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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 219-224

Endoscopic endonasal surgery in orbital decompression and orbital reconstruction


1 Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission13-Aug-2013
Date of Acceptance29-Dec-2013
Date of Web Publication29-Apr-2015

Correspondence Address:
Hosam Adel Hussein Omar
Shebein Elkom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155998

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  Abstract 

Objectiv
The aim of this study was to clarify and evaluate the role and the outcome of endoscopic endonasal surgery in both orbital decompression and orbital reconstruction.
Background
Traditional external techniques are now known to reduce proptosis significantly, but have the disadvantage of cosmetic morbidity in terms of a cutaneous scar and a high incidence of postoperative complications. Recent advances in endoscopic sinus surgery have extended its applications beyond the nose to the orbit. Orbital decompression, drainage of subperiosteal abscess, optic nerve decompression, and orbital wall reconstruction are performed very safely and effectively by endoscopic intranasal surgery.
Patients and methods
Fifty-four patients indicated for endoscopic orbital decompression or reconstruction were divided according to the cause into five groups (20 infection, eight inflammatory, eight neoplastic, eight congenital, and 10 traumatic). Preoperative evaluations performed were history taking, physical examination, and computed tomography and MRI of orbit and paranasal sinuses. After creating an endoscopic wide middle meatal antrostomy dealing with the pathology causing extraconal orbital compression and in intraconal compression penetrate the lamina papyracea and periosteum until prolapsed fat fill the ethmoid sinus. Reconstruction was performed by removal of the fractured bone, extraocular muscle reposition with support using Foley's catheter in floor fracture and a silastic sheet with Merocel packing in medial wall fracture.
Results
There was significant proptosis reduction in all groups, especially in the infection group (P < 0.001), with a mean proptosis reduction of 4 mm in the same group. Vision was significantly improved in all groups. Limited ocular motility improved significantly in traumatic and infection groups (P < 0.05). Complications were limited, and diplopia (16.7%) was the most frequent complication.
Conclusion
Endoscopic nasal decompression of the orbit is a safe and effective approach for reducing proptosis and improving vision and ocular motility in cases of orbital compression, which include infection, inflammatory, neoplastic, congenital, and traumatic causes. Endoscopic intranasal reduction of the orbital floor with a Foley's catheter balloon and with a silastic sheet and Merocel packing of the medial orbital wall provided good functional results and definite advantages. Complications were limited.

Keywords: Endoscopic orbital decompression, endoscopic orbital surgery, intranasal endoscopic orbital reconstruction


How to cite this article:
El-Banhawy OA, El-Saadany AKI, El-Fattah AA, Abd-Allah HA, Omar HA. Endoscopic endonasal surgery in orbital decompression and orbital reconstruction. Menoufia Med J 2015;28:219-24

How to cite this URL:
El-Banhawy OA, El-Saadany AKI, El-Fattah AA, Abd-Allah HA, Omar HA. Endoscopic endonasal surgery in orbital decompression and orbital reconstruction. Menoufia Med J [serial online] 2015 [cited 2019 Sep 20];28:219-24. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/219/155998


  Introduction Top


After the advent of Hopkins' rod and the technique of nasal endoscopy, visualization of the nasal cavity and paranasal sinuses has improved significantly [1].

This has led to the adoption of endoscopic sinus surgery for the treatment of nasal conditions by the majority of otolaryngologists. As surgeons' endoscopic experience improved, the spectrum of transnasal procedures extended to include cerebrospinal fluid leak repairs, hypophysectomy, orbital decompression, orbital reconstruction, and major arterial ligation [2]. The etiological basis of orbital manifestations of nose and paranasal sinus diseases can be congenital, inflammatory, vascular, neoplastic, and infections. Symptoms and signs of proptosis are manifested by the displacement of the globe and are associated with local pain, redness and swelling. It is often accompanied by decreased vision, double vision, optic-disc swelling, and impaired ocular movements [3,4]. The progression of surgery on the medial and the inferior orbital skeleton was logical, and has allowed access to the entire medial orbital wall and the floor of the orbit medial to the infraorbital nerve [5].


