The hybrid lid crease approach to address lateral frontal sinus disease with orbital extension

A minimally invasive, combined approach to the recurrent/recalcitrant sino-orbital mucocele

PURPOSE

To evaluate the results of a minimally invasive combined endoscopic and eyelid crease/medial suprabrow incision approach in collaboration with oculoplastic and sinus surgeons for the treatment of recurrent/recalcitrant sino-orbital mucoceles.

METHODS

Eighteen cases of recurrent/recalcitrant sino-orbital mucoceles, treated in collaboration with oculoplastic and sinus surgeons at the University of Michigan, were retrospectively reviewed. The recurrence of mucocele, reduction in proptosis, and complications were evaluated.

RESULTS

The mean age at the time of surgery was 49 years (range: 17-76 years). All cases had a history of previous sinus or orbital surgeries for mucoceles. Among 18 cases, eight were due to chronic sinus infections, six due to trauma, three due to Schneiderian papilloma, and one case was secondary to an inflammatory sinus disease. Thirteen cases (72%) presented with orbital or facial cellulitis, while five cases (38%) experienced periocular swelling and limited extraocular motility. Following a mean follow-up of 19 months (range: 1-76 months)), recurrence was observed in two cases (11%): one in a cystic fibrosis patient with chronic sinusitis, and the other in a case of Schneiderian papilloma. The mean pre-operative proptosis in the affected eye was 2.78 mm, with an average decrease of 2.33 mm after surgery. Complications occurred in two cases, including one case of hypoesthesia in the forehead and one case of post-operative strabismus.

CONCLUSION

Our series of 18 cases of recurrent/recalcitrant mucoceles, with only two cases of recurrence, demonstrates that this minimally invasive approach can be successfully employed for advanced sino-orbital disease, with a low rate of adverse outcomes and aesthetically pleasing results.

Combined upper lid skin crease and endoscopic approach to frontal sinus mucocoeles

PURPOSE

This case series describes the ophthalmic manifestations of frontal sinus mucoceles and reports the long-term surgical outcomes of a combined endoscopic and upper-lid skin crease drainage approach carried out jointly with otorhinolaryngology.

METHODS

We present a retrospective case review of 18 orbits and 15 patients presenting with frontal sinus mucocoeles, all of whom underwent drainage via an adapted anterior orbitotomy approach between January 2015 and July 2023. Data collection included preoperative and postoperative examination findings (visual acuity, extraocular motility, lid retraction, and lagophthalmos), mucocoele recurrence, cosmetic satisfaction, and surgical complications. Patients were followed up for an average of 22 months.

RESULTS

All patients underwent successful frontal mucocoele drainage via a modified anterior orbitotomy and simultaneous endonasal approach. At presentation, three (20%) had extraocular restriction leading to diplopia, and six (40%) had proptosis in the eye adjacent to the mucocoele. One patient presented acutely with no light perception in the affected eye due to compressive optic neuropathy. All patients who had reduced extraocular motility before surgery regained full motility post-operatively. Treatment was successful in all cases, and there was no documented mucocoele recurrence during follow-up. Satisfactory aesthetic outcomes were achieved in all cases. Reported complications included temporary forehead numbness and ptosis of the affected eyelid, which resolved without intervention.

CONCLUSION

The modified anterior orbitotomy approach to frontal mucocoeles allows optimal frontal sinus access and mucocoele treatment while preserving cosmesis.

Combined Endonasal Endoscopic and Sub-brow Orbitotomy Access to Manage a Lateral Extending Frontal Sinus Inverting Papilloma with Endo-orbital Invasion: A Case Report

Sinonasal inverting papilloma is a rare benign, locally aggressive tumour, arising from sinus and/or nasal fossa mucosa, with high recurrence rate, and risk of malignant transformation. This is a case of orbital invasive, lateral extending inverting papilloma approached via combined external and endoscopic surgery.

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base

The transorbital approaches are a group of surgical procedures performed passing through the orbital spaces and aimed to reach deeper areas. This kind of surgery has been proved to be safe and effective in the management of selected lesions of the anterior, middle and infratemporal fossa. The aim of the present study is to perform a review of the literature, in order to draw the reader’s attention on the main features of this kind of surgery, focusing on the anatomical background and the surgical setting; we will also summary the current indications and contraindications to this approach and find out the related complications and the possible alternatives. Even if we consider the transorbital approach as a promising route to the skull base, we underline that there is no better approach over another and the choice must always consider several elements. Furthermore, as for every skull base procedure, a multidisciplinary management is strongly advisable.

Transpalpebral Frontal Sinus Septectomy: Feasibility and Results

Background

Transpalpebral frontal septectomy (TFS) can be performed for unilateral frontal sinusitis drainage (into the contralateral healthy frontal sinus) or to provide access to the lateral extent of the contralateral frontal sinus. This procedure has demonstrated its usefulness in several problematic situations for the endoscopic surgeon.

