{"id":"29e3296f-e2ce-4b15-8af7-2d3369a6a534","slug":"transorbital-neuro-endoscopic-surgical-resection-of-right-orbital-cyst-and-frontal-sinus-reconstruction","title":"Transorbital neuro-endoscopic surgical resection of right orbital cyst and frontal sinus reconstruction","authors":["Gardashkhan Karımzada","Royal Mehdiyev","Tabriz Mammadov","Demet Evleksiz","Adem Dogan","Mehmet Can Ezgu","Abuzer Güngör"],"abstract":"Background: This video illustrates a minimally invasive neuroendoscopic transorbital technique used for the removal of a right orbital cyst accompanied by frontal sinus reconstruction. The approach enables a direct and efficient corridor to orbital and anterior skull base lesions, reducing the need for brain retraction while ensuring both functional and aesthetic benefits. Case Description: A 38-year-old male patient presented with progressive exophthalmos, double vision, and elevated intraocular pressure caused by a right orbital cyst. Radiological evaluation reveals a thick-walled cystic formation with hyperintense signal intensity on T1- and T2-weighted images. IV contrast-enhanced magnetic resonance ımaging was performed. No contrast enhancement was observed in the lesion. The lesion measures 35 × 30 × 26 mm and appears to be connected to the frontal sinus. Preoperative images showed that the lesion destroyed the frontal sinus and was connected to it. Eyebrow incision was preferred for intraoperative assessment of the frontal sinus to facilitate resection of the lesion within the frontal sinus and surgical maneuvers and reconstruction within the frontal sinus. Through a transorbital endoscopic route, the surgical team performed orbital rim drilling, complete cyst excision, and frontal sinus reconstruction using autologous fat graft material. Orbital rim drilling was performed at the orbital entrance within the skin incision margins, with the bone resection amount not exceeding 5 mm. The purpose of orbital rim drilling is to widen the endoscopic field of view and facilitate the maneuverability of surgical instruments. This did not cause any cosmetic problems. A 0° rigid endoscope and standard endoscopic endonasal surgical instruments were used. The postoperative period was uneventful, and the patient experienced immediate correction of exophthalmos. The histopathological evaluation was reported as an epidermoid cyst with hemorrhage. At the 4-week follow-up, eye movements and intraocular pressure were normal, and diplopia had completely resolved. Conclusion: The transorbital endoscopic approach represents a safe, efficient, and cosmetically favorable option for treating orbital cystic lesions. It provides excellent visualization of the surgical field with minimal invasiveness, allowing for rapid recovery and optimal cosmetic outcomes. This experience underlines the versatility and clinical usefulness of this technique in properly selected cases. Clinical Presentation (00.10- 00.28) Neurological exam (00.29- 00.48) Neuro-imaging findings (00.49-01.37) Rationale for the procedure (01.37- 01.49) Risks of the procedure and its potential benefits (01.50- 02:06) Alternatives and why they were not chosen (02.07- 02:35) Description of the Setup (02.36- 02:50) Key surgical steps (02.55- 03.07) Step by step surgical procedure (03.07-06.50) Patient position: (03.07- 03.11) Skin incision (03.14-03.25) Transorbital Stage. (03.26-06.15) Cadeveric Demonstration (04.06-04.15) Cadeveric Demonstration (05.00-05.06) Reconstruction Stage (06.15-06.50) Disease Background (06.51-07.32) A brief review of clinical and imaging outcome (07.33- 08.20) This video shows the excision of an orbital cystic lesion associated with the anterior cranial fossa and reconstruction of the frontal sinus with minimally invasive surgery using an endoscopic transorbital approach. The 38-year-old male patient developed swelling in his right eye approximately 1 year ago, and double vision (diplopia) has appeared in the past 2 months. The patient’s eyelid remained open during sleep, and he frequently experiences conjunctivitis attacks. There is no history of trauma or sinus infection Physical examination revealed painful eye movements and limited upward and outward gaze. Exophthalmos and diplopia were present. Visual field and pupil examination were normal. Increased pressure was observed in the right eye. Magnetic resonance ımaging evaluation revealed a hyperintense lesion located in the superior-lateral aspect of the right orbit with a connection to the frontal sinus. In the coronal sections, the mass was observed to push the eyeball inferiorly and laterally. The computed tomography scan showed that this lesion caused destruction at the base of the anterior cranial fossa and the base of the frontal sinus. Preventing neural and muscle injury due to compression, improvement in cosmetic issues due to exophthalmos, relief of symptoms and improvement in quality of life. Risks of the procedure are damage to the extraocular muscles, periorbital injury, nerve injury, and visual impairment. The potential benefits of this procedure include a minimally invasive procedure, short surgery time, short hospital stay, rapid recovery, and wide surgical field control. We have alternative surgical techniques for approach this lesion, such as percutaneous needle aspiration, microsurgical transcranial microscopic approach, endoscopic endonasal approach, and