5-STEPS TECHNIQUE FOR THE ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION (EEOD)
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1 5-STEPS TECHNIQUE FOR THE ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION (EEOD) Ranko MLADINA, MD, PhD ENT Dept. Univ. Hospital Rebro Zagreb University Croatia Mladina 1
2 Prof. Dr. RANKO MLADINA ENT Dept., Univ. Hospital Rebro, KBC Zagreb 5 STEPS Head, Referral Centre for Rhinosinusology & Endoscopic Sinus Surgery Ministry of Health & Social Care Republic of Croatia Mladina 2
3 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION 1st STEP: IDENTIFICATION OF THE SPHENOIDAL SINUS OSTIUM & THE ANTERIOR WALL OF THE SPHENOIDAL SINUS Mladina 3
4 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 4
5 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 5
6 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION 2nd STEP: IDENTIFICATION OF THE MAXILLARY SINUS OSTIUM & FORMATION OF THE MIDDLE ANTROSTOMY Mladina 6
7 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 7
8 ONODI CELL!!! Mladina 8
9 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION 3rd STEP: ANTERIOR & POSTERIOR ETHMOIDECTOMY Mladina 9
10 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 10
11 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION 4th STEP: THE REMOVAL OF THE LAMINA PAPIRACEA Mladina 11
12 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 12
13 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 13
14 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 14
15 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 15
16 MLADINA retrograde elevator (Karl Storz Comp.) Mladina 16
17 Mladina 17
18 Mladina 18
19 Mladina 19
20 Mladina 20
21 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION 5th STEP: LONGITUDINAL INCISIONS OF THE PERIORBITAL SAC Mladina 21
22 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Mladina 22
23 Mladina 23
24 Mladina 24
25 INSTEAD OF CONCLUSIONS Mladina 25
26 Mladina 26
27 PREOP 1st POSTOP DAY Mladina 27
28 Mladina 28
29 Mladina 29
30 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Preop 1 st post-op day 12 th post-op day Mladina 30
31 OCULO-CARDIAL CARDIAL REFLEX!!! COMPLICATIONS!!! Mladina 31
32 Definition Immediate cardiac dysrithmia and hypotension caused by stimulation of the anatomical structures inervated by the branches of the ophthalmic nerve Belongs to the group of vegetative trigemino-vagal reflexes As all other reflexes, consists of afferent and efferent arms Mladina 32
33 Afferent arm The branches of the ophthalmic nerve for the sensitive inervation of the orbital and periorbital anatomical structures Mladina 33
34 Efferent arm Ncl.dorsalis n.vagi N.vagus (preganglionic fibers) Plexus cardiacus Postganglionic fibers Mladina 34
35 OCR appears more frequently in: children because of physiological vagotonia (surgery for strabismus) females anxious persons persons with the history of cardiac desease surgical procedures that include traction of the medial rectus muscle (EEOD!) Mladina 35
36 TREATMENT Stop the stimulus (usualy enough) Exalt the po 2 level Apply atropine (intravenous) Mladina 36
37 WHY SHOULD WE EXPECT GOOD RESULTS? IS THERE ANY EVIDENCE? Before EEOD After EEOD p VISUAL ACUITY PROPTOSIS (mm) IOP (mmhg) 0.81± ±0.21 < ± ±2.6 < ± ±3.0 <0.001 mean±sd Mladina 37
38 PROPTOSIS before and after the surgery Expectations PREOP POSTOP 5 0 prije EEOD nakon EEOD Proptosis (Hertel) Preop Postop decrease of proptosis (mm) milimeters ± ± Mladina 38
39 Other clinical characteristics of the patients suffering from Graves' ophthalmopathy before and after EEOD RETRACTION OF UPPER EYELID RETRACTION OF LOWER EYELID EXPOSURE KERATITIS Before EEOD After EEOD p < < <0.001 Mladina 39
40 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION DIPLOPIA NON-PREOPERATIVE (48%) PREOPERATIVE DIPLOPIA (52%) Mladina 40
41 NON-PREOPERATIVE (48%) No postop-diplopia at all 87% Transient diplopia (up to seven days) 7% Permanent diplopia 6% Mladina 41
42 PREOPERATIVE DIPLOPIA (52%) Diminishing of previously existing diplopia 1% Disappearance of previously existing diplopia 4% Unchanged previously existing diplopia 14% Agravated previously existing diplopia 81% Mladina 42
43 ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION Indications: Graves disease ( Retrobulbar hemathoma Retrobulbar tumors Optic nerve decompression disease (dysthyroid orbitopathy) Mladina 43
44 Mladina 44
Revision endoscopic orbital decompression in the management of Graves orbitopathy
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