Endoscopic Transnasal Orbital Decompression David W.
Kennedy, MD; Matthew L. Goodstein, MD; Neil R. Miller, MD; S. James Zinreich, MD
\s=b\ Orbital decompression for dysthyroid orbitopathy has traditionally been performed through either an external or a transantral approach. The advent of intranasal endoscopes allowed for the development of a transnasal approach for
medial and inferior orbital wall decompression. Using this approach, orbital decompressions were performed on 13 orbits in eight patients with severe com-
plicated dysthyroid orbitopathy. Simultaneous
bilateral lateral orbitotomies
were
performed on five patients. Walsh-Ogura decompressions and lateral orbitotomies were performed on two orbits. When combined with lateral orbitotomy, Hertel mea-
Dysthyroid orbitopathy
is an au¬ toimmune disorder in which antithyroglobulin immune complexes bind to extraocular muscle mem¬ brane.1 The immune complexes incite an inflammatory reaction that culmi¬ nates in edema and fibrosis of the ex¬ traocular muscles and fat. Further ex¬ pansion of the extraocular contents results from the hydropexic properties of mucopolysaccharides deposited by fibroblasts.2 The consequent increase in the volume of extraocular orbital contents leads to increased orbital pressure resulting in protrusion of the globe anteriorly. Given an average or¬ bital volume of 26 mL, an increase of Accepted for publication November 17, 1989. From the Departments of Otolaryngology\p=n-\ Head and Neck Surgery (Drs Kennedy and Goodstein); Ophthalmology, Neurology, and Neurosurgery (Dr Miller); and Radiology and Otolaryngology\p=n-\Headand Neck Surgery (Dr Zinreich), The Johns Hopkins Medical Institutions, Baltimore, Md. Presented in part at the meeting of the American Rhinological Society, New Orleans, La, September 23, 1989. Reprint requests to Department of Otolaryngology\p=n-\Headand Neck Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21205 (Dr Kennedy).
surements improved an average of 5.7 mm in orbits decompressed transnasally and 4.5 mm in orbits decompressed with a Walsh-Ogura approach. Transnasal decompression alone improved Hertel measurements an average of 4.7 mm. Visual acuity improved in three of four patients with optic neuropathy, and in all patients with exposure keratopathy. We conclude that the endoscopic transnasal approach provides comparable decompression to traditional methods while avoiding the morbidity of an external ethmoidectomy or
Caldwell-Luc antrotomy. (Arch Otolaryngol Head Neck Surg.
1990;116:275-282)
only 4 mL (16% ) will result in 6 mm of proptosis.3 Dysthyroid orbitopathy is often a
self-limited disorder that does not visual loss.46 However, when se¬ vere, proptosis can have three signifi¬ cant visual consequences. First, expo¬ sure keratopathy can result from an inability to close the eyelids.4 Second, progressive diplopia can result from asymmetrically impaired extraocular muscle function.5-7 These sequelae are caused not only by proptosis, but also by fibrosis of the levator palpebrae superioris and by swelling or fibrosis of the extraocular muscles, respectively. Third, optic neuropathy can result from compression of the optic nerve or its vasculature by the enlarged ex¬ traocular muscles. The optic neuropa¬ thy produces progressive loss of visual acuity, decreased color vision, and de¬ fects in the visual field, usually central scotomas.4'5·8 A variety of modalities have been used to treat dysthyroid orbitopathy. Systemic corticosteroids may improve all signs and symptoms of the disorder, but the steroids may need to be concause
tinued for many months at high doses, and even then signs and symptoms of¬ ten return when the medication is tapered.4-5-9 External-beam irradiation is efficacious for treating dysthyroid optic neuropathy, but it does not usu¬
ally improve proptosis significant¬ ly.10'13 The use of the immunosuppres¬
sive agents cytoxan and cyclosporin remains experimental and may be ac¬ companied by potentially serious side effects.1415 Plasmapheresis combined with immunosuppressive agents has been used for acute vision-threatening processes.16·17 The type and timing of treatment used for the hyperthyroid component of this disorder does not appear to affect the severity of the or¬ bital component.6·1819 The mainstay of therapy for severe dysthyroid orbitopathy remains sur¬ gical decompression of the orbital con¬ tents into an adjacent real or potential
In 1911, Dollinger,20 using Kronlein's approach for access to the lateral orbit, performed a lateral wall decompression; however, the extent of decompression provided was minimal. Naffziger21 developed a superior de¬ compression of the orbital contents into the anterior cranial fossa. This approach requires a craniotomy, with consequent risks of meningitis and leakage of cerebrospinal fluid, and it results in bothersome transmission of cerebral pulsations to the eyes. Conse¬ quently, Sewall22 described a medial orbital wall decompression through an external ethmoidectomy approach. Hirsch23 was the first to employ a Caldwell-Luc approach to obtain a de¬ compression by removal of the orbital floor. In 1957, Walsh and Ogura24 ex¬ tended this approach to include a me¬ dial wall decompression. As recently reviewed by Warren et al4 and DeSanto,' the Walsh-Ogura technique space.
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remains the standard approach for or¬ bital decompression; however, this ap¬ proach requires a generous CaldwellLuc antrotomy and carries the atten¬ dant morbidity of this procedure. Our usual approach has been to combine the Walsh-Ogura approach with a lat¬ eral orbitotomy, so as to maximize the degree of decompression obtained. SUBJECTS
Eight patients with severe dysthyroid orbitopathy complicated by visual sequelae underwent orbital decompression at our institution. Seven patients underwent bi¬ lateral procedures and one patient had a unilateral procedure for a total of 15 de¬ compressions performed. The group was divided equally between men and women. The patients' ages ranged from 30 to 74 years. A complete neuro-ophthalmologic examination was performed on all patients, consisting of assessment of visual acuity, color vision, and visual field. Slit-lamp biomicroscopy, tonometry, evaluation of ocu¬ lar motility and alignment, and ophthalmoscopy were also performed. All patients had assessment of proptosis using a Hertel exophthalmometer. Nonenhanced com¬ puted tomography scans of the orbits and paranasal sinuses were obtained preopera¬ tively in all patients with 2-mm coronal and axial slices.
SURGICAL TECHNIQUE The patient is placed supine on the oper¬ ating room table with the head slightly el¬ evated. General anesthesia is provided through a right-angled endotracheal tube. Local vasoconstriction is obtained with top¬ ical cocaine and 1% lidocaine (Xylocaine) with 1:100000 epinephrine injected under endoscopie visualization. An intranasal en¬ doscopie sphenoethmoidectomy is per¬ formed as detailed by Kennedy.25 Care is taken to identify and skeletonize the medial orbital wall and the skull base. Posteriorly, the orbital apex and, when possible, the op¬ tic canal are identified. Anteriorly, the area of the frontal recess is opened. A very gen¬ erous middle meatal antrotomy is then performed, creating an opening that ex¬ tends anteriorly to the posterior margin of the nasolacrimal duct, inferiorly into the root of the inferior turbinate, and posteri¬ orly to the posterior limit of the sinus.26 The infraorbital nerve is identified laterally within the sinus and defines the lateral limit for removal of the orbital floor. At this point, the skeletonized medial or¬ bital wall is gently removed with an angled spoon, a blunt nerve hook, or fine Blakesly forceps (Pig 1). The orbital floor is removed with fine right-angle 70° or 110° Giraffe
forceps under direct endoscopie vision with a 30° or 70° telescope. Small fragments of the inferior orbital wall may also be frac¬ tured inferiorly with a curved suction or Jcurrette and removed. The medial and infe¬ rior orbital walls are removed to the orbital apex posteriorly, leaving a small rim of bone anterior to the optic canal. Bone is re¬ moved from the orbital floor laterally to the infraorbital nerve. Anteriorly, the medial orbital wall in the region of the frontal re¬ cess is preserved to avoid the possibility of stenosis and subsequent frontal sinus ob¬ struction. Care is taken not to open the periorbita at this stage of the operation. Once meticulous resection of the bony orbital wall is complete, the periorbita is incised with a sickle knife in linear strokes from posterior to anterior (Fig 2). The ini¬ tial incision is placed laterally within the maxillary sinus and is performed using a bent Beaver sickle knife (Fig 3, left). Suc¬ cessive incisions are performed medially within the maxillary sinus, so as not to ob¬ struct the surgeon's view by the herniating intraorbital contents. Similar periosteal in¬ cisions are then made high on the medial orbital wall using a straight Beaver sickle knife or a No. 12 Bard-Parker blade, and successive incisions are made inferiorly. A Beaver-Rosen knife, bent as necessary, (Fig 3, right) is then used to lyse further fibrous periorbital bands. This allows for extensive herniation of orbital fat into the opened si¬ nuses.
