Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: The value of a medial periorbital strip

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1 European Annals of Otorhinolaryngology, Head and Neck diseases (2010) 127, ORIGINAL CLINICAL RESEARCH Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: The value of a medial periorbital strip M.-A. Jimenez-Chobillon a,, R.-D. Lopez-Oliver b a Otolaryngology Department, National Institute of Respiratory Diseases Ismael Cosío Villegas, Calzada de Tlalpan 4502 Col. Sección XVI, Delegación Tlalpan, Mexico, Mexico b Ophtalmology Service, General Hospital Dr. Manuel Gea González, Mexico, Mexico Available online 20 May 2010 KEYWORDS Graves disease; Orbitopathy; Orbit decompression; Endoscopic Summary Objectives: Present our experience with orbital decompression using an endoscopic transnasal approach and test whether preservation of an anteroposterior periorbital strip overlying the medial rectus muscle can reduce the incidence of postoperative diplopia. Patient and methods: Retrospective, descriptive study conducted on 16 patients with Graves ophthalmopathy operated on with orbital decompression between 2004 and Results: Twelve women and four men (mean age, 34.6 years), a total of 30 orbits, were operated. A medial periorbital strip along the medial rectus muscle was preserved in 13 patients. A single case (7.7%) presented postoperative diplopia. The mean reduction of proptosis was 4.3 mm. Conclusions: The endoscopic transnasal approach provides comparable results to those obtained with other techniques. The incidence of postoperative diplopia seems to decrease when an anteroposterior periorbital periosteal strip is preserved along the medial rectus muscle Elsevier Masson SAS. All rights reserved. Introduction Graves ophthalmopathy is characterized by eyelid retraction, infiltrating ophthalmopathy and compressive ophthal- Work presented at the 116th Congress of the Société Française d Otorhinolaryngologie et de Chirurgie de la Face et du Cou, 6 October 2009 in Paris. Corresponding author. address: aljicho@gmail.com (M.-A. Jimenez-Chobillon). mopathy, which generally occur simultaneously with various degrees of severity [1]. Treatment is not systematically surgical, because certain patients present a favorable response to medical treatment combining corticosteroids and radiotherapy [2]. Decompressive surgery is usually reserved for Graves ophthalmopathy that is refractory to medical treatment. Its indications include exophthalmia, corneal ulcer, compressive neuropathy, ophthalmoplegia, and esthetic considerations [3]. All techniques seek to reposition the bony limits of the orbital wall [4] or reduce the volume /$ see front matter 2010 Elsevier Masson SAS. All rights reserved. doi: /j.anorl

2 98 M.-A. Jimenez-Chobillon, R.-D. Lopez-Oliver of the soft tissues contained in this cavity by fat removal [3,5,6]. Today, the endoscopic transnasal approach is one of the most frequently used for orbital decompression. Exposure of the medial wall of the orbit after endoscopic ethmoidectomy makes it possible to completely remove the lamina papyracea. The medial portion of the orbital floor and the optic nerve at the apex are also easily decompressed [7]. The functional and esthetic results obtained are generally at least as good as those obtained with external techniques. Therefore, the otorhinolaryngologist now takes part in the multidisciplinary management of this disease once reserved for the ophthalmologist and the endocrinologist. One of the most frequent complications of orbital decompression is postoperative diplopia, occurring in 20 [8] to 63% [9] of cases depending on the series. Certain authors do not consider it an actual complication, given its frequency. However, certain cases of diplopia will need to be treated surgically, and the surgeon should inform the patient of this possibility. To reduce the incidence of postoperative diplopia as much as possible, a variety of surgical techniques have been presented in the medical literature. Metson and Samaha propose preserving a medial periorbital strip along the medial rectus muscle and present excellent results [9]. This study aimed not only to present the results on a series of patients who had undergone orbital decompression via an isolated endoscopic approach, or combined with an external approach, but also to confirm the value of preserving a medial periorbital strip to reduce the incidence of postoperative diplopia. Patients and methods The files of all the patients presenting Graves ophthalmopathy who had been operated by endoscopic transnasal approach for excision of the medial orbital wall between December 2004 and February 2009 were analyzed retrospectively. The independent variables studied were sex, age, duration of postoperative follow-up, uni- or bilateral orbital involvement, whether or not a medial strip of orbital periosteum was