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Endoscopic Orbital Fracture Repair

Endoscopic Repair of a Medial Orbital Wall Facture With the “Milan Technique” Endoscopic Medial Orbital Wall Reconstruction After Removal of an Orbital Mass Via a Transnasal Approach Among the seven bones composing the orbit, the maxillary bone and the ethmoid bone represent the thinnest boundaries. Therefore blunt trauma to the orbit most often results in inferior and/or medial wall fractures rather than lateral wall and orbital…

Endoscopic Management of Mucoceles With Significant Orbital Involvement

Patient Demographics, Clinical Presentation, and Preoperative Workup Sinonasal mucoceles are benign lesions arising from progressive expansion of respiratory epithelium. Obstruction of the natural ostia of the corresponding sinus leads to noted expansion of the sinus epithelium with mucoid secretions. The mucocele can expand and exert mass effect on surrounding nasal, orbital, and intracranial structures. The inciting factor for mucocele development can range and include chronic infection,…

Transorbital Techniques to Frontal Sinus Diseases

The frontal sinus is commonly affected by inflammatory diseases, traumatic fractures, benign tumors, and malignant neoplasms. Because of its proximity to the brain, eye, and nose, disease processes originating from these anatomic sites can extend to involve the frontal sinuses. Transnasal endoscopic surgery is presently the principal approach for managing frontal sinus pathologies, with open external approaches mostly limited to the repair of frontal sinus fractures.…

Endoscopic Subperiosteal Abscess Drainage

Right Orbital Subperiosteal Abscess Drainage Acute rhinosinusitis (ARS) accounts for one-fifth of all adult and pediatric antibiotic prescriptions. Bacterial ARS can lead to orbital or intracranial infections by direct or hematogenous spread. If left untreated, this can result in permanent vision loss, meningitis, intracranial abscess, sepsis, and death. The incidence of serious complications from ARS has been estimated to be 1:12,000 in children and 1:32,000 in…

Endoscopic Orbital Exenteration

Endoscopic-Assisted Orbital Exenteration Malignant diseases involving the orbit can result in an incalculable amount of human suffering, as their natural course can progress to include bleeding, pain, disfigurement, blindness, and premature death ( Fig. 29.1 ). Orbital exenteration to treat such a malady, whether performed by open surgery or endoscopically, is challenging and is best accomplished through a multidisciplinary approach. The recommendation to exenterate the orbital…

Fibro-Osseous Lesions of the Orbit and Optic Canal

Osseous tumors represent a broad range of pathologic conditions, which can be roughly categorized into fibro-osseous lesions, cartilaginous lesions, reactive bone lesions, and vascular lesions. Most of these entities are extremely rare in the craniofacial skeleton, and particularly in the orbit. As such, this chapter predominantly focuses on fibro-osseous lesions, which represent a broad continuum of diseases with similar histopathologic features. Many of these lesions are…

Management of Intraconal Hemangioma: Techniques and Outcomes

Endoscopic orbital surgery represents a challenging arena for the endoscopic surgeon. The orbit is highly complex, with critical structures confined in a fat-filled, soft-tissue space, thereby limiting visibility, and restricting the necessary manipulation of muscles, nerves, and vessels required to resect primary orbital tumors. With the advent of increasing expertise and technology, the endoscope is now being used to transgress pneumatized sinuses and operate within the…

Orbital Apex Surgery and Tumor Removal

The orbital apex is a small, cone-shaped region located between the posterior ethmoidal foramen anteriorly and the openings of the optic canal and superior orbital fissure posteriorly. It contains many critical neurovascular structures, including the optic, oculomotor, and abducens nerves, as well as the ophthalmic branch of the trigeminal nerve. Also nearby are the cavernous sinus, carotid artery, and periarterial sympathetic plexus. At this level, the…

Intraorbital Pathology (Tumors) and Management Strategies

Orbital tumors encompass a heterogenous range of lesions, from congenital cystic masses to both benign and malignant neoplasms, and can originate from a variety of tissue types. In a large 30-year study of orbital tumors, 64% of masses were benign and 36% were malignant. The most common orbital tumors by category are vascular, secondary or metastatic, and lymphoid. Rhabdomyosarcoma is the most common malignancy in children…

Endoscopic Endonasal Approaches to the Orbit and Skull Base in the Coronal Plane

Endoscopic endonasal approaches to the skull base are classified by their orientation in the sagittal and coronal planes. The anterior coronal plane corresponds with the anterior cranial fossa and extends laterally from the midline sagittal corridor across the floor of the anterior cranial base and roof of the orbit. Access to the roof of the orbit is limited medially by the medial orbital wall, ethmoidal arteries,…

