Acta Neurochir (2015) 157:625–628 DOI 10.1007/s00701-015-2359-y
HOW I DO IT - NEUROSURGICAL TECHNIQUES
The transmaxillary endoscopic approach to the inferior part of the orbit: How I do it Tomasz Lyson & Andrzej Sieskiewicz & Marek Rogowski & Zenon Mariak
Received: 4 July 2014 / Accepted: 22 January 2015 / Published online: 10 February 2015 # Springer-Verlag Wien 2015
Abstract Background Transmaxillary endoscopic approach to the inferior part of the orbit was demonstrated on cadaveric preparations; however, its clinical application has not been reported. We describe a clinically useful technique of the transmaxillary approach to the lower orbit. Methods A four-hand technique is essential for extensive preparation within the orbit; therefore, the tools have to be introduced into the maxillary sinus through two ports: either through the canine fossa and antrostomy or through antrostomy using the bi-nostril transseptal approach. Conclusion Intraorbital pathologies located in the inferior retrobulbar space can be successfully operated on using the transmaxillary endoscopic approach. Keywords Transmaxillary approach . Endoscopy . Orbit . Intraorbital pathology
Relevant surgical anatomy The orbital floor bows slightly into the maxillary sinus, being composed of the zygoma, maxillary and palatine bones. It is Electronic supplementary material The online version of this article (doi:10.1007/s00701-015-2359-y) contains supplementary material, which is available to authorized users. T. Lyson (*) : Z. Mariak Department of Neurosurgery, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland e-mail: [email protected] A. Sieskiewicz : M. Rogowski Department of Otolaryngology, Medical University of Bialystok, Bialystok, Poland
divided into a larger medial and smaller lateral part by the infraorbital nerve running in its bony canal from the pterygopalatine fossa to the infraorbital foramen. Standard approaches to the interior of the lower orbit— transconjunctival and through the inferior lid—are rather appropriate for blow-out trauma or minor/anteriorly located lesions, whereas larger/deeply located lesions need extensive maxillotomy. The feasibility of the endoscopic approach to the lower orbit through a single-port Caldwell-Luc trephination of the maxillary sinus was demonstrated on cadaveric specimens [4]. Nevertheless, our initial experience clearly showed that in the living even the broadest possible Caldwell-Luc type bone opening is still too narrow for any effective work with a telescope and 2–3 tools introduced into the orbit. For this reason only a two-port approach seems appropriate for clinically useful exploration of the orbital interior, the more so as the Caldwell-Luc type fenestration can at the same time be reduced to a minimum to avoid the risk of postoperative patient discomfort [1]. We present two variants of the combined transmaxillary endoscopic (TME) approach to the lower part of the orbit. In the first the tools are introduced through a small trephination in the canine fossa and a middle meatal antrostomy (Fig. 1). The second is carried out through antrostomy using the binostril trans-septal approach (Fig. 2). When entering the right maxillary sinus using the Caldwell-Luc approach, the nasolacrimal duct prominence and natural ostium become visible through a 0° telescope on the right side. The prominence of the infraorbital nerve canal sometimes is difficult to discern but must always be identified, even with the aid of neuronavigation. Inspection of the maxillary sinus via antrostomy gives a somewhat different perspective of the anatomical structures. The nasolacrimal duct limits the anterior extent of the antrostomy [3]. Visualization of the lateral part of the orbital floor can also be troublesome because of the
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Acta Neurochir (2015) 157:625–628
Fig. 1 a Representative coronal CT scan showing non-homogeneously enhancing pseudotumor within the inferior retrobulbar space of the right orbit containing a vague hyperdense zone that eventually turned out to be a wood splinter (a). Inferior rectus muscle indiscernible within a tumor
mass. The arrow indicates the position of the infraorbital nerve. b Postoperative coronal T1-weighted MRI scan 3 months postoperatively showing shrinkage of the inflammatory tumor
convex shape of the sinus roof, with the infraorbital nerve often protruding further downward. Nevertheless, an endoscopic access to the far inferolateral space of the orbit can still be achieved via antrostomy, Btaking a shortcut^ across the lower, arched part of the orbit (Fig. 3). The surgeon can enter the orbit through a limited trephination, medially to the infraorbital nerve, and then move further laterally, provided that the telescope remains in the horizontal plane. This can only be achieved when the telescope is introduced through the contralateral nostril via a perforation in the nasal septum. When approaching the orbit transnasally, the medial orbital wall, i.e., lamina papyracea, is usually exposed after removal of the ethmoidal cells. The so-called Bthird lamella^ (the posterior wall of the ethmoid bulla) constitutes a landmark, corresponding to the posterior aspect of the eye globe.