The immediate extent of decompression is assessed by gently palpating the orbit and endoscopically viewing the transmis¬ sion of the palpations to the herniated or¬ bital contents. At the end of the operation a Merocel sponge in a rubber finger cot is coated with antibiotic ointment and placed lateral to the middle turbinate. Treatment with a broad-spectrum antibiotic, usually a /i-lactamase-resistant cephalosporin is be¬ gun. The sponge is removed the following day and the maxillary sinus is suctioned free of blood under endoscopie visualiza¬ tion. Five of the eight patients underwent lat¬ eral orbitotomies at the same time as the transnasal decompression, as had been our standard practice with the Walsh-Ogura approach. All lateral orbitotomies were performed by an experienced orbital sur¬ geon (N.R.M.) in the fashion previously de¬ tailed by Miller and Iliff.27 We performed Caldwell-Luc antrotomies on two of our first three patients (patients 1 and 3) in or¬ der to assess the extent of decompression obtained endoscopically. On two orbits (pa¬ tient 4, right eye; patient 5, right eye) we were unable to perform transnasal decom¬ pressions due to severely deviated nasal septums. Accordingly, Walsh-Ogura de-
compressions
were
performed along with
lateral orbitotomies.
RESULTS
Preoperative and postoperative vi¬ sual acuity and Hertel measurements for the eight patients undergoing or¬ bital decompression are presented in Table 1, along with each patient's pre¬ operative symptoms and the type of procedure performed on each orbit. Preoperative measurements were ob¬ tained within 1 month of surgery and postoperative measurements were ob¬ tained 1 to 4 months after surgery. Visual acuity remained normal in all patients, with normal vision preoper¬ atively. Marked improvement in acuity occurred in three of the four patients with optic neuropathy (patients 1, 5, and 7). The one patient whose vision did not improve (patient 4) had chronic optic neuropathy with probable pre¬ existing vascular compromise of the
optic nerve. Exposure keratopathy re¬ solved in all four patients in which it was present preoperatively (patients 3, 5, 6, and 8). Two patients with mild preoperative diplopia developed more significant diplopia postoperatively (patients 6 and 8). In all other patients, ocular motility and alignment either improved or were unaffected by the decompression. The extent of decompression ob¬
tained with each combination of pro¬ cedures performed is summarized in Table 2. Maximal decompression ap¬ pears to be obtained by a combination of transnasal decompression and lat¬ eral orbitotomy with an average of 5.7 mm (range, 4 to 7 mm) improvement in Hertel measurements, while transna¬ sal decompression alone and WalshOgura decompression combined with lateral orbitotomy yielded similarly good results with 4.5 mm (range, 3 to 6 mm) and 4.7 mm (range, 3 to 6 mm) of improvement in Hertel measure¬ ments, respectively. There was no cor¬ relation between the degree of preop¬ erative proptosis and the extent of de¬ compression obtained, either when considering all decompressions to¬ gether (Fig 4, left), or when consider¬
ing only endoscopie decompression combined with lateral orbitotomy (Fig 4, right). Due to the small number of orbits operated on, these figures are not of statistical significance.
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Fig 1.—Removal of left medial orbital wall. Left, Artist's rendition of removal of medial orbital wall with Blakesly forceps under endoscopie visualization. Right, Endoscopie photograph following removal of the medial orbital wall (30° wide-angle telescope directed laterally). Superiorly, the skull base (S), the anterior ethmoid artery (curved arrow), and the frontal si¬ nus (F) are seen. OP indicates orbital periosteum.
Fig 2.—Removal of left orbital floor and incision of orbital periosteum. Left, Endoscopie photograph demonstrating maxillary sinus (M) and widened middle meatal antrostomy (arrows) with exposure of the orbital floor (30° wide-angled telescope di¬ rected laterally). Right, Artist's rendition demonstrates incision of inferior orbital periosteum with an angled sickle knife.
All patients were discharged from the hospital on the second or third postoperative day. There were no an¬ esthetic complications. Cosmetic im¬ provement was a function of the extent of orbital decompression. The skin in¬ cisions performed as part of the lateral
orbitotomies were virtually undetectable by the third postoperative month
(Fig 5). The longest follow-up has been 21 months. To date, no patients have ex¬ perienced worsening proptosis. There have been no infectious complications
(eg, periorbital cellulitis, sinusitis). One patient, patient 3, has undergone
extraocular muscle surgery for correc¬ tion of pre-existing diplopia. The two patients who experienced increased
diplopia postoperatively similar surgery.
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may
require
REPORT OF CASES Case 1.—A 67-year-old woman developed
enlarged hyperfunctioning thyroid gland in early 1986. She was successfully
an
treated with iodine 131 radioablation. Shortly thereafter, she noted the onset of mild proptosis that progressed over the next year, resulting in diplopia by the fall of 1986. In February 1987, bilateral inferior and medial rectus muscle recessions were performed with resolution of diplopia. Vi¬ sual acuity at that time remained 20/20 in both eyes with correction. Color vision was intact with correct identification of 10 of 10 color plates with both eyes. Hertel mea¬ surements revealed 20 mm of proptosis bi¬
laterally. Over the next 8 months the
patient's vi-
suai acuity gradually deteriorated. Exter¬ nal-beam irradiation consisting of 20 Gy to each orbit was of no benefit. By October 1987, the patient's vision had deteriorated to 20/200 in the right eye, and 20/70 in the left eye. Color vision was 2.5 out of 10 in the right eye, and 4.5 out of 10 in the left eye. Visual-field examination revealed a central scotoma in the right eye and a paracentrai scotoma in the left eye. Extraocular move¬ ments were minimally restricted. Hertel measurements remained at 20 mm in both
tomographic scan of the or¬ bits demonstrated marked enlargement of all extraocular muscles with compression of both optic nerves posteriorly in the orbital apex bilaterally (Fig 6, top left and right). It was reasoned that a transnasal
1.—Preoperative and Postoperative Information Hertel,
Patient No./
Age, y/
Orbit
Sex 67 F
1 OD
Post¬
Procedure
operative
operative
E*
20
15
20
2 OD
51 M
OS 3 OD OS
61 M
4 OD
65 F
OS 5 OD
OS 6 OD OS
63 F
7 OD
74 M
E None
E/L* E/Lt
8 OD
42 F
OS
bent to allow incision
Decompression Patients* Diplopia
Post¬
Pre¬
Post¬
Pre¬
Post¬
operative
operative
operative
operative
operative
operative
16
20/200 20/70
20/50 20/40
29 26
26 26
20/50 20/25
20/50 20/25
27
20 21
20/30 20/30
20/20 20/20
20/25
20/20 5/200
28 25 28
22
31 31
25 25
E/L E/L
25
21
26
Differential
5/200 20/80
20/25 20/20
20/20 20/20
20/20 20/25
20/70
21 21
20/70 5/200
20/50
27
28 31
24 26
20/20 20/20
20/20 20/20
26 E/L E/L
Orbital
(right)
Pre¬
WO/L E/L WO/L E/L
OS
on
Rosen knife
a
Visual Acuityt
mm
Pre-
OS
this area. On November 10,1988, bilateral transna¬ sal endoscopie orbital decompressions were performed. At the conclusion of the transnasal procedure, Caldwell-Luc antrotomies verified excellent decompression of the or¬ bital floor medial to the infraorbital nerve. Further inferior decompression was per¬ formed lateral to the infraorbital nerve through the antrotomies. The patient's postoperative course was unremarkable and she was discharged on the third post¬ operative day. Visual acuity improved to 20/50 OD and 20/40 OS with correction. Color vision improved to 4.5 out of 10 in the
eyes. A computed
Fig 3.—A Beaver (Rudolph Beaver Ine, Waltham, Mass) sickle knife (left) and of the periorbita within the right maxillary sinus.
Table
endoscopie approach might provide a supe¬ rior orbital apex decompression compared with standard approaches and, therefore, better alleviate optic nerve compression in
++
++
20/50 ++
++ decompression; L, lateral orbitotomy; WO, Walsh-Ogura decompression, EK, exposure keratopathy; plus sign, present; double plus sign, increased; zero, absent; OD, right eye, and OS, left eye. tBest corrected visual acuity. exploratory Caldwell-Luc antrotomy was also performed. E indicates
endoscopie
transnasal
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right eye and 6 out of 10 in the left eye. Vi¬
erally into
sual fields were full and without scotoma. Extraocular movements remained mini¬ mally restricted. Hertel measurements de¬ creased to 15 mm in the right eye and 16 mm in the left eye. A follow-up computed tomo¬ graphic scan in March 1988 demonstrated excellent decompression of the orbits bilat-
nuses, with marked
maxillary si¬ decompression of the optic nerves posteriorly in the orbital api¬ ces (Fig 6, bottom left and right). Case 7.—In a 74-year-old man with a 22year history of hyperthyroidism, iodine 131 radioablation was successfully performed in 1985. The patient's medical history was the ethmoid and
a long history of severe Parkinson's disease requiring multiple medications for control. The patient devel¬ oped progressive bilateral exophthalmos in April 1988. Treatment with high-dose sys¬ temic corticosteroids was not beneficial, and he developed bilateral exposure kerat-
complicated by
opathy. In October 1988, bilateral lateral tar-
Table 2.— Extent of
Decompression Obtained With
sorrhaphies were performed. At that time, the patient's visual acuity was 20/60 OU
Each Procedure
Mean
Procedure Performed Transnasal endoscopy alone
No. of Orbits
Decompression,
mm
Range,
mm
3-6
endoscopy and lateral orbitotomy Walsh-Ogura and lateral orbitotomy Includes two orbits with exploratory Caldwell-Luc antrotomies. Transnasal
*
4.5
3-6
with correction. Hertel measurements were 26 mm in both eyes. Although the keratopathy improved, the patient gradually developed progressive vi¬ sual loss in the left eye. By May 1989, his visual acuity had deteriorated to 20/70 OD and 5/200 OS with correction, while Hertel measurements were minimally increased to 26 mm in the right eye, and 27 mm in the left eye. A computed tomographic scan performed in November 1988 demonstrated marked
18
20
22
24
26
28
30
32
24
Preoperative Hertel Measurement (All Decompressions)
26
28
30
32
Preoperative Hertel Measurement (E/L Decompressions)
Fig 4.—Orbital decompression as a function of preoperative proptosis. Left, For all decompres¬ 0.27. Right, For endoscopie decompression sions, correlation coefficient of linear regression combined with lateral orbitotomy (E/L) alone, correlation coefficient of linear regression 0.25. =
=
swelling of all extraocular muscles posteri¬ orly in the orbital apex (Fig 7, left). A leftsided optic neuropathy was diagnosed and bilateral transnasal endoscopie decompres¬ sions were performed on June 27,1989. Lat¬ eral orbitotomies were not performed since the primary goal was orbital apex decom¬ pression. Moreover, given the patient's pre¬ carious medical condition, it was desirable to keep the extent of the procedure to a minimum.
Postoperatively the patient's vision im¬ proved markedly to 20/50 OU with correc¬ tion. The patient noted that he was able to read the newspaper for the first time in years. Hertel measurements improved to 21
Fig 5.—Photographs of patient 6 taken preoperatively (left) and 3 months postoperatively (right).
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in both eyes. There was no evidence of exposure keratopathy or diplopia. A followup computed tomographic scan revealed an excellent decompression, especially at the posterior orbital apex (Fig 7, right). mm
COMMENT
The advent of intranasal endoscopes has significantly improved anatomic visualization of the nose and paranasal sinuses. Deflected angles of view en¬ able transnasal visualization and ac¬ cess to previously concealed areas of the paranasal sinuses and the orbital floor. This has allowed for a transnasal decompression of the medial and infe¬ rior orbital walls that compares well with traditional methods. Warren et al,4 in a review of 305 patients under¬
going Walsh-Ogura decompressions,
noted an average ocular recession of 4 Desanto et al9 reported an aver-
mm.
age recession of 5.5
undergoing sion.
mm in 200 patients transantral decompres¬
Endoscopes permit a maximal pos¬ terior orbital decompression at the or¬ bital apex, an area often not fully accessible via the transantral routes. This provides optimal decompression of the optic nerve in cases of optic neu¬ ropathy. Endoscopie visualization of the medial orbital wall is superior to either the transantral or external eth¬ moid approaches, thus permitting a more complete medial orbital decom¬ pression.
In the hands of an experienced sinus endoscopist, transnasal orbital decom¬ pression appears to be a safe procedure that can be performed with a mini¬ mum of morbidity. The scar of an ex¬ ternal ethmoidectomy and the morbid¬ ity of a Caldwell-Luc antrotomy are
avoided. Warren et al4 noted a 20% in¬ cidence of postoperative hypesthesia of the infraorbital nerve in 305 pa¬ tients undergoing Walsh-Ogura de¬ compression, 5% of which were per¬ manent. Desanto et al9 reported a 4% incidence of persistent hypesthesia and a 3.5% incidence of oroantral fis¬ tula requiring closure. Other studies have suggested a significant incidence of bothersome postoperative com¬ plaints following standard CaldwellLuc antrotomy, including hypesthesia, dysesthesia, facial swelling, and tooth
problems.28-29
As occurred in two of
our patients, diplopia may develop or worsen post¬ operatively. Desanto et al9 found an increase in diplopia from 54% preop¬ eratively to 79% postoperatively with a standard transantral decompres¬ sion. McCord30 similarly described new
Fig 6.—Preorbitai decompression and postorbital decompression computed tomographic scans of patient 1. Top left and right, Axial (left) and coronal (right) computed tomographic scans taken preoperatively demonstrate bilateral enlargement of the rectus muscles. The medial (m) and lateral (I) rectus muscles are primarily enlarged within the orbital apex. The lamina papyracea (arrows) and orbital floor (open arrows) are intact bilaterally. Bottom left and right, Axial (left) and coro¬ nal (right) computed tomographic scans taken 4 months postoperatively demonstrate abscence of lamina paparacea (curved arrow) and bony orbital floor (large arrow) bilaterally. Note the expansion of the orbital apex and medial decom¬
pression
to the extent of the middle turbinate.
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diplopia in 5.7% of patients after lat¬ eral transconjunctival decompression, and in 40% of patients after transan¬ tral decompression. The onset or pro¬ gression of diplopia may not reflect a complication of surgery so much as the sequela of a good decompression, since new-onset diplopia is more common in patients undergoing more extensive decompressions.30 In the swollen orbit, there is usually considerable restric¬
tion of eye movement in all directions. This results both from proptosis and from swelling or fibrosis of the ex¬ traocular muscles. When the external restriction of proptosis is relieved by decompression, the less affected mus-
cíes are able to function, but the more swollen and fibrotic muscles (most commonly the medial rectus, inferior rectus, or both) are not. The net result being an asymmetric limitation of eye movement instead of the pre-existing symmetric limitation. Consequently, the patient may develop new or wors¬ ening diplopia that requires correction with prisms or extraocular muscle sur¬ gery. In general, patients with diplopia should undergo decompression before muscle surgery. A potential complication that we did not experience is acute visual loss. As with all orbital surgery, vision loss can occur from direct trauma to the optic
nerve or its vasculature. This risk can be minimized through careful ana¬ tomic visualization by an experienced surgeon. Nevertheless, patients should be counseled preoperatively regarding this potential complication. The necessity that a surgeon have extensive endoscopie experience in or¬ der to safely perform the transnasal approach cannot be overemphasized. Accurate identification of vital struc¬ tures is essential in all cases, and must be performed prior to removal of the bony orbital wall. In contrast to func¬ tional endoscopie sinus surgery, or¬ bital decompression is performed un¬ der general anesthesia due to the sen¬ sitivity of the periorbital structures. Consequently, the endoscopist's task is all the more difficult since the usual feedback provided by an awake patient when vital structures are manipulated is not available. Thus, the surgeon must be well versed in the normal an¬ atomic landmarks and their abundant variations. This last point underlines the necessity of a high-quality preop¬ erative coronal computed tomographic scan, with both coronal and axial views, to serve as a road map during
decompression.
