Brazil

MD Aldo Stamm

MD São Paulo

PhD João Flávio Nogueira

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Otolaryngology–Head and Neck Surgery (2009) 141, 794-795CASE REPORT
Orbital cavernous hemangioma: Transnasal
endoscopic managementAldo Stamm, MD, PhD, and João Flávio Nogueira, MD, São Paulo, BrazilNo sponsorships or competing interests have been disclosed for
this article.
Cavernous hemangiomas (CHs) are the most commonintraorbital tumors found in adults.1 Although histo-
logically benign, they can encroach on intraorbital or adja-
cent structures and be considered anatomically or position-
ally malignant.1,2
Most of these tumors are unilateral and can increase
intraorbital volume with a resultant mass effect. Visual
acuity or field compromise, diplopia, and extraocular
muscle or pupillary dysfunction can result from compres-
sion of intraorbital contents. The morbidity associated
with orbital CH is the threat of compressive optic neu-
ropathy, extraocular muscle dysfunction, and cosmetic
disfigurement.1,2
Most orbital CHs require no intervention, but espe-
cially when there is visual compromise, surgery is indi-
cated. The approach is dictated by tumor location within
the orbit. The typical described approaches are lateral or-
bitotomy, transconjunctival, and frontotemporal.1-3 We
present a case of an orbital CH with visual compromise and
its transnasal endoscopic surgical management.
A 33-year-old male presented with a six-month history
of a progressive left visual loss that had worsened during the
last month. He did not present with proptosis, eye move-
ment limitations, or any other complaints. After a complete
ophthalmologic evaluation, he performed an eye campim-
etry that showed severe decrease of left visual acuity.
An MRI showed an intraorbital mass that filled up ho-
mogeneously on gadolinium, at the left orbital apex, with
approximately 8 mm on its largest axis, compressing the left
orbital nerve, and with close relationship with extraocular
muscles (Fig 1).
After a careful preoperative evaluation with CT to ana-
lyze the orbital cavity and its relationship with the paranasal
sinus, and an arteriography to analyze the blood vessel
supply to the tumor, an endoscopic transnasal resection of
the lesion was proposed.
After IRB approval and the patient’s informed consent,
the surgery was performed. A left maxillary antrostomy and
a complete left ethmoidectomy were performed. The leftReceived March 11, 2009; revised May 7, 2009; accepted May 14, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Nec
doi:10.1016/j.otohns.2009.05.018sphenoid sinus ostium was identified and carefully opened
to avoid any unnecessary bleeding. The patient presented an
Onodi cell that was opened in order to identify the optic
nerve channel.
After a large exposure, the left internal carotid artery, left
orbital nerve, optic-carotid recess, and papyracea lamina
were all identified. A diamond bur was used to remove the
bone and expose these structures. The periorbit was opened
and orbital fat and the medial rectus muscle were identified.
After careful dissection, the lesion was identified, re-
moved with sharp cutting instruments, and sent for patho-
logic examination (Fig 2). The nasal cavity was packed with
hemostatic reabsorbable material.
The surgery lasted approximately two hours and the
patient was discharged the day after the procedure, with
subjective improvement of his left visual acuity. Nasal
cleanings were performed to avoid any nasal obstruction or
infection, and another eye campimetry was performed one
week after the surgery that showed complete recovery of the
left visual acuity. No complications were observed.
Figure 1 T2-weighted MRI, axial view showing a hyperintense
mass at the orbital apex.k Surgery Foundation. All rights reserved.
795Stamm and Nogueira Orbital cavernous hemangioma: Transnasal endoscopic managementDISCUSSION
Patients who present with clinically significant CH usually
are middle-aged and have complaints of change in visual
acuity.1 A careful clinical history and review of symptoms
is paramount to formulate a list of differential diagnoses that
must include meningioma, fibrous histiocytoma, and he-
mangiopericytoma, among other orbital tumors. The radio-
logical and clinical features are the most important keys to
provide a preoperative diagnosis idea.1,2
Progressive and total homogeneous filling up of an or-
bital mass on gadolinium-enhanced MRI is a pathogno-
monic sign of CH.2 Most CHs are found between the optic
nerve and extraocular muscles within the intraconal space,
classically within the medial aspect of the orbit. They are
approached through an upper eyelid or a transcaruncular-
based medial orbitotomy. After adequate exposure, a well-
circumscribed purple encapsulated lesion is seen with dis-
tinct vessels on its surface. Gentle dissection allows for
en-bloc removal after all vessels have been identified and
cauterized with bipolar cautery.3-5
Although external approaches provide direct exposure
of the lesion, they are associated with significant mor-
bidity. There are very few reports of endoscopic transnasal
Figure 2 Endoscopic view with a 0-degree 5-mm endoscope of
the surgical field. (1) orbital cavernous hemangioma; (2) left in-
ternal carotid artery; (3) exposed optic nerve; (4) medial rectus
muscle.resection of intraorbital lesions, mostly because even withall the recent advances, the use of endoscopic techniques to
manage lesions beyond the paranasal sinus is still very
restricted.3-5
Transnasal endoscopic resection of intraorbital tumors is
feasible and may offer some advantages when compared to
traditional approaches. However, it is paramount to have
specialized instruments such as long handpiece drills, good
camera systems, and long bipolar forceps, as well as an
experienced endoscopic surgeon, to control vascular lesions
and potential life-threatening complications.
AUTHOR INFORMATION
From São Paulo ENT Center–Hospital Professor Edmundo Vasconcelos,
São Paulo, Brazil.
Corresponding author: João Flávio Nogueira, MD, Rua Martiniano de
Carvalho, 1049 – AP 195 C, São Paulo, Brazil.
E-mail address: joaoflavioce@hotmail.com.
AUTHOR CONTRIBUTIONS
Aldo Stamm, writer, reviewer; João Flávio Nogueira, literature review,
writer, and photo editing.
DISCLOSURES
Competing interests: None.
Sponsorships: None.
REFERENCES
1. Cohen AJ, Mercandetti M, Weinberg DA. Hemangioma, cavernous
(Aug 2008). Available at http://emedicine.medscape.com/article/
1218120-overview. Accessed March 11, 2009.
2. Wilms G, Raat H, Dom R, et al. Orbital cavernous hemangioma:
findings on sequential Gd-enhanced MRI. J Comput Assist Tomogr
1995;19:548–51.
3. Scheuerle AF, Steiner HH, Kolling G, et al. Treatment and long-term
outcome of patients with orbital cavernomas. Am J Ophthalmol 2004;
138:237–44.
4. Cheng JW, Wei RL, Cai JP, et al. Transconjunctival orbitotomy for
orbital cavernous hemangiomas. Can J Ophthalmol 2008;43:234–8.
5. Kiratli H, Bulur B, Bilgiç S. Transconjunctival approach for retrobulbar
intraconal orbital cavernous hemangiomas. Orbital surgeon’s perspec-
tive. Surg Neurol 2005;64:71–4.


Orbital cavernous hemangioma: Transnasal endoscopic management

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Orbital cavernous hemangioma: Transnasal endoscopic management

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