Description of the technique (see video)
Fig. 2 a Coronal T2-weighted MRI scan showing a vast mass of melanoma within the inferior intraconal space of the right orbit, which shifted the optic nerve medially and compressed the inferior rectus muscle. b CT
scan 1 year after surgery showing significant reduction of the tumor mass. Arrows indicate the extent of the orbitotomy
The patient is placed supine, with the head in neutral position, and registered for neuronavigation. The uncinate process is resected and a wide antrostomy carried out. The lamina papyracea can be exposed by ethmoidectomy. The region of the inferior orbital wall to be resected is defined with a neuronavigated curved suction tube. Drilling out and/or rongeuring of the inferior orbital wall can usually be performed through the ipsilateral nostril, but a second port can be created at this stage to be used for fourhand manipulations. In the first variant of the technique, the oral vestibule is incised in the canine fossa, between teeth III and IV, to create a small (10-mm-high and 7-mm-wide) bone opening for introduction of the tools and 0° telescope. The tumor mass is identified by neuronavigation, sampled and/or
Acta Neurochir (2015) 157:625–628
627
(who suddenly lost her vision), the orbital content was decompressed from the infiltrating melanoma with restoration of vision (Fig. 2). Limitations TME approach is not suitable for inferior orbit pathology localized anteriorly to the posterior aspect of the eye bulb. How to avoid complications
Fig. 3 Scheme based on the coronal CT scan with superimposed shadows to mark the regions of the orbit to be reached with different endoscopic approaches: through antrostomy/ipsilateral nostril (green), the Caldwell-Luc opening (yellow) and antrostomy/opposite nostril (blue)
removed. In our patient, a foreign body embedded within the pseudotumor mass came into view during tumor debulking; it was revealed to be a 6-mm-long splinter of wood (see the video). In the second variant of the technique, the antrostomy is supplemented with a small incision in the nasal septum. Surgical instruments and 30°/45° optics can be introduced through both nostrils to reach the inferior, medial and even far lateral parts of the orbit. Working this way in our second patient, the tumor was debulked and reduced significantly (see the video). The orbital floor can be reconstructed using different auto-, allo- or heterografts, e.g., Tachosil®, or left with no reconstruction if the defect is small or if decompression of the orbit is the goal of the surgery. The procedure is finalized with stitching the mucosa in the oral and nasal vestibule.
Detailed knowledge of the anatomy and use of neuronavigation are mandatory as well as careful postoperative ophthalmological checkups for intraorbital hematoma/ edema. The size of the Caldwell-Luc trephination should be limited to the minimum to avoid stomatological squealae. To avoid permanent perforation of the nasal septum, the mucoperichondrial incision in the opposite nasal vestibule must be followed by a perforation of the cartilage a few millimeters posteriorly and finally by mucosal incision on the opposite side of the septum even further posteriorly. Specific perioperative considerations The ostoperative course follows standard ENT guidelines after maxillary sinus endoscopy. Steroids or mannitol is administered perioperatively to minimize the risk of intraorbital edema. Ophthalmological assessment of visual acuity and eye motility is performed on a daily basis. Specific information to give to the patient about surgery and potential risks The patient must be informed that specific complications of the TME approach can include adverse stomatological effects or sinonasal dysfunction. Key points
Indications The orbital floor can be explored from the posterior aspect of the eye globe anteriorly up to the posterior wall of the sinus posteriorly. In the coronal plane, the entire width of the orbital floor can be targeted (Fig. 3). It is important to indicate that only via a two-port approach can the surgeon introduce surgical tools into the entire lower retrobulbar space and from different directions. Owing to this advantage, pathologies amenable to total resection can be removed completely, though in our instance this was not considered necessary. In the first patient the procedure was ceased after removal of the foreign body from his pseudotumor (Fig. 1), whereas in the second patient
1. Get acquainted with the relevant endoscopic anatomy of the region. 2. Be aware that the trajectory to the orbit can be awkward, and thus angled optics and curved/malleable tools may be needed. 3. Precisely define the character and localization of the pathology to choose the approach. 4. Remember that only the region behind the eye globe can be targeted with the TME approach. 5. Keep the size of anterior maxillectomy limited to avoid stomatological complications. 6. Avoid direct perforation of the nasal septum when using a bi-nostril approach.