Objective

The main objective of our study was to evaluate the feasibility of TFS. Secondary objectives were to define outcomes, early and late complications, contraindications, and failure rates of the TFS.

Methods

We reviewed patient demographics including age and gender, indication for frontal septectomy, prior surgeries, failure rates and necessity of revision surgery, early and late complications, and the side of the approach (ipsi- or contralateral to the frontal sinus pathology). Twenty patients who had undergone TFS were included. Patients were classified into 2 groups according to the surgical indication: group 1—TFS performed for unilateral frontal sinusitis to drain a frontal sinus in the contralateral frontal sinus; and group 2—TFS performed to provide access to the lateral extent of the contralateral frontal sinus. Scarring was assessed using the SCAR-Q questionnaire.

Results

TFS was performed on all patients in Groups 1 and 2 (success rate = 100%). No patients had recurrence of the pathology 6 months after surgery (0%). No patient needed revision surgery (0%). One complication (frontal hypoesthesia) was reported 6 months after surgery. Mean SCAR-Q score was 99.3 ± 2.5 (min = 91/100, max = 100/100).

Conclusion

TFS was feasible for all patients in this study. This procedure permits drainage of the frontal sinus and gives access to the lateral extent of the contralateral frontal sinus, without visible scarring, and with few lasting complications. Authorization to conduct this study was obtained from the Ethical Committee of our institution (APHM, n°2019_65).

Implication of frontal sinus mucocele's location and intrasinus septation

Mucocele of paranasal sinuses commonly affects frontal or frontoethmoidal air cells. With the evolution of endoscopic sinus surgery, the endoscopic marsupialisation has become the standard of care for these lesions. However, the external approach still has a role in selected cases of frontal sinus mucocele. The location of the mucocele and its communication with the natural outflow tract of the frontal sinus are some of the critical factors to be considered while choosing the surgical approach. We have discussed the management of three cases of frontal mucoceles having different locations and one of them having intervening septa. We emphasise that the successful management of far laterally located mucoceles and those with laterally situated septation require an external approach in conjunction with endoscopic marsupialisation.

Combined Lid Crease and Endoscopic Approach to Lateral Frontal Sinus Disease With Orbital Extension

INTRODUCTION

Functional endoscopic sinus surgery for frontal sinus disease has obviated the need for external approaches. Special circumstances such as acute infection with orbital involvement or significant lateral sinus disease frequently require adjunct access. We describe the clinical outcomes of a combined upper eyelid crease and endoscopic approach for lateral frontal sinus disease with orbital extension.

METHODS

A retrospective case series of 7 patients who underwent a combined lid crease approach for frontal sinus disease with orbital extension between April 2012 and October 2016 was performed. All patients had the presence of lateral frontal sinus disease as well as orbital extension as seen on a preoperative computed tomography (CT) scan. Patient demographics, indications for surgery, and perioperative findings were examined.

RESULTS

Six of the 7 patients were male. Mean age was 61 years, and the indication for surgery was primarily drainage of mucopyocele and inverting papilloma (IP) in 1 patient. The frontal sinus and orbit were successfully accessed, and the respective pathology was addressed in both locations. No intraoperative or postoperative complications were encountered. There was no postoperative or cosmetic complications.

CONCLUSION

The combined lid crease and endoscopic approach is a safe and effective technique for accessing the lateral frontal sinus and orbit.

Quantifying Lateral Frontal Sinus Access: The Upper Blepharoplasty Approach

OBJECTIVE

Despite advances in technology and instrumentation, access to the lateral frontal sinus remains a challenge for surgeons. We sought to quantify the reach and applicability of the upper blepharoplasty approach (UBA) to the frontal sinus.

METHODS

Twelve cadaveric specimens were obtained for anatomic research and frontal sinuses divided into 3 zones. Zone 1 was defined as medial to the supraorbital neurovascular bundle (SON). The remaining orbit was then bisected to define zone 2 (centrally) and zone 3 (laterally). Twenty-four UBAs were performed followed by 12 modified endoscopic Lothrop procedures (MELP). The ability to instrument each wall of the frontal sinus was recorded for the MELP, UBA, and combined approach.

RESULTS

The UBA provided excellent access to the lateral frontal sinus in zones 2 and 3 (89% and 100%). The MELP provided poorer access in zone 3 (67%) but improved access in zone 1 (83%-100%). Access for zone 1 through the UBA was limited. The combined approach yielded 100% access to each frontal sinus boundary.

CONCLUSION

The MELP in combination with the UBA/lateral trephination provides excellent access to each frontal sinus boundary. The UBA provides excellent access to the lateral frontal sinus but is limited medially by the SON.

Utility of intraoperative flexible endoscopy in frontal sinus surgery

Background:

Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods:

Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results:

In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion:

In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma

OBJECTIVES

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP.

STUDY DESIGN

Case series.

METHODS

Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window.

RESULTS

The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up.

CONCLUSION

Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:3-9, 2018.

Minimally invasive surgery of the anterior skull base: transorbital approaches

Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach.