Endonasal Orbital Decompression Research Articles

Recovery From Visual Loss After Endoscopic Endonasal Decompression of Iatrogenic Orbital Abscess.

Orbital complications are the second most common complications of endoscopic sinus surgery (ESS), and orbital hematoma is the most frequent orbital complication. An orbital abscess is usually associated with rhinosinusitis, and a few cases of orbital abscesses occurring after orbital trauma have been reported. However, orbital abscess occurring after ESS is rare. Herein, we present a case of a right orbital abscess that developed after bilateral ESS, performed at an outside facility, and decreased vision in the right eye to light perception only. The visual loss persisted for 3 days, after which the patient was referred to our hospital for urgent management. The cause of abscess formation might have been an infected stagnant orbital venous hematoma that occurred as a complication of ESS. A defect in the right lamina papyracea and emphysema were confirmed on computed tomography. Orbital symptoms started immediately after ESS, and vision deteriorated to light perception only and lasted for 3 days, which was considered a high-grade risk factor for irreversible blindness by the ophthalmology team. Urgent endoscopic endonasal orbital decompression was performed to drain the orbital abscess, and maximal medical treatment was initiated, which included intravenous corticosteroids, intravenous broad-spectrum antibiotics, topical intranasal corticosteroids, irrigation, and topical antibiotic eye drops. Close follow-up assessments were performed by the infectious diseases team, and the ophthalmology team performed frequent orbital assessments. The patient recovered from blindness, which was an unexpected outcome.

A clinical case of endoscopic endonasal orbital decompression in thyroid eye disease

A clinical case of endoscopic endonasal orbital decompression in thyroid eye disease

Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease.

Orbital decompression is an established surgical treatment option for a range of orbital conditions. Traditionally, Ear, Nose and Throat surgeons have adopted the endoscopic route while ophthalmologists operate via an external approach. The authors report the outcomes of endonasal decompression performed by oculoplastic surgeons experienced in endonasal techniques. This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to thyroid eye disease across 2 hospital sites between January 2011 and July 2018. Inclusion criteria were patients who had endoscopic decompression for proptosis in inactive thyroid eye disease or active disease without dysthyroid optic neuropathy. Information collected includes patient demographics, diagnosis, surgical details, preoperative and postoperative clinical findings (including, visual acuity, color vision, exophthalmometry readings, palpebral aperture, intraocular pressure, ocular motility, diplopia, and visual field), complications, and further treatment. There were 70 cases of endoscopic decompression. The majority of patients had endoscopic medial and posterior medial wall/floor decompression (44.3%; 31/70 cases). Visual acuity remained stable in 98.6% (69/70). There was an average reduction in proptosis of 3.5 ± 1.2 mm (standard deviation [SD]) in the endoscopic medial wall only group, 3.9 ± 0.9 mm (SD) in endoscopic medial wall and posterior medial portion of the floor group, and 7.6 ± 2.1 mm (SD) in the 3-wall decompression group. Motility improved in 11.4% (8/70) and worsened in 2.9% (2/70). There were no significant intraoperative or postoperative complications associated with endoscopic surgery. Oculoplastic surgeons experienced in endonasal techniques can perform endoscopic orbital decompression with outcomes comparable to the literature.The authors report the outcomes of a series of endonasal orbital decompression carried out by oculoplastic surgeons.

P.102 Expanded endoscopic endonasal approach for orbital apex decompression

Background: The Endoscopic endonasal approach (EEA) has been gaining popularity in the past decade as an alternative to traditional transcranial and transorbital approaches. We have performed orbital apex decompression for a variety of pathological entities. Methods: We performed a retrospective chart review on patients who underwent EEA orbital apex decompression between January 1st 2010 and December 1st 2018 at McMaster University. Results: Eight patients underwent endoscopic endonasal orbital decompression at our center, including five male patients and three female patients. The mean age of our patients was 50.1 years. The different pathologies we treated included nasopharyngeal carcinoma, hemangioma, fibrous dysplasia, IgG4 disease, inverted papilloma, angioleiomyoma, and neuroendocrine paraganglioma. Five patients presented with visual symptoms. Postoperatively, one of these five patients improved to baseline, three had stable vision, another one had progressive visual decline despite surgical intervention. Conclusions: Endoscopic endonasal approach can be used as an alternative to decompress orbital apex pathologies in selected patients.

Endonasal Approach for Nasal and Paranasal Sinus Tumor Removal

Patients with benign (53) and malignant (22) tumors of the nose and paranasal sinuses were treated for tumor removal via an endonasal approach. Patient selection was based on tumor location (centrally) rather than histology. Tumors attainable by the endonasal approach were located in the nasal cavity, the ethmoid sinus, the sphenoid sinus and the medial wall of the maxillary sinus. Endonasal microscopic techniques including endonasal orbital decompression and endonasal closure of CSF-leaks were combined with surgical navigation tools in selected cases. Surgical trauma and morbidity could be minimized without compromising radicality of tumor removal. Postoperative hospitalization was comparable to the period needed after chronic inflammatory disease. Growing experience with endonasal techniques is leading towards a safe and effective treatment option for centrally located, selected tumors of the nose and paranasal sinuses.

