Tr: i igations orbital decompression include comp ans fo i ems dee ys eXPONE Keratt diplopia, and comme ener and intra-nasal decompr ont external and Pression has pre oi BO pec: deseribed Otorhinolatyagolopists typically sionals ee” aloscopic approach only or mn comunchon ot 4 ral ot pre-aperall ive evaluation and studi anety of procedures possible with vorviny Given The compression, careful discussion with the é amis critical for understanding the d c Khe degree af paimovee jon necessary. In Reneral an endoscopic devon decom ndcated for paticnts with moderate to severe pee disease He may be performed in conjunc tin » proach for the orbital floor and lateral wall decompression is necessary, The procedure is orbitopathy but can also be sreafor to Ran aCe LY Orbital Lamon, binpey ily wuhzed tor thyroy nate orbital lesions, or pathative therapy: for rumours causing visnal symproms,!* alee ophthalmology examination is necessary the procedure. ae This inchides evaluation of the sis, assessment of eye movements and dip ment of visual acuity, and colour vision. Pre jc consent must include discussion of risks including nent double vision and need for strabismus surgery 2. CT scan evaluating the orbits yew relevant anatomy. Typical findings include a ter than two-told enlary nd sinuses is required quired ment of extraocular mus- . sparing the tendinous portions. The medial Jnferior rectus muscles are most commonly involved h all muscles may be enlarged (Figure 111.6)."* hould identify the middle turbinate attach- jocation and course of the anterior ethmoid artery, presence of an onodi cell as the optic nerve may course through the lateral aspect of the cell. Surgical procedure Pade 2 Frasltlaty oniicstomy, complete noidotomy ing sinus surgery. it is important to completely resect fBe|neiviate process! In addition, we advocate resec- Son of the middle turbinate for improved exposure and teased risk of adhesions. During dissection, special tion should be made to identify all ethmoid cells haye moved along. the Jamina papyracea. The maxil- spirostomy should be as large as possible ro allow for S prrure during decompression. Resection of medial orbital wall bone HOA chould he penetrated ina controlled lash: elevator can be used. stly to avond pically-afjrcurette or Ve diseaso showing the cl. decompression (axial) and compression © enlarged extraocular muscles. can bet Feet Clee andl sub Jy removed with Blakesley torceps, Take GFE HOLE erie pertobita at this tine ay prolapsing fat wi trauma to the periorbita, The tr the periorlita with the SEUFEE sequ penct Make surgery more iffical. AU uc should be resecteinuses is required gs include a ocular mus tions. The medial 1 commonly involved d (Figure 111.6). niddle turbinate attach- of the anterior ethmoid artery, od cell as the optic nerve may al aspect of the cell Jn addition, we Sle turbinate for improved expo fick of adhesion ba. papyrac ‘as possible to allo trated ma controlled fash seer elevator use disoase decompression (axial) ‘enlarged extraocular enetrate the pe rT th time as prot make swrgery more ditticult, AlLbaye should be resecteall cull py M pRroreR q Mor PROS sea tintoay mMaselfed ) Com ta the face of the sphenaid sims, Care should fe taken when skull base enjary that il Hat inithe Hor p So ieiston af pororbita Down racture of tl re insion sul Hein 24 Bot ln fg Stary by ecvaving she puvibitg olf teen orbital | IESE ie Sa ata TOR on tion, A series of Pat fashion. Hnypatient Ean be left ph ‘A eurved seeker can be u Tor. Use a spoon enrette to LOE 11 he bone fone often fractures i one spitateanal junction. NoreNNaeTY remaining. Farge picce at the ant fibrous bands between prolapse of orbital fat into mauillary and ethimoid sine If done completely, a sie apse inthe sinuses, Th herniation and allow fu icant mount of fat wil pr may be balloted to contre her prolapse Post-operative considerations prior to extubation and in the immedine It is critical iod to have a clear discussion with the post-operative peri Anaesthesia ream, post-extubation mask ventilation, which can Pepial subcutaneous emphysema. Expect large anv Sf postoperative swelling, oedema, and erythema. Our rs are typically observed overnight and discharg This: potentially: will a pati fon broa nasal