Clinical Manifestations and Computed Tomography Findings of Trapdoor Type Medial Orbital Wall Blowout Fracture

PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.

Endoscopic Transnasal versus Transcaruncular Reconstruction in Isolated Medial Orbital Wall Fractures

PURPOSE: To compare 2 surgical techniques, endoscopic transnasal reconstruction and transcaruncular reconstruction in isolated medial orbital wall fractures. METHODS: This study included 79 isolated medial orbital wall fracture patients from January 2011 to December 2012 of Department of Ophthalmology, Inha University Hospital. The authors compared computed tomographic scans, diplopia, extraocular muscle (EOM) movements, and Hertel's exophthalmometer exams pre- and post-surgery. Thirty-five patients received endoscopic transnasal reconstruction and 44 received transcaruncular reconstruction. RESULTS: The 2 surgical methods showed no significant differences in primary gaze diplopia (p = 0.50), restriction of EOM movements (p = 0.48), remaining enophthalmos of more than 2 mm (p = 0.99), and improvement in enophthalmos (p = 0.07) when compared 6 months after surgery. Statistically significant differences were observed in peripheral diplopia (p = 0.04) 6 months after surgery. CONCLUSIONS: The 2 surgical methods present similar effectiveness in postoperative primary gaze diplopia, EOM restriction, and enophthalmos. With respect to postoperative peripheral diplopia, endoscopic transnasal reconstruction method showed advantages. The surgical method should be selected by comparing advantages and disadvantages.

Anatomy and preliminary clinical applications of endoscopic endonasal approach to optic canal and orbit / 解剖学报

Objective To provide the endoscopic anatomic basis and anatomic parameters for endoscopic surgical therapy on orbital lesions , and to analyze the advantages and key points of this surgical approach .Methods Five fresh adult heads were used in this experiment .Endonasal thanslamina approach and endoscopic technique were applied to observe important anatomic marks while intraoperative medicalization of the medical rectus muscle was applied to observe the exposure and positioning of important structures and trends of the optic canal and intra orbit .Results Uncinate process was at the lower front corner of middle nasal concha; ethmoidalis bulla was behind the uncinate process , and ethmoidei sinus was reachable after an incision was made on ethmoidalis bulla;anterior ethmoidal artery and posterior ethmoidal artery were the important anatomic landmarks of the inner ethmoidei sinus;optic canal prominence , carotid artery prominence and OCR were the important anatomic landmarks of the inner sphenoid sinus; lamina papyracea was at the lateral wall of ethmoidei sinus , and orbital contents were approacchable after lamina papyracea was cut off ;inside orbit , the optic nerve was approachable through the gap between the medial rectus muscle and inferior rectus muscle .The ophthalmic artery of 9 out of 10 sides of the specimens was originated from the supraclinoidal segment of the internal carotid artery while the remaining one was originated from the cavernous segment of internal carotid artery .There were 7 sides in which ophthalmic artery was located at the inferior lateral of the optic nerve;there were 2 sides in which ophthalmic artery was located at the inferior of the optic nerve; the remaining one was located at the inferior medial of the optic nerve .Conclusion The endoscopic endonasal thanslamina approach can sufficiently expose the optic nerve and the structures in the medical space of the orbit.Uncinate process, ethmoid bulla, anterior ethmoidal artery, posterior ethmoidal artery and posterior ethmoid sinus are the important landmarks of the endoscopic endonasal thanslamina approach .Optic canal prominence , internal carotid artery prominence and OCR are the important landmarks for optic canal decompression .Ophthalmic artery , orbital branches , anterior ethmoidal artery , posterior ethmoidal artery , internal carotid artery are the important vessels . Medialization of the medial rectus muscle is effective to approach the orbital anatomical structures .

Outcomes of Isolated Medial Orbital Wall Fracture Reconstructions

PURPOSE: To evaluate surgical results after the reconstruction of isolated medial orbital wall fractures. METHODS: We performed a retrospective chart review of patients with isolated medial orbital wall fractures who underwent reconstruction using the transcaruncular approach from March 2012 to October 2013. Computed tomography (CT) was performed before and after surgery. Postoperative follow-ups were conducted at 1 week, 1 month, and 3 months. Diplopia, ocular motility, postoperative complication, and exophthalmometry were recorded at each follow-up visit. Preoperative and postoperative enophthalmos was quantified using Hertel exophthalmometry and a quantitative method for the area of the circular sector under the chord (CA)/orbital area (OA) ratio at the CT scan. Patients were divided into either the incomplete or complete reduction groups based on the degree of reduction observed on postoperative CT. RESULTS: We evaluated 55 patients (42 males, 13 females) with an average age of 36 years. Five of 55 patients with preoperative enophthalmos of more than 2 mm obtained good symmetry after surgery. Diplopia at primary gaze was resolved in 9 of 9 patients and 2 patients had residual diplopia on lateral gaze. The difference of exophthalmometry and CA-to OA ratio between before and after reconstruction was not significantly changed in either the incomplete or complete groups. CONCLUSIONS: Enophthalmos and diplopia were well corrected in all subjects. If reduction was successfully performed in the anterior portion of medial orbital wall fracture, clinically significant enophthalmos might be preventable even if complete reduction was not obtained.

