Endonasal Endoscopic Transfrontal Approach and Periorbital Suspension for Management of Supraorbital Cholesteatoma Extending to the Middle Fossa and Temporal Muscle

Background: We present a unique case with a giant supraorbital cholesteatoma with posterolateral extension, who underwent endonasal endoscopic resection. The aim of this video is to discuss possibilities of transfrontal endoscopic approach and periorbital suspension to reach far lateral areas along the skull base. Material: A 49-year-old female had a 1-year history of proptosis. Imaging studies demonstrated a mass at left frontal sinus and supraorbital area with extra-axial extension and bony erosions, which was pushing the globe and optic nerve inferiorly, and frontal lobe posteriorly, extending far back to the middle fossa and temporal muscle. Endonasal endoscopic transfrontal surgery was performed through Draf III procedure. By sacrificing anterior ethmoidal artery which enables periorbital suspension, a wide opening was achieved to evacuate and washout cholesteatoma debris and resect the matrix as much as possible. Result: Using periorbital suspension technique it was possible to visualize and reach every corner of the giant cholesteatoma cavity by angled optics and instruments. Like in a radical cavity surgery it was possible to remove all debris and leave a large frontal opening. Postoperative MRI showed aeration of the cavity. There were no intraoperative complications and no recurrences during the 27-month follow-up. Conclusion: In suitable cases like this one, Draf III procedure and ligation of anterior ethmoidal artery that enables periorbital suspension let us reach and manipulate lesions going posterolateral in the frontal sinus and leave adequate drainage pathway for cavity aeration and future controls.