preserved along the course of the medial rectus muscle, and whether or not the orbital floor was excised. The dependent variables sought were pre- and postoperative measurements obtained with Hertel exophthalmometry for each orbit operated on and the presence or absence of pre- and/or postoperative diplopia. The values obtained with exophthalmometry were considered normal between 14 and 21 mm [10]. Exophthalmia was considered mild with values between 21 and 24 mm and moderate to severe for any value above 24 mm [3]. In all cases, diplopia, ocular motricity and the degree of infiltration of the extraocular muscles were assessed by the ophthalmologist, but only the presence or absence of diplopia was described and retained as a variable in the study. The postoperative complications and the pre- and postoperative visual fields were also noted. Except for diplopia, which depends directly on the simultaneous action of both eyes, the rest of the data were analyzed in relation to the total number of orbits operated and not on the number of patients, because of the individual and independent behavior of each orbital unit. Finally, our results were compared with those reported by various series reported in the relevant literature. Surgical technique Except for preservation of the medial periorbital strip in certain patients, the same surgical technique was used under general anesthesia for all patients. An external infiltration of the supraorbital, supratrochlear, and infraorbital nerves was performed at the beginning of the intervention with a Xylocaine 2% solution with adrenaline 1:100,000, and tamponading of the nasal fossa was done with dressings soaked in a 0.05% oxymetazoline solution, which were removed after 10 min. Dissection of the ethmoid was begun using the 0-degree endoscopic lens, by resecting the anterior and posterior ethmoid cells. The base of the skull was identified and followed between the lamina papyracea and the conchal lamina as landmarks for the rest of the dissection. The agger nasi cell and the upper portion of the uncinate process were resected near the frontal recess, but the latter structure was preserved intact along with its mucosal lining. After ethmoid dissection (or before depending on the surgeon s decision), a middle meatotomy is performed. It should be large enough to prevent its obliteration with the orbital fat and thus avoid maxillary sinusitis. Then a large sphenoidotomy is made to join the lateral wall of the sphenoidal sinus and the lamina papyracea. Once this has been achieved, resection of the medial wall of the orbit is begun using a sickle knife, then continued with a Freer dissector and a Blakesley forceps, taking care to resect all of this structure up to the sphenoethmoidal union and the orbital apex. The bone resection stops below the frontal recess, preserving the lamina papyracea and the lacrimal bone at this level. Finally, the medial portion of the orbital floor is resected in the same way as the medial orbital wall. Once the periorbit has been exposed along the entire length of the ethmoid, a superior horizontal incision is made parallel to the base of the skull. A similar incision is carried 1 cm below and parallel to the first one, thus retaining an anteroposterior medial fringe of periosteum along the course of the medial rectus muscle (Fig. 1). After a light massage on the ocular globe so that the adipose tissue will partially occupy the dissected ethmoid, a partial lipectomy is performed with thin Blakesley forceps, while monitoring any substantial movement of the globe that could indicate direct traction on the medial rectus muscle. If necessary, the procedure is completed by enlarged excision of the orbital floor via an external approach. In this case, a transconjunctival or subciliary incision is made at the lower eyelid. After dissection of the orbicular muscle, the orbital septum is identified and followed on its anterior side up to the orbital ridge. Here, the periosteum is incised and lifted back, exposing the bone of the orbital floor. With a thin chisel, a fenestration is made on each side of the infraorbital nerve toward the maxillary sinus, so that the bony floor can be removed with bone-cutting Kerrison forceps. Medially, the dissection is carried toward the middle