Relation between enlarged volume of medial wall and degree of enophthalmos after orbital fracture / 中华医学美学美容杂志

Objective To explore the relation between the enlargement of orbital volume and the degree of enophthalmos, and that between the enlarged volume of floor together with that of medial wall and the degree of enophthalmos. Methods A total of 17 patients of unilarteral orbital fracture were scanned by MSCT (slice width 0.625mm), who suffered late enophthalmos as a results of combination fracture of the medial wall and floor. The clinical data were collected, and input into a software named MIMICS in order to measure orbital volume, the degree of enophthalmos, the enlarged volume of medial wall, and that of orbital floor. Simple linear correlation and regression were carried out between the enlargement of orbital volume and the degree of enophthalmos. Mutiple linear correlation and regression were carried out between the enlarging volume of floor together with that of medial wall and the degree of enophthalmos. Results The equation of the enlargement of orbital volume (V) and the degree of enophthalmos (E) was E= 0.851 V-0.197 (Pearson r=0.969, P＜0.01, the 95% confidence intervals of 0.732-0.970). The standardized equation between the enlarged volume of floor together with that of medial wall and the degree of enophthalmos was E= 0.690 VF+0.413 VM-0. 086 (setpwise, entry =0.5, removal= 0. 11,P＜0.01 ); Comparing the standardized coefficients of independent variables, the outcome was bF (0.690) ＞ bM(0.413). Conclusion Significant linear correlation between the increment of the orbital volume and the degree of enophthalmos is found that 1.0 ml enlargeement in bony volume causes approximately 0.9 mm of enophthalmos; enlarged volume of floor has more powerful influence on the degree of enophthalmos than enlarged volume of medial wall, the former is 1.56 times of the latter.

Inlay Grafting for the Treatment of the Posterior Comminuted Fracture of Medial Orbital Wall

PURPOSE: For blowout fracture of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomic reconstruction of the wall without surgical complications. Surgeons frequently worry about damage to the optic nerve from the dissection, when the part over the posterior ethmoidal foramen was fractured. The authors performed small incision and inlay grafting for reconstruction of medial orbital wall fracture. METHODS: Between January 2007 and April 2008, 15 out of 32 patients were included in an analysing the outcome of corrected medial orbital wall fracture. In 15 patients of posterior comminuted fracture of medial orbital wall, insertion of porous polyethylene(Medpor(R) channel implant, Porex, USA) to ethmoidal sinus was performed in multiple layer, through the transconjunctival approach (inlay grafting). RESULTS: In all cases, the orbital bone volume was reconstructed in its normal anatomical position. The associated ocular problems disappeared except for mild enophthalmos in 2 patients and there were no surgical complications associated with inlay grafting. CONCLUSION: The advantage of inlay grafting include anatomical reconstruction of the orbital wall; the avoidance of optic nerve injury; the simplicity of the procedure; and consequently, the absence of surgery-related complications. This technique is presented as one of the preferred treatments for posterior comminuted fracture of medial orbital wall.

A Case of Pseudo-Duane's Retraction Syndrome With Old Medial Orbital Wall Fracture

We report a case of pseudo-Duane's retraction syndrome with entrapment of the medial rectus muscle in an old medial orbital wall fracture presenting identical clinical symptoms as Duane's retraction syndrome. A 15-year-old boy presented with persistent limited right eye movement since a young age. Examination showed marked limited abduction, mildly limited adduction, and globe retraction accompanied by narrowing of the palpebral fissure during attempted adduction in the right eye. He showed a right esotropia of 16 prism diopters and his head turned slightly to the right. A slight enophthalmos was noted in his right eye. A computed tomography scan demonstrated entrapment of the medial rectus muscle and surrounding tissues in an old medial orbital wall fracture. A forced duction test revealed a marked restriction of abduction in the right eye. A 5 mm recession of the right medial rectus muscle was performed. Postoperatively, the patient's head turn and esotropia in the primary position were successfully corrected, but there was still some limitations to his ocular movement. The importance of several tests such as the forced duction test and an imaging study should be emphasized in making a diagnosis for limitation of eye movement.