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7. Define the limits of the inferior orbitotomy using anatomical landmarks and/or neuronavigation. 8. Avoid violation of the infraorbital nerve and inferior rectus muscle. 9. While working close to the eye globe and optic nerve, remember that the endoscope generates intense heat [2]. 10. With limited orbitotomy, reconstruction of the orbital floor is not mandatory.
Conflict of interest None. Presentation at a conference None.
Acta Neurochir (2015) 157:625–628
References 1. DeFreitas J, Lucente FE (1988) The Caldwell-Luc procedure: institutional review of 670 cases: 1975-1985. Laryngoscope 98:1297–1300 2. Lyson T, Sieskiewicz A, Sobolewski A, Rutkowski R, Kochanowicz J, Turek G, Baclawska A, Krajewski J, Rogowski M, Mariak Z (2013) Operative field temperature during transnasal endoscopic cranial base procedures. Acta Neurochir 155:903–908 3. Peris-Celda M, Pinheiro-Neto CD, Scopel TF, Fernandez-Miranda JC, Gardner PA, Snyderman CH (2013) Endoscopic endonasal approach to the infraorbital nerve with nasolacrimal duct preservation. J Neurol Surg B Skull Based 74:393–398 4. Schultheiß S, Petridis AK, El Habony R, Maurer P, Scholz M (2013) The transmaxillary endoscopic approach to the orbit. Acta Neurochir 155:87–97
HOW I DO IT - NEUROSURGICAL TECHNIQUES
The transmaxillary endoscopic approach to the inferior part of the orbit: How I do it Tomasz Lyson & Andrzej Sieskiewicz & Marek Rogowski & Zenon Mariak
Received: 4 July 2014 / Accepted: 22 January 2015 / Published online: 10 February 2015 # Springer-Verlag Wien 2015
Abstract Background Transmaxillary endoscopic approach to the inferior part of the orbit was demonstrated on cadaveric preparations; however, its clinical application has not been reported. We describe a clinically useful technique of the transmaxillary approach to the lower orbit. Methods A four-hand technique is essential for extensive preparation within the orbit; therefore, the tools have to be introduced into the maxillary sinus through two ports: either through the canine fossa and antrostomy or through antrostomy using the bi-nostril transseptal approach. Conclusion Intraorbital pathologies located in the inferior retrobulbar space can be successfully operated on using the transmaxillary endoscopic approach. Keywords Transmaxillary approach . Endoscopy . Orbit . Intraorbital pathology
Relevant surgical anatomy The orbital floor bows slightly into the maxillary sinus, being composed of the zygoma, maxillary and palatine bones. It is Electronic supplementary material The online version of this article (doi:10.1007/s00701-015-2359-y) contains supplementary material, which is available to authorized users. T. Lyson (*) : Z. Mariak Department of Neurosurgery, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland e-mail: [email protected] A. Sieskiewicz : M. Rogowski Department of Otolaryngology, Medical University of Bialystok, Bialystok, Poland
divided into a larger medial and smaller lateral part by the infraorbital nerve running in its bony canal from the pterygopalatine fossa to the infraorbital foramen. Standard approaches to the interior of the lower orbit— transconjunctival and through the inferior lid—are rather appropriate for blow-out trauma or minor/anteriorly located lesions, whereas larger/deeply located lesions need extensive maxillotomy. The feasibility of the endoscopic approach to the lower orbit through a single-port Caldwell-Luc trephination of the maxillary sinus was demonstrated on cadaveric specimens [4]. Nevertheless, our initial experience clearly showed that in the living even the broadest possible Caldwell-Luc type bone opening is still too narrow for any effective work with a telescope and 2–3 tools introduced into the orbit. For this reason only a two-port approach seems appropriate for clinically useful exploration of the orbital interior, the more so as the Caldwell-Luc type fenestration can at the same time be reduced to a minimum to avoid the risk of postoperative patient discomfort [1]. We present two variants of the combined transmaxillary endoscopic (TME) approach to the lower part of the orbit. In the first the tools are introduced through a small trephination in the canine fossa and a middle meatal antrostomy (Fig. 1). The second is carried out through antrostomy using the binostril trans-septal approach (Fig. 2). When entering the right maxillary sinus using the Caldwell-Luc approach, the nasolacrimal duct prominence and natural ostium become visible through a 0° telescope on the right side. The prominence of the infraorbital nerve canal sometimes is difficult to discern but must always be identified, even with the aid of neuronavigation. Inspection of the maxillary sinus via antrostomy gives a somewhat different perspective of the anatomical structures. The nasolacrimal duct limits the anterior extent of the antrostomy [3]. Visualization of the lateral part of the orbital floor can also be troublesome because of the
