Dysthyroid orbitopathy is autoimmune inflammation of thyroid diseases such as Graves' disease. It causes proptosis, eyelid swelling, diplopia and visual loss. Treatment with corticosteroids and orbital irradiation is usually applied to sustain the activity of inflammatory phases. An indication of orbital decompression surgery or eyelid surgery should be considered in the severe or ineffective cases, and in patients who want cosmetic or rehabilitative surgery.

　We here introduce indications and the outcomes of endoscopic transnasal orbital decompression techniques together with a survey of the literature review. The surgical dissection begins with total ethmoidectomy with complete skeletonizing of the medial orbital wall including the lamina papyracea followed by removing the medial portion of the orbital floor with the preservation of the inferior-medial strut. Two or three horizontal incisions are sharply made in the periorbital periosteum alongside the superior and inferior margins of the medial rectus muscle. The orbital contents are then manually prolapsed into the space in the ethmoid and the maxillary sinuses.

　We so far experienced a total of 14 surgeries (orbits) on 6 patients. All patients reported improvement in their subjective eye symptoms after decompression. The mean reduction in proptosis was 2.6mm (range 0.5-5.5mm). In two patients who suffered visual loss due to compressive optic neuropathy, visual acuity remarkably improved after orbital decompression. Postoperatively, one patient reported improvement of diplopia, whereas one patient reported worsening of his existing diplopia.

　Endoscopic transnasal orbital decompression has become popular in western countries since it was first introduced in 1990. We consider that the procedure provides both good cosmetic and functional outcomes for Japanese, while minimizing postoperative complications. It also provides otolaryngologists with collaborative contribution for the treatment in symptomatic orbitopathy patients.

　A 37-year-old female patient visited our hospital with the chief complaints a history of pulsating tinnitus and a gradually enlarging mass in the right posterior pinnacle. CT Angiography was performed via the right external carotid artery, and based on the findings, the patient was diagnosed as having arteriovenous malformation; the main feeding arteries were the posterior auricular artery, occipital artery, and superficial temporal artery. We performed vascular embolization and resected the lesion, as it was a localized superficial tumor and could be completely extracted, and any bleeding was completely controlled by the embolization. At the time of the resection, fluorescence microscopy using ICG was performed to reconfirm the feeding arteries. Thus, the AVM could be completely extracted with little hemorrhage. At present, about 50 months since the surgery, the patient has shown evidence of relapse.

　Venous malformations are common in the head and neck region, but are relatively rare in the sinuses. We report a case of venous malformation (old nomenclature; cavernous hemangioma) that occurred in the maxillary sinus and manifested as repeated nasal bleeding. A 16-year-old man visited our hospital with the chief complaint of nose bleeds. There was no significant past medical history. Accurate identification of the bleeding point was difficult, but we suspected bleeding from the back of the right uncinate process. Hemostasis was accomplished by cauterization. Six days later, the patient again developed a nose bleed, and it was difficult to control the bleeding this time. Intranasal examination revealed no significant findings, such as mass lesions. Because of the atypical findings in respect of the bleeding site and amount of bleeding, imaging examinations were for evaluation. Contrast-enhanced CT suggested the presence of a mass lesion in the right maxillary sinus. Contrast-enhanced MRI revealed a tumor with a well-defined border showing contrast enhancement. Based on the finding of the contrast enhancement effect persisting until the delayed phase, we suspected venous malformation.

　Therefore, tumor resection by Endoscopic Sinus Surgery (ESS) was scheduled, after angiography. Angiography identified the feeding vessels as the right sphenopalatine artery and descending palatine artery. After selective vascular embolization, the right anterior ethmoid sinus and maxillary sinus were opened by the ESS approach. The tumor was found in the maxillary sinus and removed. There was little bleeding during the surgery, the histopathological diagnosis was venous malformation, and the postoperative course was satisfactory.

　Nasal bleeding is a commonly encountered symptom by otolaryngologists. It could be caused by a hyper vascular tumor, as in the case reported herein, or by organic diseases, such as coagulation disorders. We consider that imaging studies should definitely be performed in patients presenting with atypical nasal bleeding.