The transcaruncular approach of the medial orbital wall fracture

Advantage of Middle Meatal Antrostomy in Transnasal Endoscopic Reconstruction of Medial Orbital Blow-out Fracture

PURPOSE: Blowout fracture is an outward fracture of the orbital wall. That usually occurs at inferior or medial wall of the orbit. The main pathophysiology is high intraocular pressure derived from impact of trauma. Among the four orbital wall, the medial wall is thinnest and most vulnerable to trauma. Many kinds of methods were introduced for correction of medial orbital wall fracture. Recently, transnasal endoscopic reconstruction methods were widely used. Endoscopic methods had many advantages. However, we experienced some cases of postoperative maxillary sinusitis. This study was planned to find out the effectiveness of middle meatal antrostomy after endoscopic reconstruction of medial orbital wall fracture. METHODS: This study was retrospective analysis of 28 patients who underwent transnasal endoscopic repair of medial orbital wall fracture. The 18 male and 10 female patients were ranged from 17 to 57 years of age(mean, 30.9 years). Among 28 patients, randomly selected 17 patients underwent middle meatal antrostomy as additional procedure by the same surgeon. After at least 12 months of follow-up period, we examined the nasal symptom, endoscopic and CT findings. RESULTS: One patient complained of nasal obstruction in middle meatal antrostomy group and four patients complained nasal symptoms in non middle meatal antrostomy group. On the endoscopic findings, three patients of non middle meatal antrostomy group had continuous nasal discharge. But middle meatal antrostomy group had no abnormal endoscopic findings. The abnormal CT finding(abnormal mucosal hypertrophy) were detected in four patient of non middle meatal antrostomy group. There were no abnormal CT findings in middle meatal antrostomy group. The data were statistically significant at comparative study. CONCLUSION: Authors think that the middle meatal antrostomy has some advantages as a additional procedure of endoscopic reconstruction of medial orbital wall fracture. Especially, it is good at preventing post- operative maxillary sinusitis. But, more larger group and strict application of disease entity are need for correct evaluation of middle meatal antrostomy effect.

The Transcaruncular Approach for the Reduction of Medial Orbital Wall Fracture

The evolution of surgical approaches to the medial orbit has been driven by the need to achieve safe, versatile, and direct access, while minimizing unwanted structural changes and scarring. Previous approaches such as medial skin incision or inferior transconjuntival incision have limited overview and may leave visible scar or lid retraction. Transcaruncular approach may successfully resolve such problems and maybe the first choice of method in reduction of medial orbit. The anatomy underlying the transcaruncular approach suggests that it offers the same excellent exposure of the medial wall as the Lynch approach. An incision through the caruncle and dense fibrous condensation passes along a natural plane between Horner's muscle and the medial orbital septum. So minimal bleeding occurs and can exposure the fracture site in the shortest time. We used this method in 22 patients for reduction of medial orbital wall fractures and it provides excellent surgical exposure, easy and rapid, and no visible scar remained.

Transcaruncular Approach to Blowout Fractures of the Medial Orbital Wall

Transcutaneous and transconjunctival approaches are still frequently used to repair orbital wall fractures. However, medial orbital wall fracture remains a challenging area for plastic surgeons due to technical difficulties and postoperative scars. The transcaruncular approach is described and we present our experience with this approach to access the medial orbital wall in 10 patients with blowout fracture in the medial orbital region. All patients were corrected satisfactorily without cutaneous scar. The transcaruncular approach is a useful technique to repair medial orbital wall fractures.

Management Of Medial Orbital Wall Fracture

Treatment of the Medial Orbital Wall Fracture using Transcaruncular Approach

Medial orbital wall fracture can easily be overlooked because typical clinical symptoms appear in only a few instances. However, if it is left untreated in case of no diplopia, cosmetically undesirable enophthalmos may develop. Various cutaneous approaches, previously used, may leave noticeable scar or provide a limited overview of the orbit medial wall fracture site. We used the transcaruncular approach in 36 cases of 35 patients for reconstruction of the medial orbital wall fracture. The incision was made at the junction of the medial 3/4 and lateral 1/4 of the caruncle, and extended along the conjunctival fornix superiorly and inferiorly to or beyond both puncta for 10 - 15 mm long respectively. After soft tissue was dissected, periosteum was incised at the posterior to the posterior lacrimal crest. Implants up to a height of 2.5 cm could be inserted.The diplopia was resolved in all cases after the surgery, and enophthalmos measured 0 to 2 mm in all patients. Postoperative computed tomographic scans showed favorable reduction of the herniated soft tissues and anatomic reduction of the medial wall without complication related to the surgical approach in all cases. Transcaruncular approach is a better alternative to transcutaneous incisions because it provides wide exposure of the medial orbital wall, no visible cutaneous scar, short operation time, and no damage of important internal structures.

