Combined Endonasal and Transorbital Approach for Management of Sinonasal Inverting Papilloma with Extensive Frontal Sinus Involvement

Title: Combined Endonasal and Transorbital Approach for Management of Sinonasal Inverting Papilloma with Extensive Frontal Sinus Involvement.

Topic: Endoscopic Technique.

Objectives: Sinonasal Inverting papilloma is benign but locally aggressive mucosal neoplasm with a high recurrence rate if not completely resected. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitocranial approach for managing extensive inverting papilloma.

Study Type: Case Series.

Methods: Three patients seen at Johns Hopkins Hospital between (2010–2015) with biopsy proven sinonasal inverting papilloma with far lateral frontal sinus extension underwent a combined endonasal and transorbital approach for resection of the tumor. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess and orbit. Tumors were first approached via endonasal route until the frontal recess is reached. A Draf IIB or Draf II procedure was then performed to gain better exposure of the lesion. Orbitofrontal exposure was achieved through either a supratarsal crease or a precaruncular conjunctival incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic assisted dissection through the orbitofrontal window.

Results: The transorbital approaches provided surgical access to all walls of the ipsilateral frontal sinus, the intersinus septum and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients in this series. There were no recurrences after 2 years of follow up. There were no orbital complications and all patients also had preserved forehead sensation. There was no visible eyelid asymmetry or scar resulting from this approach.

Conclusion: Combining a minimal-access orbitofrontal craniotomy with the traditional endoscopic endonasal approach allows complete resection of invasive inverting papilloma with extension into the frontal sinus. This is achieved with great cosmetic results.