Endoscopic Endonasal Repair of Orbital Floor Fracture

ORIGINAL ARTICLE Endoscopic Endonasal Repair of Orbital Floor Fracture

Katsuhisa Ikeda, MD; Hideaki Suzuki, MD; Takeshi Oshima, MD; Tomonori Takasaka, MD

Background: High-resolution endoscopes and the ad- (mean age, 24 years). These patients had undergone pri- vent of endoscopic instruments for sinus surgery pro- mary repair of pure orbital blowout fractures and were vide surgeons with excellent endonasal visualization and followed up at least 6 months after surgery. access to the orbital walls. Results: There were no intraoperative or postoperative Objective: To demonstrate repair of orbital floor blow- complications. Nine patients showed a complete im- out fractures through an intranasal endoscopic ap- provement of their diplopia. Two patients with poste- proach that allows repair of the orbital floor fracture and rior fractures showed persistent diplopia, which was well elevation of the orbital content using a balloon catheter managed by prisms. without an external incision. Conclusion: Endoscopic repair of the orbital floor blow- Design: This study was a retrospective analysis of 11 out fracture using an endonasal approach appears to be a patients who underwent surgical repair of orbital floor safe and effective technique for the treatment of diplopia. fractures from September 1994 to June 1997. There were 10 male patients and 1 female patient, aged 12 to 32 years Arch Otolaryngol Head Neck Surg. 1999;125:59-63

HE ORBITAL floor blowout RESULTS fracture is characterized by the involvement of Demographic and clinical patient pro- only the wall of the orbit files are given in the Table. There were with an intact orbital rim1 no intraoperative or postoperative com- Tafter blunt trauma. Medial orbital wall plications. All patients had some improve- fractures are known to occur concomi- ment in their diplopia by 2 weeks. Based tantly with floor fractures.2 Recent clini- on the degree of diplopia, scores of 0 to 3 cal studies have recommended prompt (severe = 3, moderate = 2, slight = 1, none = surgical repair in patients with large frac- 0) were assigned in each field of gaze. A tures (Ͼ50% of the orbital floor) and in total score of 27 was possible. In 8 pa- those with disability diplopia or enoph- tients, the diplopia in all fields of gaze was thalmos of greater than 2 mm, or both, almost completely resolved by 2 months. 10 to 14 days after trauma.3-6 Surgical Three patients continued to have slight ver- repair of the blowout fracture includes tical diplopia in the reading position the transorbital approach and transantral (Figure 2). Computed tomographic find- approach. High-resolution endoscopes ings and endoscopic observations during and the advent of endoscopic instru- surgery indicated that the patients with ments for sinus surgery can now provide persistent diplopia after surgery had pos- the surgeon with excellent endonasal terior fractures with entrapped extraocu- visualization and access to the orbital lar muscles. Six months after surgery, 1 of walls.7-10 Yamaguchi et al11 first reported these 3 patients had no diplopia in any po- the application of an endoscopic endona- sition whereas the other 2 patients with sal technique to the reconstruction of a residual diplopia in the primary gaze could From the Department of blowout fracture of the medial orbital obtain good alignment with the use of Otorhinolaryngology, Tohoku wall. We report herein the surgical repair prisms. University School of Medicine, of orbital floor fractures using an endo- All patients showed a notable im- Sendai, Japan. scopic endonasal approach. provement in results of the Hess screen test

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 PATIENTS AND METHODS was used. With both local and general anesthesia, theop- erative site was injected with 1% lidocaine hydrochloride with 1:100 000 dilution epinephrine,and the nose was This study was a retrospective analysis of 11 patients un- packed with epinephrine-soaked (1:5000 dilution) cotton dergoing surgical repair of orbital floor fractures from Sep- pads and gauzes. An infundibulectomy was first per- tember 1994 to June 1997. There were 10 male patients and formed, whereby the medial infundibular wall was 1 female patient, aged 12 to 32 years (mean age, 24 years). removed with a sickle knife. The uncinate process was These patients had undergone primary repair of pure or- then subluxed medially and removed with forceps. The bital blowout fractures and were followed up at least 6 maxillary ostium was generously enlarged to provide opti- months after surgery. One patient showed a combined frac- mal exposure of the orbital floor. A 30° or 70° endoscope ture of both medial and inferior walls, whereas the infe- was used to identify the orbital floor fracture. The region rior wall was involved in the other 10 patients. Preopera- of the orbital floor fracture was carefully skeletonized tive and postoperative orthoptic measurements were using curved forceps. Bony fragments and periorbita, recorded. Forced duction testing was performed before and which entrapped the orbital contents, were minimally after surgery. removed and opened, respectively, until improvement of The indications for surgery included disabling diplo- forced duction testing during surgery. A ureteral balloon pia 2 weeks after trauma and large fracture size as deter- catheter was inserted into the maxillary sinus through the mined by computed tomographic scans and/or magnetic ostium. Eight to twelve milliliters of physiological saline resonance images. At the time of surgery, all patients had solution was introduced into the balloon at the tip of the restriction in forced duction testing. Surgical repair of catheter, which elevated the orbital contents out of the blowout fractures was performed in 3 patients under local fracture depression (Figure 1). The catheter was anesthesia and in 8 patients under general anesthesia. Sur- removed 10 to 14 days after surgery. When removal of the gery was performed with the patient’s head slightly catheter resulted in an exacerbation of diplopia or enoph- elevated. The head was turned slightly toward the sur- thalmos, the catheter was left in the maxillary sinus for an geon. For topical anesthesia, 4% lidocaine hydrochloride additional few days.

