endoscopic transnasal orbital decompression

Intraorbital hematoma caused by hyperthyroidism (Graves disease) caused by exophthalmos, trauma or surgery, in addition to keratitis caused by corneal exposure, corneal ulcer eventually blind, can also cause optic nerve compression. In the past, external wall decompression (Kronlein surgery, 1888), craniotomy wall decompression (Naffziger surgery, 1931), external sinus sinus decompression (Sewall surgery, 1936) and maxillary The sinus wall decompression (Walsh-Ogura operation, 1957), in order to remove the eye tissue to the outside of the sputum, reduce pressure, protect the cornea, vision and improve the face. In 1988, Kennedy of the United States underwent endoscopic transnasal decompression. The procedure is small in trauma and effective in treatment without facial incisions. Treatment of diseases: hyperthyroidism Indication 1. Serious eyeballs caused by hyperthyroidism, eyelids can not be closed, corneal ulcers. When patients begin to have corneal symptoms, decompression should be performed in time to prevent corneal lesions leading to blindness. Because surgery has the risk of causing vision loss, it is not advisable to have simultaneous surgery on both eyes. Another eye surgery should be performed at intervals of 10 days. 2. Intraorbital hematoma caused by trauma or surgery increases the internal pressure of the iliac crest, oppresses the optic nerve, and is at risk of blindness. Contraindications Poor general condition, unable to tolerate surgery, including heart, liver, lung, renal insufficiency and coagulopathy and unsatisfactory control of hyperthyroidism. If there is nasal polyps, sinusitis and nasal septum deviation, nasal lesions should be treated first. Preoperative preparation 1. Ophthalmic examination includes eyeball protrusion, eye movement degree, width of upper and lower jaws that cannot be closed, corneal state, visual acuity, visual field, color vision, pupillary reflex, fundus examination, etc. The average value of normal eyeball protrusion is 14mm (11~16mm), and the difference between the two eyes is no more than 1mm. 2. Nasal examination includes front and back nasal examination, nasal endoscopy, to understand whether there is nasal septum deviation, sinusitis and so on. Acute inflammation of the nasal cavity and sinuses should be treated without rushing to surgery. Chronic inflammation should also be actively treated for about 1 week. 3. The CT scan of the eyelids and sinuses included horizontal and coronal positions, and the thickness of the scan layer was 3 to 5 mm. The relationship between the ethmoid sinus, maxillary sinus and eyelid was observed. Surgical procedure 1. Remove the uncinate process. 2. Expand the natural opening of the maxillary sinus, forward to the posterior edge of the nasolacrimal duct, taking care not to damage the nasolacrimal duct; down to the base of the lower turbinate, up to the plane of the sacral floor, as far as possible to expand backwards, fully revealing the posterior wall of the maxillary sinus. Do not damage the infraorbital nerve at the top of the maxillary sinus. Through the wide maxillary sinus opening, the medial side of the fundus can be revealed and removed. 3. Excision of the anterior wall of the sieve and sphenoid Identify and protect the pre-screen and posterior stencil located at the top of the sieve. Fully reveal the inner side wall and the bottom of the raft. Surgery range: backwards to the tip of the eye, it is best to recognize the optic canal, reveal the frontal crypt, and see the frontal sinus opening; down to the upper edge of the inferior turbinate; outward to reveal the paper template. At this time, the middle turbinate can be removed to fully reveal the inner wall of the ankle, and it is beneficial for surgical care. 4. Under the 30° endoscope, use a small curette, a blunt nerve hook or a small ethmoid sinus to remove the ethmoid paper sample. When removing the broken bone piece, the direction should be inward, taking care not to damage the periosteum. 5. Excision of the ethmoid paper plate to the top plane of the sieve, followed by the zinn ring of the apex (where the bone is thickened, the extraocular muscle originates from the Zinn ring, the optic nerve passes through the Zinn ring), and the anterior to the tear bone. The lacrimal sac can be revealed, but not cut; the inner wall of the iliac fossa should be preserved to avoid stenosis and occlusion of the frontal sinus opening. The sacral bone is thicker than the sieving paper sample, and the operation range is limited when it is removed, so it is difficult. You can use a different angle of the maxillary sinus ring spoon or curette to apply a force at 30° or 70° endoscopically to fracture the posterior aspect of the infraorbital nerve and then remove it. The infraorbital nerve is the external part of the retina, and the inferior wall is removed posteriorly to the tip of the palate. 6. After fully exposing the fascia to remove the broken bone pieces, use the sickle knife to cut the periosteum from the back to prevent the fat from escaping the line of sight. When cutting the periosteum, do not insert the tip too deep, do not damage the sputum, pay special attention not to damage the medial rectus. 7. From the ethmoid sinus, down to the bottom of the sputum to make several parallel incisions from the posterior and posterior, and cut the periosteum. In the sacral floor, the lateral incision should be made first, then the medial incision should be made. In the iliac crest, the upper incision is made first, and then the lower incision is made to prevent the sputum fat from affecting the surgical field. 8. The periosteum between the incisions can be removed with an angled sinus occlusion forceps. The band was cut with a sickle knife so that the sputum fat was fully exfoliated to the ethmoid sinus and maxillary sinus. In order to judge the degree of decompression in the iliac crest, the operator can gently touch the eyeball, and at the same time observe the fluctuation of the sputum content in the surgical field under the endoscope. 9. The range of bone resected during surgery includes the stenosis of the inside of the incision and the inside of the infraorbital tube. For severe eye, you can also add Krolein lateral decompression for better decompression. After the operation, the eyes are wrapped, not filled with nasal cavity, or gently filled with a gelatin sponge containing antibiotics. complication 1. Cerebrospinal fluid rhinorrhea. 2. Meningitis. 3. Double vision and loss of vision (damaged nerves or blood vessels supplying the optic nerve and retina). 4. Infection within the sputum. At present, endoscopic transnasal decompression is still in the exploratory stage, and should be operated by experienced physicians and continuously sum up experience. In 1994, Metson et al reported the surgical results of endoscopic decompression of 22 patients in 14 patients, 16 of whom underwent lateral decompression (external incision). The average eyeball retraction after simple endoscopic decompression was 3.2±1.1mm (24.5mm). After endoscopic decompression and external decompression, the average eyeball retraction was 5.6±1.7mm (28mm).