Endoscopic Endonasal Orbital Surgery

Background: Through an endoscopic endonasal route, it is possible to access the medial orbital structures as well as the orbital apex without a facial skin incision or the need for brain retraction. There is documented use of the endoscopic endonasal approach for several orbital pathologies. The purpose of this study is to evaluate outcomes of the use of the endoscopic endonasal approach in the treatment of a variety of orbital pathologies.

Methods: Medical records were reviewed and data were collected on patients who underwent endoscopic endonasal orbital surgery by a single surgical team at a tertiary care medical center between March 1, 2013 and July 1, 2019. Data were analyzed using simple statistical techniques including sums, ratios, and averages.

Results: From March 2013 to July 2019, 59 patients underwent endoscopic endonasal orbital surgery. This approach was performed for indications including: infection (n = 19, 32.2%), trauma (n = 13, 22.0%), neoplasm (n = 13, 22.0%), Grave’s ophthalmopathy (n = 8, 13.6%), epistaxis (n = 3, 5.1%), and cranial nerve V2 neuralgia (n = 2, 3.3%). Seventeen patients underwent endoscopic endonasal drainage of an orbital subperiosteal abscess. This was performed in conjunction with external orbitotomy in 13 (76.4%) of cases. Of these cases 94.1% of patients went on to complete resolution, one required reoperation prior to full resolution. Neoplasms were either identified by biopsy, debulked, or radically resected. Pathology identified includes: lymphoma (3), adenoidcystic carcinoma (2), cavernous hemangioma (2), meningioma (2), sinonasal adenocarcinoma, metastatic melanoma, plasmocytoma, and dacrocystocele. Orbital trauma was addressed by this approach for reduction and rigid fixation of the orbital floor fracture (6) or medial orbital wall fracture (4), and removal of infected retained orbital implants (3). Endoscopic endonasal orbital decompression for Grave’s opthalmopathy was performed unilateral in 4 (50%) and bilateral in 4 (50%) of cases. In two of the bilateral procedures, the patient developed persistent diplopia that was corrected with subsequent medial rectus muscle surgery. One patient required reoperation for revision of a displaced medial orbital wall implant. In two patients, V2 nerve decompression was performed for neuralgia; in one case, this leads to resolution of symptoms. The endoscopic endonasal approached was also used to perform an intraorbital anterior ethmoid artery ligation in three patients with persistent episodes of epistaxis despite prior ligation of both sphenopalatine arteries.

Conclusion: The endoscopic endonasal orbital approach provides unique access and is an effective method of addressing multiple different pathologies involving the orbit, allowing increased clarity and avoiding morbidity associated with open approaches. No irreversible complications were noted in our dataset.