  Patients and methods Top


Our prospective study was carried out from August 2010 to August 2013. Patients were subjected to operative intervention at Menoufia University Hospitals and Dr Omar Elbanhawy Center (El-Mansoura); 54 patients were divided according to the etiological cause into five groups: group 1, infection group (20 patients); group 2, inflammatory noninfectious group (eight patients); group 3, neoplastic group (eight patients); group 4, congenital group (eight patients); and group 5, traumatic group (10 patients).

History was obtained, and ocular examinations for the degree of proptosis, visual acuity, diplopia, and eye movement limitation were performed; ORL examination, computed tomography (CT) [Figure 1]a, MRI, and MRV were performed, if indicated [Figure 2]. Surgery was performed under general anesthesia.
Figure 1: Computed tomography (CT) scan without contrast of a patient with allergic fungal rhinosinusitis. (a) The preoperative image shows a left hyperdense mass opacifi ed ethmoiditis with expansion to the medial orbital wall with left proptosis (intraorbital extaconal orbital compression). (b) A postoperative follow-up CT scan of the same patient shows complete ethmoidectomy with orbital decompression (proptosis reduction), with bone remodeling of the medial orbital wall.

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Figure 2: Preoperative magnetic resonance venography of a patient with chronic invasive fungal rhinosinusitis: (a) the axial view shows right superior ophthalmic vein occlusion along its course. (b) Coronal cut of the same patient.

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Inclusion criteria

Patients in whom proptosis progressed despite appropriate treatment, those who had a deterioration of vision, and patients with afferent pupillary defect, limited ocular motility, and persistent diplopia were included.

Exclusion criteria

Patients unfit for general anesthesia, and those having active Graves' ophthalmopathy, combined fractures, enophthalmos greater than 2 mm, or a large defect exceeding an area of 2 cm 2 (50% floor) were excluded.

Endoscopic intraconal orbital decompression

The first step was to perform a complete uncinectomy and to enlarge the maxillary sinus ostium until the posterior wall of the maxillary sinus is exposed. It is important to establish a large ostium as fat prolapse may block the ostium. The agger nasi cells were removed and the frontal sinus ostium was exposed. The bulla ethmoidalis was removed and the posterior ethmoids was entered through the basal lamella. All posterior ethmoid cells were cleared and the skull base was clearly identified so that the junction of the lamina papyracea and the skull base were clear.

The sphenoid anterior face was identified and exposed. A blunt-tipped Freer elevator was used to penetrate the lamina papyracea directly posterior to the thin lacrimal bone and then to gently flake off the lamina papyracea from the underlying periosteum.

The periosteum was kept intact at all times as rupture of the periosteum would lead to prolapse of orbital fat and obscure further dissection of the lamina papyracea. The lamina papyracea was removed up until the junction of the lamina with the skull base and up to the anterior face of the sphenoid. It is important to keep the lamina papyracea bone intact in the region of the frontal recess to prevent prolapsed fat from blocking the frontal sinus drainage pathway. All of the orbital periosteum must be removed to achieve maximal prolapse of orbital fat. The medial rectus muscle lies 1 or 2 mm under the prolapsed fat. If the orbital floor is to be removed, curved instruments are placed through the maxillary ostium and the orbital floor can be removed up to the infraorbital nerve. Again, the periosteum was either excised or incised to allow maximal fat prolapse into the maxillary sinus.

Endoscopic extraconal orbital decompression

Complete uncinectomy, sphenoethmoidectomy was performed. Dealing with the different extraconal disorders, till the medial orbital wall was exposed to relieve the extraconal orbital pressure.

Endoscopic orbital floor reconstruction

After a wide antrostomy was made, the fractured orbital floor and its herniated orbital contents were identified and mobilized. A Foley's catheter balloon was inserted into the antrum and the fracture-displaced orbital floor was supported by the saline-filled balloon. Care was taken not to entrap the orbital contents between the balloon and the orbital floor. A packing was placed in the middle meatus. The catheter connected with the balloon was passed through the nostril, and fixed on the cheek.