A limitation of the transnasal ap¬
Fig 7.—Preorbitai and postorbital decompression computed tomographic scans of patient 7. Left, Preoperative axial computed tomographic scan reveals enlarged medial (m) and lateral (I) rectus muscles with compression of the orbital apex bilaterally. Right, Postoperative axial computed to¬ mographic scan demonstrates left (L) sphenoidotomy (solid arrow) with bilateral orbital decom¬ pression (open arrow) allowing medial expansion of orbital soft tissue to the middle turbinate with resultant increase in orbital apex space.
proach is that decompression of the
orbital floor lateral to the infraorbital nerve is not possible due to the ana¬ tomic constraints of the widened mid¬ dle meatal antrotomy. Similarly, an-
Fig 8.—Postoperative axial (left) and coronal (right) computed tomographic scans of patient 4 demonstrate a greater de¬ gree of orbital decompression on the endoscopie (left) side than on the opposite (transantral) side. Left, There is less proptosis on the endoscopie side (solid arrows) with a more extensive medial decompression to the level of the middle turbinate (open arrow). Right, An increased medial and a comparable inferior decompression is observed on the endo¬ scopie (left) side. Bilateral lateral orbitotomies were performed. There is a wide middle meatal antrostomy on the left (curved arrow) and evidence of a Caldwell-Luc procedure on the right (star).
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terior orbital floor
decompression
is
restricted. However, it appears that these limitations are counterbalanced by the excellent extent of medial and
posterior floor decompression pro¬ vided by this approach. Leone et al31 have suggested that preserving a sig¬ nificant portion of the orbital floor may be of benefit in preventing subsequent
hypophthalmia diplopia.
and
vertical
gaze
Anatomic variations may provide a relative contraindication or preclude the use of the transnasal approach, as evidenced by two of our patients with severely deviated septums. Although a concurrent septal mobilization could have been performed in these patients, it was thought that this would increase procedure morbidity and thus obviate a significant advantage of the endo¬ scopie approach. It was therefore elected to perform a transantral de¬ compression on the narrow side. This approach also allowed comparison of the decompressions obtained with the two approaches (Fig 8). A more signif¬ icant contraindication to the endo¬ scopie approach is the presence of a thickened orbital floor on the preoper¬ ative coronal computed tomographic scan. Current instrumentation does not allow for removal of a thick orbital floor through a middle meatal antrostomy; thus, a standard WalshOgura decompression should be em¬ ployed in these circumstances. Optimum orbital decompression ap¬ pears to be obtained when the transnasal procedure is combined with a lateral orbitotomy. Performing a lat¬ eral decompression has the theoretical advantage of balancing the slight me¬ dial rotation of the globe that can oc¬ cur following medial decompression.31 The external scar encountered with this procedure is minimal when hidden in the abundant skin tension relax¬ ation lines present in this area. How¬ ever, a lateral decompression is not required when proptosis is not severe, and the primary aim of surgery is de¬ compression of the optic nerve in the orbital apex. The extent of decompression ob¬ tained in our cases was independent of the degree of preoperative proptosis. This suggests that it is unnecessary to allow proptosis to become severe be-
fore intervening surgically in order to obtain an optimum decompression. Rather, surgical decompression should be considered when complicating vi¬ sual symptoms first appear or when the disability of proptosis becomes
significant.
CONCLUSIONS
We have described our initial expe¬ rience with eight patients undergoing transnasal endoscopie orbital decom¬ pression for dysthyroid orbitopathy. This approach appears to provide com¬ parable results to traditional methods of orbital decompression while avoid¬ ing the morbidity of an external eth¬ moidectomy or Caldwell-Luc antroto¬ my. However, it requires a surgeon with extensive experience in endo¬ scopie intranasal surgery. We believe that this technique provides unparal¬ leled decompression of the medial or¬ bital wall and of the orbital apex. However, decompression of the ante¬ rior orbital floor is limited and decom¬ pression is impossible lateral to the infraorbital nerve. The transnasal en¬ doscopie approach may be combined with a lateral orbitotomy in order to provide maximal decompression, as was our preference when performing a Walsh-Ogura procedure. The develop¬ ment of new instrumentation for this technique should facilitate removal of the orbital floor and allow more exten¬ sive decompression, even when the bone is thickened. References 1. Konishi J, Herman MM, Kriss JP. Binding of thyroglobulin and thyroglobulin-antithyroglobulin immune complex to extraocular muscle membrane. Endocrinology. 1974;95:434-466. 2. Riley FC. Orbital pathology in Graves' disease. Mayo Clin Proc. 1972;47:975-979. 3. Gorman CA. The presentation and management of endocrine ophthalmopathy. Clin Endocrinol Metab. 1978;7:67-96. 4. Warren JD, Spector JG, Burde R. Long-term
follow up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopa-
thy. Laryngoscope. 1989;99:35-40.
5. Trobe JD, Glaser JS, Laflamme P. Dysthyroid optic neuropathy. Arch Ophthalmol. 1978; 96:1199-1209. 6. Hedges TR Jr, Rose E. Hyperophthalmopathic Graves' disease. Arch Ophthalmol. 1953; 50:479-490. 7. Hodes BL, Shoch DE. Thyroid ocular myopathy. Trans Am Ophthalmol Soc. 1979;77:80-103. 8. Calcaterra TC. Management of exopthalmos. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, eds. Otolaryngology\x=req-\ Head and Neck Surgery. St Louis, Mo: CV Mosby Co; 1986:2543-2551.
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9. Desanto LW. The total rehabilitation of Graves' ophthalmopathy. Laryngoscope. 1980; 90:1652-1678. 10. Hurbli T, Char DH, Harris J, Weaver K, Greenspan F, Sheline G. Radiation therapy for thyroid eye diseases. Am J Ophthalmol. 1985; 99:633-637. 11. Leone CR Jr. The management of ophthalmic Graves' disease. Ophthalmology. 1984; 91:770-779. 12. Brennan MW, Leone CR Jr, Janaki L. Radiation therapy for Graves' disease. Am J Ophthalmol. 1983;96:195-199. 13. Threlkeld A, Miller NR, Wharam M. The efficacy of supervoltage radiation therapy in the treatment of dysthyroid optic neuropathy. Orbit. In press. 14. Wall JR, Strakosch CR, Fang SL, Ingbar SH, Braverman LE. Thyroid binding antibodies and other immunological abnormalities in patients with Graves' ophthalmopathy: effects of treatment with cyclophosphamide. Clin Endocrinol. 1979;10:79-91. 15. Weetman AP, Ludgate M, Mills PV, et al. Cyclosporin improves Graves' ophthalmopathy. Lancet. 1983;2:486-489. 16. Glinoer D, Etienne-Decerf J, Schrooyen M, et al. Beneficial effects of intensive plasma exchange followed by immunosuppressive therapy in severe Graves' ophthalmopathy. Acta Endocrinol. 1986;111:30-38. 17. Dandona P, Marshall NJ, Bidey SP, Nathan A, Havard CWH. Successful treatment of exophthalmos and pretibial myxoedema with plasmapheresis. Br Med J. 1979;1:374-376. 18. Calcaterra TC, Thompson JW. Antral-ethmoidal decompression of the orbit in Graves' disease:
ten-year experience. Laryngoscope. 1980;
90:1941-1949. 19. Barbosa J, Wong E, Doe RP. Ophthalmopathy of Graves' disease. Arch Intern Med. 1972; 130:111-113. 20. Dollinger J. Die drickentlastlung der Augenhokle durch entfurnung der aussern Orbitalwand bei hochgradigen Exophthalmos und Koneskutwer Hornhauterkronkung. Dtsch Med
Wochenschr. 1911;37:1888-1890. 21. Naffziger HC. Progressive exophthalmos following thyroidectomy: its pathology and treatment. Ann Surg. 1931;94:582-586. 22. Sewall EC. Operative control of progressive exophthalmos. Arch Otolaryngol Head Neck Surg.
1936;24:621-624.
23. Hirsch O. Surgical decompression of exophthalmos. Arch Otolaryngol Head Neck Surg.
1950;51:325-331. 24. Walsh TE, Ogura JH. Transantral orbital decompression for malignant exophthalmos. Laryngoscope. 1957;67:544-549. 25.
Kennedy DW. Functional endoscopic sinus technique. Arch Otolaryngol Head Neck
surgery
Surg. 1985;111:643-649. 26. Kennedy DW, Zinreich SJ, Kuhn F, Shaalan H, Naclerio R, Loch E. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope. 1987;97(suppl 43):1-9. 27. Miller NR, Iliff WJ. Surgery of the orbit. In: Rice TA, Michels RG, Stark WJ, eds. Ophthalmic Surgery. 4th ed. St Louis, Mo: CV Mosby Co; 1984:383-398. 28. Murray JP. Complications after treatment of chronic maxillary sinus disease with Caldwell\x=req-\ Luc procedure. Laryngoscope. 1983;93:282-284. 29. DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: 1975\x=req-\ 1985. Laryngoscope. 1988;98:1297-1300. 30. McCord CD Jr. Current trends in orbital
decompression. Ophthalmology. 1985;92:21-33. 31. Leone CR Jr, Piest KL, Newman RJ. Medial and lateral wall decompression for thyroid ophthalmopathy. Am J Ophthalmol. 1989;108:160-166.
