Nose is now the gateway to skullbase lesions and orbit, making the treatment minimally invasive with minimal postoperative complications delivery better results to patient satisfaction in terms of disease cure and affordability

1. EndoscopicEndoscopic
Approach toApproach to
Orbit andOrbit and
PituitaryPituitary
Prof.Dr.G.SundharProf.Dr.G.Sundhar
KrishnanKrishnan
Dr. P.PramodDr. P.Pramod
VenugopalVenugopal

2.  WhyWhy
endoscope toendoscope to
approach theapproach the
orbit?orbit?
 Lateral wall ofLateral wall of
nose is thenose is the
medial wall ofmedial wall of
the orbitthe orbit
 Approach theApproach the
orbit throughorbit through
the ethmoids.the ethmoids.

3.  Orbital TumorsOrbital Tumors
 Superior orbital fissure syndrome/OrbitalSuperior orbital fissure syndrome/Orbital
Apex syndrome/Cavernous sinus – OCRApex syndrome/Cavernous sinus – OCR
Syndrome and othersSyndrome and others
 Orbital decompressionOrbital decompression
 Other lesions affecting the visual pathwayOther lesions affecting the visual pathway
like pituitary tumorslike pituitary tumors
IndicationsIndications

4.  Minimally invasiveMinimally invasive
 Excellent magnification and visualizationExcellent magnification and visualization
 Intracranial procedure / OrbitotomyIntracranial procedure / Orbitotomy
avoidedavoided
 No external scarNo external scar
Advantages with the EndoscopeAdvantages with the Endoscope

5.  Medial tumorsMedial tumors
 IntraconalIntraconal
TumorsTumors

6.  25 year old male with protrusion and pain25 year old male with protrusion and pain
Right eye 9 months durationRight eye 9 months duration
 Underwent surgery twice [LateralUnderwent surgery twice [Lateral
orbitotomy 4 years ago and craniotomy 6orbitotomy 4 years ago and craniotomy 6
months]months]
 Confirmed as a case of optic nerveConfirmed as a case of optic nerve
schwannomaschwannoma
Case 1 - Pre OpCase 1 - Pre Op

7.  Gross non-pulsatile proptosis with outward andGross non-pulsatile proptosis with outward and
downward deviation of Right eyedownward deviation of Right eye
 Ocular movements – Only abduction presentOcular movements – Only abduction present
 Visual Acuity – 1/60Visual Acuity – 1/60
 Pupil – Mid Dilated and FixedPupil – Mid Dilated and Fixed
 Fundus – Marked Disc pallorFundus – Marked Disc pallor
 Left eye - NormalLeft eye - Normal
Pre OpPre Op

9.  Immediate and drastic reduction inImmediate and drastic reduction in
Proptosis and agonyProptosis and agony
 Follow up at 1 year – No recurrence ofFollow up at 1 year – No recurrence of
proptosisproptosis
 Improvement in visual acuity from 1/60 toImprovement in visual acuity from 1/60 to
3/603/60
 Total oculomotor nerve palsy (pre op)Total oculomotor nerve palsy (pre op)
persistedpersisted
Post OpPost Op

10.  40yrs old female who underwent inferior40yrs old female who underwent inferior
orbitotomy - fungal granuloma by eyeorbitotomy - fungal granuloma by eye
surgeon 1 year agosurgeon 1 year ago
 Presented with Right Eye proptosis,Presented with Right Eye proptosis,
upward displacement and headacheupward displacement and headache
 Vision was normal.Vision was normal.
Case 2 - Pre OpCase 2 - Pre Op

11. Orbital Lesion
Mass on the floor of
the orbit

12. Post OpPost Op

13. Superior Orbital Fissure/Superior Orbital Fissure/
Orbital Apex/Orbital Apex/
Cavernous Sinus SyndromeCavernous Sinus Syndrome
 OCR SyndromeOCR Syndrome
– AspergillosisAspergillosis
– MucormycosisMucormycosis
 Space occupying lesionsSpace occupying lesions

14.  Severe pain – left eye-6 monthsSevere pain – left eye-6 months
 Inability to open left eye/ DiplopiaInability to open left eye/ Diplopia
 Defective vision/ Slight protrusionDefective vision/ Slight protrusion
 T/N endoscopic removal elsewhereT/N endoscopic removal elsewhere
 Known diabeticKnown diabetic
 RecurrenceRecurrence
 VA 6/18 NIPVA 6/18 NIP
 Fundus normal / RE normalFundus normal / RE normal
OCR Syndrome – AspergillosisOCR Syndrome – Aspergillosis
Clinical HistoryClinical History

15. Pre OpPre Op

16. Lesion at the Left
orbital apex
extending into
cavernous sinus
CT ScanCT Scan

17. Early, aggressive endoscopicEarly, aggressive endoscopic
debridement eliminates the need fordebridement eliminates the need for
orbital exenteration even in cases oforbital exenteration even in cases of
invasive fungal lesionsinvasive fungal lesions

18. Orbital DecompressionOrbital Decompression
 BenignBenign
– MucocelesMucoceles
– Fibrous dysplasiaFibrous dysplasia
– Grave’s ExophthalmosGrave’s Exophthalmos
 MalignantMalignant
– Tumor involving orbit without invasion ofTumor involving orbit without invasion of
orbital periosteiumorbital periosteium

19. SphenoethmoidalSphenoethmoidal
Fibrous DysplasiaFibrous Dysplasia
 Left Eye - ProptosisLeft Eye - Proptosis

20. Surgical VideoSurgical Video

21.  Immediate reduction in proptosisImmediate reduction in proptosis
 Decompression done under magnifiedDecompression done under magnified
visualization – Hence no injury to opticvisualization – Hence no injury to optic
nervenerve
AdvantagesAdvantages

22.  Especially useful in cases with suprasellarEspecially useful in cases with suprasellar
extensionextension
 Avoids need for craniotomyAvoids need for craniotomy
 Precise visualization with angledPrecise visualization with angled
endoscopesendoscopes
 Patient can go home in 1 dayPatient can go home in 1 day
Endoscopic Pituitary SurgeryEndoscopic Pituitary Surgery

23. MRIMRI

24. Surgical VideoSurgical Video

25.  Provides a good method of approach toProvides a good method of approach to
orbit and adnexaorbit and adnexa
 Minimally invasive surgeryMinimally invasive surgery
 Minimal bleedingMinimal bleeding
 Reduced post op stay/Reduced morbidityReduced post op stay/Reduced morbidity
 Good resultsGood results
Navigation systems – The futureNavigation systems – The future
To concludeTo conclude