Operative Techniques in
Otolaryngology
Head and Neck Surgery
Operative Techniques in Otolaryngology–Head and Neck Surgery (ISSN 1043-1810) is published quarterly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Months of issue are March, June, September and December. Business Office: 1600 John F. Kennedy Blvd., Ste. 1800, Philadelphia, PA 19103-2899. Editorial Office: 360 Park Avenue South, New York, NY 10010-1710. Customer Service Office: 11830 Westline Industrial Drive, St. Louis, MO 63146. Periodicals postage paid at New York, NY and additional mailing offices.
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Operative Techniques in
Otolaryngology
Head and Neck Surgery
EDITORIAL BOARD
VIJAY K. ANAND, MD |
HOWARD L. LEVINE, MD |
New York, NY |
Beachwood, OH |
DAVID D. CALDARELLI, MD |
MAHMOOD MAFEE, MD |
Chicago, IL |
Chicago, IL |
JAMES CHOW, MD |
ROBERT OSSOFF, MD |
Maywood, IL |
Nashville, TN |
LAWRENCE DESANTO, MD |
STEPHEN S. PARK, MD |
Scottsdale, AZ |
Charlottesville, VA |
ISAAC ELIACHAR, MD |
HAROLD C. PILLSBURY, III, MD |
Cleveland, OH |
Chapel Hill, NC |
RAPHAEL FEINMESSER, MD |
DALE H. RICE, MD |
Petah-Tiqva, Israel |
Los Angeles, CA |
ALFIO FERLITO, MD |
DAVID E. SCHULLER, MD |
Udine, Italy |
Columbus, OH |
DAN M. FLISS, MD |
JAMES STANKIEWICZ |
Tel Aviv, Israel |
Maywood, IL |
JEREMY FREEMAN, MD, FRCSC |
ELLIOT STRONG, MD |
Toronto, Canada |
New York, NY |
PHILLIP FRIEDMAN, MD |
DAVID J. TERRIS |
Southfield, MI |
Augusta, GA |
BRUCE J. GANTZ, MD |
DEAN M. TORIUMI, MD |
Iowa City, IA |
Chicago, IL |
JOSEPH JACOBS, MD |
HARVEY TUCKER, MD |
New York, NY |
Cleveland, OH |
YOSEF KRESPI, MD |
B. TUCKER WOODSON, MD |
New York, NY |
Milwaukee, WI |
ROEE LANDSBERG, MD |
|
Tel Aviv, Israel
Operative Techniques in
Otolaryngology
Head and Neck Surgery
FUTURE ISSUES
HEAD AND NECK TUMORS
Elizabeth A. Blair, MD, FACS
December 2008, Vol 19, No 4
THYROID-PARATHYROID SURGERY
David J. Terris, MD, FACS
March 2009, Vol 20, No 1
RECENT ISSUES
MANAGEMENT OF FACIAL TRAUMA
D. Gregory Farwell, MD, FACS
June 2008, Vol 19, No 2
MINIMALLY INVASIVE HEAD AND NECK SURGERY
Conrad Timon, MB, FRCSORL, MD
March 2008, Vol 19, No 1
IMPLANTS AND GRAFTS IN RHINOPLASTY
Craig D. Friedman, MD, FACS
December 2007, Vol 18, No 4
COSMETIC SURGERY
Raghu S. Athre, MD
September 2007, Vol 18, No 3
ACUTE SURGICAL MANAGEMENT OF THE AIRWAY
David Goldenberg, MD
June 2007, Vol 18, No 2
Operative Techniques in
Otolaryngology
Head and Neck Surgery
VOLUME 19, NUMBER 3, September 2008
ENDOSCOPIC ORBITAL AND
LACRIMAL SURGERY
CONTENTS
INTRODUCTION |
161 |
Raj Sindwani, MD, FACS, FRCS |
|
ENDOSCOPIC ORBITAL DECOMPRESSION |
162 |
Michael P. Platt, MD, Raj Sindwani, MD, Ralph Metson, MD |
|
ENDOSCOPIC SURGERY OF THE ORBITAL APEX |
167 |
Angelo Tsirbas, MD, Benjamin O. Burt, MD, Ronald Mancini, MD, |
|
Peter John Wormald, MD |
|
ENDOSCOPIC DACRYOCYSTORHINOSTOMY |
172 |
Raj Sindwani, MD, Ralph B. Metson, MD |
|
REVISION ENDOSCOPIC DACRYOCYSTORHINOSTOMY |
177 |
Vijay R. Ramakrishnan, MD, Vikram D. Durairaj, MD, |
|
Todd T. Kingdom, MD |
|
ENDOSCOPIC BALLOON-ASSISTED LACRIMAL SURGERY |
