endoscopic Endonasal Excision of an Intraorbital Intraconal Cavernous Hemangioma:

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.

Removal of Small Cavernous Hemangioma in Orbital Apex Through an Endoscopic Transethmoidal-Sphenoidal Approach

OBJECTIVE

To investigate the feasibility, efficacy, and safety of an endoscopic transethmoidal-sphenoidal approach in removing a small cavernous hemangioma (CH) located in the deep lateral orbital apex.

METHODS

This study involved 19 patients diagnosed with a CH located in the deep lateral orbital apex. All patients underwent an endoscopic transethmoidal-sphenoidal approach for removal of the CH. The best-corrected visual acuity (BCVA), visual field, and surgery-related complications were analyzed and compared.

RESULTS

All tumors in this study were completely removed. The mean BCVA was LogMAR 0.97 ± 0.97 preoperatively and LogMAR 0.38 ± 0.64 postoperatively (p < 0.05). The mean visual field index was 52.26% ± 33.26% preoperatively and 75.47% ± 30.49% postoperatively (p < 0.05). The mean deviation index was -17.48 ± 12.43 dB preoperatively and -10.10 ± 10.85 dB postoperatively (p < 0.05), and the pattern standard deviation was 6.37 ± 3.77 dB preoperatively and 4.90 ± 3.56 dB postoperatively (p > 0.05). Four (21.1%) patients developed oculomotor limitations and two (10.5%) patients developed ptosis after surgery. All of these symptoms resolved spontaneously, and no other complications occurred. The mean follow-up time was 6.71 ± 3.89 months.

CONCLUSION

The endoscopic transethmoidal-sphenoidal approach is an effective and minimally invasive treatment for removing small CH in the deep lateral orbital apex.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2022.

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.

The superior eyelid crease approach with retroseptal dissection: A modified access to the superomedial intraconal space. Treatment of a cavernous hemangioma: Case report and literature review

The orbit can be affected by primary intraconal lesions as well as cavernous hemangiomas. This article illustrates for the first time the retroseptal dissection (RD) route combined to the superior eyelid crease approach (SECA) to treat a symptomatic hemangioma inside the superomedial intraconal space. It also reviews the main studies about the argument. A 42-year-old woman affected by a mild painful proptosis and some accommodation difficulties in her right eye. The magnetic resonance imaging revealed a soft intraconal mass in the superomedial quadrant of the right orbit. The lesion was removed performing a SECA with RD through an incision inside a natural eyelid crease. Disappearance of pain with an improvement of accommodation was reported immediately. During the whole follow-up, the visual acuity, field examinations, and ocular motility did not reveal any impairment. Our approach represents a valid, quick, not technically demanding and mini-invasive method to access the superomedial intraconal space. Finally, it gives excellent functional and cosmetic results.

Exclusively endoscopic endonasal resection of benign orbital tumors: a systematic review and meta-analysis

BACKGROUND

The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) classification system was developed to standardize prospective outcome analysis following orbital cavernous hemangioma (OCH) resection. The goal of this study was to retroactively apply the CHEER system to all prior existing reports of endoscopic resection of primary benign orbital tumors (BOTs) to: (1) compare patient presentations, perioperative characteristics, and outcomes between OCH and other BOTs; and (2) determine whether the CHEER categorization regime could be expanded to other BOTs.

METHODS

A systematic review of studies reporting exclusively endoscopic resections of OCH and other BOTs (eg, solitary fibrous tumor, schwannoma, and meningioma) was performed. Patient, tumor characteristics, and operative outcomes were recorded. All tumors with adequate reporting were retrospectively assigned a CHEER stage. Outcomes were compared using chi-square or Fisher's exact tests.

RESULTS

Ninety-three studies met inclusion criteria, and sufficient data were available in 36 studies, comprising 105 tumors (n = 87 OCHs; n = 18 other BOTs). Baseline patient and tumor characteristics, as well as intraoperative and short-term postoperative outcomes were not significantly different between OCHs and other BOTs. Long-term outcomes (eg, visual deficits, diplopia, eye position, and recurrence) also did not differ when controlling for CHEER stage.

CONCLUSION

This review represents the largest collection of outcomes data following exclusively endoscopic endonasal resection of BOTs. Short-term and long-term outcomes appear similar between OCHs and other BOTs. These results suggest that exclusively endoscopic resection of orbital tumors may be effective in a range of benign pathologies. Furthermore, these results support a broader application of the CHEER system to other benign primary orbital tumors.

Navigation-Guided Endoscopy Combined with Deep Lateral Orbitotomy for Removal of Small Tumors at the Lateral Orbital Apex

Purpose

To evaluate the efficacy, feasibility, and safety of the navigation-guided endoscopy combined with deep lateral orbitotomy for removal of small tumors at the lateral orbital apex.

Design

A retrospective, noncomparative case series.

Methods

Retrospective analysis of ten patients (10 eyes) with small tumors at the lateral orbital apex comprised navigation-guided endoscopy combined with deep lateral orbitotomy at the Eye Hospital of Wenzhou Medical University from November 2015 to November 2017. In each case, the indication of surgery was existing or imminent visual impairment due to the tumor. The removal was believed to be complete if the mass was removed intactly during the surgery. The tumor character was confirmed by pathological examination after surgery. Patients were followed up to 3 months after surgery. Best corrected visual acuity before and after surgery was compared.

