Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 3  |  Page : 284-288  

Swinging door lateral orbitotomy for management of anteriorly placed orbital tumours


Department of Ophthalmology, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, India

Date of Web Publication5-Jul-2013

Correspondence Address:
Atreyee Pradhan
Bandh Road, Abhirampur, Mokdumpur, Malda - 732 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.114646

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  Abstract 

A 70 years old female; who came to us; with drooping of right upper eyelid, gradual progressive diminution of vision with a slowly progressive swelling over right upper outer orbit of 1 year duration. Examination revealed non-axial proptosis with downward and inward deviation of the right eye. An irregular, lobulated nontender swelling was present in the superolateral orbit. CT scan revealed a well circumscribed oval encapsulated lesion with no bony destruction. The mass was removed by a modified lateral orbitotomy without removing lateral orbital rim. Histopathological evaluation showed it to be a pleomorphic adenoma of the lacrimal gland. Patient made an uneventful postoperative recovery. This presentation describes a method of lateral orbitotomy for anterior orbital lesions in which the lateral orbital rim is swung outwards without detaching it from its attachment to the temporalis muscle. This surgical approach may reduce the chance of avascular necrosis of the lateral orbital wall bone and infections of the orbit.

Keywords: Lateral orbitotomy, orbital tumour, pleomorphic adenoma of lacrimal gland


How to cite this article:
Pradhan A, Radhakrishnan OK, Patra S, Sukharamwala D. Swinging door lateral orbitotomy for management of anteriorly placed orbital tumours. Med J DY Patil Univ 2013;6:284-8

How to cite this URL:
Pradhan A, Radhakrishnan OK, Patra S, Sukharamwala D. Swinging door lateral orbitotomy for management of anteriorly placed orbital tumours. Med J DY Patil Univ [serial online] 2013 [cited 2021 Apr 19];6:284-8. Available from: https://www.mjdrdypu.org/text.asp?2013/6/3/284/114646


  Introduction Top


Surgical approaches to the orbit may be anterior, lateral, medial or superior depending on location of the lesion and exposure needed. Lateral orbitotomy involves removal of the lateral orbital rim and various amounts of greater wing of sphenoid. After making necessary cuts in the lateral bony orbital rim, the bony rim is grasped with a rongeur between cuts and fractured outward. [1] The removed bone is placed in a bowl of saline mixed with antibiotics. Avascular necrosis of the removed bone can thus occur since it is cut off from its blood supply. Chances of infection also increase. We report a case of pleomorphic adenoma of lacrimal gland removed by a modified lateral orbitotomy in which the lateral wall of the orbit is retracted outwards to expose the lacrimal gland.


  Case Report Top


A 70 year old female patient reported with history of drooping of right upper eyelid and gradual, progressive and painless diminution of vision in right eye of 1 year duration along with a painless, slowly enlarging swelling in the right upper eyelid Ocular examination revealed a best corrected visual acuity (BCVA) of 10/200 in right eye. The globe was displaced 6 mm anteriorly and 3 mm inferiorly with restriction of right eye in dextroelevation [Figure 1]. There was drooping of the right upper eyelid with the lid covering more than 4 mm of clear cornea. A swelling 3 cm × 3 cm in size was felt in superolateral orbit, non pulsatile, not increasing in size on Valsalva manoeuvre or on change of head position. It was firm to hard in in consistency, nontender and mobile. No bruit or crepitus was present. The pupillary reactions and corneal sensations were normal. Lens showed cataractous changes. Rest of the anterior segment was normal. The optic disc was normal and there were no retinochoroidal folds. Ocular examination of left eye revealed a BCVA of 20/200 with lens showing cataractous changes. Investigation including complete hemogram, blood sugar levels, liver and renal function tests, serum ACE levels, X-ray orbit and chest were within normal levels. CT scan brain and orbit showed soft tissue mass of uniform consistency in the lacrimal fossa, free from the globe, muscles and the bone, with no bony erosion [Figure 2]. MRI BRAIN and ORBITS revealed a well-defined ovoid lesion measuring approx. 2 cm (antero-posterior) × 2.5 cm (superoinferior extent) in the extraconal compartment of the right eye, superolateral to the right globe involving the lacrimal gland. [Figure 3] and [Figure 4] Patient underwent Swinging door Lateral Orbitotomy under general anaesthesia without removal of lateral orbital rim [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10] and [Figure 11]. The tumour mass was excised and sent for histopathological examination which revealed it to be a pleomorphic adenoma of lacrimal gland [Figure 12]. The postoperative appearance is shown in [Figure 13].
Figure 1: Swelling of right upper eyelid and downward inward deviation of right eyeball