ierigations. Patients should avoid nose blow 3 weeks to prevent subcutaneous emphysema or even pre despeetrum antibiories and instructed to lapse of the globe. Results Post-operative diplopia is frequently encountered 15-63% of post-operative patients reporting new'o) or worsening diplopia. porary and resolves spontancously over weeks to mont Strabismus surgery will be considered in $-10 months lowing decompression if diplopia persists. “The average ocular recession from endoscopic decom pression ranges from 3,2-5. Lm reduction of proptess with an inferior and medial wall Concurrent lateral decompression provid 1m of recession.!? Post-operative deterioration of ‘euity is demonstrated in fess than 5% of patents Tin most cases, this is tem decompression!" es an addi jul OPTIC NERVE COMPRESSION intiny requiring Optic nerve compression isa rare ¢ pression. The optie nerve may: be decompress er? ber of indications. ‘ ., ion Figure 111.7 (a) Avil and (b) coronal CT scans of patient Endoscopic optic nerve decompress! ae with thyroid eye disease before and after endost whitomieve Traumatic optic neuropathy is the most & B. tion for endoscopic or apen optic mer¥e ‘Yecompres™niort’ atic optic neuropar ¥ was initially: tel eels cu congerone Tae sere es ay qocett wee Mesults in a conduction black and tex ; reacts pene Eh oc eae paket singer i ee onasal tmmonrs ean in foe Noni ol the apes or the optic neve nel : san utferent approaches have been deseribed for optic sen decompression inslading tramsorbital, teansantal enemy apprenches. We be i i approach enon as HC olfers 2 number of advantages aver other as preservation of olfaction, quick recavery ack of external sears, and excellent intra-operative reer uo. However, the ideal approach shoul he de sana he pathology and its location paE-OPERATIVE CONSIDERATIONS No STUDIES. A thorough ophthalmologic history and physical exami- hould be performed. A fine cut CT sean of the Mand orbit should be evaliated Tor opne canatcom- Tracture, oF bone displacement and sinus anat mnsidezasions. An MRT of the orbits hlso be considered for evaluation of the optic nerve ital contents. "Perform a complete ethmoidectomy and sphenoidotom Pay special attention ¥ Femoving all boney partitions off the lamina papyracea. Additionally, open up the sphe- noidotomy maximally, especially laterally. Identify the | optic nerve, carotid artery and the opticocarotid recess (Figure 111.8). Image guided surgery is ideally employed here, Bh ccuze the lemina panyracea in posterior eInmoId res) Asin orbital decompression, eggshell fracture and remove bone of the lamina in the posterior ethmoids. Again, pay special care not to penetrate the periorbita Use a diamond drill wit Copious irriga thermal injury to the optie nerve. Daill along the nerve, Tan aeron AC the bone thins, gently flake it away, The sper Beds om the. pat logy ot eneuropathyrandjthyroiureye aa er inld be decompressed for” ai Lem posterior to the face of the sphenoid siniis (igure 111.9). Further decompression of the nerve can tion 10 avoid Figure 111.8 Silent sinus syndrome with inferior collapse of orbit: Hloor associated with maaillary sinus outflow obstruction. Figure 111.9 Axial T1-weighted post-contrast MRI demonstrating 2 large infiltrative orbital mass. It was initially reported to be & Aggressive malignant neoplasm. Subsequent biopsy demon strated orbital pseudotumor. oereateUy with inicision/ ofthe" sheath itself IF this Ike performed, the incision should be in the superomed quadrant as the ophthalmic artery: may fie in the in finedial quadrant offile optic nerve sheath in apps «of cases." The cision should be made tr.aw rated in less than $ OPTIC NERVE COMPRESSION Pression is a rare entity req pre nerve may be decompre Endoscopic optic nerve decompre CW /fiion for endoscopic ¢ open « ve AW a~1250 Suet Rbinoloay 2aBe Pate cnt 2 which ineludes the e in. Re prepared for a possile CSE leak which can be closed with a mucosal Map POST-OPERATIVE CONSIDERATIONS Close communication wath the ophthalmotogte | rant is ertival, They will aid in serial eve examinanion St helps guide the penerally required high dose eral Additionally, antibiones and gentle saline rinses are al pressures, wommended, To mininiize intra-c ae Jk nose blowing panent should be mstructed