Results

All tumors were completely removed by the navigation-guided endoscopic approach. The mean preoperative best corrected visual acuity was 6/15 (95% confidence interval (95% CI) 6/40–6/8.5), and the mean postoperative best corrected visual acuity was 6/10 (95% CI 6/15–6/7.5). 5 of 7 (71%) patients with vision loss gained visual improvement in different degrees after surgery, and the rest of the patients had preoperative best corrected visual acuity. Visual field of all patients also improved. 8 cavernous hemangiomas and 2 schwannomas were confirmed postoperatively by pathology. 4 patients accompanied with limitation of eye abduction, which recovered spontaneously in an average of 4 weeks. No other serious complications occurred.

Conclusions

Navigation-guided endoscopy combined with deep lateral orbitotomy seems to be a feasible, efficient, and safe approach for removing small tumors at the lateral orbital apex. This trial is registered with ChiCTR1800019244.

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 Transnasal Removal of Cavernous Hemangiomas of the Optic Canal

PURPOSE

To assess the feasibility and efficacy of endoscopic transnasal removal of cavernous hemangiomas of the optic canal.

DESIGN

Retrospective, noncomparative case series.

METHODS

Eleven consecutive patients (11 eyes) with cavernous hemangioma of the optic canal underwent endoscopic trans-ethmoidal-sphenoidal removal of the tumor at the Eye Hospital of Wenzhou Medical University from January 2009 to March 2016. In each case, the indication for surgery was decreased visual acuity due to the tumor. The removal was believed to be complete if the tumor was removed en bloc during the surgery. A mucoperiosteal flap was used to cover the defect in the optic nerve sheath after tumor removal. The tumor was pathologically confirmed to be cavernous hemangioma after surgery. The mean follow-up time was 9.9 ± 5.5 months. Visual acuity before and after surgery was compared.

RESULTS

All tumors were completely removed by the endoscopic approach. The best-corrected visual acuity (BCVA) improved after surgery in all patients. The mean preoperative BCVA was 6/30 (95% confidence interval [CI] 6/60-6/20) and the mean postoperative BCVA was 6/10 (95% CI 6/12-6/7.5). All patients showed cerebrospinal fluid rhinorrhea, which resolved with strict bed rest. Other complications included hyposmia in 2 patients; nasal bleeding in 3 patients, which resolved spontaneously; and temporary headache.

CONCLUSIONS

Endoscopic trans-ethmoidal-sphenoidal approach is a feasible option for cavernous hemangiomas of the optic canal.

Neuronavigation-guided endoscopic endonasal resection of extensive skull base mucormycosis complicated with cerebral vasospasm

A 24-year-old woman presented with double vision since 6 months. Examination revealed left eye ptosis and bilateral abducens nerve palsy. Brain computed tomographic scan and magnetic resonance imaging revealed a bone-eroding mass lesion located in the middle skull base, occupying the posterior ethmoidal cells, the planum sphenoidale, the sphenoid sinus, the lateral recesses of the sphenois sinus, the pterygoid apexes, and the middle and lower clivus, with compression of the inferior wall of the cavernous sinus and the parasellar and paraclival parts of the internal carotid artery. The patient was operated on with extended endoscopic endonasal approach guided with neuronavigation. Total mass resection was achieved. Histopathologic examination revealed mucormycosis infectious mass. On postoperative day 5, the patient developed right hemiplegia, and brain imaging revealed left internal carotid vasospasm. After treatment, the patient improved and was discharged.

Purely endoscopic trans-nasal management of orbital intraconal cavernous haemangiomas: a systematic review of the literature

The surgical management of medial and inferior orbital lesions is demanding via traditional external approach, since the conic-shaped surgical field is narrow and damage to neural, muscular or vascular structures of the orbit can have serious consequences. In recent years, the evolution of endoscopic endonasal approaches for lesions that goes beyond the nose brought the orbit to the attention of rhinosurgeons. If procedures such as transnasal orbital decompression and lacrimal pathways surgery have been described some decades ago, the last frontier of transnasal orbital surgery, namely intraconal tumor surgery, is a new and rapidly expanding field. Papers describing endoscopic endonasal approaches to the orbit appeared in the international literature, but most of them contain a small number of cases, also because the relatively rarity of intraorbital lesions. We herein report the results of a systematic review of the literature regarding the endoscopic endonasal approach to intraconal cavernous haemangiomas, the most common benign orbital lesion. The endoscopic management of intraconal cavernous haemangiomas results feasible and safe. A critical step of this kind of surgery is the management of the medial rectus muscle, mandatory to expose the intraconal space.

Short-term outcomes of purely endoscopic endonasal resection of orbital tumors: a systematic review

BACKGROUND

The purpose of this review was to evaluate outcomes in transnasal endoscopic approaches for the management of extraconal and intraconal orbital tumors.

METHODS

A systematic review of studies on purely endoscopic endonasal orbital tumor resections was conducted using the MEDLINE database. Data extracted and analyzed from selected studies included study type, sample size, demographics, symptomatology, tumor characteristics, complications, follow-up time, and recurrence.

RESULTS

Thirty-nine studies were identified and included, containing patient data for 71 cases. Mean patient age was 47 years (range, 1-75 years), and 53.5% of patients were male. Primary site of the tumor was orbital in 69.0% of the cases, of which 51.0% were intraconal and 30.6% were extraconal. The most common reported histopathology was cavernous hemangioma (45.1%). Intraoperative complications were reported in 5.6% of cases. Postoperative complications were noted in 29.6% of cases, the majority of which were transient (76.2%). There was no significant difference in postoperative complication rate between intraconal and extraconal primary site tumors (p = 0.302). Recurrence rate was 4.2%.

CONCLUSION

Purely endoscopic endonasal resection of orbital tumors is a viable alternative technique to traditional external procedures, with the inherent advantages of minimally invasive surgery. This study of 71 cases represents the largest pooled sample size to date, and the increasing use of endoscopic procedures will allow for future analyses with greater statistical power.

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.