Postoperative Care of the Endoscopic Orbital Decompression Patient

Postoperative treatment of patients undergoing endoscopic orbital decompression (EOD) shares many similarities with that of patients who have standard functional endoscopic sinus surgery. Important distinctions that must be accounted for relate to the herniation of orbital contents into the nose and specific potential complications. Potential orbital complications include corneal abrasion, epiphora, new or worsening diplopia, worsening vision, and vision loss. Potential sinus complications include postoperative hemorrhage,…

Complications in Endoscopic Orbital Surgery

Orbital decompression has been performed for more than 100 years and is aimed at decompressing the orbital content by partially removing its bony boundaries. It has evolved from a transfrontal orbital roof approach to the classical external transantral approach. The endoscopic orbital decompression (EOD) was first described by Kennedy et al. in the early 1990s as a surgical treatment for thyroid eye disease (TED), and it…

Endoscopic Optic Nerve Decompression: Intracanalicular Portion

Optic Nerve Decompression The Evolution of Optic Nerve Decompression Although endoscopic transnasal surgery has become a widely used method for optic nerve decompression, its emergence would not be conceivable without technological advances in modern endoscopic surgery. Improvements in optics, instrumentation, and image-guided surgical navigation have transformed the approach to the optic nerve from an open craniotomy to the minimally invasive methodology of today. Historically, the route…

Endoscopic Orbital Decompression

Endoscopic orbital decompression was developed soon after the advent of endoscopic sinus surgery. The technique was first described by Kennedy et al. in 1990 and Michel et al. in 1991 and has gained popularity over the past several decades, now representing about a quarter of orbital decompressions performed in the United States annually. The major advantages of the endoscopic approach include avoidance of an external facial…

Surgical Indications and Outcomes of Orbital Decompression Surgery

Orbital decompression surgery is being increasingly used in the treatment of urgent and nonurgent complications related to Graves ophthalmopathy. An understanding of the specific indication for pursuing surgery is critical in deciding the optimal timing of the surgery, formulating the surgical plan, and determining the most relevant clinical outcomes. Quality-of-life (QOL) outcomes are also gaining increasing importance in assessing surgical success. Surgical Indications Graves Ophthalmopathy Graves…

Thyroid Eye Disease

Thyroid eye disease (TED) is an autoimmune inflammatory disorder that affects the periocular soft tissues. TED is associated with Graves disease (GD) and is synonymous with Graves orbitopathy/ophthalmopathy and thyroid-related orbitopathy/ophthalmopathy, among other names. The term TED is used by the authors because it is simple, universal, and understandable to patients and multidisciplinary clinicians. Although the majority of patients with TED experience mild disease, marked primarily…

Outcomes of Endoscopic Dacryocystorhinostomy: Enhancing the Patency of the Rhinostomy

Dacryocystorhinostomy (DCR) is the definitive treatment for epiphora caused by nasolacrimal duct obstruction (NLDO). The procedure creates a functioning passageway for tears from the lacrimal sac into the nasal cavity by bypassing the obstructed nasolacrimal duct. The cause of NLDO can be idiopathic, as in primary acquired NLDO, or it can be secondary to other disease entities. Secondary causes include infectious, inflammatory, neoplastic, traumatic, and mechanical…

Endoscopic Management of Pediatric Nasolacrimal Obstruction

Epiphora in the pediatric population often originates from a disorder of the lacrimal drainage system. In most cases, the cause is congenital nasolacrimal duct obstruction (CNLDO), which often presents during the first year of life, with a prevalence ranging from 1.2% to 6% ( Fig. 16.1 ). Additional symptoms and signs of CNLDO may include a high tear meniscus, positive dye disappearance test result, recurrent mucopurulent…

Revision Endoscopic Dacryocystorhinostomy and Conjunctivodacryocystorhinostomy

Pearls Outcomes after revision endoscopic dacryocystorhinostomy (endoscopic DCR) are excellent and the preferred approach when possible. Endoscopic DCR allows the surgeon to thoroughly evaluate the neo-ostium and address concomitant nasal pathology at the time of surgery in a minimally invasive fashion Understanding the critical endonasal anatomic relationships is essential to successful revision endoscopic DCR If patients have concomitant severe canalicular stenosis, conjunctivodacryocystorhinosotomy (CDCR) should be considered…

Endonasal Dacryocystorhinostomy With Mucosal Flaps

Diseases within the tear duct system can interfere with tear drainage and result in epiphora. Poor drainage with secretion retention may result in inflammation and infection. In the majority of cases, epiphora is attributed to an outflow obstruction of the nasolacrimal duct. To date, the exact etiology is not completely understood, but inflammatory alterations with stenosis at the junction between the lacrimal sac and nasolacrimal duct…