Endoscopic medial orbital wall reconstruction

After antrostomy and ethmoidectomy were performed, fractured bones of the lamina papyracea and herniated orbital contents were identified behind the resected air cells. The fractured lamina papyracea was removed. Orbital contents were pushed back into the orbit. A thin silastic sheet (0.020 inches in thickness) was inserted in a U-shape to cover the lamina papyracea and the ethmoidectomy cavity. The ostial drainage of the frontal sinus and the maxillary antrum were not disturbed. Merocel packing was placed and soaked with a broad-spectrum antibiotic solution.

Postoperative care

Full ophthalmic examination was performed 1 day postoperatively. Orbital fracture was confirmed by CT scanning. The packing was removed 2 days postoperatively. An endoscopic nasal examination was performed in cases of orbital decompression. Three weeks after surgery, the Merocel packing, the silastic sheet and the Foley's catheter balloon were removed under topical anesthesia in the outpatient clinic. Ocular examinations for the degree of proptosis, visual acuity, diplopia, eye movement limitation, and ORL examination were performed 4 weeks postoperatively; CT [Figure 1]b, MRI, and MRV were performed, if indicated.

Statistical analysis

Data were analyzed using the SPSS (version 16.0; SPSS Inc., Chicago, Illinois, USA) software. Qualitative data were expressed as number and percentage and analyzed by applying the c2 -test of association, and the level of significance was set as P-value less than 0.05. Quantitative data were expressed as mean and SD and were analyzed by applying analysis of variance for a comparison between more than two groups of normally distributed variables.


  Results Top


The study showed a significant association between groups regarding their demographic data [Table 1] and [Table 2]. Descriptive data of the studied group showed a mean age of 29.6 years [Table 3]. Significant postoperative proptosis reduction was detected in all groups, and it was highly significant in the infection and the congenital groups [Table 4], with a mean proptosis reduction of 4 and 3.8 mm in the infection and the congenital groups, respectively [Table 5]. Vision improved significantly in all groups, especially in the inflammatory and the congenital groups [Table 6]. Significant postoperative improvement was observed in the ocular motility and diplopia in all groups, especially in the traumatic group, but the neopastic group showed a nonsignificant postoperative relation [Table 7]. Diplopia was the most common complication [Table 8],[Table 9],[Table 9] and [Table 10].
Table 1: Descriptive data of the studied patients with regard to age

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Table 2: Demographic criteria of the studied groups

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Table 3: The prevalence of patients indicated for endoscopic endonasal orbital decompression or reconstruction

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Table 4: Comparison between preoperative and postoperative outcomes with regard to proptosis

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Table 5: The mean of the degree of postoperative proptosis reduction

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Table 6: Comparison between preoperative and postoperative outcomes with regard to the visual acuity

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Table 7: Comparison between preoperative and postoperative outcomes with regard to ocular motility

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Table 8: Comparison between preoperative and postoperative outcomes with regard to diplopia

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Table 9: Prevalence of postoperative complications

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Table 10: Postoperative endoscopic endonasal orbital decompression and reconstruction surgery outcomes

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  Discussion Top


Our study showed a significant association between groups regarding their demographic data, with a mean age of 29.6 years, a minimum age of 7 years and a maximum of 67 years; these figures are compatible with Masud et al. [4], who found a mean age of 31.6 years in their study on proptosis. There was a significant statistical difference between the five studied groups with regard to the sex distribution (P < 0.05). The male sex was significantly more predominant in each of the traumatic and the neoplastic groups, whereas the female sex was significantly more predominant in the infection, the inflammatory noninfectious and the congenital groups.

Postoperative proptosis reduction was significantly reported in all groups [Table 4]. Regarding the infection group, the following inclusion criteria matched with studies [6],[7],[8]:

  1. A decrease in vision;
  2. An afferent pupillary defect;
  3. Progressive proptosis despite appropriate therapy;
  4. The size of the abscess does not reduce on CT scan within 48-72 h after appropriate antibiotics or systemic antifungal drugs administration.


In the infection group, postoperative proptosis assessment showed proptosis reduction to normal in 70% of the patients, mild proptosis in 25%, and severe proptosis in one patients with uncontrolled diabetes with chronic invasive fungal rhinosinusitis with a delayed presentation to rhinological consultation, and this matched with other studies [6-8], with a mean 4 mm of proptosis reduction; this was in agreement with the study by Jahnke [9].

