Endoscopic Surgery of the Orbit E-Book

Raj Sindwani

• Publisher: Elsevier
• Year: 2020
• ISBN:
  9780323613309
• Topic: Medicine
• Subtopic: Ear, Nose & Throat Medicine

Endoscopic orbital procedures are at the forefront of today's multidisciplinary patient care and team approach to problem-solving. Endoscopic Surgery of the Orbit offers state-of-the-art, expert guidance on minimally invasive orbit techniques that promise a more streamlined approach to comprehensive patient care, improved patient satisfaction, and superior outcomes. This unique resource reflects the contemporary, unparalleled partnership between otolaryngology, neurosurgery, and ophthalmology that often also includes a cohesive team of clinicians from many other specialties.

• Provides expert perspectives from thought leaders in various specialties, including otolaryngologists, ophthalmologists, neurosurgeons, endocrinologists, medical and radiation oncologists, radiologists, and pathologists.
• Details the two-surgeon, multi-handed surgical techniques that have revolutionized the management of complex pathologies involving the orbit and skull base.
• Covers the full breadth of endoscopic orbital procedures —from advanced intraconal tumor removal and intracranial techniques involving the optic nerve and optic chiasm to more routine endoscopic procedures such as orbital decompressions, E-DCR, fracture repair, and subperiosteal abscess drainage.
• Reviews key topics such as neuromonitoring in orbital and skull base surgery, endoscopic surgery of the intraconal space for tumor resection, Transorbital NeuroEnodscopic Surgery (TONES), and reconstruction of the orbit.
• Includes tips and pearls on safe and effective procedures as well as novel approaches and innovations in the equipment used to perform these popular procedures.
• Provides superb visual reinforcement with more than 400 high-definition images of anatomy, imaging, and surgical techniques, as well as procedural videos.

Part 1

Perspectives and Evolution in Techniques

1

Endoscopic Orbital Surgery: The Rhinologist’s Perspective

Ralph B. Metson, MD Professor, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA

Abstract

The specialties of otolaryngology and ophthalmology are separated by little more than the width of the lamina papyracea. Since the early 1900s, transnasal approaches have been described for the treatment of patients with orbital disorders. It was not until the introduction of high-resolution nasal endoscopes for sinus surgery in the 1980s, however, that surgeons had the necessary instrumentation to perform safe and effective orbital surgery through the nose. This chapter describes the evolution of endoscopic orbital surgical techniques, including dacryocystorhinostomy (DCR) and orbital decompression, over the past 30 years. A team approach utilizing skills of both the otolaryngologist and ophthalmologist is emphasized.

Keywords

dacryocystorhinostomy; endoscopic dacryocystorhinostomy; exophthalmos; Graves' orbitopathy; lacrimal obstruction; optic nerve decompression; orbital decompression; orbital tumor; proptosis

Chapter Outline

• Endoscopic Dacryocystorhinostomy
  • Key Concepts and Lessons Learned
• Endoscopic Orbital Decompression
  • Key Concepts and Lessons Learned
• Endoscopic Optic Nerve Decompression
• Endoscopic Resection of Orbital Tumors
• Future Directions
• Conclusion
• References

The specialties of otolaryngology and ophthalmology are separated by little more than the width of the lamina papyracea. This paper-thin bone that forms the boundary between the orbital and sinonasal cavities serves as a metaphor for the aligned interests of two specialties whose practitioners often find themselves operating in close anatomic proximity. Indeed, cooperative surgical endeavors between otolaryngologists and ophthalmologists have risen rapidly since the introduction of nasal endoscopes to treat patients with orbital disorders.

Endoscopic Dacryocystorhinostomy

Before the endoscopic age, attempts to surgically treat orbital disease through a transnasal approach were often fraught with poor visualization and poor outcome. The best documented attempt to perform a dacryocystorhinostomy (DCR) through the nose was described in 1921 by Harris P. Mosher, who then served as chairman of the Department of Otology and Laryngology at Harvard Medical School.¹ Using a headlight and nasal speculum, he described the drainage of pus from the infected lacrimal sacs of 12 patients. Although this intranasal approach avoided the need for a facial incision, a postoperative orbital infection developed in one patient who almost lost her eye, prompting Mosher to abandon the procedure in favor of a combined external-intranasal approach. In his words, “Where light is possible it is folly to work in the dark. The best surgery is done by sight.” For the next 70 years, DCRs were performed almost exclusively in an external manner through a medial canthal incision, and largely by ophthalmologists.

With the advent of small-diameter, high-resolution nasal endoscopes for sinus surgery in the mid-1980s, a renewed interest developed in the possibility of accessing orbital pathology through the nose. Otolaryngologists found themselves routinely operating in the vicinity of the lacrimal sac as they cleared disease from adjacent ethmoid air cells under excellent visualization. While doing so, the potential to readily access the medial orbital structures via a transnasal approach became readily apparent, and early reports in the literature supported the concept.²

In 1989, I was approached by Daniel Townsend, an ophthalmologist at Massachusetts Eye and Ear Infirmary, who had recently performed an external DCR on a 52 year-old woman, only to have her troublesome tearing return 3 months later. When I examined the patient in the office with a nasal endoscope, a dense scar band could be seen overlying the region of the lacrimal sac along the lateral nasal wall. She appeared to be an ideal candidate to revisit Mosher’s intranasal DCR approach, this time with the necessary “light” and visualization to perform a safe and effective surgery.

The trip to the operating room proved to be a fruitful one. The ophthalmologist passed lacrimal probes through the canaliculi to localize the obstructed lacrimal sac while I resected the scar tissue and made a wide opening around the probes into the sac. The patient tolerated the 90-minute procedure well, and her epiphora has not returned in more than 30 years.

The early success of endoscopic DCR led to its relatively rapid adoption by other surgeons at our hospital and across the country. The benefits of avoiding a facial incision and reducing patient morbidity offered by endoscopic DCR were obvious. However, not so obvious at the time were the subtleties of patient selection and surgical technique that affected clinical outcome.

One such example was the use of surgical lasers, which were quite popular at the time, for the performance of endoscopic DCR.³ Although laser fibers could be passed through either the tear duct or nose to remove bone overlying the lacrimal sac, their use led to postoperative scar formation and restenosis. Laser endoscopic DCR had a success rate of 78% compared with a rate of more than 90% for conventional DCR. Because of these early setbacks, endoscopic DCR lost favor among many ophthalmologists who continued to perform conventional external DCR. Nevertheless, with increasing clinical experience, the performance of endoscopic DCR was refined and its adoption grew worldwide. Numerous reports over the past decade have described the safety and efficacy of this technique with results comparable to those of external DCR.⁴

Key Concepts and Lessons Learned

Over the past 30 years, personal experience supported by evidenced-based studies has taught me many lessons regarding the performance of endoscopic DCR. These lessons have been reinforced by the more than two do...