|Year : 2014 | Volume
| Issue : 2 | Page : 125-129
Pedicled lateral orbitotomy: A new technique and a case report
Lingaraj Balihallimath, Umesh Harkuni, Sarvesh Urologin, Vikram Pandit, Tejraj Kale
Department of Oral and Maxillofacial Surgery, KLE's V.K. Institute of Dental Sciences, KLE's Prabhakar Kore Hospital andResearch Centre, Belgaum, Karnataka, India
|Date of Web Publication||7-Jan-2015|
Dr. Lingaraj Balihallimath
Department of Oral and Maxillofacial Surgery, KLE's V.K. Institute of Dental Sciences, Nehru Nagar, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
A number of pathologies is encountered in inaccessible areas of head and neck region such as lesions in the cranial base, orbital or deep nasal cavities and also in deep spaces of the neck. The diagnosis of such deep lesions has been revolutionary due to the advance in technologies in the field of radiology. The surgical treatment of these lesions poses a significant challenge to the operating surgeon due to anatomic complexity, difficulty in access, and surrounding vital structures. A team approach is often necessary for complete removal of the pathologies without damaging the vital structures. Access osteotomies are routinely performed for improved access to such lesions. In this, osteotomy of the maxillofacial skeleton is carried out, and repositioning of the bony skeleton is done after removal of the associated lesion. Lateral orbital osteotomies are used for improved access to deep orbital tumors. After original description of this technique by Kronlein, various modifications have been introduced by different surgeons. We present a new technique of lateral orbital osteotomy in which a pedicle is maintained for improved blood supply and faster healing of the osteotomized segment. This osteotomy technique provided satisfactory exposure of the lesion and was fixed with miniplates resulting in esthetic reconstruction of the facial morphology and function. This method enabled us to decrease the morbidity and hastens healing without compromising on the advantage of good access.
Keywords: Access osteotomy, lacrimal gland, pedicled osteotomy, pleomorphic adenoma
|How to cite this article:|
Balihallimath L, Harkuni U, Urologin S, Pandit V, Kale T. Pedicled lateral orbitotomy: A new technique and a case report. Indian J Health Sci Biomed Res 2014;7:125-9
|How to cite this URL:|
Balihallimath L, Harkuni U, Urologin S, Pandit V, Kale T. Pedicled lateral orbitotomy: A new technique and a case report. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2019 May 19];7:125-9. Available from: http://www.ijournalhs.org/text.asp?2014/7/2/125/148817
| Introduction|| |
Lateral orbitotomy originally was popularized by Kronlein  in 1888. Basic and conventional approach to superolateral orbital lesions is lateral orbitotomy. ,,,,,, It provides excellent access to deep lesions in the subperiosteal, peripheral, or intraconal space lateral to the optic nerve. Lateral approach can be further extended posteriorly by drilling the sphenoid wing to allow access to posterolateral lesions. 
Historically, an exploratory orbitotomy, often with removal of the lateral orbital wall, and subsequent fixation with plating, frequently was required to establish a diagnosis in patients with proptosis and a presumed orbital mass. Although deeper orbital lesions may require access by either lateral orbitotomy with removal of the lateral wall, transcranial orbitotomy with removal of the orbital roof, medial orbitotomy with removal of the ethmoid sinus (medial orbital wall), or inferior orbitotomy with removal of the orbital floor. Modifications in the incision and osteotomy have been proposed to increase the access. We report a new technique of lateral orbitotomy to decrease morbidity, hasten healing and mean time maintaining the advantage of good access.
| Subjects and Methods|| |
A 45-year-old female patient presented with a complaint of swelling and protrusion of right eye since 2 months. The swelling was gradually increasing in size, painless and no associated vision changes. Clinically the swelling at superolateral region on right eye was diffused, firm to hard in consistency and nontender on palpation. Overlying upper eyelid was free from the mass underneath. The right eyeball was deviated downward and medially with drooping of the upper eyelid. Patient had exophthalmos, but neurological examination including visual acuity was within normal limits [Figure 1].
Axial computed tomography revealed a laterally situated, well-circumscribed, solid extraconal tumor which was measuring 2 cm × 2.5 cm 2 in size. The tumor mass was extending from the lacrimal fossa to posteromedially and posterolaterally displacing the globe downward. There was no evidence of bony erosion. The left eye was within normal limits [Figure 2].
|Figure 2: Axial computed tomography scan showing extraconal tumor in lacrimal fossa|
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The incision begins in the upper lid crease below the brow parallel to the orbital rim and crosses the lateral orbital rim (modified Stallard-Wright lateral orbitotomy incision). Skin flaps are undermined to expose the temporalis muscle which is attached to the lateral orbital wall. The orbital rim was exposed on the superolateral, lateral and inferolateral and the temporalis muscle fiber attachment maintained on the lateral part of the orbital wall. The lateral canthal tendon is elevated from Whitnall's tubercle, and the periorbita is elevated to the level of the inferior and superior orbital fissures. Two separate osteotomy cut are made on the lateral orbital rim, one superior to the frontozygomatic suture line, and another at the root of the zygomatic arch on the zugomatic bone. The upper osteotomy cut is carried across the orbital rim and downwards along the lateral orbital rim inferior to frontozygomatic suture [Figure 3], [Figure 4], [Figure 5]. On the medial side, osteotomy cut runs downwards till the frontozygomatic suture in the orbit. The inferior osteotomy crosses the orbital rim with an angulation at the origin of the zygomatic arch on the zygomatic bone. Medially the cut enters the orbit to reach thin lateral orbital wall made by the zygomatic bone [Figure 3] and [Figure 4]. At this point, the osteotomized segment at the lateral wall is out fractured and mobilized keeping the temporalis muscle attachment to the osteotomized segment [Figure 6]. Lesion was extraconal, firm and blunt dissection carried out to achieve a clean, bloodless dissection of the mass [Figure 7]. The lesion is excised [Figure 9] with precautions to maintain the pedicle intact [Figure 8]. The periorbita is closed, and the lateral orbital rim is plated into position, and the lateral canthal tendon is reattached with sutures and reconstruction done with miniplates [Figure 10]. Skin incision was closed in layers leaving a minimal scar [Figure 11]. Histopathological diagnosis was compatible with pleomorhic adenoma of lacrimal gland.
