"Push-Pull Technique" for the Management of a Selected Superomedial Intraorbital Lesion

Endoscopic Endonasal Approach to Intraconal Orbital Tumors: Outcomes and Lessons Learned

BACKGROUND

Lesions involving the intraconal space of the orbit are rare and challenging to manage. Operative techniques and outcomes for the endoscopic endonasal approach (EEA) to tumors in the medial intraconal space (MIS) remain poorly characterized.

OBJECTIVE

We present our experience with a wide range of isolated intraconal pathology managed via an EEA.

METHODS

A retrospective review of all cases (2014-2021) performed by a single skull base team in which the EEA was employed for the management of an intraconal orbital lesion.

RESULTS

Twenty patients (13 men, 7 women) with a mean age of 59 years (range, 40-89 years) were included. All lesions were isolated to the MIS, pathology addressed included: cavernous hemangioma (6), schwannoma (4), lymphoma (4), inflammatory pseudotumor (2), chronic invasive fungal sinusitis (2), and metastatic disease (2). Either a biopsy (10/20) or a complete resection (10/20) was performed. In all cases, the MIS was accessed via an endonasal corridor between the medial and inferior rectus muscles. Retraction and safe, intra-orbital dissection of the lesion was performed using a two-surgeon, multi-handed technique. Gross total resection of benign lesions was achieved in 90% (9/10) of cases; a pathologic diagnosis was achieved in 100% (10/10) of biopsy cases. No orbital reconstruction was required. Visual acuity returned to normal in 80% (8/10) of planned resection cases and postoperative diplopia resolved by 3 months in 90%. Mean follow-up was 15 months.

CONCLUSION

This study demonstrates that the EEA is safe and effective for accessing lesions in the MIS. This technique affords very favorable outcomes with minimal postoperative morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:47-55, 2024.

Lipoma Rarely Involving Multiple Suprahyoid Fascial Spaces: A Large Lesion Removed With Bimanual Transcervical Finger Dissection Using a "Push-Pull Down" Maneuver

Lipoma involving multiple fascial spaces is extremely rare and poses a challenge to surgeons using less invasive procedures. Although blunt dissection using a finger is often used in excisional surgeries as a supplementary maneuver, few cases have been described using the bimanual technique for the removal of these extensive lesions.Herein, the authors present a large lipoma of the oral floor extending to the unilateral submandibular and parapharyngeal spaces, which was excised only via a submandibular approach using the "push-pull down" maneuver, blunt finger dissection of the tumor with counter-pushing on the overlying mucosa to the submandibular direction facilitated tumor separation. The tumor was consequently pulled down and removed without an additional intraoral incision.Based on accurate preoperative examinations, this maneuver, provides a less invasive surgery for well-encapsulated benign tumors involving multiple fascial spaces.