Discordant Radiographic and Endoscopic Findings Regarding Orbital Invasion in Esthesioneuroblastoma: Case Report and Review of the Literature

Endoscopic resection plays an important and expanding role in the surgical management of esthesioneuroblastomas (ENB). Preoperative planning, including high-resolution CT and MRI, is crucial for accurate patient selection and to inform optimal surgical modality. Orbital invasion is generally considered to be a relative contraindication to endoscopic-only resection, particularly if orbital exenteration may be required for oncologic margins. Preoperative imaging is considered the sole opportunity for informing decisions regarding orbital preservation, but may not always delineate the presence or degree of orbital invasion. Here we present a case of discordant radiographic and intraoperative, endoscopic findings during endoscopic ENB resection that allowed for avoidance of orbital exenteration.

A 42-year-old male presented with initial left-sided followed by bilateral nasal obstruction progressing over one year, copious left-sided nasal drainage, and most recently left-sided tearing with proptosis. Anterior rhinoscopy showed a soft, fleshy mass in the left nasal passage which on biopsy was confirmed to be ENB. Initial MRI showed a 7.2 × 7.2 × 3.2 cm mass in the left nasal cavity with intracranial extension and invasion through the left medial orbit with involvement of the left medial rectus and superior oblique making this a modified-Kadish C esthesioneuroblastoma. Repeat imaging after neoadjuvant chemotherapy yielded equivocal findings regarding orbital involvement, though proptosis was still present. After tumor board discussion, surgical intervention was favored with a combined endoscopic and open approach including orbital exenteration. Intraoperatively, however, we did not detect any obvious left orbital involvement and disease was readily freed off of the lamina papyracea and periorbita with no obvious defects noted. The left medial orbit was negative for malignancy on intraoperative biopsy after gross total tumor resection. With these findings, we were able to avoid orbital exenteration and preserve meaningful visual function without compromising on an oncologically sound resection.

There is a paucity of literature comparing radiologic and intraoperative, endoscopic visualization for invasive sinonasal malignancies, including ENB. While increasing consideration in the literature is being given to orbital preservation even in the setting of modest orbital invasion, preoperative imaging is often considered the sole opportunity for such crucial decision making. Endoscopic endonasal approaches allow for superior visualization, including the utilization of intraoperative image guidance and, as such, may provide an additional opportunity for operative decision making, surgical optimization, and avoidance of unnecessary procedures. Here we provide an example of careful intraoperative visualization allowing for reduction in patient morbidity.

Fig. 1 Preoperative MRI, coronal view.

Fig. 2 Preoperative MRI, axial view.

Fig. 3 Endoscopic view of pushing tumor border.

Fig. 4 Endoscopic view of intact periorbita.