on avoid) straining post-operatively. imploding maxillary sinus as or silent sinus syndrome of the ostcomeatal Jing to hypoventil Imploding maxillary sinu beheved to origmate from obstruction comples of the paranasal sinuses | ‘velopment of a pressure ¥a | in turn, results in the accumulation ntrum, subclin 1e maxillary is symptoms occasionally CT imaging, igure 111.8). ing maxillary sinusitis is correcting the underlying pre: ‘Although historically enn ending on the severity of bone resorption, the patient may also requi surgical intervention to restore height to the orbital floor. This can be done as a single procedure or in a staged fashion. Orbital pseudotumor Orbital pseudotumor, or idiopathic orbital inflammation, is a diagnosis of exclnsion. ‘The exact etiology of this con dition is unclear, but it should be in the differential diag- nosis of orbital pathology as it comprises 10% of orbital lesions.” The clinical signs include proptosis. diplopia, pain, eyelid swelling, ptosis and chemosis. Similar lesior can arise elsewhere in the head and neck including the prerygopalatine and infratemporal fossac. Pseudotumor presents as a nonspecific orbital mass on CT and/or MRI (Figure 111.9).?” Diagnosis is one of exclu- sion, most commonly ruling out lymphoma. Most clin cians should have a low threshold for biopsy if the clinical course is not typical of pseudorumo: ology generall demonstrates pa= SEITE Feature SPHENOID SINUS May indica implications Important noi mig wil Involvement cease risk of Inadvertent on Mesentory SUS ‘suggestive of intra-cro prasal exter Lateral pneumatized May contain optic sSeptations may requiring great c3re Possible site Perineural invasion of tumour inieat imi roinvolverent of oF ad THP.NCE Tor Ota ogg for ‘soploctomy jude the use of the naseceptal fap, ‘and binasal approach a require ‘may prec try and CSF teak during surgery pended arteries are at INCreased risk of injury ial extension of sinonasal patho 099 or ny ‘cranial pathology BY oF ina ion of intra: sinuses may place the carotid at risk lerve and be confused with sph be closely related to carotid artery and optic nerve “when removing, te of tumour origin Nerve sheath tumour ‘see to varying degree chondrosarcoma, osteoma, ‘Tends to indicate the 1s with aesthesioneuroblastoma, chondrems, ‘ossifying fibroma and osteosarcoma presence of a mass withi the space as dural involvement or perineural spread. Figure 114. demonstrates the complementary features of CT and MRI in the work-up of skull hase tumours. Clinical Positron Emission ‘Tomography (PET) relies on the preferential uptake of 18-fluorodeoxyglucose (18-FDG) by tumour cells that exhibit a higher density of GLUTI glucose transporters. When combined with CT it can improve rumour localization. although the increased 18-FDG avidity in areas of sinonasal inflammation or infection can confound its utility in the paranasal sinuses. Figure 114.2 Corona ct ant [MRI of a sinonasal tumour. Although the CT would suggest involvement of the extra-ocular muscles, the MRI demonstrates clear preservation ofthe fat plane. The MAl also facilitates a ctteentaton of tumour from retained secrations seen intra ma ilary sinus. These images highlight the importance of obtaining both @ CT and MRI for skull base ‘uous In the evaluation of these tumours its usefulness © £0 dominantly confined to the derection of distant metas Biopsy ould be take Pre-operative endoscopic-guid fed biopsies sh nitive surgical prior to performing the defi a eet Biopsies should typically be performed ae or Jude vascular ks Whenever P ing the relevant radiology to exc! prolapsed meningo-encephaloceles.0 app fe fhe WAPROVING LATERAL ACCESS roaches has 1 Pp ted en now be resec seats tumours, but ¢ tion. Tumour: for instrunt f y with no extension by al notes Petr sbsiully beaanaged thtonghithe : : y with the use atera Tac can os im : z tranceptal approac me ha : J near the skull base and orbit h cttieal current trans: ARKCuRET various tanseptal approaches have been of the conc ACEPL OF nop, bed by Douglas ex described, they are all variation ing septal incisions descri technology PI ology is considered a useful aid v ie skull ate « y. It provides the he additional advan ‘ry dateesugeal the allows ¢sccnd etna han Domes antic