Endoscopic transnasal approach for resection of locally aggressive tumors in the orbit

Abstract

OBJECT In recent years, application of endoscopic transnasal surgery (ETS) has been expanded to orbital lesions, and preliminary results have started to be published for medially located soft mass lesions. However, reports on experience with endoscopic intraorbital surgery aimed at resection of invasive skull base tumors remains quite limited. This report presents the authors’ experience with ETS for locally aggressive tumors involving the orbit. METHODS ETS was performed for 15 cases of aggressive tumors involving the orbit: 5 meningiomas (meningothelial, n = 3; atypical, n = 1; anaplastic, n = 1), 4 chordomas, 2 chondrosarcomas, and 4 others (metastasis from systemic myxofibrosarcoma, schwannoma, inverted papilloma, and acinic cell carcinoma, n = 1 each). Among these, 9 tumors were located outside the periorbita and 6 inside the periorbita. In 6 intraperiosteal tumors, 5 were intraconal lesions, of which 3 arose in the muscle cone (anaplastic meningioma, optic sheath meningioma, and metastatic myxofibrosarcoma), and 2 meningothelial meningioma had invaded from the sphenoid ridge or the cavernous sinus into the muscle cone through the optic canal and the superior orbital fissure. A case of schwannoma originated around the cavernous sinus and pterygopalatine fossa and extended extraconally into the periorbita. Intraoperatively, ethmoid air cells and the lamina papyracea were removed, and extraperiosteal tumors were safely approached. For intraperiosteal tumors, the periorbita was widely opened, and the tumors were approached through the surgical window between the rectus and oblique muscles. RESULTS Gross-total resection was achieved for 12 of the 15 tumors, including 2 intraconal lesions. After surgery, exophthalmos resolved in all 8 patients with this symptom, and diplopia resolved in 5 of 6 patients. Improvement of visual symptoms was reported by 4 of 5 patients with loss of visual acuity or constriction of the visual field. Postoperatively, 1 patient showed mild, transient worsening of existing facial dysesthesia, and another showed transient ptosis and mild hypesthesia of the forehead on the affected side. All those symptoms resolved within 3 months. No patients showed enophthalmos, worsening of diplopia or visual function, or impairment of olfaction after surgery. CONCLUSIONS ETS appears acceptable as a less-invasive alternative for treating aggressive tumors involving the orbit. For extraperiosteal tumors, gross-total removal can generally be achieved without neurological complications. For intraperiosteal tumors, surgical indications should be carefully discussed, considering the relationship between the tumor and normal anatomy. Wide opening of the periorbital window is advocated to create a sufficient surgical pathway between the extraocular muscles, allowing a balance between functional preservation and successful tumor resection.

A systematic review of sinonasal oncocytomas and oncocytic carcinomas: Diagnosis, management, and technical considerations

“…A multidisciplinary, team‐based approach can help facilitate appropriate resection when disease involves the orbit and skull base. Collaboration with oculoplastics and neurosurgery colleagues when appropriate can help facilitate complete resection and optimal outcome …”

New instrumentation in endoscopic medial orbital decompression

“…Some therefore recommend using steristrips to cover the sickle knife, except at the distal 2‐mm tip . Other authors have described the use of a microknife and scissors, a straight Beaver arachnoid knife, or a number 12 knife blade for various procedures involving transnasal periorbita incisions.…”

New surgical option for optic nerve sheath meningiomas: fully endoscopic transnasal approach

“…The endoscopic transnasal approach for optic nerve sheath meningioma has been reported only once in the literature. 5 In this paper, we describe our experience and discuss the surgical indications, advantages, and limits of this new approach.…”

“…In recent years, various articles describing the use of endoscopic transnasal techniques for the treatment of orbital diseases have appeared in the literature. In particular, these approaches have been repeatedly reported to allow neurosurgeons to dominate both the superior and the infero-medial part of the orbit and the optic canal, 5 whereas the central part of the orbit, where the optic nerve lies, has been addressed only once. 6 In this article, we have presented our experience with a fully endoscopic transnasal approach for the treatment of an optic nerve sheath meningioma.…”

“…3,4 The distinctive feature of LSS is the residual lacrimal sac formed after DCR with normal lacrimal irrigation and dye disappearance tests. LSS classically occurs due to inadequate marsupialization of the lacrimal sac inferiorly or because the ostium is situated too high 5 or is too small. 2,3 In many patients with LSS, probing and syringing of the lacrimal drainage system may appear normal 6 ; hence, a high index of suspicion is required among patients with LSS after DCR.…”