After endoscopic orbital wall decompression with fat removal in inflammatory orbital disorders, proptosis reduced significantly [10-12], and it was matched with our results in both cases of Graves' ophthalmopathy with a mean regression of proptosis of about 3.7 mm and cases of orbital pseudotumor with a mean proptosis reduction of 3.5 mm.

The vision improved significantly in all groups, especially in the congenital and the inflammatory groups [Table 5]. Postoperative endoscopic orbital decompression in meningoencephalocele showed improvement in vision, proptosis, and ocular motility, and it was in agreement with Schaberg et al. [13]. Skull base defect repair was performed using middle turbinate graft with no recorded complicated cases [14], and this is matched with our results. Significant vision improvement was noted postoperatively in the inflammatory group [11,12], and it was matched with our results, which showed vision improvement in all patient groups.

The neoplastic group in our study included orbital hemangioma and juvenile angiofibroma. Significant proptosis reduction and vision improvement were reported, which matched with Haruna et al. [15], with regard to orbital hemangioma in their study on endoscopic transnasal approach in benign orbital tumor, and also with Xu et al. [16] with regard to proptosis reduction and vision improvement after the endoscopic transnasal approach before the optic fundus, the macula, the retina, and the optic nerve were severely affected. Ocular motility and diplopia improved significantly postoperatively, especially in the traumatic group. In our study, postoperative endoscopic reconstruction showed one case (total 10) of limited ocular motility with enophthalmos, but vision improved, and it showed an intraoperative fibrotic inferior rectus muscle in the floor blowout fracture; the patient went for muscle resection with a second fracture repair using the open approach, and our result was in agreement with that of Jeon et al. [17], but in their study, they used a balloon-catheter made of a latex glove tip, whereas an infant feeding tube in another hand Foley's catheter was used in our study.

Silbert et al. [18] reported that diplopia may occur or increase after endoscopic orbital surgery, and it was noticed in our study also in 16.7% of the cases, and similar to the results of the previous study, it was transient and did not require surgical intervention, except in the complicated traumatic case of enophthalmos. Generally, our results matched with those of Michel et al. [19] who stated that the transnasal orbital decompression procedure improved vision, decreased proptosis at a range comparable to more invasive techniques, and had favorable cosmetic results without additional disfiguration by scars. Morbidity was far lesser than with other approaches.


  Conclusion Top


Endoscopic endonasal surgery in both orbital decompression and reconstruction is effective in proptosis reduction and vision improvement, improves ocular motility and is safe, with limited complications.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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El-Banhawy OA, Halaka AN, Altuwaijri MA, Ayad H, El-Sharnoby MM. Long-term outcome of endonasal endoscopic skull base reconstruction with nasal turbinate graft. Skull Base 2008; 18 :297-308.  Back to cited text no. 14
    
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Haruna S, Tukidate T, Konno W, Fukami S, Nakajima I. Transnasal endoscopic surgery for benign orbital tumors. Auris Nasus Larynx 2013; 40 :227-230.  Back to cited text no. 15
    
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Xu Y, Lin G, Lin C, Fang Z, Li Z, Zhou A, et al. Treatment and prognosis of nasopharyngeal angiofibroma involving the eye and optic nerve. J Laryngol Otol 2012; 126 :1108-1113.  Back to cited text no. 16
    
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Jeon SY, Kwon JH, Kim JP, Ahn SK, Park JJ, Hur DG, Seo SW. Endoscopic intranasal reduction of the orbit in isolated blowout fractures. Acta Otolaryngol Suppl 2007; 558 :102-109.  Back to cited text no. 17
    
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Silbert DI, Maatta NS, Singman EL. Diplopia secondary to orbital surgery. Am Orthopt J 2012; 62 :22-28.  Back to cited text no. 18
    
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Michel O, Oberlander N, Neugebauer P, Neugebauer A, Rußmann W. Follow-up of transnasal orbital decompression in severe Graves′ ophthalmopathy. Ophthalmology 2001; 108 :400-404.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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