ee lice and additional i con ties? The eee ey choca td addon in ethiopian: cam beredaced Eee extent of aime resection and the tal cartilage, and ensurin, rics between the tumour and normal _ either side of the septum, ves and neurovascular structures,” BC it confers ic ‘olved to provide strumentation wi Principles of oncologic resection The comp fitetion of a tumour with as little mor 1 final, he primary goal of any oncolonieg] Althoush traditional surgical Paradigm dictates be performed in an en bloc my anner, the anatomi al cavity prevent this % I tumou of origin or ts : imvasio 2'euft of formal surround; eon seal tthe tumouy Te Sue, the remaind, an be selectively debuted down to attach. il ‘emamnemi ig the completeness of Surgical acce: Priow sd "10 ts de aos Mth ti ge f ose Pepe the pro. Figure 114, ‘ent trad, tne urged nee The purp me \ OFM. Viet, sr 0 fo inten entation septal Ths image demonstrates the utility of the trans-septal he surge POs FPBROREH. Here pane semana Juvenile Nasal Angifirom "and improve ype cU*BEOM more P&S the mace” ca ulated via an instrument in the contla- TPO the vectors neces ral non Placed sMtOugh the transeptal incision (arrow) and © ipsilateral nostn,414: ENDOSCOPIC A NDOSCOPIC MANAGEMENT OF SivONASAL TUMOURS 1275 aches is considered 1 vi ving, ne aia Sis 9m hea sch ie ae sosconicall it on 3 Ae cece? Ga Rue enalabca aay ‘eeribed by Zhou et" res eens Fe asillary Ost Depending on diteet aces A the Deikersprocedre, that ee 80 ses ahs aren wh eed 3 revaction i 3 ei ere can aie ti ce cannot this procedut Pac of te Me of the wm ‘cording git following reflection of the soft anterior aspect of the inferior used to remove a small butt Posteriorly based lesions, the prerygonala can usually be ily 3 janes : ine F038, i medial max the anterior and lareral a N modifies ring, them Fy of the maxillar tong: tissues and mut turbi mies are of bon era nira-orbital ner’ al Wega anttoseorns meeaenocareaarer) enter aoa ally ofthe maxillary sinus 2 neentt? rth aren of aetving the infratems tle PE oe reves, wth he nasolaerial al gfe OT ire MOFE qmtensive resection of the medial nized and left intact Through this window eerraliows bas,sieet sere ro he -entitesmaxillat fay YE pe Terie det Py jorly below Hasner's valve to the piriform remove from these re ny Pee ineriltere 268° wen ae ciel arsed (PE 114.6) on mt sions, a total medial may J improvine pOsTERIOR ‘AGCESS: Far aransection of he ve sncrinal Binal soe key 10 80 de approach COREE 2 reerent isk OF spend arene’ with lean vam 8 nen mized wig and slaying RS aon of ana poking and SPIYI"E SS (gg afods ICS nde) e770" ni 10 CD), sown and cat Flack row114: ENp¢ jaca can wilize an endoscope on and up t 0 _860F jpaermemts 10 reach the aTOrementioned cept) : _ oi 3 POSEFIOT SEPTECTOMY, the surgeon (at jee whether a nasoseptal flap wil be required si ction. This flap is based on the posterior sep- Hench of the sphenopalatine artery, and runs Hatt” peeaphenoid ostium to supply the majority of jc baow cosa. If a CSF leak is anticipated, the naso- pes typically raised before performing the septec- goat hen stored cither ‘in the nasopharynx or in the 1) sinus.jff a leak is not anticipated, the surgeon ier take care to preserve the pedicle in case a flap st Sequired later. At this stage, the sphenoid ostia are sy DE ncither side and enlarged superiorly to the skull Jaterally to the lamina papyracea, Wide exposure ie 00 fae’ 0 pose and OSCOPIC AAS MANAGER "OF SINONASAL TUMOURS. 1277 ‘alization of the Tal carotid an cn Of the bony landmarks of the inter- {tery and optic nerves and avoids inadver injury. Ww; nt any With this exposure, the uirgeon can then per 1 an appr surgeon can then pe SPPropriately-sized septectomy deper he acces septectomy depending on the Access required. For sellar lee Timi ' lar lesions, a limited septectomy ‘cessary and this typically involves rand inferior aspect of the septum with powered instrumentation or retroprade forceps, The Septal window should ext complete visualization of the entire surgical field and limit ontralateral instrument clash ien larger septectomy be required) for surgery involving the middle cranial” fossa, clivus and infratemporal fossae. Where possible, surgeons should attempt to preserve at least’ 1.5¢m of postero-superir