title: Two- versus four-handed techniques for endonasal resection of orbital apex tumors.
abstract: BACKGROUND
  Open versus endonasal resection of orbital apex (OA) tumors is generally based on tumor size, location, and pathology. For endonasal resection, two- and four-handed techniques have been reported, but whether one technique is more optimal based on these tumor features has not been evaluated.
  
  
  OBJECTIVE
  To determine whether two- versus four-handed techniques result in better outcomes after endoscopic resection of OA tumors, and whether either technique is better suited for intra- versus extraconal location and for benign versus malignant pathology.
  
  
  METHODS
  A retrospective review of all expanded endonasal approaches for OA tumors was performed at a single institution from 2009 to 2013. A PubMed database search was also performed to review series published on endonasal OA tumor resection. Across all the cases reviewed, the following data were recorded: two- versus four-handed techniques, intra- versus extraconal tumor location, and benign versus malignant pathology. The relationship between these variables and resection extent was analyzed by the Fisher exact test. Postoperative visual status and complications were also reviewed.
  
  
  RESULTS
  Ten cases from the institution and 94 cases from 17 publications were reviewed. Both two- and four-handed techniques were used to resect extra- and intraconal OA tumors, for both benign and malignant pathology. Four-handed techniques included a purely endonasal approach and a combined endonasal-orbital approach. On univariate analysis, the strongest predictor of complete resection was benign pathology (p = 0.005). No significant difference was found between the extent of resection and a two- versus a four-handed technique. Visual status was improved or unchanged in 94% of cases, and other complications were rare.
  
  
  CONCLUSIONS
  Benign tumors that involve the medial extraconal and posterior inferomedial intraconal OA can be treated by either two- or four-handed endonasal techniques. Selecting two- versus four-handed techniques and endonasal versus endonasal-orbital four-handed techniques depends mainly on surgeons' experience. Endonasal approaches for malignant OA tumors are less likely to result in complete resection.
authors.affiliation: 1Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: John R
authors.initials: JR
authors.lastname: Craig
authors.forename: John Y K
authors.initials: JY
authors.lastname: Lee
authors.forename: Dmitriy
authors.initials: D
authors.lastname: Petrov
authors.forename: Sonul
authors.initials: S
authors.lastname: Mehta
authors.forename: James N
authors.initials: JN
authors.lastname: Palmer
authors.forename: Nithin D
authors.initials: ND
authors.lastname: Adappa
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009666:Nose; D009918:Orbital Neoplasms / Q000175:diagnosis / Q000601:surgery*; D013517:Otorhinolaryngologic Surgical Procedures / Q000379:methods*