CLINICAL STUDY

Endoscopic Reduction of Orbital Medial Wall Fracture Using Rotational Repositioning of the Fractured: Lamina Papyracea Fragment Tae-Hoon Lee, MD, PhD, Ho Min Lee, MD, Jung Min Lee, MD, and Jung Gwon Nam, MD, PhD Abstract: Orbital fractures are frequently observed in maxillofacial trauma and can cause a wide range of functional impairments and esthetic deformities. Many approaches have been used for the repair of medial orbital wall fractures. It has been necessary to use grafts or splints in these approaches. We introduced a new technique to treat our patient with diplopia that resulted from a medial orbital fracture. In this new method that involves rotational repositioning of the fractured segment, there is no need for a graft from another location or synthetic material. This technique has several advantages compared with using synthetic materials or other types of autogenous grafts. However, the limitation of this method is that our technique cannot be applied to all cases of medial orbital wall fracture. Key Words: Orbital wall fracture, endoscopic reduction, lamina papyracea (J Craniofac Surg 2014;25: 460–462)

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rbital fractures are frequently observed in maxillofacial trauma and can cause a wide range of functional impairments and esthetic deformities. Fractures occur mainly in the orbital floor, with the medial wall as the second most frequent location of orbital fractures.1 The symptoms of medial orbital wall fracture are various and depend on the site and the degree of fracture. The typical signs and symptoms are diplopia with lateral or medial diversion of gaze, limited eye movement, and enophthalmos.2,3 Complications of medial wall fracture are rare. However, complications from medial rectus muscle entrapment include restricted and painful abduction and pseudo–sixth-nerve paresis. Massive orbital emphysema can be responsible for temporary loss of vision before definitive treatment. Some patients develop severe enophthalmos secondary to the medial wall fracture.4 Many approaches have been used to repair medial orbital wall fractures, including the transorbital and/or maxilloethmoidal approaches. Some of these approaches may result in facial scarring and provide insufficient exposure for reduction of defects. In contrast, endoscopic endonasal reconstruction has been reported to provide several advantages, including direct surgical access to the fracture site, From the Department of Otolaryngology-Head and Neck Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea. Received August 1, 2013. Accepted for publication October 28, 2013. Address correspondence and reprint requests to Dr. Jung Gwon Nam, Department of Otolaryngology-Head and Neck Surgery, Ulsan University Hospital, 290-3 Jeonha-dong, Dong-gu, Ulsan, Republic of Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000507

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the opportunity to eradicate concomitant pathologies in the ethmoid region, and better cosmetic effects by avoiding external incisions.5 However, the conventional endoscopic endonasal technique using splints composed of Silastic sheet and Merocel (Medtronic Xomed, Jacksonville, FL) has several disadvantages, including difficulty in producing complete reduction of large defects, disturbance of ostial drainage of dependent sinuses, infection of the packing material, and rebulging of the repaired orbital wall.6 We describe an alternative technique of endoscopic endonasal reduction that avoids these problems, using the fractured bone itself. In this article, we present a 16-year-old boy with medial orbital wall fracture that was successfully treated by using an endonasal endoscopic approach and the fractured autologous lamina papyracea.

CLINICAL REPORT A 16-year-old boy was referred to us 7 days after facial trauma. He complained of diplopia and left eye pain on superior, inferior, and lateral gaze. Visual acuity was measured as 20/20 OD and 20/20 OS, and intraocular pressure was within the reference range. The patient did not have enophthalmos, and extraocular movements were intact. A preoperative computed tomographic (CT) scan of the orbit revealed that the patient had a fracture of the medial wall of the left orbit and soft tissue prolapse in the ethmoid sinus (Fig. 1). Endoscopic surgery was carried out under general anesthesia 10 days after the injury. A rigid 0-degree or 30-degree telescope with a 4-mm diameter was used. The surgical procedure using the endoscopic approach was performed while observing a video monitor of the nasal findings. A total of 0.5 mL of 2% Lidocaine and 1:100,000 epinephrine solutions were injected at the posterior end of the middle turbinate. After resection of the uncinate process, anterior and posterior ethmoidectomy were carried out. The fractured bones of the lamina papyracea and herniated orbital fat were identified behind the resected air cells of the ethmoid (Fig. 2). The fractured lamina papyracea segment was a large piece of bone that was long in the vertical line and approximately 2  3 cm in size. After careful harvesting of the lamina

FIGURE 1. Preoperative coronal CT shows a blowout fracture of the left medial orbital wall with orbital tissue herniation. Note that the distance from the nasal septum to the medial wall is much reduced compared with the right side.

