Transcaruncular Approach With Orbital Protection for Resection of Sinonasal Lesions: How I do it

Background Minimally invasive techniques for the resection of sinonasal masses have become increasingly important over the past few decades. Sinonasal disease involving the lamina papyracea remains difficult to manage given the risk of injury to critical orbital structures and hemorrhage from nearby vessels. Objective Detail the transcaruncular approach with orbital protection for the resection of benign and malignant sinonasal pathologies. Methods Description of surgical technique and presentation of 2 representative cases that were successfully managed with this surgical technique. Results The transcaruncular approach involves incising the lateral 1/3 of the caruncle in a vertical plane between the upper and lower puncta. Dissection is then carried through the retrocaruncular fascia posterior to Horner's muscle to the posterior lacrimal crest along the medial orbital wall. Dissection can then be performed in a subperiosteal or supraperiosteal plane with subsequent ligation of the anterior ethmoidal artery. Once dissected, a nylon sheet used for orbital reconstruction and colored orbital shield can then be placed to aid in protection and visualization or orbital contents during endonasal tumor resection. Conclusion The transcaruncular approach with orbital protection provides intraoperative protection of the orbital contents, allowing for safer removal of the mass irrespective of integrity of the lamina papyracea.