626
Acta Neurochir (2015) 157:625–628
Fig. 1 a Representative coronal CT scan showing non-homogeneously enhancing pseudotumor within the inferior retrobulbar space of the right orbit containing a vague hyperdense zone that eventually turned out to be a wood splinter (a). Inferior rectus muscle indiscernible within a tumor
mass. The arrow indicates the position of the infraorbital nerve. b Postoperative coronal T1-weighted MRI scan 3 months postoperatively showing shrinkage of the inflammatory tumor
convex shape of the sinus roof, with the infraorbital nerve often protruding further downward. Nevertheless, an endoscopic access to the far inferolateral space of the orbit can still be achieved via antrostomy, Btaking a shortcut^ across the lower, arched part of the orbit (Fig. 3). The surgeon can enter the orbit through a limited trephination, medially to the infraorbital nerve, and then move further laterally, provided that the telescope remains in the horizontal plane. This can only be achieved when the telescope is introduced through the contralateral nostril via a perforation in the nasal septum. When approaching the orbit transnasally, the medial orbital wall, i.e., lamina papyracea, is usually exposed after removal of the ethmoidal cells. The so-called Bthird lamella^ (the posterior wall of the ethmoid bulla) constitutes a landmark, corresponding to the posterior aspect of the eye globe.
Description of the technique (see video)
Fig. 2 a Coronal T2-weighted MRI scan showing a vast mass of melanoma within the inferior intraconal space of the right orbit, which shifted the optic nerve medially and compressed the inferior rectus muscle. b CT
scan 1 year after surgery showing significant reduction of the tumor mass. Arrows indicate the extent of the orbitotomy
The patient is placed supine, with the head in neutral position, and registered for neuronavigation. The uncinate process is resected and a wide antrostomy carried out. The lamina papyracea can be exposed by ethmoidectomy. The region of the inferior orbital wall to be resected is defined with a neuronavigated curved suction tube. Drilling out and/or rongeuring of the inferior orbital wall can usually be performed through the ipsilateral nostril, but a second port can be created at this stage to be used for fourhand manipulations. In the first variant of the technique, the oral vestibule is incised in the canine fossa, between teeth III and IV, to create a small (10-mm-high and 7-mm-wide) bone opening for introduction of the tools and 0° telescope. The tumor mass is identified by neuronavigation, sampled and/or
Acta Neurochir (2015) 157:625–628
627
(who suddenly lost her vision), the orbital content was decompressed from the infiltrating melanoma with restoration of vision (Fig. 2). Limitations TME approach is not suitable for inferior orbit pathology localized anteriorly to the posterior aspect of the eye bulb. How to avoid complications
Fig. 3 Scheme based on the coronal CT scan with superimposed shadows to mark the regions of the orbit to be reached with different endoscopic approaches: through antrostomy/ipsilateral nostril (green), the Caldwell-Luc opening (yellow) and antrostomy/opposite nostril (blue)
removed. In our patient, a foreign body embedded within the pseudotumor mass came into view during tumor debulking; it was revealed to be a 6-mm-long splinter of wood (see the video). In the second variant of the technique, the antrostomy is supplemented with a small incision in the nasal septum. Surgical instruments and 30°/45° optics can be introduced through both nostrils to reach the inferior, medial and even far lateral parts of the orbit. Working this way in our second patient, the tumor was debulked and reduced significantly (see the video). The orbital floor can be reconstructed using different auto-, allo- or heterografts, e.g., Tachosil®, or left with no reconstruction if the defect is small or if decompression of the orbit is the goal of the surgery. The procedure is finalized with stitching the mucosa in the oral and nasal vestibule.
