Technical Nuances: Indications for Transorbital Compared to Endoscopic Endonasal Approach

While there is overlap between areas of anatomic access provided by the endonasal and transorbital approaches, several considerations based on anatomy and pathology are key determinants. Inherently, the surgical view with the endonasal approach is (infero)medial to lateral, and vice versa for transorbital approaches. The endonasal approach is bound by the medial orbit in the coronal plane and the frontal sinus in the sagittal plane. The transorbital approach has several variations, and its anatomic limits are dependent on the approach, pathology, and surgeon familiarity. Common pathologies addressed include meningioma, schwannoma, hemangioma, sinonasal cancers and encephaloceles. Control of critical neurovascular structures, access to the neoplastic epicenter and borders, safe anatomic access, pathology relation to the internal carotid artery and orbit, and reconstruction options are important considerations when selecting an approach. In particular cases, staged surgeries with both approaches or multi-portal approaches should be considered.