182 |
Gabriela M. Espinoza, MD |
|
ENDOSCOPIC MANAGEMENT OF PEDIATRIC |
|
NASOLACRIMAL ANOMALIES |
186 |
Michael J. Cunningham, MD |
|
ENDOSCOPIC CONJUNCTIVODACRYOCYSTORHINOSTOMY |
192 |
Rhonda Barrett, MD, Dale Meyer, MD |
|
ENDOSCOPIC DRAINAGE OF SUBPERIOSTEAL ORBITAL |
|
ABSCESSES |
195 |
Samer Fakhri, MD, FACS, FRCS(C) |
|
ENDOSCOPIC TRANSORBITAL LIGATION OF THE |
|
ANTERIOR ETHMOID ARTERY |
199 |
Steven D. Pletcher, MD, Ralph Metson, MD |
|
ENDOSCOPIC POWER-ASSISTED ORBITAL EXENTERATION: |
|
A NOVEL TECHNIQUE |
202 |
Pete S. Batra, MD, Donald C. Lanza, MD |
|
ENDOSCOPIC OCULAR MUSCLE SURGERY |
205 |
Siew Yoong Hwang, FRCS (Glasg), Michael Flanders, FRCSC, |
|
Martin Desrosiers, MD, FRCSC |
|
ENDOSCOPIC REPAIR OF ORBITAL FLOOR FRACTURES |
209 |
Rui Fernandes, DMD, MD, E. Bradley Strong, MD |
|
MANAGEMENT OF SKULL BASE FRACTURES |
214 |
John L. Frodel, Jr, MD, FACS |
|
TRANSORBITAL ENDOSCOPIC SURGERY |
224 |
Venkatesh C. Prabhakaran, MS, MRCOphth, |
|
Dinesh Selva, FRANZCO |
|
Operative Techniques in Otolaryngology (2008) 19, 161
Introduction
During the past decade, the field of otolaryngology has experienced an endoscopic revolution. Improved facility with endoscopes, empowered by technological advances in surgical navigation and operative equipment, has extended our ability to endoscopically manage disorders affecting structures beyond the paranasal sinuses. The pursuit of minimally invasive but equally efficacious surgery has fueled the development of innovative endoscopic approaches to the orbit and lacrimal apparatus. Endoscopic orbital techniques can be used to exploit key anatomic relationships, the most notable being that the sinonasal tract and orbit are separated by very thin bone. Many of these approaches are routinely performed in tandem by an otolaryngologist and an ophthalmologist. Successful outcomes from this type of surgery require an intimate understanding of the anatomy and physiology of structures on both sides of the lamina papyracea. Many of these approaches are not difficult to do, but they may be difficult to get to do—as a result of political barriers that may be at play between specialties.
The goal of the following series of articles is to reinforce fundamental concepts and techniques useful for endoscopic surgery of the orbit. Technical nuances of well-established procedures such as endoscopic dacryocystorhinostomy, subperiosteal abscess drainage, and orbital decompression will be highlighted, whereas early experience with novel techniques, including endoscopic extraocular muscle surgery, orbital exenteration, and anterior ethmoidal artery ligation, will also be presented. It should be mentioned that the safety and utility of some of the more recently described procedures, although innovative and forward–thinking, have yet to be validated through extensive clinical experience and scientific scrutiny. Nevertheless, I am certain that the reader will be surprised and hopefully inspired by what some of our well-trained and experienced colleagues are able to accomplish with the endoscope.
