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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 35-37

Endoscopic orbital transposition for inverted papilloma in an unusually large supra orbital ethmoidal cell

1 Consultant ENT Surgeon, SUT Pattom Hospital, Thiruvananthapuram, Kerala, India
2 Smriti ENT Clinic, Chennai, Tamil Nadu, India
3 Pragathi ENT Clinic, Chennai, Tamil Nadu, India

Date of Submission25-Aug-2020
Date of Acceptance30-Jan-2021
Date of Web Publication03-Jul-2021

Correspondence Address:
Dr. Mariappan Vivek
Smriti ENT Clinic, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aiao.aiao_13_20

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The management of inverted papilloma involving frontal sinus and supraorbital ethmoidal cells is still challenging even for the well-trained rhinologists. These cases sometimes require an external approach, but now with the technique of endoscopic orbital transposition many such cases are handled effectively endonasally. Here in our case report, we are describing an unusually large supraorbital ethmoidal cell, which has pneumatized all the way above the orbit, from the frontal sinus to the anterior clinoid process and hence with the optic nerve lying inside this cell. We will be describing how we still could tackle this endoscopically with the modified endoscopic Lothrop and orbital transposition.

Keywords: Endoscopic modified Lothrops procedure, inverted papilloma, orbital transposition, supraorbital ethmoidal cell

How to cite this article:
Felix V, Vivek M, Narendrakumar V. Endoscopic orbital transposition for inverted papilloma in an unusually large supra orbital ethmoidal cell. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:35-7

How to cite this URL:
Felix V, Vivek M, Narendrakumar V. Endoscopic orbital transposition for inverted papilloma in an unusually large supra orbital ethmoidal cell. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Oct 7];5:35-7. Available from: https://www.aiaohns.in/text.asp?2021/5/1/35/320569

  Introduction Top

As per the international frontal sinus working group anatomy classification (IFAC),[1] supraorbital ethmoidal cell is defined as an anterior ethmoidal cell that pneumatises around, anterior to or posterior to the anterior ethmoidal artery over the roof of the orbit. However, these cells were described much earlier by many authors, though the descriptions were not so accurate as of the IFAC classification.

Van Alyea described about 70 years ago about the frontal cells and he called them as frontal group of the ethmoidal labyrinth or ethmofrontal cells. The supraorbital ethmoid cell in development extends superolaterally between the usual boundaries of the lamina papyracea and the roof of the ethmoid to pneumatize the orbital plate of the frontal bone.[2] Cryer in 1906 called them supra orbital sinuses.

On the sagittal computed tomography (CT) scan images, frontal bullar cell (FBC) and supraorbital ethmoidal cell (SOEC) had a similar appearance. The difference in the two types of cells was the degree of frontal pneumatization. On coronal CT images, the SOEC was lateral to the frontal sinus, while the FBC was medial to the frontal sinus.[3]

It typically arises from the anterior ethmoid cell group, although it may arise in the posterior ethmoids. The degree of pneumatization and thus the size of the cell may vary. On occasion, even more than one supra-orbital ethmoid cell may be present.[4]

David W. Jang and Stilianos E. Kountakis in 2014 published their work that SOEC is a consistent landmark for endoscopic identification of anterior ethmoidal artery.[5] They described the SOEC as an ethmoidal cell immediately posterior and lateral to frontal ostium with lateral pneumatization beyond the plane of most medial aspect of lamina papyracea. As per their pioneering work, the anterior ethmoidal artery lies posterior to the ostium of the supraorbital ethmoidal cell. Most other work on the relationship of these two structures suggests the same. However, as per the latest IFAC definition, SOEC can pneumatize anterior to or posterior to the anterior ethmoidal artery.

The frontal sinus is an anatomically challenging region, both functionally and aesthetically: Its anterior wall gives shape to the forehead, while its posterior wall encloses the frontal lobes, i.e., the ventral edge of the anterior cranial fossa. Inverted papilloma involving the frontal sinus represents only 2.5% of all cases[6] and has been traditionally managed through external transcranial approaches. Nowadays, the endoscopic endonasal technique is considered the gold standard approach for the treatment of sinonasal Schneiderian papillomas.[7]

  Case Report Top

A 55-year-old male patient, came to us with complaints of the right nasal block and right frontal headache for 10 years, gradual onset slowly progressive.

Examination revealed a pinkish proliferative mass in the right nasal cavity and biopsy of the same was done in the outpatient department endoscopy room, which was reported as inverted papilloma.

CT paranasal sinuses shows that there is disease involving the right frontal sinus and an unusually large right SOEC, the disease has extended partly into the left frontal sinus and right nasal cavity.

