Combined Endonasal and Orbital Approach for Resection of Orbital Apical Tumors

Purpose: Tumors of the medial orbital apex are difficult to resect, as there are many critical structures present, and space is at a premium. Utilization of the adjacent paranasal sinuses to assist in orbital tumor resection via the endoscopic approach has been well-described in both the ophthalmic and rhinology literature.[1] [2] However, very few reports of using a combined endonasal and orbital approach to dissect the lesion from both sides exist in the literature.[3] This technique has the benefit of utilizing the nasal space to prolapse the lesion, allowing for orbital dissection on the lateral and posterior aspects of the lesion, areas that are otherwise difficult to visualize from an orbital or endoscopic approach alone. Herein, we report our experience with orbital apex tumor excision utilizing a combined endonasal and orbital 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, symptomatology, examination findings, and complications were extracted from patient charts. Imaging characteristics, surgical technique, and histopathology were reviewed.

Results: There were 6 patients (3 men, 3 women) with mean (SD) age 52.8 (14.6) years who were included in the study. Presenting symptoms included blurry vision (3), pain (2), diplopia (1), upper eyelid ptosis (1), and no symptoms (2). Preoperative examination findings included proptosis (6), optic neuropathy (3), and motility restriction (2). Imaging demonstrated a tumor in the inferomedial (4) or superomedial (2) orbital apex. In each case, medial orbitotomy and endoscopic ethmoidectomy ± sphenoidotomy was performed, the medial orbital wall was removed, and the periosteum was opened to expose the lesion. The lesion was prolapsed into the sinus and dissected laterally and posteriorly at the apex via the orbital approach. The tumor was removed through the nose, and in 3/6 cases the medial wall was reconstructed. The pathologic diagnosis was cavernous venous malformation (4), venolymphatic malformation (1), and metastatic carcinoid (1). Improvement in pain (2/2), optic neuropathy (2/3), and proptosis (6/6) was noted. The patient with metastatic carcinoid required removal of the superior oblique muscle to completely resect the tumor, and she developed postoperative diplopia, which was successfully managed with strabismus surgery. One patient developed a partial visual field defect.

Conclusion: The combined endonasal and orbital approach involves prolapsing an orbital mass lesion into the nasal cavity, allowing for visualization of the lateral and posterior portions of the lesion for transorbital dissection at the orbital apex.

Publication History

Article published online:
12 February 2021

• References

• 1 Wu W, Selva D, Jiang F. et al. Endoscopic transethmoidal approach with or without medial rectus detachment for orbital apical cavernous hemangiomas. Am J Ophthalmol 2013; 156 (03) 593-599
• 2 Bleier BS, Castelnuovo P, Battaglia P. et al. Endoscopic endonasal orbital cavernous hemangioma resection: global experience in techniques and outcomes. Int Forum Allergy Rhinol 2016; 6 (02) 156-161
• 3 Kim M, Gudis DA, Tooley AA, Kazim M. Trans-septal suture retraction for endoscopic orbital surgery. Orbit 2020; 39 (05) 336-341