An Update on the Endoscopic Endonasal Approach to Orbital and Orbital Apex Lesions: A Series of 97 Patients

Background: Traditional approaches to the orbit include transcranial, transconjunctival, and “open” transorbital approaches. The endonasal endoscopic approach (EEA) has been employed for skull base lesions with success and can easily extend to the inferior and medial orbit and orbital apex.

Objectives: Compare clinical outcomes for extraorbital, extraconal, and intraconal orbital pathology with endoscopic endonasal surgery.

Methods: A retrospective review was conducted of all patients who underwent EEA for access to orbital pathology from 2002 to 2019. Patient outcomes including vision (both subjective, as well as by ophthalmologic evaluation), and complications were assessed.

Results: A total of 101 endoscopic endonasal procedures for resection or decompression of symptomatic orbital pathology was identified. Of them, 50.5% patients were female and the average age was 47.9 years. The most common presenting symptom was vision change (64.9%). Nineteen (18.8%) surgeries were combined/staged open and EEA. The most common pathology (33.7%) was meningioma with 34 procedures. Other pathologies included squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, osteoma, fibrous dysplasia, schwannoma, hemangioma, glioma, chondrosarcoma, arteriovenous fistula, Graves’ associated inflammatory disease, and trauma. The average follow-up was 21.6 months. Thirty-eight procedures (37.6%) were for compressive extraorbital symptoms. Sixty-three procedures (62.4%) were for intraorbital lesions, 34 (33.7%) of which were intraconal. Of the 38 extraorbital lesions, 10 patients (26.3%) had improved vision (visual acuity) postoperatively, and 28 (73.7%) had stable vision. Of the 29 patients with intraorbital, extraconal lesions, 13 patients (44.8%) had improved symptoms postoperatively (improved vision or decreased proptosis); 14 patients (48.3%) had stable vision postoperatively. Two patients (6.9%) suffered new deficits postoperatively; one abducens palsy, the other ptosis and difficulty with convergence. Of the 34 patients with intraconal lesions, 14 (41.2%) had improvement; 16 (47.1%) were stable and, 2 patients (5.9%) suffered from perioperative orbital hematomas with worsening vision following surgery. The worsening thought to be unrelated to the hematomas. One required an anterior orbitotomy via a transconjunctival approach and one which required a repeat endonasal endoscopic approach. One patient (2.9%) suffered a postoperative medial rectus palsy and diplopia, with slow improvement. One patient (2.9%) has slowly worsening vision on the ipsilateral side approximately 2 years after surgery with no recurrence noted on follow-up imaging. Other local complications included cerebrospinal fluid leaks in four patients (3.9%), postoperative infection (0.9%), delayed mucocele (1.9%), severe epistaxis (0.9%), enophthalmos (0.9%), and palatal numbness and facial pain (0.9%). Two cases (1.9%) included nondiagnostic biopsies as part of a decompression for presumed meningiomas which were treated as such without additional tissue. Of the 21 cases where gross total resection occurred, 3 patients (14.3%) suffered from tumor recurrence.

Conclusion: The endoscopic endonasal approach is a safe and effective option for the treatment of select orbital and orbital apex lesions. Similar outcomes were noted for extraconal and intraconal tumors, with improved or stable vision in 93.1 and 88.3%, respectively. Hematomas occurred only in the intraconal group.