CT [Figure 1] and [Figure 2] also clearly shows the very unusual huge SOECs on both sides and the right SOE cell involved by inverted papilloma had the anterior and posterior ethmoidal arteries and even the optic nerve lying inside the cell; as this cell has pneumatised all the way above the orbit, from the frontal sinus to the anterior clinoid process.
Figure 1: (a-d) Computed tomography scan para nasal sinuses showing lesion involving frontal sinus (*), ethmoidal sinus (^) and supra orbital ethmoidal cell as in (d)

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Figure 2: Computed tomography scan para nasal sinuses showing lesion involving supra orbital ethmoidal cell extending over the optic nerve and anterior clinoid process

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We did a Modified Endoscopic Lothrop's procedure and to remove the pathology from the lateral corners of the frontal sinus and SOEC, we did the orbital transposition [Figure 3] and [Figure 4].
Figure 3: (a-d) Intra operative pictures of Modified Endoscopic Lothrop's procedure. (a and b) Orbital transposition, (c and d) showing frontal sinus (*); supra orbital ethmoidal cell (^); right optic nerve in optic canal (#)

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Figure 4: Intra operative picture showing pneumatisation of supra orbital ethmoidal cell extending to optic nerve (#) and anterior clinoid process (>)

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  Discussion Top

The paper on SOEC published by Nikhil J Bhatt in 2004, suggests that in very few cases with the more posterior extension of supraorbital ethmoidal cell the posterior ethmoid artery was exposed.[8] Probably, this was the only paper which suggests that rarely even the posterior ethmoidal artery may be related to SOEC.

However, there is not any description of a SOEC being related to the optic nerve, as in our case. Our patient as depicted by the scans had a huge SOEC which had the ethmoidal arteries and optic nerve lying inside the cell. This added to the challenge to find the optic nerve inside the SOEC filled with the tumor.

James K Liu published his article titled Modified Hemi-Lothrop procedure for supraorbital ethmoid lesion access in 2012, where he suggested that a Draf 3 approach would be necessary to address mucocele in a large SOEC.[9] However, to address a tumor-like inverted papilloma even a Draf 3 was not sufficient in our case, as we were not able to address the pathology in the lateral aspect of SOEC and frontal sinus with a Draf 3 alone. Hence, we widened our approach by using endoscopic orbital transposition.

Endoscopic orbital transposition was described by Prof Castelnuovo in this paper published in 2015 Endoscopic endonasal orbital transposition to expand the frontal sinus approaches.[10] This technique needs superomedial orbital wall decompression with preservation of the periorbital integrity which allows lateral dislocation of the orbital content, making the surgeon able to reach further in the lateral recess, thanks to a combined Draf type IIb or Draf type III frontal sinusotomy. As a consequence, inverted papilloma arising in the frontal sinus, laterally to a sagittal plane passing through the lamina papyracea, may no longer be considered as an absolute contraindication to EEA. In his paper, it is described that inverted papillomas with or without dysplasia with extension into SOEC need orbital transposition.[11]

  Conclusion Top

Inverted papillomas of the frontal sinus extending far lateral can very well be managed with Endoscopic endonasal approach by adopting Modified Lothrop's and Orbital Transposition even if there is an unusually large SOEC involving the optic nerve.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wormald PJ, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, et al. The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS). Int Forum Allergy Rhinol 2016;6:677-96.  Back to cited text no. 1
Van Alyea OE. Ethmoid labyrinth: Anatomic study, with consideration of the clinical significance of its structural characteristics. Arch Otolaryngol Head Neck Surg 1939;29:881-90.  Back to cited text no. 2
Zhang L, Han D, Ge W, Tao J, Wang X, Li Y, et al. Computed tomographic and endoscopic analysis of supraorbital ethmoid cells. Otolaryngol Head Neck Surg 2007;137:562-8.  Back to cited text no. 3
Glenowen R Jr., Kuhn F. Supraorbital ethmoidal cell. Otolaryngol Head Neck Surg 1997;16:254-6.  Back to cited text no. 4
Jang DW, Lachanas VA, White LC, Kountakis SE. Supraorbital ethmoid cell: A consistent landmark for endoscopic identification of the anterior ethmoidal artery. Otolaryngol Head Neck Surg 2014;151:1073-7.  Back to cited text no. 5
Bhatt NJ, Yardimci S. Supraorbital ethmoidal cell: Anatomical prevalence and surgical significance. Otolaryngology – Head and Neck Surgery 2004;131:P52.  Back to cited text no. 6
Lawson W, Patel ZM. The evolution of management for inverted papilloma: An analysis of 200 cases. Otolaryngol Head Neck Surg 2009;140:330-5.  Back to cited text no. 7
Karligkiotis A, Bignami M, Terranova P, Gallo S, Meloni F, Padoan G, et al. Oncocytic schneiderian papillomas: Clinical behavior and outcomes of the endoscopic endonasal approach in 33 cases. Head Neck 2014;36:624-30.  Back to cited text no. 8
Friedel ME, Li S, Langer PD, Liu JK, Eloy JA. Modified hemi-lothrop procedure for supraorbital ethmoid lesion access. Laryngoscope 2012;122:442-4.  Back to cited text no. 9
Karligkiotis A, Pistochini A, Turri-Zanoni M, Terranova P, Volpi L, Battaglia P, et al. Endoscopic endonasal orbital transposition to expand the frontal sinus approaches. Am J Rhinol Allergy 2015;29:449-56.  Back to cited text no. 10
Pietrobon G, Karligkiotis A, Turri-Zanoni M, Fazio E, Battaglia P, Bignami M, et al. Surgical management of inverted papilloma involving the frontal sinus: A practical algorithm for treatment planning. Acta Otorhinolaryngol Ital 2019;39:28-39.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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