endoscopic transorbital approach. Percutaneous needle aspiration was not preferred due to the high risk of recurrence; the endoscopic endonasal approach was not preferred as it would limit access to the lateral compartment of the cyst; the transcranial approach was not preferred as it is a larger approach and requires extensive tissue damage. The patient was placed in the supine position under general anesthesia. Head flexion and rotation were achieved. The head was secured with head holder. It consists of surgical equipment, 0° rigid endoscope, and standard endoscopic endonasal pituitary surgery instruments. Periorbita retraction Cyst aspiration and capsule peeling Cyst capsule and mucocele removing from frontal sinus The patient was placed in supine position under general anesthesia and the head was rotated 10° to the right side and fixed with a head holder. The TV screen is on the head side of the patient. Both surgeons are positioned opposite each other. Preoperative images showed that the lesion destroyed the frontal sinus and was connected to it. Eyebrow incision was preferred for intraoperative assessment of the frontal sinus to facilitate resection of the lesion within the frontal sinus and surgical maneuvers and reconstruction within the frontal sinus. After 5 mL of jetokain (lidocaine+epinephrine) injection, an eyebrow incision was made. The skin layers were retracted superiorly and inferiorly. Then periosteal incision was made and the orbital rim was exposed. The periorbital was separated from the orbital rim and the cyst was ruptured. We did orbital rim drilling. This gave us a working angle toward the frontal base. The cadaveric dissections illustrate that the right-sided endoscopic transorbital approach to the skull base with 0° endoscope. A “C-”shaped working corridor was created. Irrigation and suction were performed inside the cyst. The cyst capsule was peeled over the periorbita. The cyst capsule was then dissected from the upper orbital wall with a curette. It was seen that the floor of the anterior fossa and the floor of the frontal sinus were destructed by the cyst. The cadaveric figure illustrates the transcranial view of the connection of the cyst with the frontal sinus and anterior cranial fossa. It was observed that the cyst capsule was connected to the frontal sinus. The cyst capsule was disconnected from the frontal sinus and resected. A mucocele was observed in the frontal sinus and suction was performed. Then, the sinus mucosa was peeled. Irrigation and hemostasis were performed. No cerebrospinal fluid (CSF) leakage was observed. Subcutaneous fat tissue was removed from the right lower abdomen at the umbilical level. Frontal sinus pockets were filled with fat tissue. Spongostan was placed on the fat tissue. Then, fat tissue was laid on the borders of the dura in the defect in the anterior cranial fossa and supported with spongostan. A Penrose drain was placed in the cavity. The skin was primarily closed with Prolene. Total operation time is 45 min from skin incision. Endoscopic transorbital approach is a minimally invasive surgery for orbital and skull base pathologies. Compared to conventional approaches in selected skull base pathologies, it has advantages such as short operative time, rapid recovery, absence of cerebral cortex retraction, and short hospital stay. Endoscopic transorbital surgery offers superiority in orbital cystic masses causing damage to the skull base, cyst resection with minimal eyeball retraction, skull base repair, and prevention of cerebrospinal fluid fistula. Cosmetic results are more satisfactory. Transorbital neuro-endoscopic surgical resection of right orbital cyst and frontal sinus reconstruction.[ 1 – 14 ] The patient’s exophthalmos resolved immediately after surgery. Ice was applied around the eye 15 min/h for 36 h. The drain was removed after 18 h. No CSF fistula was observed. The patient was discharged 24 h postoperatively with prophylactic artificial tear drops and systemic antibiotics. Edema around the eye peaked between 24 and 72 h and then regressed. Diplopia was absent and the visual field was normal at 4-week follow-up. Proptosis was completely resolved. Intraocular pressure was normal. There was no limitation in eye movements. Artificial tear drops were discontinued because there was no dry eye. No complications were observed. As this case presentation is a retrospective case report, it does not require ethics committee approval. The patient was thoroughly informed that the current surgical images, personal information, and the patient’s face would be clearly shared. An informed consent form was signed stating that the patient’s data and face would be clearly shared in the video, and the participant in the case presentation gave permission for their images to be published. Institutional Review Board approval is not required. The authors certify that they have obtained all appropriate patient consent. There are no conflicts of ınterest. The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI. https://doi.org/10.25259/SNI_1086_2025 The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/placeholders/specialty/skull-base.png","publishDate":"2026-01-16T00:00:00.000Z","doi":"10.25259/SNI_1086_2025","categories":["Skull Base","Video Abstract"],"fullTextUrl":"https://surgicalneurologyint.com/wp-content/uploads/2026/01/14236/SNI-17-28.pdf"}