septal mucosa in the region of the olfac- {tory.cleft for preservation of smell and taste (Figure 11 Obviously in the case of malignant tumours, surgical may be all that is ne Temoving the posterio, end anteriorly enough to enable clearance of the tumour takes precedence but patientshon AhunologY Mal bore (acd crater nant tumours may also be palliateg ye possi Timing morbid Irom theres HH ay, _-Resonstruction menus 5 pase can be nonasal tumour rescetion may result jy wor skull nase st renee ckull base. He the dhira remains stacey pao aspects oF the a ic Sait glenn the crmnlere eT Som. mally it may be left alone, but tance dep dura should be repaired to anna th in the dura mater oii lif’ type repair ag armed re-open shoud be a : anetion of these sone LPERIOR ACCESS Dingy, typical described ually fhe EMEP also improves Through wu hevond! the frontal recess rior septestom ‘This not only avoids Tesions well bey pupillary line. bu , ; The surgical site can be reducing the need for o reaeh xen beyond the F aly avs Sen Oe for eaternal incisions, bur also increases the 2 crative survellane Of post-operative st Rp isvalized endoscopically avr site with a rig tress of septal cartilage or titanium mesh is aleg fa = necessary, prior to coverage with the mucosal fag tae imize the risk of encephalocele formation," jour resection ications 6! a ; or am s has been created, the tumour can Complica f endoscopic techniques ee ee iked ina controlled manner down to its site Endoscopic approaches to sinonasal tumours share the aoe ae es chulking can be performed using variz minor and major complications seen in endoscope sinus sre Nharuments including powered micro-debriders and surgery. Surgeons who wish to perform endoscopic skull eBistrequency ablation wands. Specimen traps should be base surgery must make themselves familiar with these Epplied to instcoments, so that all of the cumour removed complications and their management. A thorough under- iin the patient can be sent for histopathological analy- standing of the surgical and radiological anatomy of the Sx Following debulking of the tumour, the site of attach- sinuses and skull base and the attendance of skull base front is weually visualized. The management of this region courses may help to minimize their frequency and sever. depends on numerous factors, including the age and func- ity. Of all the complications, major vascular injury i one tional state of the patient, the histology of the tumour and of the most serious and anxiety provoking. Through an- the location and extent of the attachment, Where possible, mal wet labs, Valentine and Wormald have developed and attainment of clear surgical margins should be attempted. evaluated several techniques for controlling such injuries Frozen sections taken from the margins of the tumour including the use of the muscle patch.” They showed thst field have been shown to be reliable for ensuring complete the application of crushed muscle to the site of a major resection of most sinonasal tumours, with the exception of arterial bleed could primarily control the bled in all cass ae eee and adenoid ¢ysti¢ tumours.” In addi- + while maintaining vascular patency. This led to reduced eld es be cae iments surgical margin specimens blood loss and overall improved sweat fllwan and close discussion with the histopatholoiss should be, Saki moat ull ecco ae srlesakee a ath the histopahologsts should be taking complex skal base cases" to aid in the generation of an accurate histological report and to avoid errors such as POST-OPERATIVE CARE AND the air-tumour interface being erroneously reported ag a positive margin. oe hii pst anya sagpeennn, TUMOUR SURVEILLANCE logical resection of the tumou pues eee We of the tumour Once the initial perioperative period dccasion, necestate 8 depsc ay Weal Patient may, on of the surgeon moves 10 one of surveil rome gee a2 see of sompromi. Benign ence Sursluce i prfrmed oral resections wit : Post-operative surveillance where theres significa en, umaRIONS and serial imagine am nt eaily be j ‘0 critical structures or in the elderly frail populat in early post-operative CT or MRI a0 ih een om Post-surgery provides a baseline that ¢a" | Once appropriate acces comple, the HE nee for Ur ar endos ance OF 6 months