Detailed knowledge of the anatomy and use of neuronavigation are mandatory as well as careful postoperative ophthalmological checkups for intraorbital hematoma/ edema. The size of the Caldwell-Luc trephination should be limited to the minimum to avoid stomatological squealae. To avoid permanent perforation of the nasal septum, the mucoperichondrial incision in the opposite nasal vestibule must be followed by a perforation of the cartilage a few millimeters posteriorly and finally by mucosal incision on the opposite side of the septum even further posteriorly. Specific perioperative considerations The ostoperative course follows standard ENT guidelines after maxillary sinus endoscopy. Steroids or mannitol is administered perioperatively to minimize the risk of intraorbital edema. Ophthalmological assessment of visual acuity and eye motility is performed on a daily basis. Specific information to give to the patient about surgery and potential risks The patient must be informed that specific complications of the TME approach can include adverse stomatological effects or sinonasal dysfunction. Key points
Indications The orbital floor can be explored from the posterior aspect of the eye globe anteriorly up to the posterior wall of the sinus posteriorly. In the coronal plane, the entire width of the orbital floor can be targeted (Fig. 3). It is important to indicate that only via a two-port approach can the surgeon introduce surgical tools into the entire lower retrobulbar space and from different directions. Owing to this advantage, pathologies amenable to total resection can be removed completely, though in our instance this was not considered necessary. In the first patient the procedure was ceased after removal of the foreign body from his pseudotumor (Fig. 1), whereas in the second patient
1. Get acquainted with the relevant endoscopic anatomy of the region. 2. Be aware that the trajectory to the orbit can be awkward, and thus angled optics and curved/malleable tools may be needed. 3. Precisely define the character and localization of the pathology to choose the approach. 4. Remember that only the region behind the eye globe can be targeted with the TME approach. 5. Keep the size of anterior maxillectomy limited to avoid stomatological complications. 6. Avoid direct perforation of the nasal septum when using a bi-nostril approach.
628
7. Define the limits of the inferior orbitotomy using anatomical landmarks and/or neuronavigation. 8. Avoid violation of the infraorbital nerve and inferior rectus muscle. 9. While working close to the eye globe and optic nerve, remember that the endoscope generates intense heat [2]. 10. With limited orbitotomy, reconstruction of the orbital floor is not mandatory.
Conflict of interest None. Presentation at a conference None.
Acta Neurochir (2015) 157:625–628
References 1. DeFreitas J, Lucente FE (1988) The Caldwell-Luc procedure: institutional review of 670 cases: 1975-1985. Laryngoscope 98:1297–1300 2. Lyson T, Sieskiewicz A, Sobolewski A, Rutkowski R, Kochanowicz J, Turek G, Baclawska A, Krajewski J, Rogowski M, Mariak Z (2013) Operative field temperature during transnasal endoscopic cranial base procedures. Acta Neurochir 155:903–908 3. Peris-Celda M, Pinheiro-Neto CD, Scopel TF, Fernandez-Miranda JC, Gardner PA, Snyderman CH (2013) Endoscopic endonasal approach to the infraorbital nerve with nasolacrimal duct preservation. J Neurol Surg B Skull Based 74:393–398 4. Schultheiß S, Petridis AK, El Habony R, Maurer P, Scholz M (2013) The transmaxillary endoscopic approach to the orbit. Acta Neurochir 155:87–97