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Figure 2: CT scan brain and orbit showing soft tissue mass in right lacrimal fossa

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Figure 3: MRI orbit showing ovoid lesion

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Figure 4: MRI contrast enhanced showing ovoid lesion

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Figure 5: Modified Wright Stallard incision given

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Figure 6: Skin muscle flaps were retracted and were held taught with appropriate number of retraction sutures

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Figure 7: Periosteum was incised

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Figure 8: Periosteum elevated from lateral orbital wall

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Figure 9: Bone was cut with an oscillating saw. First cut along sphenozygomatic suture line and second one through orbital rim above zygomatic arch. Instead of removing the bone it was retracted in swinging door fashion without hampering blood supply

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Figure 10: With the bonein place the lesion was identified and separated from surrounding tissue and was excised with intact capsule

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Figure 11: Bony lateral orbital wall swung back to its normal position. Wound was closed in three layers. Peristeum, muscle and skin sutured with 4-0 vicryl, 6-0 chromic catgut and 6-0 silk respectively

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Figure 12: Mass sent for histopathological examination. It was Pleomorphic Adenoma of Lacrimal Gland

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Figure 13: Post-operative photograph (post op day 1)

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  Discussion Top


Orbital surgery requires a good understanding of ocular, adnexal and orbital anatomy in association with familiarity with the differential diagnoses and relative incidence of various orbital diseases. [2] Surgical approach to the orbit maybe anterior, medial, lateral or transfrontal (neurosurgical). An approach to the orbit through the maxillary antrum has been described. Anterior orbitotomy is a good approach for tumours in front of equator of the eyeball in extraconal space. Incision for this may be superior, superomedial or inferior. Trans-conjunctival approach for anterior orbitotomy can be used if the end of the tumour is palpable. In this procedure, no bony structure is removed.

Lateral orbitotomy and its numerous modifications have been used for more than 100 yrs. Although Kronlein is generally thought to have introduced lateral orbitotomy, Wagner in Germany and Pakavant from Germany developed methods to access the retro-orbital space by removing the lateral bony rim and orbital wall. Kronlein first described a surgical technique for removal of orbital dermoid cysts in 1888. [2] Lateral orbitotomy approach is used for deeper orbital lesions that cannot be reached through an anterior incision or that require wider exposure for excision. It allows wide access to the deep orbital contents and optic nerve; it is preferred for most retrobulbar lesions. Lateral orbitotomy provides good access to lacrimal gland tumors and enables their complete removal which is important to prevent recurrence.

The current technique for lateral orbitotomy uses a lazy S shaped or curvilinear skin and muscle incision in a vertical plane along the lateral orbital rim which is extended in a horizontal manner from level of lateral canthus to the ear. The periosteum is elevated and lateral orbital wall is separated from temporalis muscle and fascia. Lateral orbital wall bone is cut and removed and is kept in a bowl filled with saline containing antibiotics. After tumour removal, the bony part is replaced and secured with microplate fixation or 4-0 Prolene or nylon sutures. [3] This increases the chances of infection and avascular necrosis of the bone.

