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

Abstract

The surgical management of medial and inferior orbital lesions is demanding via traditional external approach, since the conic-shaped surgical field is narrow and damage to neural, muscular or vascular structures of the orbit can have serious consequences. In recent years, the evolution of endoscopic endonasal approaches for lesions that goes beyond the nose brought the orbit to the attention of rhinosurgeons. If procedures such as transnasal orbital decompression and lacrimal pathways surgery have been described some decades ago, the last frontier of transnasal orbital surgery, namely intraconal tumor surgery, is a new and rapidly expanding field. Papers describing endoscopic endonasal approaches to the orbit appeared in the international literature, but most of them contain a small number of cases, also because the relatively rarity of intraorbital lesions. We herein report the results of a systematic review of the literature regarding the endoscopic endonasal approach to intraconal cavernous haemangiomas, the most common benign orbital lesion. The endoscopic management of intraconal cavernous haemangiomas results feasible and safe. A critical step of this kind of surgery is the management of the medial rectus muscle, mandatory to expose the intraconal space.

ICAR: endoscopic skull‐base surgery

“…Both transseptal techniques provide the greatest intraconal exposure by surface area; however, the 4‐handed approach allows for continuous adjustments in tension, leading to increased protection of the neuromuscular inputs to the medial rectus muscle . This view is supported by other studies in which avoidance of prolonged tonic medialization is recommended over concerns of potential neurovascular traction injury…”

“…The majority of data has been acquired by retrospective case reports and case series. The highest LOE has been provided by 2 systematic reviews as well as 2 multicenter retrospective review studies …”

“…The medial rectus muscle represents the doorway to the intraconal space and must be safely retracted to provide adequate access. Described retraction techniques include external medial rectus muscle retraction at the globe insertion point by using a vessel loop, static transseptal and retrochoanal retraction using a vessel loop, and dynamic 4‐handed transseptal retraction using an instrument such as a ball‐tipped probe . Both transseptal techniques provide the greatest intraconal exposure by surface area; however, the 4‐handed approach allows for continuous adjustments in tension, leading to increased protection of the neuromuscular inputs to the medial rectus muscle .…”

Analysis of anterior and posterior maneuvers to enhance intraconal exposure

“…Access to the medial intraconal orbit has posed great challenges, and different approaches have been described including medial orbitotomy and transconjunctival approaches . The endoscopic endonasal approach provides a direct route to the medial orbit, making this the preferred approach among endoscopic skull base surgeons . Some advantages include lack of external incisions, no brain retraction, no displacement of orbital structures including the globe, no need for reconstruction when ocular muscle detachment is not performed, and shorter hospitalization time .…”

“…It requires extensively trained surgeons because 3‐dimensionl (3D) perception of the orbit can be difficult. Depending on the histology type, stage, or grade of some lesions, an additional open approach may also be necessary …”