Combined Endonasal-Transorbital Approach to Manage the Far Lateral Frontal Sinus: Surgical Technique

In recent decades, the ever-expanding use of endoscopes and development of dedicated instrumentation have reshaped the panorama of surgical approaches to the frontal sinus.¹ Nonetheless, the far lateral portion of the sinus might still represent a concern, especially in cases with unfavorable or distorted anatomy.^2,3 We report the case of a 52-year-old man, referred to our department for recurrent episodes of left orbital swelling and supraorbital headache, 3 months after Draf III frontal sinusotomy for marsupialization of multiple frontal mucoceles. Computed tomography and magnetic resonance imaging scans were consistent with persistent inflammatory tissue in the far lateral left frontal sinus. Revision surgery was performed, adopting a combined endonasal orbital transposition³ and superior eyelid transorbital approach.^4,5 The postoperative course was uneventful, and the microbiologic and histologic examinations demonstrated noninvasive Aspergillus fumigatus infection. The radiologic control showed patency of the frontal recess and complete clearance of the sinus. The patient is asymptomatic after 16 months (Video 1). The transorbital approach is effective in managing orbital and frontal sinus diseases,⁶ and the combination with the endonasal route grants complete access to the frontal sinus, even in cases of high pneumatization and lateral extension.^4,7 Multiportal transorbital approaches represent additional techniques in the rhinologist's surgical armamentarium, which can overcome the limits of a single port approach.^8,9 Reports on their use providing technical hints and critical considerations are to be encouraged to ease and stimulate the surgical training in this field.