Introduction: Tumors in the supraorbital region are most commonly accessed through transcranial approaches, including fronto-orbital, orbitozygomatic, and eyebrow supraorbital keyhole approaches. Purely endoscopic endonasal approaches (EEAs) are more challenging to perform because of limitations in access and visualization for lateral extension beyond the midline corridor. The endoscopic modified hemi-Lothrop procedure, a variation of an extended EEA, allows for binostril access and visualization of the lateral supraorbital region while preserving the contralateral frontal sinus drainage pathway. Angled endoscopy and curved instrumentation are critical for success.
Methods: The operative technique and nuances are illustrated in a rare case of a supraorbital juvenile psammomatoid ossifying fibroma (JPOF) causing symptomatic orbital compression.
Results: This 26-year-old male presented with progressive headaches and intermittent blurry vision in the left eye due to orbital compression from an expansile supraorbital JPOF. A gross-total resection was achieved with excellent orbital decompression using an endoscopic modified hemi-Lothrop procedure. The key components of the approach consisted of an endoscopic Draf IIB (left frontal sinusotomy) ipsilateral to the tumor, and a superior septectomy for binostril bimanual instrumentation. Excellent visualization, access, and tumor removal of the supraorbital region was achieved with angled endoscopy and instrumentation from the contralateral nasal cavity and through the septectomy window (“cross-court” trajectory).
Conclusions: The modified hemi-Lothrop procedure with angled endoscopy is a safe and effective alternative route to traditional transcranial approaches to access the supraorbital region. To our knowledge, this is the first case of a supraorbital JPOF that was successfully resected via a purely EEA.
Patient Care: By providing a novel purely endoscopic approach to the supraorbital region, surgeons have an additional option for treatment of lesions that is safe and efficacious.
Learning Objectives: By the conclusion of this session, participants should be able to:
1. Discuss the nuances of the modified hemi-Lothrop procedure.
2. Understand in what cases the modified hemi-Lothrop procedure provides an advantage.
3. Describe the clinical nature of a supraorbital juvenile psammomatoid ossifying fibroma.
References: 1.Eloy JA, Kuperan AB, Friedel ME, Choudhry OJ, Liu JK. Modified hemi-Lothrop procedure for supraorbital frontal sinus access: a case series. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. Jul 2012;147(1):167-169.
2.Eloy JA, Friedel ME, Murray KP, Liu JK. Modified hemi-Lothrop procedure for supraorbital frontal sinus access: a cadaveric feasibility study. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. Sep 2011;145(3):489-493.
3.Friedel ME, Li S, Langer PD, Liu JK, Eloy JA. Modified hemi-Lothrop procedure for supraorbital ethmoid lesion access. The Laryngoscope. Feb 2012;122(2):442-444.