Kennedy, MD; Matthew L. Goodstein, MD; Neil R. Miller, MD; S. James Zinreich, MD
\s=b\ Orbital decompression for dysthyroid orbitopathy has traditionally been performed through either an external or a transantral approach. The advent of intranasal endoscopes allowed for the development of a transnasal approach for
medial and inferior orbital wall decompression. Using this approach, orbital decompressions were performed on 13 orbits in eight patients with severe com-
plicated dysthyroid orbitopathy. Simultaneous
bilateral lateral orbitotomies
were
performed on five patients. Walsh-Ogura decompressions and lateral orbitotomies were performed on two orbits. When combined with lateral orbitotomy, Hertel mea-
Dysthyroid orbitopathy
is an au¬ toimmune disorder in which antithyroglobulin immune complexes bind to extraocular muscle mem¬ brane.1 The immune complexes incite an inflammatory reaction that culmi¬ nates in edema and fibrosis of the ex¬ traocular muscles and fat. Further ex¬ pansion of the extraocular contents results from the hydropexic properties of mucopolysaccharides deposited by fibroblasts.2 The consequent increase in the volume of extraocular orbital contents leads to increased orbital pressure resulting in protrusion of the globe anteriorly. Given an average or¬ bital volume of 26 mL, an increase of Accepted for publication November 17, 1989. From the Departments of Otolaryngology\p=n-\ Head and Neck Surgery (Drs Kennedy and Goodstein); Ophthalmology, Neurology, and Neurosurgery (Dr Miller); and Radiology and Otolaryngology\p=n-\Headand Neck Surgery (Dr Zinreich), The Johns Hopkins Medical Institutions, Baltimore, Md. Presented in part at the meeting of the American Rhinological Society, New Orleans, La, September 23, 1989. Reprint requests to Department of Otolaryngology\p=n-\Headand Neck Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21205 (Dr Kennedy).
surements improved an average of 5.7 mm in orbits decompressed transnasally and 4.5 mm in orbits decompressed with a Walsh-Ogura approach. Transnasal decompression alone improved Hertel measurements an average of 4.7 mm. Visual acuity improved in three of four patients with optic neuropathy, and in all patients with exposure keratopathy. We conclude that the endoscopic transnasal approach provides comparable decompression to traditional methods while avoiding the morbidity of an external ethmoidectomy or
Caldwell-Luc antrotomy. (Arch Otolaryngol Head Neck Surg.
1990;116:275-282)
only 4 mL (16% ) will result in 6 mm of proptosis.3 Dysthyroid orbitopathy is often a
self-limited disorder that does not visual loss.46 However, when se¬ vere, proptosis can have three signifi¬ cant visual consequences. First, expo¬ sure keratopathy can result from an inability to close the eyelids.4 Second, progressive diplopia can result from asymmetrically impaired extraocular muscle function.5-7 These sequelae are caused not only by proptosis, but also by fibrosis of the levator palpebrae superioris and by swelling or fibrosis of the extraocular muscles, respectively. Third, optic neuropathy can result from compression of the optic nerve or its vasculature by the enlarged ex¬ traocular muscles. The optic neuropa¬ thy produces progressive loss of visual acuity, decreased color vision, and de¬ fects in the visual field, usually central scotomas.4'5·8 A variety of modalities have been used to treat dysthyroid orbitopathy. Systemic corticosteroids may improve all signs and symptoms of the disorder, but the steroids may need to be concause
tinued for many months at high doses, and even then signs and symptoms of¬ ten return when the medication is tapered.4-5-9 External-beam irradiation is efficacious for treating dysthyroid optic neuropathy, but it does not usu¬
ally improve proptosis significant¬ ly.10'13 The use of the immunosuppres¬
sive agents cytoxan and cyclosporin remains experimental and may be ac¬ companied by potentially serious side effects.1415 Plasmapheresis combined with immunosuppressive agents has been used for acute vision-threatening processes.16·17 The type and timing of treatment used for the hyperthyroid component of this disorder does not appear to affect the severity of the or¬ bital component.6·1819 The mainstay of therapy for severe dysthyroid orbitopathy remains sur¬ gical decompression of the orbital con¬ tents into an adjacent real or potential
In 1911, Dollinger,20 using Kronlein's approach for access to the lateral orbit, performed a lateral wall decompression; however, the extent of decompression provided was minimal. Naffziger21 developed a superior de¬ compression of the orbital contents into the anterior cranial fossa. This approach requires a craniotomy, with consequent risks of meningitis and leakage of cerebrospinal fluid, and it results in bothersome transmission of cerebral pulsations to the eyes. Conse¬ quently, Sewall22 described a medial orbital wall decompression through an external ethmoidectomy approach. Hirsch23 was the first to employ a Caldwell-Luc approach to obtain a de¬ compression by removal of the orbital floor. In 1957, Walsh and Ogura24 ex¬ tended this approach to include a me¬ dial wall decompression. As recently reviewed by Warren et al4 and DeSanto,' the Walsh-Ogura technique space.
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remains the standard approach for or¬ bital decompression; however, this ap¬ proach requires a generous CaldwellLuc antrotomy and carries the atten¬ dant morbidity of this procedure. Our usual approach has been to combine the Walsh-Ogura approach with a lat¬ eral orbitotomy, so as to maximize the degree of decompression obtained. SUBJECTS
Eight patients with severe dysthyroid orbitopathy complicated by visual sequelae underwent orbital decompression at our institution. Seven patients underwent bi¬ lateral procedures and one patient had a unilateral procedure for a total of 15 de¬ compressions performed. The group was divided equally between men and women. The patients' ages ranged from 30 to 74 years. A complete neuro-ophthalmologic examination was performed on all patients, consisting of assessment of visual acuity, color vision, and visual field. Slit-lamp biomicroscopy, tonometry, evaluation of ocu¬ lar motility and alignment, and ophthalmoscopy were also performed. All patients had assessment of proptosis using a Hertel exophthalmometer. Nonenhanced com¬ puted tomography scans of the orbits and paranasal sinuses were obtained preopera¬ tively in all patients with 2-mm coronal and axial slices.
SURGICAL TECHNIQUE The patient is placed supine on the oper¬ ating room table with the head slightly el¬ evated. General anesthesia is provided through a right-angled endotracheal tube. Local vasoconstriction is obtained with top¬ ical cocaine and 1% lidocaine (Xylocaine) with 1:100000 epinephrine injected under endoscopie visualization. An intranasal en¬ doscopie sphenoethmoidectomy is per¬ formed as detailed by Kennedy.25 Care is taken to identify and skeletonize the medial orbital wall and the skull base. Posteriorly, the orbital apex and, when possible, the op¬ tic canal are identified. Anteriorly, the area of the frontal recess is opened. A very gen¬ erous middle meatal antrotomy is then performed, creating an opening that ex¬ tends anteriorly to the posterior margin of the nasolacrimal duct, inferiorly into the root of the inferior turbinate, and posteri¬ orly to the posterior limit of the sinus.26 The infraorbital nerve is identified laterally within the sinus and defines the lateral limit for removal of the orbital floor. At this point, the skeletonized medial or¬ bital wall is gently removed with an angled spoon, a blunt nerve hook, or fine Blakesly forceps (Pig 1). The orbital floor is removed with fine right-angle 70° or 110° Giraffe
forceps under direct endoscopie vision with a 30° or 70° telescope. Small fragments of the inferior orbital wall may also be frac¬ tured inferiorly with a curved suction or Jcurrette and removed. The medial and infe¬ rior orbital walls are removed to the orbital apex posteriorly, leaving a small rim of bone anterior to the optic canal. Bone is re¬ moved from the orbital floor laterally to the infraorbital nerve. Anteriorly, the medial orbital wall in the region of the frontal re¬ cess is preserved to avoid the possibility of stenosis and subsequent frontal sinus ob¬ struction. Care is taken not to open the periorbita at this stage of the operation. Once meticulous resection of the bony orbital wall is complete, the periorbita is incised with a sickle knife in linear strokes from posterior to anterior (Fig 2). The ini¬ tial incision is placed laterally within the maxillary sinus and is performed using a bent Beaver sickle knife (Fig 3, left). Suc¬ cessive incisions are performed medially within the maxillary sinus, so as not to ob¬ struct the surgeon's view by the herniating intraorbital contents. Similar periosteal in¬ cisions are then made high on the medial orbital wall using a straight Beaver sickle knife or a No. 12 Bard-Parker blade, and successive incisions are made inferiorly. A Beaver-Rosen knife, bent as necessary, (Fig 3, right) is then used to lyse further fibrous periorbital bands. This allows for extensive herniation of orbital fat into the opened si¬ nuses.