A B C

Figure 1. The endoscopic endonasal approach to the orbital blowout fracture. A, Enlargement of the maxillary natural ostium. B, Removal of bony fragments and opening of periorbita entrapped by the orbital contents. C, Insertion of the ureteral balloon catheter into the maxillary sinus through the ostium and elevation of the orbital contents.

after surgery. Figure 3 shows typical charts of the pre- images in a representative case, in which the right operative and postoperative Hess screen test in a repre- orbital contents are prolapsed from the orbital floor. sentative case. The postoperative image (Figure 5) demonstrates that Postoperative computed tomographic scans or the extruded orbital contents were effectively resolved magnetic resonance images were not obtained routinely and that the inferior rectus returned to a more normal since they all showed steady clinical improvement. position, consistent with the resolution of the patient’s Figure 4 shows preoperative magnetic resonance diplopia.

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Patient No./ Mechanism Site of Clinical Medical Time From Trauma Type of Follow-up, Sex/Age, y Side of Injury Fractures Findings Therapy Until Operation, d Anesthesia mo 1/M/12 R Fight OF D, EE, O S 14 G 6 2/M/32 L Assault OF D, E, H S 15 L 8 3/M/30 L Assault OF D, H None 47 L 6 4/M/14 R Fight OF D S 23 G 7 5/M/13 L Fight OF D, E S 42 G 6 6/F/38 L MVC OF D, EE S 27 L 8 7/M/26 L Softball OF D, EE S 21 G 6 8/M/17 R Football OF D, EE None 25 G 8 9/M/34 R Snowboard OF D S 20 G 6 10/M/29 R MVC OF D S 24 G 8 11/M/19 R MVC OF, LP D, EE, O None 20 G 10

*R indicates right; L, left; MVC, motor vehicle crash; OF, orbital floor; LP, lamina papyracea; D, double vision; EE, eyelid ecchymosis; O, ophthalmoplegia; E, enophthalomos; H, hypesthesia to the infraorbital nerve; S, corticosteroid; G, general anesthesia; and L, local anesthesia.

25 Left Right

20 S S

15 M L M L

I 10

Symptomatic Score I

5 A

0 Preoperative Postoperative

Figure 2. Preoperative and postoperative scores of diplopia. S S

L M L M

I I COMMENT The advent of endoscopic techniques has greatly en- B hanced surgeons’ ability to operate on orbital structures through the nose. Orbital decompression,7 drainage of Figure 3. Preoperative (A) and postoperative (B) Hess screen test results in a subperiosteal abscess,9 endoscopic dacryocystorhinos- representative case. S indicates superior; I, inferior; M, medial; and L, lateral. tomy,10 and optic nerve decompression11 can be safely and effectively performed without external incision. Endo- scopic endonasal repair of orbital floor fractures affords ery et al14 failed to show a significant difference in the the surgeon excellent visualization for safe removal of incidence of enophthalmos between the surgical and non- bony fragments and correction of periorbita in the or- surgical groups. During the past decade, many studies3-6 bital floor. In contrast to the transantral approach, the have advocated early surgical exploration in patients with endoscopic approach avoids postoperative infraorbital large fractures and in those with disabling diplopia or en- nerve hypesthesia. Another advantage of the endo- ophthalmos. scopic approach is that it results in less intraoperative The excellent visualization of the fractured orbital blood loss and shorter hospitalization than the transan- floor provided by the endoscope may enable better tral and transorbital approaches. Because implants of sili- manipulation than that afforded by the naked eyes. cone sheets or metallic mesh to support the orbital con- The fracture location is one of the important factors tent are not needed, inflammatory reactions against foreign that determines the persistence of diplopia. The bodies are reduced. inferoposterior orbital fat tissue is fibrous and dense There is a controversy about the timing of surgical with connective tissue septae that attach to the extra- repairs for blowout fractures. Smith and Regan12 advo- ocular muscles.13 If this residual fat is trapped by a cated surgical repair of any blowout fracture within 7 to posterior floor fracture, diplopia may easily result.6,15 10 days. On the other hand, Putterman13 recommended One of 3 cases with a posterior floor fracture in this delaying surgery for at least 4 to 6 months. Similarly, Em- study could be repaired under endoscopic control.

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Figure 4. Preoperative magnetic resonance images in a representative case at the level of the anterior ethmoid (A) and the posterior ethmoid (B).

A B

Figure 5. Postoperative magnetic resonance images in a representative case at the level of the anterior ethmoid (A) and the posterior ethmoid (B).

The use of the endoscope may improve the success and reduced intraoperative and postoperative compli- rate of surgical repairs of diplopia even in cases of pos- cations. terior floor fracture. In conclusion, we performed surgical repair of Accepted for publication September 29, 1998. orbital floor fractures using an endoscopic endonasal Reprints: Katsuhisa Ikeda, MD, Department of Oto- approach. The endoscopic approach provided better rhinolaryngology, Tohoku University School of Medicine, visualization of the fractured structures of the orbital 1-1 Seiryomachi, Aoba-ku, Sendai 980-8574, Japan (e- floor, enabled meticulous manipulation of the repair, mail: [email protected]).

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