Endoscopic surgery for intraconal orbital tumors

Traditionally, external craniofacial approaches have been used for orbital tumor resection. Over the last 30 years, endoscopic sinonasal and skull base techniques have become widely used throughout the world. These experiences paved the way for the extension of transnasal endoscopic techniques to the intraconal orbit. Transnasal endoscopic intraconal surgery has several advantages regarding morbidity and outcome as compared with purely external approaches. However, the anatomical knowledge and experience of the surgeon is crucial for the success of the surgery. Endoscopic approaches for intraconal tumor removal are feasible for medial and inferior lesions as well as for lesions lateral to the optic nerve provided they remain inferior to the "plane of resectability" and no optic nerve retraction is required. As intraorbital tumors are rare, new international staging systems including CHEER (Cavernous Hemangioma Exclusively Endonasal Resection) and ORBIT (Orbital Resection by Intranasal Technique) help to standardize safety, efficacy, and outcome.

Minimally Invasive 360-Degree Approach to Intraconal Orbital Tumors

PURPOSE

To evaluate clinically the efficacy of 360-degree minimally invasive endoscopic surgery in patients with orbital intraconal tumors.

DESIGN

Retrospective interventional case series.

METHODS

A series of consecutive patients with orbital intraconal tumors were treated with minimally invasive surgery using an endonasal endoscopic approach or an anterior endoscopic orbitotomy over a 5-year period between January 2015 and January 2020 at the National Institute of Oncology and Radiobiology of Cuba.

RESULTS

In 22 patients, the mean age was 52.3 ± 11 years (range 18-71 years) with a female to male ratio of 1.8:1. Visual loss was present in 3 patients and proptosis was present in 19 patients. The most common diagnosis was cavernous hemangioma (72.7%) followed by orbital sheet meningioma (9.1%). The lower-inner (type II) location was the most usual, followed by the lower-outer (type IV). A gross total resection was achieved in 95.5% of patients. In only 1 case with an orbital pseudotumor was the resection subtotal because of the fibrous consistency, irregularity, and adherences to the medial rectus muscle. All patients with visual loss improved to normal visual function after surgery at follow-up and orbital proptosis recovered in all patients with these symptoms. Both immediate and long-term morphologic and aesthetic results were good in all patients.

CONCLUSION

The minimally invasive 360-degree surgical approach with a full endoscopic visualization can be safe and efficient in patients with select orbital intraconal tumors. Optic nerve location constitutes the main aspect in the surgical approach selection. A large case series is necessary to standardize this surgical philosophy.