The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014

Lamina Papyracea Repositioning

FIGURE 2. Intraoperative endoscopic view of fractured lamina papyracea (arrow) and herniated orbital fat (star).

papyracea segment, we cut out its border using surgical scissors (Fig. 3). With a 30-degree endoscope, the soft tissue was repositioned meticulously, and the fractured lamina papyracea was rotated 90 degrees sagittally over the horizontal axis (Fig. 4). The edge of this segment was caught in the fracture site. The orbital contents were pushed back into the orbit (Fig. 5). Continuity of the reduction site was well maintained according to the gentle bulb pressure test. Fibrin glue was applied to the reduction site. We did not need to insert Merocel to fill the ethmoid cavity. No intraoperative and postoperative complications were observed. The diplopia resolved completely by day 1 after surgery. Oral antibiotics were recommended for 2 weeks for prevention of postoperative infection. Postoperative CT 6 weeks after surgery showed the reconstructed medial orbital wall to be in the proper position (Fig. 6). At the final examination 6 months postoperatively, there were no complications or recurrence of ocular symptoms.

DISCUSSION Many patients with an isolated blowout fracture of the medial orbital wall need only conservative management. The occurrence of

FIGURE 3. Harvested fractured lamina papyracea, which is 2  3 cm in size.

FIGURE 4. Schematic drawing of the fracture site and rotational repositioning of the fractured segment. Dashed line shows some parts of the fractured segment hidden behind the surrounding bones.

diplopia or limitation of eye movements is a frequent indication for surgery of blowout fractures of the medial orbital wall. Usually, orbital edema and contusion or hematoma of the ocular muscles subside within 1–2 weeks of the trauma. Most patients have conservative management for 1–2 weeks for accurate assessment of their ocular function before they undergo surgery. In our case, the patient complained of diplopia 10 days after the facial trauma. We applied these indications and performed endoscopic reduction of the medial orbital wall soon after the eye function was able to be assessed accurately. Another indication for surgery is the acute development or the anticipation of development of enophthalmos. Enophthalmos of greater than 2 mm is an indication for surgery because it can cause cosmetic problems for the patient.7

FIGURE 5. Endoscopic finding shows repositioning of the fractured segment (arrow). Complete reduction of herniated tissue.

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Lee et al

The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014

several advantages such as no scar formation, less morbidity of the donor site, and lesser pain. The limitation of this method is that our technique cannot be applied to all medial orbital wall fractures. It is possible only when the size of the fractured segment is large enough to cover the fractured area and the shape of the segment is oval. When harvesting the lamina papyracea, the operator should be careful not to damage the medial rectus muscle and cause muscle entrapment. However, this method is the best one to use in suitable cases.

FIGURE 6. Postoperative coronal CT 6 weeks after surgery shows accurately reduced medial orbital wall.

Recent advances in endoscopic techniques have extended the application of endoscopic surgery from beyond the nose to the orbit. An endoscopic approach to medial orbital wall fractures provides the surgeon with excellent visualization of the fracture site and offers safe removal of bony fragments during reduction of the medial orbital wall. The excellent visualization of the fractured medial wall provided by the endoscope may enable better manipulation than that afforded by the naked eye.2 The endoscopic endonasal approach, first presented by Yamaguchi et al5 in 1991, also provides the opportunity to eradicate concomitant pathologies in the ethmoid space. The study by Yamaguchi et al5 also reported endoscopic intranasal repair of orbital floor fractures. In their reports, the investigators stated that this approach provided good functional results and cosmetic advantages (by avoiding the need for an external skin incision) and that there was less incidence of postoperative ectropion and no risk for complications related to implants or grafts seen in the transorbital approach. As a result, this approach is rapidly gaining widespread use.8 Methods of providing support for the medial orbital wall in blowout fractures are also controversial. Synthetic and autogenous grafts have been used at the fracture site to prevent reherniation of orbital contents. Silastic sheet,9 porous polyethylene sheet,10 hydroxyapatite ceramic,11 and titanium mesh implants12 are the synthetic materials commonly used. Many authors recommend fixing the medial orbital wall with an inverted U-shaped Silastic sheet and Merocel packing; however, this method has problems. If the Merocel remains in the nasal cavity for more than 4 weeks, there may be problems, such as increased risk for infection and patient discomfort due to nasal obstruction. Maxillary sinusitis or frontal sinusitis can be caused by obstruction of the sinus ostium.11 However, if the Merocel is removed early, the support for the medial orbital wall decreases, with movement of the Silastic sheet.13 Autogenous grafts have been harvested most commonly from the ribs, the calvaria, the iliac bone, or the maxillary sinus wall.14 The anterior iliac crest remains the most common site for graft tissue. These grafts have lesser risk for infection, foreign body reaction, or migration than do grafts using synthetic materials. However, this technique has a higher risk for morbidity and donor site complications, such as pain, scar formation, hematoma, and sensation disturbance.15 In this case, we successfully used lamina papyracea to reinforce the medial orbital wall. Compared with the conventional endoscopic endonasal approach using a Silastic sheet, the technique using fractured lamina papyracea offers several advantages. The conventional approach requires nasal packing for up to 6 weeks, whereas our technique does not require any nasal packing for support, and as a result, there is a lower risk for sinus infection, a shorter period of postoperative antibiotic use, and less nasal discomfort. In addition, because lamina papyracea is an autogenous graft, it carries a lower risk for infection than do synthetic materials. Compared with other types of autogenous graft, a graft using autogenous lamina papyracea has

