2016 Section 5 Green Book

Bleier et al.

TABLE 1. Preoperative characteristics

TABLE 2. Approach vs tumor location

Presenting symptoms, n (%) Visual impairment

Location

n (%)

15 (65.2)

Intraconal (n = 16) Approach Single nostril

Proptosis

8 (34.8)

Pain

6 (26.1)

10 (62.5)

Diplopia

5 (21.7)

Binarial

6 (37.5)

On-head swelling

1 (4.3)

Number of hands/surgeons 2/1

Location, n (%) Intraconal

5 (31.3)

14 (60.9)

3/2

5 (31.3)

Optic canal

5 (21.7)

4/2

6 (37.5)

Extraconal

3 (13.0)

Extraconal (n = 7) Approach Single nostril

Mixed

1 (4.3)

Imaging, n (%) CT

7 (100.0)

23 (100.0)

Binarial

0 (0.0)

MRI

22 (95.7)

Number of hands/surgeons 2/1

Angiography

1 (4.3)

2 (28.6)

Tumor size (cm), mean ± SD Anterior-posterior

3/2

5 (71.4)

1.57 ± 0.70 1.15 ± 0.65

4/2

0 (0.0)

Medial-lateral

Superior-inferior 1.09 ± 0.48 CT = computed tomography; MRI = magnetic resonance imaging; ON = optic nerve; SD = standard deviation.

Discussion Although endoscopic skull base and orbital surgery share a common historical origin in time, 3,4 their proliferation has diverged over the subsequent decades. The reasons for this are likely multifactorial and may include the rela- tive paucity of medial intraorbital pathology, 15 the lack of widespread collaborative oculoplastic and rhinology teams, as well as a general unfamiliarity among rhinologists with respect to medial intraconal neurovascular anatomy 16 and intraorbital dissection techniques. As endoscopic skull base techniques have become more widely utilized and accepted, however, approaches to the orbit have experienced a re- birth, with an increasing number of papers being published on the subject in recent years. 13,17 Consequently, this study was conceived in an effort to examine the independent en- doscopic techniques developed at multiple experienced in- stitutions to deal with a single type of lesion. The preoperative workup for OCH was found to be sim- ilar among all groups. The vast majority of patients un- derwent both CT and MRI whereas only 1 underwent an- giography. In general, angiography is not necessary because OCHs tend to have characteristic imaging findings that are generally sufficient to make the diagnosis. 14 Furthermore, the majority of procedures were undertaken using image guidance, which may be helpful, particularly when utilizing a limited orbitotomy to identify a small intraconal lesion that is mobile and obscured by periorbital fat. Intraoperatively, there was general consensus that le- sions located in the extraconal space could be sufficiently

FIGURE 1. Endoscopic view of a right intraconal OCH demonstrating a 3-handed approach for exposure (white arrow represents the OCH). IR = inferior rectus muscle; MR = medial rectus muscle, OCH = orbital cavernous hemangioma.

Intraconal lesions were more likely to be associated with incomplete resection (31.25%) as compared to extraconal lesions (14.29%). Intraconal lesions also carried a higher risk of immediate postoperative diplopia and enophthalmos and were more likely to lead to a decision to reconstruct the orbit (Table 5). Among all patients with postoperative diplopia, only one-half were associated with medial rectus retraction (Table 6).

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