Comparison of Computerized Tomography(CT) and Ultrasonography(US) in the Diagnosis of Nasal Bone Fracture and Medial Orbital Wall Fracture

For the diagnosis of nasal bone fracture and medial orbital wall fracture, plain radiography and computerized tomography(CT) have been utilized. But plain radiography is less reliable due to its low specificity. So CT has been given a preference to plain radiography in examining both fractures. However, CT has some disadventages; high expense, heavy radiation hazard, and coexistent injuries may restricted a patient,s positioning and so thus preventing or delaying the diagnosis. By comparison, ultrasonography(US) represents a safe, inexpensive, noninvasive, portable, and wide availability. This paper compares the relative values of CT and US in the diagnosis of both fractures. In nasal bone fracture, US proved to be more accurate than CT. Thirty-seven nasal bone fractures were diagnosed by US; whereas only thirty-two of these were revealed on CT. Compared with US, CT demonstrated 87% sensitivity. In examining medial orbital wall fracture, eight cases were diagnosed by CT; whereas seven of these were revealed on US. Compared with CT, US demonstrated 88% sensitivity. In medial orbital wall fracture, US was almost as accurate as CT. In this research, it is concluded that in the investigation of nasal bone fracture and medial orbital wall fracture, US is an accurate diagnostic modality and correlates well with CT.

Repair of Medial Orbital Wall Fracture

From March 1997 to August 2001, Titanium mesh screen 1.0 (SYNTHES(R)) were applied to the repair of 29 medial orbital fractures; 18 patients with orbital inferior wall fracture, 16 patients with nasal bone fracture and 6 patients with pure medial wall fracture. Clinically, the periorbital ecchymosis and subconjunctival hemorrage were sensitive indications of orbital wall fracture. Even though there are no sign of diplopia or enophthalmos, in cases of simple nasal bone fracture with periorbital ecchymosis and subconjunctival hemorage, the evaluations of medial orbital wall fracture were strongly recommended because the medial orbital wall fractures occurred frequently combined with simple nasal bone fractures. Titanium mesh screen 1.0 was used as onlay implant to fit the anatomical shape on the fracture portion needed to be reconstructed and 1.3mm microscrews (SYNTHES(R)) were used to fix titanium mesh screen. The patients were followed up for 18 months with no significant enophthalmos or diplopia.

Surgical Treatment of Medial Orbital Wall Fracture According to Proper Indication

Compared with orbital floor fracture, the frequency and significance of medial orbital wall fracture has been relatively ignored because of the lack of proper diagnosis and the difficulty of surgical approach. The surgical delay results to the troublesome complications like enophthalomos, extraocular muscle movement dysfunction. For the reason, it is necessary to measure the exact fracture part and bone defect size with CT scan, the ophthalmologic evaluation and the proper treatment for the indication. We operated on 17 medial orbital wall fracture patients with transnasal endoscopic approach, open reduction through minimal medial canthus incision(6-7 mm), or both methods according to the fracture type. We classified them into three types according to the degree of periosteal injury, the size of the bone defect and the degree of comminution with CT scanning and ophthalmologic evalution. In the case of Type 1, there is no herniation of orbital contents and periosteum is intact despite fracture. The patients of Type 1 can be treated by packing with Foley catheter, Merocel(R) sponge, etc. after bone reduction with transnasal endoscope. In the case of Type 2, which has the herniation of orbital contents and bone defect of approximately 1 cm or less in diameter with periosteum injury, after the bone defect site can be confirmed with an endoscope, the medial wall can be reconstructed by Titanium Mesh, silastic sheet or autogenous bone graft through minimal medial canthus incision. In the case of Type 3, the bone defect is over 1 cm in diameter accompanying comminuted fracture. The fractured medial wall of type 3 can be reconstructed with bone graft through coronal incision or open sky incision. Minor complications occurred in 7 patients but all patients were successfully treated without patient's complaints during the follow-up period of 6-18 months. In addition, the scar by minimal medial canthus incision is imperceptible. The indicaions make the fracture reduction easy and accurate. Especially, it is proper to pediatric patients and young female patients because it corresponds to minimal invasive Technique.