|Figure 4: Osteotomy cut on the medial side of the lateral wall of the orbit on a model skull|
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|Figure 5: Intraoperative orbititomy cuts superior to the frontozygomatic suture area|
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|Figure 6: Intraoperative pedicled ostetomy of lateral orbit exposing the tumor|
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|Figure 7: Intaoperative dissection of tumor medial to the temporalis pedicle attachment|
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|Figure 8: Intaoperative osteotomized segment along with temporalis pedicle attachment after the excision of the tumor|
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| Discussion|| |
Epithelial neoplasms represent approximately 30% of the lesions of the lacrimal gland. The most common epithelial tumors are, in order of descending frequency, pleomorphic adenoma (benign mixed tumor), adenoid cystic carcinoma and adenocarcinoma. ,,,,,,
The typical age at presentation of the patient with pleomorphic adenoma is 30-40 years. The tumor is firm with a lobulated surface. The orbital lobe of the lacrimal gland is most commonly involved.  The clinical presentation of the benign neoplasm of the lacrimal gland is characterized by painless palpable mass, slow growth and displacement of the globe off axis. ,,,,,, The tumor tends to extend backward and may cause proptosis, ophthalmoplegia, and choroidal folds.  Less commonly, the tumor arises from the palpebral lobe. It tends to grow anteriorly, does not displace the globe, and produces early visible swelling of the upper eyelid. The crucial aspect of management of all lacrimal gland tumors is to suspect pleomorphic adenoma. Radiographic findings often show demonstrable enlargement of the lacrimal fossa without any bony destruction. Although this tumor is histologically benign, incomplete excision is likely to result in recurrences, leading to the increased orbital dysfunction and even malignant transformation.  In our case, palpable mass was located in the superolateral region of the right orbit. Patient had exophthalmos, but neurological examination including visual acuity was within normal limits. There was drooping of upper eyelid with inferomedial displacement of the globe.
Lateral orbitotomy originally was popularized by Kronlein  in 1888. Hemangiomas, dermoids, and other common tumors tend to occur in the lateral orbit, and this approach is the standard in dealing with these tumors. In 1888, Kronlein described a limited resection of the lateral orbital wall that subsequently was modified by Berke  to create a larger opening (6-7 cm 2 ) to provide greater access to the orbit. With the removal of the deeper bone of the greater wing of the sphenoid, exposure can be as deep as the superior orbital fissure  and to posterolateral lesions.  Nevertheless, intraconal orbital tumors with well-demarcated margins, lateral localization may be removed with lateral orbitotomy. ,
Orbital rim could be removed from supraorbital notch to attachment of the zygomatic arch without any complication since there are no neural or vascular attachments to rim. Additional bone removal from posterolateral cone should be determined according to lesion size and position with respect to the orbital rim cone. In our case, we have modified this lateral orbitotomy by maintaining the pedicle attached to the osteotomized segment. Once the ostetomy is carried out the osteotomized segment with the temporalis muscle pedicle is retracted laterally to access the orbit. This modification provides adequate access to the lesions with minimal dissection of the tissues from the bony segment.
The lateral orbitotomy incision described by Kronlein in 1888 revolutionized orbital surgery because it enabled the surgeon to access the retrobulbar compartment. This incision, however, left an unsightly scar over the temple. Stallard popularized the S-shaped under-brow lateral orbitotomy incision that was initially described by Cirincione in 1901. In 1907, Rollet reported the first anterior orbitotomy, which involved making an incision beneath the brow and dissecting subperiosteally in order to gain entry into the orbit.  Subsequently, a number of other superior skin incisions have been devised to allow exposure of the bony lateral orbital wall and access to the lateral retrobulbar space. ,,, Currently, the lateral wall is most often approached through either a canthotomy incision (modified Berke),  or an upper eyelid crease incision extending into a lateral "laugh line" to carefully preserve the frontal branch of the facial nerve.  Rarely, a coronal incision in the hairline with subgaleal dissection of a scalp flap carried down to the lateral rim is useful. ,
Undoubtedly, lateral orbitotomy approach is the preferred method in the surgical management of suspected pleomorphic adenoma of lacrimal gland. Modified technique of lateral orbitotomy maintaining the pedicle attachment advocated by us can decrease morbidity, hasten healing and in the mean time maintaining the advantage of good access. This method can further be evaluated in future infeasible cases.
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