Modified hemi-lothrop procedure for supraorbital ethmoid lesion access

Authors

  • Mark E. Friedel MD, MPH,

    1. Department of Otolaryngology–Head and Neck Surgery, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
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  • Shawn Li BA,

    1. Department of Otolaryngology–Head and Neck Surgery, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
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  • Paul D. Langer MD, FACS,

    1. Department of Ophthalmology and Visual Sciences, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
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  • James K. Liu MD,

    1. Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
    2. Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey, U.S.A.
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  • Jean Anderson Eloy MD, FACS

    Corresponding author
    1. Department of Otolaryngology–Head and Neck Surgery, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
    2. Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey, U.S.A.
    • MD, Assistant Professor and Vice Chairman, Director of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, UMDNJ–New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

The supraorbital ethmoid (SOE) cell is an accessory ethmoid cell in the frontal area that extends into and pneumatizes superolaterally along the orbital plate of the frontal bone. The outflow pathway of the SOE cell can become obstructed, leading to an SOE mucocele. Given their lateral location, SOE lesions are traditionally treated through external approaches, although some authors have advocated treatment through standard endoscopic routes. We present a case of a large, supraorbital ethmoid mucocele treated with a novel modified hemi-Lothrop procedure (MHLP). This technique provides the benefit of an angulated approach to increase lateral visualization and bimanual, binostril instrumentation through a superior septectomy window.

INTRODUCTION

The supraorbital ethmoid (SOE) cell is an accessory ethmoid cell in the frontal area that extends into and pneumatizes superolaterally along the orbital plate of the frontal bone.1, 2 This cell is located posterolateral to the frontal sinus and drains posterolaterally to the frontal sinus recess.1, 2 A common wall separates the frontal sinus from this cell, which is often mistaken as a lateral extension of the frontal sinus. The outflow pathway of the SOE cell can become obstructed, leading to an SOE mucocele. Given their lateral location, SOE lesions are traditionally treated through external approaches. Nevertheless, some authors have advocated treatment through standard endoscopic routes.1 Intranasally, the SOE cell is accessed along the anterolateral aspect of the ethmoid sinus. Previously, we described the modified hemi-Lothrop procedure (MHLP) for supraorbital laterally located frontal sinus access.3 In this report, we apply our previously described technique to access and drain an SOE mucocele. This technique provides the benefit of an angulated approach to increase lateral visualization and bimanual instrumentation through the septectomy window. Approval by the institutional review board of the University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ was obtained.

CASE REPORT

A 43-year-old male presented with a 5-year history of progressive diplopia and right eye proptosis. He denied change in visual acuity, history of sinusitis, anosmia, nasal congestion, or previous trauma. Oculoplastic examination revealed 6 mm of right proptosis, 7 mm of right hypoglobus, and diplopia on upward gaze with slight hypotropia. Nasal endoscopy revealed a rightward deviated nasal septum.

A computed tomography (CT) scan showed a large right SOE mass with significant proptosis of the right eye with marked inferior displacement and minimal lateral displacement. There was erosion of the right anterior skull base and orbital roof (Fig. 1A,B). Magnetic resonance imaging showed a right SOE mass consistent with an SOE mucocele (Fig. 1C,D).

Figure 1.

Axial (A) and coronal (B) computed tomography scans of the orbits and paranasal sinuses show a right supraorbital ethmoid lesion with downward compression and displacement of the globe. Axial (C) and coronal (D) T2-weighted magnetic resonance imaging show a hyperintense supraorbital mass consistent with a mucocele.

The patient underwent endoscopic drainage of the SOE mucocele using our previously described MHLP technique.3 The procedure consisted of a right anterior ethmoidectomy/maxillary antrostomy and an endoscopic Draf IIB with a superior septectomy to gain access from the contralateral nasal cavity and allow bimanual, binostril dissection. After entering the mucocele cavity, the wall between the right frontal sinus and the SOE cavity was resected to combine and enlarge the drainage pathway of these adjacent cavities (Fig. 2).

Figure 2.

Intraoperative view (A) of right frontal sinus and right supraorbital ethmoid cavity after drainage via MHLP using a 30° endoscope. (B) Intraoperative photograph showing illumination of the cavity after drainage. Axial coronal (C) and postoperative (D) computed tomography scans show a patent right frontal and supraorbital ethmoid cavity. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Postoperatively, the patient's proptosis was decreased. He maintained full extraocular movement and reported resolution of diploplia. His postoperative CT scan showed widely patent right frontal sinus and SOE cavities (Fig. 2). At 4 months postoperatively he was asymptomatic.

DISCUSSION

The SOE cell is an accessory cell in the frontal area that extends superolaterally along the orbital plate of the frontal bone.1, 2 Various cadaveric studies report an incidence of 5% to 15%. Endoscopically, it is accessed along the anterolateral superior aspect of the ethmoid sinus.2, 4, 5 SOE mucoceles typically extend laterally above the orbit and can be incorrectly diagnosed as frontal sinus mucoceles. When this mistake occurs, standard frontal sinusotomy may be performed without addressing the mucocele.

Mucoceles in the frontoethmoidal region can be divided into three general types: frontal sinus mucoceles arising from the frontal sinus (including laterally based frontal sinus mucoceles), ethmoid mucoceles, and SOE mucoceles arising from an SOE cell. Although there could be variations, in general they can be characterized on oculoplastic examination and radiographically based on the main vector of globe displacement. A frontal sinus mucocele mainly displaces the globe inferolaterally. The main vector of globe displacement caused by an ethmoid mucocele is laterally. An SOE mucocele displaces the globe mainly inferiorly.

Established endoscopic techniques exist that provide sufficient access to accomplish adequate drainage and removal of most sinus disease. However, in far laterally based sinus disease, an ipsilateral view is often insufficient in providing proper visualization due to the confines of a limited surgical field. Oftentimes, rhinologists must resort to more extensive external-based procedures to manage these cases. Recently, we described the MHLP as an alternative to open surgery or endoscopic modified Lothrop procedure for the management of laterally based frontal sinus disease.3 The key to the success of the MHLP compared to traditional techniques is a superior septectomy that allows increased lateral visualization and angulation, and bimanual instrumentation through the contralateral nasal cavity while preserving the integrity of the contralateral frontal sinus recess. In the present case, we successfully used our novel MHLP technique to access and drain the SOE region.

CONCLUSION

The SOE cell can be difficult to access endoscopically. The MHLP represents a novel and feasible way to access this area from the contralateral nasal cavity through a superior septectomy window. This approach is useful in addressing difficult-to-access supraorbital ethmoid lesions that may otherwise require more extensive endoscopic or external approaches.

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