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CONCLUSIONS Endonasal endoscopic rotational repositioning of the fractured segment is an alternative treatment of isolated medial orbital wall fracture in selected cases. This technique has several advantages: (1) no need for nasal packing, so fewer antibiotics are used and patient discomfort is lessened; (2) lower risk for infection than when synthetic materials are used for the graft; (3) less donor site morbidity; and (4) no scar formation at the donor site.

REFERENCES 1. Belli E, Matteini C, Mazzone N. Evolution in diagnosis and repairing of orbital medial wall fractures. J Craniofac Surg 2009;20:191–193 2. Park CH, Choi DJ, Lee JH, et al. Endoscopic reduction of medial orbital wall fractures using the rolled Silastic sheet technique. J Trauma 2009;66:1421–1424 3. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839–1849 4. Lee JH, Shim HS, Woo KI, et al. Inferior oblique underaction: a transient complication related to inferior orbital wall fracture in childhood [published online ahead of print]. Acta Ophthalmol 2013;91:685–690 5. Yamaguchi N, Arai S, Mitani H, et al. Endoscopic endonasal technique of the blowout fracture of the medial orbital wall: inoperative techniques. Otolaryngol Head Neck Surg 1991;25:269–274 6. We JW, Kim YH, Jung TY, et al. Modified technique for endoscopic endonasal reduction of medial orbital wall fracture using a resorbable panel. Ophthal Plast Reconstr Surg 2009;25:303–305 7. Jin HR, Jeon JY, Shin SO, et al. Endosopic versus external repair of orbital blowout fractures. Otolaryngol Head Neck Surg 2007;136:38–44 8. Ikeda K, Suzuki H, Oshima T, et al. Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg 1999; 125:59–63 9. Jeon SY, Kim C, Ma Y, et al. Microsurgical intranasal reconstruction of isolated blowout fractures of the medial wall. Laryngoscope 1996;106:910–913 10. Choi JC, Fleming JC, Atiken PA, et al. Porous polyethylene channel implants: a modified porous polyethylene sheet implant designed for repairs of large and complex orbital wall fractures. Ophthal Plast Reconstr Surg 1999;15:56–66 11. Ono I, Gunji H, Suda K, et al. Orbital reconstruction with hydroxyapatitie ceramic implants. Scand J Plast Reconstr Surg Hand Surg 1994;28:193–198 12. Sugar AW, Kuriakose M, Walshaw ND. Titanium mesh in orbital wall reconstruction. Int J Oral Maxillofac Surg 1992;21:140–144 13. Bai CH, Ye SB, Park KS, et al. Transnasal endoscopic reconstruction of medial orbital wall fracture. Korean J Otolaryngol 2005; 48;1468–1472 14. van der Wal KG, de Visscher JG. Bone grafting for enophthalmos due to medial wall fracture: case report with 13-year follow-up. J Craniomaxillofac Surg 1999;27:177–179 15. Al-Sukhun J, Lindqvist C. A comparative study of 2 implants used to repair inferior orbital wall bony defects: autogenous bone graft versus bioresorbable poly-L/DL-Lactide [P(L/DL)LA 70/30] plate. J Oral Maxillofac Surg 2006;64:1038–1048

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Endoscopic reduction of orbital medial wall fracture using rotational repositioning of the fractured: lamina papyracea fragment.

Orbital fractures are frequently observed in maxillofacial trauma and can cause a wide range of functional impairments and esthetic deformities. Many ...
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