3 Transnasal endoscopic approach in the treatment of Graves ophthalmopathy 99 maxillary sinus. When a transconjunctival incision is made, it is not closed. On the other hand, the subciliary incision is sutured with a continuous, nonresorbable suture. Nasal packing is not required unless substantial postoperative bleeding is present. Postoperative care Nasal lavages with saline solution and antalgics are initiated during the 1st postoperative day. Cold compresses are regularly placed on the eyelids for the first 24 h and eyedrops combining a corticosteroid and an antibiotic are instilled three times a day for 1 week. Per os antibiotics are only prescribed for patients requiring nasal tamponing. The patient is seen in consultation on the 3rd day and every week thereafter until satisfactory healing is achieved. Results Figure 1 Illustration showing orbital periosteal incisions with medial periosteal strip. C: cavum; IT: inferior turbinate; MS: maxillary sinus; SS: sphenoid sinus; ER: ethmoid roof; MPB: medial periosteal strip. meatus; laterally, it reaches the zygomatic angle. Finally, the bony canal of the infraorbital nerve is dissected and raised with a periosteal elevator, and the inferior orbital periosteum is opened via two or three anteroposterior incisions to allow prolapsus of the orbital fat into the Twelve women (75%) and four men (25%) between 21 and 61 years of age were operated. Two cases (12.5%) were operated on one side and 14 (87.5%) on both sides. A total of 30 orbits were operated. The duration of the postoperative follow-up was 6 36 months. The two cases of unilateral involvement were both men, in each case involving the left eye. In one of the unilateral cases, the orbital floor was not excised by the external approach because the endoscopic excision of the medial wall was sufficient. For the 29 remaining orbits, endoscopic transnasal resection of the medial wall was associated with resection of the orbital floor via the external subciliary or transconjunctival approach, depending on the surgeon s preference. Five orbits (16.7%) in our first three patients were operated without a periorbital medial strip on the medial Table 1 Pre- and postoperative exophthalmometric measurements (mm) obtained for each patient and each eye. Patient Right eye Left eye Preoperative Postoperative Follow-up Preoperative Postoperative Follow-up No No No No No Mean The Follow-up columns show the reduction in exophthalmia. No: not operated.

4 100 M.-A. Jimenez-Chobillon, R.-D. Lopez-Oliver Table 2 Relation between preservation of the medial periorbital strip and the presence of pre- and postoperative diplopia for each case. Patient Preserved periorbital strip Diplopia Right eye Left eye Preoperative Postoperative 1 No No No No 2 Not operated No No No 3 No No No Yes a 4 Yes Yes No No 5 Yes Yes No No 6 Yes Yes No No 7 Yes Yes No No 8 Yes Yes No No 9 Yes Yes No Yes a 10 Yes Yes No No 11 Yes Yes No No 12 Yes Yes No No 13 Yes Yes No No 14 Not operated Yes No No 15 Yes Yes No No 16 Yes Yes Yes a Yes a a Presence of diplopia. rectus muscle. The 25 following orbits (83.3%) underwent this preservation technique. Fifteen orbits presented slight proptosis and the 15 remaining orbits moderate or severe proptosis. The postoperative proptosis reduction was a mean 4.3 mm (Table 1), ranging from 2 to 8 mm. Three patients (18.7%) presented postoperative diplopia; one of them (6.2%) presented diplopia before surgery, which remained after the intervention. Of the 13 patients in whom the periorbital medial strip was preserved, a single patient (7.7%) presented diplopia caused by the operation. One case of postoperative diplopia occurred in one of the three patients (33.3%) who had not been treated with this technique (Table 2). Other postoperative complications were noted: presence of synechiae in four cases, including one bilateral (five ethmoids), malar hypesthesia after excision of the orbital floor in one case, unilateral postoperative epistaxis in one case, and one case of left frontoethmoid mucocele. No cases of meningeal rupture were noted. In all the patients, the visual fields were measured preand postoperatively. Eleven cases presented compressive neuropathy of the optic nerve, which improved in all cases after the surgery. The five patients who did not present alterations of the visual fields underwent surgery for purely esthetic reasons. Of the three patients who presented diplopia, two were operated on by a strabismus specialist and the third refused additional surgical treatment. All the patients were discharged from the hospital within 24 h of the intervention. Discussion Our series is comparable to most of those published in the literature, both in terms of its demographic data and its results. The various studies show that approximately 70% of affected patients are female [6,8,11], similar to the percentage reported in the present series (75%). However, the mean age of our patients was 34.6 years, whereas other authors reported means of 46.6 [8] and 49 years [11], which suggests that overall our patients were younger. The two cases of unilateral involvement presented in men, both on the left side. Other authors studying Graves exophthalmia did not find this male predominance or laterality [12,13]. The most important objective of the surgical treatment for Graves ophthalmopathy remains preserving vision. Blindness can result from elevation of intraorbital pressure with compression of the optic nerve. For this reason, we prefer endoscopic transnasal resection of