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Case Series Volume 18 Issue 2
Combined transpalpebral and endonasal approach for the treatment of frontal sinus, orbital, and supraorbital cell pathology: evaluation of surgical exposure
Federica Fernandez Long, Micaela Redivo, Carlos Santiago Ruggeri
Received: September 07, 2026 | Published: September 24, 2026
Citation: Long FF, Redivo M, Ruggeri CS. Combined transpalpebral and endonasal approach for the treatment of frontal sinus, orbital, and supraorbital cell pathology: evaluation of surgical exposure. J Otolaryngol ENT. 2026;18(2):74‒79. DOI: 10.15406/joentr.2026.18.00591
Abstract
Objective: To determine whether a combined transpalpebral and endonasal surgical approach allows adequate exposure of the frontal sinus (medial and lateral sectors), the supraorbital cells, and the orbital roof, and to evaluate the cosmetic outcome of the superior palpebral incision. Study design: Descriptive, retrospective, observational case-series study, reported following the PROCESS guidelines. Level of evidence IV . Methods: Preoperative coronal computed tomography scans were analyzed, and the frontal sinus was divided into a medial and a lateral sector using a vertical line drawn at the level of the supraorbital pedicle. During surgery, the degree of exposure obtained in the medial and lateral frontal sinus, the supraorbital cells, and the orbital roof was assessed separately using a predefined four-category ordinal scale, applied by the operating surgeon. The cosmetic outcome of the palpebral incision was assessed by the surgical team using an ordinal scale, without independent or patient-reported evaluation. Results: Seven patients treated for inflammatory/infectious disease of the frontal sinus, supraorbital cells, or orbit were included: five presented with a superior subperiosteal orbital abscess and two with complicated frontal sinusitis originating in the supraorbital cell. All patients underwent a transpalpebral approach combined with a Draf II or III endonasal frontal drainage procedure. Exposure of the medial and lateral frontal sinus, orbital roof, and supraorbital cells, when involved, was rated adequate (+++) in all cases by the operating team. The cosmetic outcome of the transpalpebral incision was satisfactory in all patients. Two of the seven patients — both with disease originating in the supraorbital cell — experienced recurrence at that site and required revision surgery consisting of a transpalpebral approach with resection of the cell mucosa and fat obliteration (“mini-obliteration”). One patient with allergic fungal rhinosinusitis had an intraoperative cerebrospinal fluid leak during endonasal removal of allergic mucin adherent to the dura, which was repaired intraoperatively with an intracranial fat graft and an extracranial septal mucosal graft, with no reported postoperative sequelae. Median follow-up was 18 months (range 12–84 months). Conclusion: In this small, retrospective case series, the combined transpalpebral and endonasal Draf-type approach was technically feasible and provided adequate surgical exposure of the lateral frontal sinus, orbital roof, and supraorbital cells, with a satisfactory cosmetic outcome. Two of seven patients with supraorbital cell disease developed recurrence requiring revision surgery, and one patient had an intraoperative cerebrospinal fluid leak that was successfully repaired. Given the small sample size, heterogeneous etiology, absence of a comparison group, and unblinded assessment of outcomes, these findings should be regarded as hypothesis-generating; whether this combined approach reduces the need for more invasive procedures compared with alternative techniques cannot be determined from this series and requires evaluation in larger, prospective, comparative studies.
Keywords: frontal sinus, frontal sinusitis, orbital abscess, transpalpebral approach, endoscopic sinus surgery, Draf III, supraorbital ethmoid cell
©2026 Long, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.