Repair of Orbital Wall Fracture Using Transcaruncular Approach

Transcutaneous and transconjunctival approaches are still the most frequently used techniques in repairing orbital wall fractures. However, medial wall fracture is still a challenging area to the oculoplastic surgeons due to technical difficulties and postroperative scars. Transcaruncular approach is an effective way to repair medial or combined medial and inferior orbital wall fractures without visible scars. Ten cases of orbital wall fractures are repaired using the transcaruncular approach alone or combined with transconjunctival approch. All patients were corrected satisfactorily without leaving any visible scar. We think transcaruncular approach is a useful technique to repair medial orbital wall fracture.

Clinical Analysis of Medial Orbital Wall Fractures / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Medial orbital wall fractures are seen in association with fractures of the orbital floor or more complex bony disruptions. It is important to diagnose and manage medial orbital wall fractures as early as possible, because of the possibility of functional orbital damage later. In this study, fractures were divided into the following types based on location and severity of injury according to Nolasco and Mathog: type I (confined to the medial orbital wall), type II (medial orbital wall continuous with floor, type III (medial orbital wall with floor-malar fractures), and type IV (medial orbital wall and complex midfacial injuries). MATERIALS AND METHODS: We reviewed 22 cases of medial orbital wall fractures according to the classification of Nolasco and Mathog at Soonchunhyang University Chunan Hospital. RESULTS: 1) Types of fractures observed were type I (9 cases), type II (10 cases), type III (2 cases), and type IV (1 case). 2) The most common age groups were the thirties and the fourties. The male-to-female ratio was 3:1, and more injuries were found at the left orbit. 3) Assault was the most common cause, as observed in 10 of 22 cases (45.5%), and types III and IV injuries only occurred in falls. 4) Diplopia was the most common symptom, as in 15 of 22 cases (68.2%). Ecchymosis and periorbital swelling were more common with type I; diplopia was more common with type II. 5) Type I fractures were generally explored through intranasal approach, whereas the other types were commonly treated with subciliary or Caldwell-Luc approach. SUMMARY: Medial orbital wall fractures were more common in type I and II, the male, and the left side. Commonly, type I fractures caused ecchymosis and periorbital swelling and were treated with conservative treatment. In most cases, type II fractures caused diplopia and were treated with surgery 1 or 2 weeks after trauma.

Endonasal Endoscopic Reduction of Blowout Fractures of the Medial Orbital Walls / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Until recently, blowout fractures (BOFs) of the medial orbital walls were treated using external approach. With recent advances in endoscopy, many cases of BOFs of the medial orbital walls are now treated endonasaly using an endoscope. This article describes endonasal endoscopic reduction (EER) of BOFs of the medial orbital walls and reports the clinical results. MATERIALS AND METHODS: Twelve patients with BOFs of the medial orbital walls underwent EER. Their records were reviewed for surgical indications, operative techniques, operative results, and postoperative complications. RESULTS: Surgical indications were persistent diplopia, limitation of eye movement, and significant enophthalmos. Ten patients showed complete resolution of symptoms after the operation. One patient underwent medial wall reconstruction with transorbital approach after failure of EER, and is now free of symptoms. Another patient with both zygomatic fracture and BOF of the orbital floor remained enophthalmic after EER. There were no other significant complications postoperatively. CONCLUSION: The results indicate that EER is a safe and effective method of treating BOFs of the medial orbital walls.

Relationship between the Extent of Fracture and the Degree of Enophthalmos in Isolated Blowout Fracture of the Medial Orbital Wall / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: In blowout fracture (BOF) of the medial orbital wall, the presence of significant enophthalmos indicates a need for surgery. In early post-traumatic period, it is usually difficult to measure the degree of enophthalmos due to orbital edema. So, in order to decide on the correct treatment method, it will be useful if we can predict the degree of enophthalmos according to the extent of fracture observed in computed tomography (CT). We studied the relationship between the extent of fracture measured in CT scans and the degree of enophthalmos in BOF of the medial orbital wall. MATERIALS AND METHODS: Nine patients with isolated BOF of the medial orbital wall confirmed by CT scans were studied. The severity of enophthalmos was measured by exophthalmometry. The area of fracture site and the volume of herniated orbital tissue were measured in CT scans. The statistical significance was analyzed using linear regression method. RESULTS: The degree of enophthalmos increased as the area of fracture site or the volume of herniated orbital tissue increased. The area of the fracture site and the volume of the herniated orbital tissue that caused enophthalmos of 2 mm were 1.9 cm2 and 0.9 ml, respectively. CONCLUSION: In BOF of the medial orbital wall, surgical intervention may be recommended to prevent significant enophthalmos when the area of fracture site is 1.9 cm2 or more, or the volume of herniated orbital tissue is 0.9 ml or more.