the medial wall of the orbit, which allows easy decompression of the optic nerve at the orbital apex [7]. Moreover, it can be noted that our results on the compressive component of the ophthalmopathy are satisfactory, with all patients who presented altered visual fields showing clear functional recuperation after the intervention. Reduction of the exophthalmia is also as important as the optic nerve decompression, since proptosis of the globe can result in corneal ulcer and esthetic sequelae. In some cases, endoscopic excision of the medial wall and the medial portion of the orbital floor seems sufficient for treating exophthalmia [7]. However, in our series, only one case was resolved via a purely endoscopic approach; the others had to undergo a combined procedure with excision of the orbital floor via the external approach. This suggests that excision of several walls is often necessary to obtain good results, but also that the medial strip of orbital periosteum, kept intact in most of our cases, could be a limitation to the reduction of ocular globe protrusion during decompression. On the other hand, we observed that the mean regression of the exophthalmia obtained in our patients is comparable to what has been obtained by other authors who did not preserve this periosteal strip and who also resected

5 Transnasal endoscopic approach in the treatment of Graves ophthalmopathy 101 Table 3 Comparison of the means of reduced exophthalmia obtained for each author with the orbital walls resected and preservation or not of the medial strip of orbital periosteum. Author Resected orbital walls MSP Reduced proptosis Medial ½ Floor Floor Lateral Kennedy X X 4.7 Kasperbauer et al. X X 2.5 a Schaefer X X 3.65 Silver et al. 1 X X 4.37 Silver et al. 2 X X X 4.59 Sellari-Franceschini et al. X X 5.3 Cansiz et al. 1 X X 4.38 Cansiz et al. 2 X X X 7.75 a Bailey et al. X X X 5 Metson and Samaha X If necessary X 5.1 MEAN 4.73 Jiménez and López X X X 4.3 Our results are reported in the Jiménez et López. row. ½ floor, medial portion of the floor; MSP, medial strip of orbital periosteum. a The lower mean was obtained with excision limited to the medial wall of the orbit with the medial portion of the orbital floor, whereas the higher mean was obtained with resection of the medial, inferior, and lateral walls. two, sometimes three, orbital walls [7,14,15] (Table 3). Metson and Samaha reported a mean 5-mm reduction of exophthalmia, ranging from 4 to 7.5 mm, despite preservation of this orbital periosteal strip [9], whereas Schaefer et al. obtained a lower mean (3.65 mm) after excising the medial and inferior medial walls while not preserving the periosteal strip [15]. This allowed us to confirm that the medial periosteal strip does not seem to seriously limit the reduction of exophthalmia. In most series, substantial variations in the results obtained on exophthalmia reduction were reported [8,9,16]. The same phenomenon was found in our series, with a reduction of proptosis ranging from 2 to 8 mm. Cansiz et al. reported comparable ranges, from 3 to 7 mm for the group of patients who underwent excision of two orbital walls (medial and inferior), and from 5 to 12 mm when three orbital walls were excised (medial, inferior, and lateral) [17]. This would seem to justify excision of three walls for the most severe cases of exophthalmia. The results of a study by Silver et al., however, did not follow the same direction in that they reported a reduction of exophthalmia ranging from 0.5 to 8 mm for decompression of two orbital walls and a nearly identical variation ranging from 1 to 8 mm for decompression combining three walls [16]. In our series, the excision of the lateral wall was not required in any of the cases. It is also important to remember that reduction of exophthalmia is not solely dependent on the surgical technique used or the number of walls resected, but also in large part on the degree of fibrosis and infiltration of the orbit s soft tissues, notably around the extraocular muscles, which may explain the variability of the surgical results obtained in all of the series reviewed [11]. In our series, we chose to combine excision of the orbital floor via the external approach with excision of the medial wall, particularly in view of our experience in each of these techniques. This combination is associated with low morbidity, shorter hospital stays, fewer complications, and excellent recuperation of visual function in most cases [15]. It should be noted that all our patients were discharged from hospital in the first 24 h after surgery and that the complications presented were minor. In most series, diplopia is the most frequent complication in orbital decompressions [9], explaining why several techniques have been proposed to reduce its incidence. For example, some authors propose balanced orbital decompression of the medial and lateral walls, while the