Sinh thiết dây thần kinh dưới hốc mắt - Biospy of infra orbital nerve

Enlargement of the infraorbital nerve can occur for a number of reasons. Recently, the finding of an enlarged infraorbital nerve with orbital inflammation has been found to be suggestive of Ig4-related disease. In any patient with a history of a cutaneous squamous cell carcinoma, enlargement of the infraorbital nerve should make one suspicious of perineural spread. Biopsy of the nerve will result in some hypoesthesia. In this case, a full-thickness section of the nerve is biopsied. Alternatively, one could take a strip or longitudinal biopsy of the nerve.

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This video demonstrates biopsy of the infraorbital nerve. The patient has a history of an unknown skin cancer on the cheek. The patient has noted some hypoesthesia on the cheek and imaging showed an enlarged infraorbital nerve. Biopsy is being performed to investigate perineural invasion of the presumed carcinoma. A 4-0 silk suture is placed through the lower eyelid at the level of the tarsus. The needle tip cautery is then used to make an incision inferior to the inferior border of the tarsus. Dissection is carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Once the inferior orbital rim is identified the needle tip cautery is used to make an incision through the periosteum. The Freer periosteal elevator is then used to elevate the periosteum from the orbital floor. The infraorbital nerve can usually be visualized along the orbital floor. The thin bone can be gently peeled up with a Freer and then rongeurs are used to remove the bone overlying the infraorbital nerve. The nerve is then transected posteriorly. Cautery should be applied prior to doing this due to the vascular structures associated with the nerve. The nerve can then be excised. The trans-conjunctival incision is then closed with 7-0 Vicryl sutures. Due to the risk of bleed in this patient, a drain is being placed. Dissection is carried out laterally to accommodate the drain. The lateral cantholysis is repaired by suturing the tarsus of the lower lid to the lateral tarsus of the upper lid. The lateral canthotomy incision is closed with interrupted 7–0 Vicryl sutures. The drain is placed to active suction, as demonstrated.