The immediate extent of decompression is assessed by gently palpating the orbit and endoscopically viewing the transmis¬ sion of the palpations to the herniated or¬ bital contents. At the end of the operation a Merocel sponge in a rubber finger cot is coated with antibiotic ointment and placed lateral to the middle turbinate. Treatment with a broad-spectrum antibiotic, usually a /i-lactamase-resistant cephalosporin is be¬ gun. The sponge is removed the following day and the maxillary sinus is suctioned free of blood under endoscopie visualiza¬ tion. Five of the eight patients underwent lat¬ eral orbitotomies at the same time as the transnasal decompression, as had been our standard practice with the Walsh-Ogura approach. All lateral orbitotomies were performed by an experienced orbital sur¬ geon (N.R.M.) in the fashion previously de¬ tailed by Miller and Iliff.27 We performed Caldwell-Luc antrotomies on two of our first three patients (patients 1 and 3) in or¬ der to assess the extent of decompression obtained endoscopically. On two orbits (pa¬ tient 4, right eye; patient 5, right eye) we were unable to perform transnasal decom¬ pressions due to severely deviated nasal septums. Accordingly, Walsh-Ogura de-
compressions
were
performed along with
lateral orbitotomies.
RESULTS
Preoperative and postoperative vi¬ sual acuity and Hertel measurements for the eight patients undergoing or¬ bital decompression are presented in Table 1, along with each patient's pre¬ operative symptoms and the type of procedure performed on each orbit. Preoperative measurements were ob¬ tained within 1 month of surgery and postoperative measurements were ob¬ tained 1 to 4 months after surgery. Visual acuity remained normal in all patients, with normal vision preoper¬ atively. Marked improvement in acuity occurred in three of the four patients with optic neuropathy (patients 1, 5, and 7). The one patient whose vision did not improve (patient 4) had chronic optic neuropathy with probable pre¬ existing vascular compromise of the
optic nerve. Exposure keratopathy re¬ solved in all four patients in which it was present preoperatively (patients 3, 5, 6, and 8). Two patients with mild preoperative diplopia developed more significant diplopia postoperatively (patients 6 and 8). In all other patients, ocular motility and alignment either improved or were unaffected by the decompression. The extent of decompression ob¬
tained with each combination of pro¬ cedures performed is summarized in Table 2. Maximal decompression ap¬ pears to be obtained by a combination of transnasal decompression and lat¬ eral orbitotomy with an average of 5.7 mm (range, 4 to 7 mm) improvement in Hertel measurements, while transna¬ sal decompression alone and WalshOgura decompression combined with lateral orbitotomy yielded similarly good results with 4.5 mm (range, 3 to 6 mm) and 4.7 mm (range, 3 to 6 mm) of improvement in Hertel measure¬ ments, respectively. There was no cor¬ relation between the degree of preop¬ erative proptosis and the extent of de¬ compression obtained, either when considering all decompressions to¬ gether (Fig 4, left), or when consider¬
ing only endoscopie decompression combined with lateral orbitotomy (Fig 4, right). Due to the small number of orbits operated on, these figures are not of statistical significance.
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Fig 1.—Removal of left medial orbital wall. Left, Artist's rendition of removal of medial orbital wall with Blakesly forceps under endoscopie visualization. Right, Endoscopie photograph following removal of the medial orbital wall (30° wide-angle telescope directed laterally). Superiorly, the skull base (S), the anterior ethmoid artery (curved arrow), and the frontal si¬ nus (F) are seen. OP indicates orbital periosteum.
Fig 2.—Removal of left orbital floor and incision of orbital periosteum. Left, Endoscopie photograph demonstrating maxillary sinus (M) and widened middle meatal antrostomy (arrows) with exposure of the orbital floor (30° wide-angled telescope di¬ rected laterally). Right, Artist's rendition demonstrates incision of inferior orbital periosteum with an angled sickle knife.
All patients were discharged from the hospital on the second or third postoperative day. There were no an¬ esthetic complications. Cosmetic im¬ provement was a function of the extent of orbital decompression. The skin in¬ cisions performed as part of the lateral
orbitotomies were virtually undetectable by the third postoperative month
(Fig 5). The longest follow-up has been 21 months. To date, no patients have ex¬ perienced worsening proptosis. There have been no infectious complications
(eg, periorbital cellulitis, sinusitis). One patient, patient 3, has undergone
extraocular muscle surgery for correc¬ tion of pre-existing diplopia. The two patients who experienced increased
diplopia postoperatively similar surgery.
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may
require
REPORT OF CASES Case 1.—A 67-year-old woman developed
enlarged hyperfunctioning thyroid gland in early 1986. She was successfully
an
treated with iodine 131 radioablation. Shortly thereafter, she noted the onset of mild proptosis that progressed over the next year, resulting in diplopia by the fall of 1986. In February 1987, bilateral inferior and medial rectus muscle recessions were performed with resolution of diplopia. Vi¬ sual acuity at that time remained 20/20 in both eyes with correction. Color vision was intact with correct identification of 10 of 10 color plates with both eyes. Hertel mea¬ surements revealed 20 mm of proptosis bi¬
laterally. Over the next 8 months the
patient's vi-
suai acuity gradually deteriorated. Exter¬ nal-beam irradiation consisting of 20 Gy to each orbit was of no benefit. By October 1987, the patient's vision had deteriorated to 20/200 in the right eye, and 20/70 in the left eye. Color vision was 2.5 out of 10 in the right eye, and 4.5 out of 10 in the left eye. Visual-field examination revealed a central scotoma in the right eye and a paracentrai scotoma in the left eye. Extraocular move¬ ments were minimally restricted. Hertel measurements remained at 20 mm in both
tomographic scan of the or¬ bits demonstrated marked enlargement of all extraocular muscles with compression of both optic nerves posteriorly in the orbital apex bilaterally (Fig 6, top left and right). It was reasoned that a transnasal
1.—Preoperative and Postoperative Information Hertel,
Patient No./
Age, y/
Orbit
Sex 67 F
1 OD
Post¬
Procedure
operative
operative
E*
20
15
20
2 OD
51 M
OS 3 OD OS
61 M
4 OD
65 F
OS 5 OD
OS 6 OD OS
63 F
7 OD
74 M
E None
E/L* E/Lt
8 OD
42 F
OS
bent to allow incision
Decompression Patients* Diplopia
Post¬
Pre¬
Post¬
Pre¬
Post¬
operative
operative
operative
operative
operative
operative
16
20/200 20/70
20/50 20/40
29 26
26 26
20/50 20/25
20/50 20/25
27
20 21
20/30 20/30
20/20 20/20
20/25
20/20 5/200
28 25 28
22
31 31
25 25
E/L E/L
25
21
26
Differential
5/200 20/80
20/25 20/20
20/20 20/20
20/20 20/25
20/70
21 21
20/70 5/200
20/50
27
28 31
24 26
20/20 20/20
20/20 20/20
26 E/L E/L
Orbital
(right)
Pre¬
WO/L E/L WO/L E/L
OS
on
Rosen knife
a
Visual Acuityt
mm
Pre-
OS
this area. On November 10,1988, bilateral transna¬ sal endoscopie orbital decompressions were performed. At the conclusion of the transnasal procedure, Caldwell-Luc antrotomies verified excellent decompression of the or¬ bital floor medial to the infraorbital nerve. Further inferior decompression was per¬ formed lateral to the infraorbital nerve through the antrotomies. The patient's postoperative course was unremarkable and she was discharged on the third post¬ operative day. Visual acuity improved to 20/50 OD and 20/40 OS with correction. Color vision improved to 4.5 out of 10 in the
eyes. A computed
Fig 3.—A Beaver (Rudolph Beaver Ine, Waltham, Mass) sickle knife (left) and of the periorbita within the right maxillary sinus.