orbital floor is preserved to prevent inferior displacement of the globe [8,16]. This technique seems to reduce the incidence of postoperative diplopia. However, in a series of 13 patients, Kacker et al. reported 15.35% diplopia after this intervention [18]. Other studies report good results with preservation of a horizontal bony bridge at the angle of the medial and inferior walls of the ocular globe, attempting to prevent its inferomedial displacement [14,19], even though the preservation of this bony bridge presents certain difficulties [9], and Wright et al. only managed to preserve it in 71% of their cases, with their series nevertheless reporting 18% diplopia [20]. In this context, Metson and Samaha propose to preserve the anteroposterior strip of orbital periosteum along the course of the medial rectus muscle to prevent convergent strabismus and the resulting diplopia [9]. The technique is much simpler and the results are very encouraging because, in a series of 13 patients and 20 orbits operated, they report no cases of diplopia. These results have motivated us to use this technique. Of 13 patients operated preserving the medial strip of orbital periosteum, only one (7.7%) presented diplopia. However, our group of patients and our experience remain modest; prospective and comparative studies with larger groups would be necessary for definitive conclusions to be drawn. The appearance of synechiae is the most frequent complication of ethmoid surgery and we have observed

6 102 M.-A. Jimenez-Chobillon, R.-D. Lopez-Oliver this in five ethmoids (16.7%) on the operated sides. Even if the limited number of cases makes it impossible to carry out a multivariate analysis, there is a clear trend toward forming synechiae in narrow ethmoids given that the operative reports describe this anatomical variant in three of the four patients who presented this complication. The appearance of mucoceles is also classical after orbital decompression [21]. The case observed in our series accounts for 3.3% of the ethmoids operated and is also associated with the presence of ipsilateral synechiae and a narrow ethmoid. This patient was reoperated and the mucocele was marsupialized in the nasal fossa with no complications. The case of malar hypesthesia reported is undoubtedly related to excision of the bony conduit of the infraorbital nerve during excision of the inferior wall of the orbit. This complication is more frequent when the orbital floor approach is reached using a transmaxillary approach [22,23]. Carrasco et al. report that the incidence of postoperative malar hypesthesia after excision of the orbital floor via the transmaxillary approach is 46%, while it decreases to 6.1% when using the transconjunctival approach [22]. In our series, this accounted for only 3.4% of the cases (one case out of 29 resected orbital floors). It is also important to note that we found no cases of meningeal rupture. This complication can be present particularly during decompression of the lateral orbital wall, near the inferior orbital fissure and the middle cranial fossa [8], or during excision of the medial wall toward the orbital apex [11]. Conclusion The endoscopic transnasal approach allows complete excision of the medial wall of the orbit in excellent conditions and better access to the orbital apex. It, therefore, makes it possible to treat not only exophthalmia, but also compressive neuropathy. Combined with resection of the orbital floor via the external subciliary or transconjunctival approach, this technique provides results that are at least as good as those obtained with other techniques, with reduced morbidity. The incidence of postoperative diplopia seems to decrease when a horizontal anteroposterior strip of orbital periosteum is retained along the medial rectus muscle, a simple procedure that can be performed by a trained surgeon. Conflict of interest statement None. References [1] El-Kaissi S, Frauman AG, Wall JR. Thyroid-associated ophthalmopathy: a practical guide to classification, natural history and management. Intern Med J 2004;34: [2] Stiebel-Kalish H, Robenshtok E, Hasanreisoglu M, Ezrachi D, Shimon I, Leibovici L. Treatment modalities for Graves ophthalmopathy: systematic review and meta-analysis. J Clin Endocrinol Metab 2009;94: [3] Chiarelli A. 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7 Transnasal endoscopic approach in the treatment of Graves ophthalmopathy 103 [22] Carrasco JR, Castillo I, Bilyk JR, et al. Incidence of infraorbital hypesthesia and sinusitis after orbital decompression for thyroid-related orbitopathy: a comparison of surgical techniques. Ophtal Plast Reconstr Surg 2005;21: [23] Pribitkin EA, McJunkin J, Kung B, Carrasco JR, Bilyk JR, Savino PJ. Technique selection for orbital decompression: combined endoscopic and transconjunctival versus combined endoscopic and transantral approach. Ear Nose Throat J 2009;88:E12.