Endoscopic Bimanual Approach to an Intraconal Cavernous Hemangioma of the Orbital Apex With Vascularized Flap Reconstruction

Abstract

The aim of this study was to describe a transnasal endoscopic bimanual technique for the removal of an intraconal orbital apex cavernous hemangioma. Report of a surgical technique. A 39-year-old woman with unilateral visual loss and proptosis was found to have an intraconal orbital apex mass consistent radiographically with cavernous hemangioma. Because of its posteromedial location within the orbit, a transnasal 4-handed endoscopic technique was used with pedicled nasoseptal flap reconstruction. The tumor was excised, and the patient had no complications. The transnasal endoscopic approach to orbital apex cavernous hemangioma excision is a viable surgical approach for these difficult to access lesions. The medial orbital wall may be simultaneously reconstructed to prevent diplopia and enophthalmos.

Purely endoscopic trans-nasal management of orbital intraconal cavernous haemangiomas: a systematic review of the literature

“…Twelve papers were identified and included which contained patient data for 17 cases [5][6][7][8][9][10][11][12][13][14][15][16]. Six patients were male and eleven were female.…”

“…As in other endoscopic skull base procedures, a two-handed dissection permits a precise manipulation of the mass and surrounding structures but, on the contrary, requires a more extensive manipulation of nasal structures. In particular, the four-handed binostril approach includes, at least, a posterior septectomy [16]. This can result in a higher rate of postoperative nasal crusting.…”

The nasoseptal flap for reconstruction of the medial and inferior orbit

“…3 Unlike more traditional endoscopic orbital procedures such as decompression and dacryocystorhinostomy, which rarely violate the extraconal plane, tumor excision generally mandates a large volume of periorbital fat dissection and, in some cases, release or even partial resection of the inferior and medial rectus muscles. 8,9 Delayed enophthalmos, infection, ocular muscle fibrosis, strabismus, and visual defects including diplopia are all possible complications stemming from these approaches.…”

“…12 Based on our findings, a flap from either side of the nose would likely be able to provide adequate coverage of the orbit. We elected to highlight use of a contralateral flap as endoscopic intraconal surgery is optimally performed using a 4-handed binarial technique to allow for delicate handling of intraconal neurovascular elements 3 (Fig. 4A).…”

“…Only recently have endoscopic approaches been described for orbital neoplasms. [1][2][3] Historically, surgery for orbital tumors was almost entirely reserved for external approaches. Laterally based tumors were often accessed through transcutaneous or transconjunctival orbitotomy incisions whereas tumors of the me-dial corridor required an upper eyelid or medial approach as the optic nerve precludes lateral access.…”