Ancillary Procedures in Microscopic Endonasal Orbital Decompression for Thyroid-Associated Ophthalmopathy

In 35 patients with thyroid-associated orbitopathy, nonresponsive to conservative treatment, an endonasal microscopic approach with bimural osteotomy was performed for decompression in two ways. While in group A the periorbita was resected, and fat septa were cut, in group B periorbital strips were left, and fat septa were respected. In accordance with other authors, resection of the periorbital and cutting fat septa will improve vision and proptosis, but in up to 30% of the patients de novo diplopia occurs. Our data favor the assumption that a more conservative endonasal microscopic decompression of the orbita leaving periorbital strips and fat septa achieves similar good results for reduction of proptosis and visual gain but creates less often de novo diplopia in primary gaze. Based on our experience, rehabilitation for thyroid-associated arbitopathy comprises as a first step orbital endonasal decompression with cooperation of the ophthalmologist, then if necessary as a second step strabismus surgery, and thirdly eyelid repair for scleral show.

Transnasale Chirurgie der Orbita

The endonasal surgery has a branch in the transnasal orbital surgery. For this transnasal approach the anterior skull base, the medial and infero-medial orbita, the orbital apex with the optical nerve and the sphenoid sinus are within reach. In all primary and secondary malignant lesions with extension into the orbita, the transnasal biopsy is of importance for diagnosis, particularly in metastasis to the orbit and pseudo-tumors. Benign lesions like mucoceles and osteomas are accessible and fully removable. Good results have been obtained in endonasal orbital decompression and inhomogeneous space occupying intraorbital lesions like bleedings. Among the orbital traumatism, with restrictions fractures of the medial orbital wall, medial orbital floor and foreign bodies could be operated. The transnasal approach is not indicated in all diseases, which are situated mostly intraconally, supraorbitally and lateral of the bulbus as well as in tumors with intracranial extension. In summary, the transnasal orbital approach has its place as helpful addition to the transfacial and transcranial techniques and can even replace them in certain selected indications.

Endoscopically controlled surgical decompression of the orbit in malignant ophthalmopathy

From May 1988, an endoscopically controlled endonasal orbital decompression was performed in 17 patients with malignant ophthalmopathy. Indications were exclusively acute loss of visual acuity or visual field defects, when medical and radiation therapy had failed. The new minimal invasive technique proceeds in three steps. First, an endonasal, endoscopically controlled ethmoidectomy with resection of the middle turbinate is done and the medial wall of the maxillary sinus is widely opened. Second, the medial and inferior orbital walls are removed, preserving the infraorbital nerve. In the last step, the periorbita is incised and the orbital fat herniates. The advantages of this procedure consist of the absence of exterior scars, the avoidance of lacrimal duct stenosis and bony defects in the maxilla and the prevention of the known morbidity of a Caldwell-Luc antrotomy with hypesthesia, dysesthesia and oro-antral fistula. The results were documented by computerized tomographic scans (CT), magnetic resonance imaging (MRI), Hertel measurements, evaluation of ocular motility and ophthalmoscopy. All patients had a postoperative improvement of visual acuity. An average of 3-4 mm improvement in Hertel measurements was reached. Four patients who had a diplopia before the interventions developed a more significant diplopia postoperatively, whereas in all other patients ocular motility either improved (five patients) or remained the same. In conclusion, the endoscopically controlled endonasal procedure enables greater preservation of normal structures and provides results comparable with the common extranasal and transantral procedures without the disadvantages of the latter.

Endoskopisch kontrollierte endonasale Orbitadekompression beim malignen Ophthalmus*

In 6 patients with endocrine ophthalmopathy, indications, surgical technique and results of the endoscopic controlled endonasal orbital decompression are described in comparison to the common surgical procedures. When medical and radiation therapy fail, indications for decompression are a) loss of visual acuity or visual field defects, b) increasing strabismus, c) severe keratopathy due to eyelid retraction. The endoscopic-controlled endonasal surgical decompression technique is proceeded in three steps. First, an endonasal ethmoidectomy with resection of the middle turbinate is performed and the medial wall of the maxillary sinus is widely opened. Second, the medial and inferior wall of the orbital walls are removed, preserving the infraorbital nerve. In the last step, the periorbital area is incised and the orbital fat herniates. The advantages of this procedure consist in the absence of exterior scars and the known morbidity of a Caldwell-Luc antrotomy. The results were documented by computed tomographic scans (CT), magnetic resonance imaging (MRI), Hertel measurements, evaluation of ocular motility and ophthalmoscopy. An average of 3-4 mm improvement in Hertel-measurements could be reached. All patients had a postoperative improvement of visual acuity. 2 patients developed more significant diplopia postoperatively, whereas in all other patients ocular motility either improved or rested unaffected. Therefore, the endoscopic controlled endonasal procedure allows to obtain comparable results to the common extranasal and transantral procedures without the disadvantages of the latter.