Table
endoscopie approach might provide a supe¬ rior orbital apex decompression compared with standard approaches and, therefore, better alleviate optic nerve compression in
++
++
20/50 ++
++ decompression; L, lateral orbitotomy; WO, Walsh-Ogura decompression, EK, exposure keratopathy; plus sign, present; double plus sign, increased; zero, absent; OD, right eye, and OS, left eye. tBest corrected visual acuity. exploratory Caldwell-Luc antrotomy was also performed. E indicates
endoscopie
transnasal
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right eye and 6 out of 10 in the left eye. Vi¬
erally into
sual fields were full and without scotoma. Extraocular movements remained mini¬ mally restricted. Hertel measurements de¬ creased to 15 mm in the right eye and 16 mm in the left eye. A follow-up computed tomo¬ graphic scan in March 1988 demonstrated excellent decompression of the orbits bilat-
nuses, with marked
maxillary si¬ decompression of the optic nerves posteriorly in the orbital api¬ ces (Fig 6, bottom left and right). Case 7.—In a 74-year-old man with a 22year history of hyperthyroidism, iodine 131 radioablation was successfully performed in 1985. The patient's medical history was the ethmoid and
a long history of severe Parkinson's disease requiring multiple medications for control. The patient devel¬ oped progressive bilateral exophthalmos in April 1988. Treatment with high-dose sys¬ temic corticosteroids was not beneficial, and he developed bilateral exposure kerat-
complicated by
opathy. In October 1988, bilateral lateral tar-
Table 2.— Extent of
Decompression Obtained With
sorrhaphies were performed. At that time, the patient's visual acuity was 20/60 OU
Each Procedure
Mean
Procedure Performed Transnasal endoscopy alone
No. of Orbits
Decompression,
mm
Range,
mm
3-6
endoscopy and lateral orbitotomy Walsh-Ogura and lateral orbitotomy Includes two orbits with exploratory Caldwell-Luc antrotomies. Transnasal
*
4.5
3-6
with correction. Hertel measurements were 26 mm in both eyes. Although the keratopathy improved, the patient gradually developed progressive vi¬ sual loss in the left eye. By May 1989, his visual acuity had deteriorated to 20/70 OD and 5/200 OS with correction, while Hertel measurements were minimally increased to 26 mm in the right eye, and 27 mm in the left eye. A computed tomographic scan performed in November 1988 demonstrated marked
18
20
22
24
26
28
30
32
24
Preoperative Hertel Measurement (All Decompressions)
26
28
30
32
Preoperative Hertel Measurement (E/L Decompressions)
Fig 4.—Orbital decompression as a function of preoperative proptosis. Left, For all decompres¬ 0.27. Right, For endoscopie decompression sions, correlation coefficient of linear regression combined with lateral orbitotomy (E/L) alone, correlation coefficient of linear regression 0.25. =
=
swelling of all extraocular muscles posteri¬ orly in the orbital apex (Fig 7, left). A leftsided optic neuropathy was diagnosed and bilateral transnasal endoscopie decompres¬ sions were performed on June 27,1989. Lat¬ eral orbitotomies were not performed since the primary goal was orbital apex decom¬ pression. Moreover, given the patient's pre¬ carious medical condition, it was desirable to keep the extent of the procedure to a minimum.
Postoperatively the patient's vision im¬ proved markedly to 20/50 OU with correc¬ tion. The patient noted that he was able to read the newspaper for the first time in years. Hertel measurements improved to 21
Fig 5.—Photographs of patient 6 taken preoperatively (left) and 3 months postoperatively (right).
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in both eyes. There was no evidence of exposure keratopathy or diplopia. A followup computed tomographic scan revealed an excellent decompression, especially at the posterior orbital apex (Fig 7, right). mm
COMMENT
The advent of intranasal endoscopes has significantly improved anatomic visualization of the nose and paranasal sinuses. Deflected angles of view en¬ able transnasal visualization and ac¬ cess to previously concealed areas of the paranasal sinuses and the orbital floor. This has allowed for a transnasal decompression of the medial and infe¬ rior orbital walls that compares well with traditional methods. Warren et al,4 in a review of 305 patients under¬
going Walsh-Ogura decompressions,
noted an average ocular recession of 4 Desanto et al9 reported an aver-
mm.
age recession of 5.5
undergoing sion.
mm in 200 patients transantral decompres¬
Endoscopes permit a maximal pos¬ terior orbital decompression at the or¬ bital apex, an area often not fully accessible via the transantral routes. This provides optimal decompression of the optic nerve in cases of optic neu¬ ropathy. Endoscopie visualization of the medial orbital wall is superior to either the transantral or external eth¬ moid approaches, thus permitting a more complete medial orbital decom¬ pression.
In the hands of an experienced sinus endoscopist, transnasal orbital decom¬ pression appears to be a safe procedure that can be performed with a mini¬ mum of morbidity. The scar of an ex¬ ternal ethmoidectomy and the morbid¬ ity of a Caldwell-Luc antrotomy are
avoided. Warren et al4 noted a 20% in¬ cidence of postoperative hypesthesia of the infraorbital nerve in 305 pa¬ tients undergoing Walsh-Ogura de¬ compression, 5% of which were per¬ manent. Desanto et al9 reported a 4% incidence of persistent hypesthesia and a 3.5% incidence of oroantral fis¬ tula requiring closure. Other studies have suggested a significant incidence of bothersome postoperative com¬ plaints following standard CaldwellLuc antrotomy, including hypesthesia, dysesthesia, facial swelling, and tooth
problems.28-29
As occurred in two of
our patients, diplopia may develop or worsen post¬ operatively. Desanto et al9 found an increase in diplopia from 54% preop¬ eratively to 79% postoperatively with a standard transantral decompres¬ sion. McCord30 similarly described new
Fig 6.—Preorbitai decompression and postorbital decompression computed tomographic scans of patient 1. Top left and right, Axial (left) and coronal (right) computed tomographic scans taken preoperatively demonstrate bilateral enlargement of the rectus muscles. The medial (m) and lateral (I) rectus muscles are primarily enlarged within the orbital apex. The lamina papyracea (arrows) and orbital floor (open arrows) are intact bilaterally. Bottom left and right, Axial (left) and coro¬ nal (right) computed tomographic scans taken 4 months postoperatively demonstrate abscence of lamina paparacea (curved arrow) and bony orbital floor (large arrow) bilaterally. Note the expansion of the orbital apex and medial decom¬
pression
to the extent of the middle turbinate.
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diplopia in 5.7% of patients after lat¬ eral transconjunctival decompression, and in 40% of patients after transan¬ tral decompression. The onset or pro¬ gression of diplopia may not reflect a complication of surgery so much as the sequela of a good decompression, since new-onset diplopia is more common in patients undergoing more extensive decompressions.30 In the swollen orbit, there is usually considerable restric¬
tion of eye movement in all directions. This results both from proptosis and from swelling or fibrosis of the ex¬ traocular muscles. When the external restriction of proptosis is relieved by decompression, the less affected mus-
cíes are able to function, but the more swollen and fibrotic muscles (most commonly the medial rectus, inferior rectus, or both) are not. The net result being an asymmetric limitation of eye movement instead of the pre-existing symmetric limitation. Consequently, the patient may develop new or wors¬ ening diplopia that requires correction with prisms or extraocular muscle sur¬ gery. In general, patients with diplopia should undergo decompression before muscle surgery. A potential complication that we did not experience is acute visual loss. As with all orbital surgery, vision loss can occur from direct trauma to the optic
nerve or its vasculature. This risk can be minimized through careful ana¬ tomic visualization by an experienced surgeon. Nevertheless, patients should be counseled preoperatively regarding this potential complication. The necessity that a surgeon have extensive endoscopie experience in or¬ der to safely perform the transnasal approach cannot be overemphasized. Accurate identification of vital struc¬ tures is essential in all cases, and must be performed prior to removal of the bony orbital wall. In contrast to func¬ tional endoscopie sinus surgery, or¬ bital decompression is performed un¬ der general anesthesia due to the sen¬ sitivity of the periorbital structures. Consequently, the endoscopist's task is all the more difficult since the usual feedback provided by an awake patient when vital structures are manipulated is not available. Thus, the surgeon must be well versed in the normal an¬ atomic landmarks and their abundant variations. This last point underlines the necessity of a high-quality preop¬ erative coronal computed tomographic scan, with both coronal and axial views, to serve as a road map during
decompression.
