Periorbital Suspension for Endonasal Endoscopic Access to the Lateral Portion of the Frontal Anterior Skull Base

Aims: Although Draf procedures improve endoscopic ease of access to the frontal sinuses, in well pneumatized sinuses, lesions located at the far lateral regions still pose a challenge to the rhinoendoscopists. In this study, we investigated the role of our exclusive technique that we use since 2010, enabling periorbital suspension to address pathologies at the far lateral portion of the anterior skull base at frontal sinuses and supraorbital recess, otherwise remaining inaccessible through an endonasal endoscopic approach.

Method: Retrospective analysis of all patients operated with periorbital suspension technique between 2010 and 2016 at our tertiary care unit were included. Open or combined surgeries were excluded. Clinical examination results, radiological studies, operative findings and treatment outcomes were evaluated.

Results: Fourteen patients were identified that periorbital suspension technique was utilized in diverse grades for different pathologies. Among the patients, 4 had frontal CSF leaks, 3 fibroosseous lesions, 3 inverted papillomas, 2 mucoceles, one frontal cholesteatoma and one malignant mesenchymal tumor. All lesions were completely removed. According to the level of lateral extension of the pathology, diverse grades of periorbital suspension method was used. We were most laterally able to reach even middle cranial fossa dura and inner temporal muscle periosteum through a transfrontal approach. As the only medial attachment of periorbita, anterior ethmoidal artery ligation provided the most important key-role in periorbital suspension.

Conclusion: Periorbital suspension technique yields a whole new option in the endoscopic management of far lateral frontal sinus and supraorbital region pathologies. It expands our limits enabling us to adequately address anterior skull base areas earlier unreachable through the endonasal approach.