Raj Sindwani, MD, FACS, FRCS
Guest Editor
1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.09.002
Operative Techniques in Otolaryngology (2008) 19, 162-166
Endoscopic orbital decompression
Michael P. Platt, MD,a Raj Sindwani, MD,b Ralph Metson, MDa,c
From the aDepartment of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; bDepartment of Otolaryngology, Head and Neck Surgery, St. Louis University School of Medicine, St. Louis, Missouri; and the cDepartment of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts.
KEYWORDS
Orbital decompression; Graves disease; Graves orbitopathy; Proptosis; Diplopia; Endoscopic sinus surgery
Orbital decompression for the treatment of Graves’ orbitopathy is an invaluable technique for patients with proptosis, exposure keratopathy, or optic neuropathy. The expanding role for transnasal endoscopic surgery leads to a natural extension for the management of selected orbital tumors and fibro-osseous lesions with orbital extension. Traditional open approaches that have been described over the past century are limited by suboptimal visualization and carry the morbidity of incisions within the facial skin, oral cavity, or conjunctiva. Endoscopic orbital decompression allows for safe and effective decompression of the medial and inferior orbital walls with minimal morbidity to the patient.
© 2008 Elsevier Inc. All rights reserved.
Graves’ disease is an autoimmune disorder that most commonly presents in patients with hyperthyroidism. In 30% to 50% of patients, an ophthalmopathy develops caused by enlargement of orbital fat and muscles with resultant proptosis.1,2 Although the mechanism for these changes is not completely understood, autoantibodies directed against the extraocular muscles and intraorbital adipose tissue are thought to stimulate a lymphocytic inflammation and deposition of mucopolysaccharides into the orbital tissues. In addition to proptosis, clinical manifestations of Graves’ orbitopathy include tearing, photophobia, and conjunctival injection. More severe disease can lead to diplopia and visual loss from exposure keratopathy with corneal ulceration and optic neuropathy.
In Graves’ disease, the clinical course of the thyroid disease is independent to the progression of orbitopathy. Patients may experience ophthalmic findings at any point during the course of Graves’ disease, even after the hyperthyroidism has been treated.
During the past century, a variety of techniques for decompressing the orbit by removal of 1 to 4 bony walls have been described by specialists in the fields of ophthalmology, otolaryngology, plastic surgery, and neurosur- gery.2-6 In the early 1990s, advancement of endoscopic sinus surgery led to the application of these techniques for transnasal decompression of the orbit.7,8 Experience has
Address reprint requests and correspondence: Ralph Metson, MD, Zero Emerson Place, Boston, MA 02114.
E-mail address: Ralph_metson@meei.harvard.edu.
demonstrated endoscopic orbital decompression to be a safe and effective technique for the treatment of Graves’ orbitopathy. Compared with previously described approaches for orbital decompression, the endoscopic technique allows for enhanced visualization of the orbital walls and skull base with decreased patient morbidity.
Patient selection
Endoscopic orbital decompression is indicated for patients with moderate-to-severe symptoms of Graves’ orbitopathy. Indications include exophthalmos, exposure keratopathy, diplopia, and optic neuropathy. Corticosteroids may be used as a temporizing measure to decrease orbital inflammation and halt enlargement of orbital contents, but are not successful in providing long-term benefit without prolonged usage. Orbital radiation for Graves’ disease is controversial, and its efficacy has been challenged by 2 randomized prospective trials.9,10 It is preferable to perform orbital decompression at least 18 months after the onset of Graves’ orbitopathy, however, severe symptoms with optic neuropathy during the acute phase may warrant immediate treatment.
Endoscopic orbital decompression also can be used to gain access to the orbit for removal of benign orbital tumors, biopsy of indeterminate lesions, or as palliative therapy for malignant tumors causing visual symptoms. This endoscopic orbital decompression approach may be suitable for tumors located medial to the optic nerve, as well as sinona-
1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.09.010