In the recent past, minimally invasive ″keyhole″ surgery performed using endoscopic visualization is increasing in popularity and is being used widely by almost all surgical subspecialties including orbital surgery. [4] In literature, there is very little mention of lateral orbitotomy without removing lateral orbital wall. One technique describes use of an air-driven "acorn-tipped" bur which removes the posterolateral lip of the frontal process of the zygomatic bone and helps to straighten the external surface of the lateral orbital wall. This is said to allow removal of the bone without serious injury to the periorbita. The technique creates a trapezoidal orbitotomy. [5]

Our technique was different in that after the two cuts were made in the lateral orbital wall, the lateral orbital wall was retracted outward without separating it from its attachment to the temporalis muscle and fascia. Since the cut bone's blood supply from the temporalis muscle and fascia was not compromised at any stage of surgery, we feel that our approach to lateral orbitotomy will prevent avascular necrosis of lateral wall of orbit which could occur with the conventional technique. After the lacrimal gland tumour was completely excised, the lateral orbital wall was swung back into its normal position. No material was used to fixate the bone. The exposure obtained was adequate for complete removal of the tumour. Since the bone is not removed from the field of surgery, we feel that the chance of infection is also reduced.

Tumours of the lacrimal gland are relatively rare. Among the expanding lesions of the lacrimal gland, 50% originate from the epithelial elements of which 50% are pleomorphic adenomas, 25% are adenoid cystic carcinomas and the remaining 25% are comprised of myoepithelioma, oncocytoma, Warthin's tumour, acinic cell carcinoma etc. [6] Pleomorphic adenoma is most common benign tumour of the lacrimal glands. Various hallmarks of pleomorphic adenoma include presence of symptoms for more than 1yr and an absence of pain. [7] On USG studies, pleomorphic adenomas are medium to highly reflective, with a regular structure and moderate sound attenuation. [8] Recurrent lacrimal gland pleomorphic adenomas tends to develop multifocally and may be widespread in the operative field with potential lifelong risk of malignant transformation. [9] Management of pleomorphic adenoma of lacrimal gland is by complete excision of mass (excisional biopsy). Incisional biopsy and needle biopsy are generally contraindicated. Incomplete excision can lead to recurrence and malignant transformation. Since the lateral orbitotomy described by us permits good visualization for complete excision of the lacrimal gland tumors, we feel that this procedure is ideal for complete removal of these tumors.

This presentation describes a method of lateral orbitotomy for anterior orbital lesions in which the lateral orbital rim is swung outwards without detaching it from its attachment to the temporalis muscle and fascia. This surgical approach may reduce the chance of avascular necrosis of the lateral orbital wall bone and infections of the orbit while permitting good visualisation for complete removal of anteriorly placed orbital tumours.

 
  References Top

1.Wirtschafter JD, Chu AE. Lateral orbitotomy without removal of the lateral orbital rim. Arch Ophthalmol 1988;106:1463-8.  Back to cited text no. 1
[PUBMED]    
2.Townsend DJ. Orbital surgical techniques. In: Jakobiec AF, editor. Principles and practice of Ophthalmology. 2 nd ed. Philadelphia: W B Saunders Company; 2000. p. 3067-70.  Back to cited text no. 2
    
3.Dutton JJ. Orbital surgery. In: Yanoff M, Duker JS, editors. Ophthalmology. 3 rd ed. Mosby: Elsevier; 2009. p. 1469.  Back to cited text no. 3
    
4.Venkatesh CP, Dinesh SF. Orbital endoscopic surgery. Indian J Ophthalmol 2008;56:5-8.  Back to cited text no. 4
    
5.Wirtschafter JD, Chu AE. Lateral orbitotomy without removal of the lateral orbital rim. Arch Ophthalmol 1988;106:1463-8.  Back to cited text no. 5
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6.Tse DT, Hui JI. Epithelial tumours of lacrimal gland. In: Jakobiec A, editor. Principles and practice of Ophthalmology Third edition. USA: Elsevier; 2008. p. 2977-86.  Back to cited text no. 6
    
7.Stewart WB, Krohel GB, Wright JE. Lacrimal gland and fossa lesions: An approach to diagnosis and management. Ophthalmology 1979;86:886-95.  Back to cited text no. 7
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8.Byrne SF, Green RL. Ultrasound of the Eye and Orbit. 2 nd ed. St. Louis: Mosby; 2002. p. 324.  Back to cited text no. 8
    
9.McNab AA, Satchi K. Recurrent lacrimal gland pleomorphic adenoma: Clinical and computed tomography features. Ophthalmology 2011;118:2088-92.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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