A limitation of the transnasal ap¬
Fig 7.—Preorbitai and postorbital decompression computed tomographic scans of patient 7. Left, Preoperative axial computed tomographic scan reveals enlarged medial (m) and lateral (I) rectus muscles with compression of the orbital apex bilaterally. Right, Postoperative axial computed to¬ mographic scan demonstrates left (L) sphenoidotomy (solid arrow) with bilateral orbital decom¬ pression (open arrow) allowing medial expansion of orbital soft tissue to the middle turbinate with resultant increase in orbital apex space.
proach is that decompression of the
orbital floor lateral to the infraorbital nerve is not possible due to the ana¬ tomic constraints of the widened mid¬ dle meatal antrotomy. Similarly, an-
Fig 8.—Postoperative axial (left) and coronal (right) computed tomographic scans of patient 4 demonstrate a greater de¬ gree of orbital decompression on the endoscopie (left) side than on the opposite (transantral) side. Left, There is less proptosis on the endoscopie side (solid arrows) with a more extensive medial decompression to the level of the middle turbinate (open arrow). Right, An increased medial and a comparable inferior decompression is observed on the endo¬ scopie (left) side. Bilateral lateral orbitotomies were performed. There is a wide middle meatal antrostomy on the left (curved arrow) and evidence of a Caldwell-Luc procedure on the right (star).
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terior orbital floor
decompression
is
restricted. However, it appears that these limitations are counterbalanced by the excellent extent of medial and
posterior floor decompression pro¬ vided by this approach. Leone et al31 have suggested that preserving a sig¬ nificant portion of the orbital floor may be of benefit in preventing subsequent
hypophthalmia diplopia.
and
vertical
gaze
Anatomic variations may provide a relative contraindication or preclude the use of the transnasal approach, as evidenced by two of our patients with severely deviated septums. Although a concurrent septal mobilization could have been performed in these patients, it was thought that this would increase procedure morbidity and thus obviate a significant advantage of the endo¬ scopie approach. It was therefore elected to perform a transantral de¬ compression on the narrow side. This approach also allowed comparison of the decompressions obtained with the two approaches (Fig 8). A more signif¬ icant contraindication to the endo¬ scopie approach is the presence of a thickened orbital floor on the preoper¬ ative coronal computed tomographic scan. Current instrumentation does not allow for removal of a thick orbital floor through a middle meatal antrostomy; thus, a standard WalshOgura decompression should be em¬ ployed in these circumstances. Optimum orbital decompression ap¬ pears to be obtained when the transnasal procedure is combined with a lateral orbitotomy. Performing a lat¬ eral decompression has the theoretical advantage of balancing the slight me¬ dial rotation of the globe that can oc¬ cur following medial decompression.31 The external scar encountered with this procedure is minimal when hidden in the abundant skin tension relax¬ ation lines present in this area. How¬ ever, a lateral decompression is not required when proptosis is not severe, and the primary aim of surgery is de¬ compression of the optic nerve in the orbital apex. The extent of decompression ob¬ tained in our cases was independent of the degree of preoperative proptosis. This suggests that it is unnecessary to allow proptosis to become severe be-
fore intervening surgically in order to obtain an optimum decompression. Rather, surgical decompression should be considered when complicating vi¬ sual symptoms first appear or when the disability of proptosis becomes
significant.
CONCLUSIONS
We have described our initial expe¬ rience with eight patients undergoing transnasal endoscopie orbital decom¬ pression for dysthyroid orbitopathy. This approach appears to provide com¬ parable results to traditional methods of orbital decompression while avoid¬ ing the morbidity of an external eth¬ moidectomy or Caldwell-Luc antroto¬ my. However, it requires a surgeon with extensive experience in endo¬ scopie intranasal surgery. We believe that this technique provides unparal¬ leled decompression of the medial or¬ bital wall and of the orbital apex. However, decompression of the ante¬ rior orbital floor is limited and decom¬ pression is impossible lateral to the infraorbital nerve. The transnasal en¬ doscopie approach may be combined with a lateral orbitotomy in order to provide maximal decompression, as was our preference when performing a Walsh-Ogura procedure. The develop¬ ment of new instrumentation for this technique should facilitate removal of the orbital floor and allow more exten¬ sive decompression, even when the bone is thickened. References 1. Konishi J, Herman MM, Kriss JP. Binding of thyroglobulin and thyroglobulin-antithyroglobulin immune complex to extraocular muscle membrane. Endocrinology. 1974;95:434-466. 2. Riley FC. Orbital pathology in Graves' disease. Mayo Clin Proc. 1972;47:975-979. 3. Gorman CA. The presentation and management of endocrine ophthalmopathy. Clin Endocrinol Metab. 1978;7:67-96. 4. Warren JD, Spector JG, Burde R. Long-term
follow up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopa-
thy. Laryngoscope. 1989;99:35-40.
5. Trobe JD, Glaser JS, Laflamme P. Dysthyroid optic neuropathy. Arch Ophthalmol. 1978; 96:1199-1209. 6. Hedges TR Jr, Rose E. Hyperophthalmopathic Graves' disease. Arch Ophthalmol. 1953; 50:479-490. 7. Hodes BL, Shoch DE. Thyroid ocular myopathy. Trans Am Ophthalmol Soc. 1979;77:80-103. 8. Calcaterra TC. Management of exopthalmos. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, eds. Otolaryngology\x=req-\ Head and Neck Surgery. St Louis, Mo: CV Mosby Co; 1986:2543-2551.
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9. Desanto LW. The total rehabilitation of Graves' ophthalmopathy. Laryngoscope. 1980; 90:1652-1678. 10. Hurbli T, Char DH, Harris J, Weaver K, Greenspan F, Sheline G. Radiation therapy for thyroid eye diseases. Am J Ophthalmol. 1985; 99:633-637. 11. Leone CR Jr. The management of ophthalmic Graves' disease. Ophthalmology. 1984; 91:770-779. 12. Brennan MW, Leone CR Jr, Janaki L. Radiation therapy for Graves' disease. Am J Ophthalmol. 1983;96:195-199. 13. Threlkeld A, Miller NR, Wharam M. The efficacy of supervoltage radiation therapy in the treatment of dysthyroid optic neuropathy. Orbit. In press. 14. Wall JR, Strakosch CR, Fang SL, Ingbar SH, Braverman LE. Thyroid binding antibodies and other immunological abnormalities in patients with Graves' ophthalmopathy: effects of treatment with cyclophosphamide. Clin Endocrinol. 1979;10:79-91. 15. Weetman AP, Ludgate M, Mills PV, et al. Cyclosporin improves Graves' ophthalmopathy. Lancet. 1983;2:486-489. 16. Glinoer D, Etienne-Decerf J, Schrooyen M, et al. Beneficial effects of intensive plasma exchange followed by immunosuppressive therapy in severe Graves' ophthalmopathy. Acta Endocrinol. 1986;111:30-38. 17. Dandona P, Marshall NJ, Bidey SP, Nathan A, Havard CWH. Successful treatment of exophthalmos and pretibial myxoedema with plasmapheresis. Br Med J. 1979;1:374-376. 18. Calcaterra TC, Thompson JW. Antral-ethmoidal decompression of the orbit in Graves' disease:
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Wochenschr. 1911;37:1888-1890. 21. Naffziger HC. Progressive exophthalmos following thyroidectomy: its pathology and treatment. Ann Surg. 1931;94:582-586. 22. Sewall EC. Operative control of progressive exophthalmos. Arch Otolaryngol Head Neck Surg.
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Kennedy DW. Functional endoscopic sinus technique. Arch Otolaryngol Head Neck
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Surg. 1985;111:643-649. 26. Kennedy DW, Zinreich SJ, Kuhn F, Shaalan H, Naclerio R, Loch E. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope. 1987;97(suppl 43):1-9. 27. Miller NR, Iliff WJ. Surgery of the orbit. In: Rice TA, Michels RG, Stark WJ, eds. Ophthalmic Surgery. 4th ed. St Louis, Mo: CV Mosby Co; 1984:383-398. 28. Murray JP. Complications after treatment of chronic maxillary sinus disease with Caldwell\x=req-\ Luc procedure. Laryngoscope. 1983;93:282-284. 29. DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: 1975\x=req-\ 1985. Laryngoscope. 1988;98:1297-1300. 30. McCord CD Jr. Current trends in orbital
decompression. Ophthalmology. 1985;92:21-33. 31. Leone CR Jr, Piest KL, Newman RJ. Medial and lateral wall decompression for thyroid ophthalmopathy. Am J Ophthalmol. 1989;108:160-166.
