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Cena P, Raco I, Roccia F, Federica S, Dediol E, Kos B, Bottini GB, Goetzinger M, Samieirad S, Gorla LFDO, Pereira-Filho VA, Pechalova P, Sapundzhiev A, Lazíc M, Konstantinovic VS, Zavattero E, Sivrić A, Kordić M, Rahman SA, Rahman T, Sohal KS, Aladelusi T, Rae E, Laverick S, Vesnaver A, Birk A, Politis C, Dubron K. An 11-year multicentric surgical experience on pediatric orbital floor trapdoor fracture: A World Oral Maxillofacial Trauma (WORMAT) project. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:102033. [PMID: 39233052 DOI: 10.1016/j.jormas.2024.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/30/2024] [Accepted: 09/02/2024] [Indexed: 09/06/2024]
Abstract
INTRODUCTION Trapdoor fractures of the orbital floor occur almost exclusively in the paediatric population. Despite being widely discussed in the literature, their management remains controversial. The objective of this retrospective study was to analyse the surgical experiences on paediatric trapdoor fractures in the maxillofacial centres participating in the WORMAT project. MATERIALS AND METHODS 14 centres collected data for patients aged ≤16 years operated between January 2011 and December 2022. The demographic, cause and type of fracture, timing from injury to surgery, surgical approach, type of floor repair and outcomes were recorded. Diplopia, surgical wound infection, hardware loosening and dysesthesia in the infraorbital nerve area were recorded at follow-up. RESULTS 43 patients were included: 25 children (0-12 y) and 18 adolescents (13-16 y) (mean age, 11.1 years). Surgical treatment was performed within 24 h in 51 % of the patients, within 24-72 h in 33 %, and beyond 72 h in the remaining. The orbital floor was repaired with a resorbable implant/membrane in 63 % of the patients, open reduction without an implant in 30 %, a titanium mesh implant in 3 adolescent patients. At follow-up (mean 16.3 months), 14 patients had residual diplopia in the upper fields, only two of these resolved within 6 months. DISCUSSION A tendency toward an increased incidence of postoperative diplopia with longer intervals between trauma and surgery was observed. This study showed different choices regarding the material placed on the floor, with a preference for open reduction without implants in children, compared to the use of resorbable implants or membranes in adolescents.
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Affiliation(s)
- Paolo Cena
- Department of Surgical Sciences, Division of Maxillofacial Surgery, Città della Salute e della Scienza Hospital, University of Turin, Via Genova 3, Turin 10131, Italy
| | - Immacolata Raco
- Department of Surgical Sciences, Division of Maxillofacial Surgery, Città della Salute e della Scienza Hospital, University of Turin, Via Genova 3, Turin 10131, Italy
| | - Fabio Roccia
- Department of Surgical Sciences, Division of Maxillofacial Surgery, Città della Salute e della Scienza Hospital, University of Turin, Via Genova 3, Turin 10131, Italy
| | - Sobrero Federica
- Department of Surgical Sciences, Division of Maxillofacial Surgery, Città della Salute e della Scienza Hospital, University of Turin, Via Genova 3, Turin 10131, Italy.
| | - Emil Dediol
- Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Boris Kos
- Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Gian Battista Bottini
- Department of Oral and Maxillofacial Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Maximilian Goetzinger
- Department of Oral and Maxillofacial Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Sahand Samieirad
- Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Luis Fernando de Oliveira Gorla
- Department of Diagnosis and Surgery, Division of Oral and Maxillofacial Surgery, São Paulo State University, UNESP, Araraquara, São Paulo, Brazil
| | - Valfrido Antonio Pereira-Filho
- Department of Diagnosis and Surgery, Division of Oral and Maxillofacial Surgery, São Paulo State University, UNESP, Araraquara, São Paulo, Brazil
| | - Petia Pechalova
- Department of Oral surgery, Faculty of Dental medicine, Medical University of Plovdiv, Bulgaria
| | - Angel Sapundzhiev
- Department of Oral surgery, Faculty of Dental medicine, Medical University of Plovdiv, Bulgaria
| | - Marko Lazíc
- Clinic of Maxillofacial Surgery, School of dentistry, University of Belgrade, Belgrade, Serbia
| | | | - Emanuele Zavattero
- Department of Surgical Sciences, Division of Maxillofacial Surgery, Città della Salute e della Scienza Hospital, University of Turin, Via Genova 3, Turin 10131, Italy
| | - Anamaria Sivrić
- Clinic for ENT and OMS, University Clinical Hospital, Mostar, Bosnia and Herzegovina
| | - Mario Kordić
- Clinic for ENT and OMS, University Clinical Hospital, Mostar, Bosnia and Herzegovina
| | - Sajjad Abdur Rahman
- Department of Oral and Maxillofacial Surgery, Aligarh Muslim University, Aligarh, India
| | - Tabishur Rahman
- Department of Oral and Maxillofacial Surgery, Aligarh Muslim University, Aligarh, India
| | - Karpal Singh Sohal
- Department of Oral and Maxillofacial Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Timothy Aladelusi
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Euan Rae
- Department of Oral and Maxillofacial Surgery, University of Dundee, Dundee, United Kingdom
| | - Sean Laverick
- Department of Oral and Maxillofacial Surgery, University of Dundee, Dundee, United Kingdom
| | - Aleš Vesnaver
- Department of Maxillofacial and Oral Surgery, University Medical Centre, Ljubljana, Slovenia
| | - Anže Birk
- Department of Maxillofacial and Oral Surgery, University Medical Centre, Ljubljana, Slovenia
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Kathia Dubron
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
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Vasile VA, Pirvulescu RA, Iancu RC, Garhöfer G, Schmetterer L, Ghita AM, Ionescu D, Istrate S, Piticescu RM, Cursaru LM, Popa-Cherecheanu A. Titanium Implants Coated with Hydroxyapatite Used in Orbital Wall Reconstruction-A Literature Review. MATERIALS (BASEL, SWITZERLAND) 2024; 17:1676. [PMID: 38612189 PMCID: PMC11012370 DOI: 10.3390/ma17071676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
With the increasing incidences of orbital wall injuries, effective reconstruction materials and techniques are imperative for optimal clinical outcomes. In this literature review, we delve into the efficacy and potential advantages of using titanium implants coated with nanostructured hydroxyapatite for the reconstruction of the orbital wall. Titanium implants, recognized for their durability and mechanical strength, when combined with the osteoconductive properties of hydroxyapatite, present a potentially synergistic solution. The purpose of this review was to critically analyze the recent literature and present the state of the art in orbital wall reconstruction using titanium implants coated with nanostructured hydroxyapatite. This review offers clinicians detailed insight into the benefits and potential drawbacks of using titanium implants coated with nanostructured hydroxyapatite for orbital wall reconstruction. The highlighted results advocate for its benefits in terms of osseointegration and provide a novel strategy for orbital reconstruction, though further studies are essential to establish long-term efficacy and address concerns.
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Affiliation(s)
- Victor A. Vasile
- Department of Ophthalmology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.A.V.)
- Department of Ophthalmology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Ruxandra A. Pirvulescu
- Department of Ophthalmology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.A.V.)
- Department of Ophthalmology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Raluca C. Iancu
- Department of Ophthalmology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.A.V.)
- Department of Ophthalmology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Gerhard Garhöfer
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria
| | - Leopold Schmetterer
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore 168751, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
- SERI-NTU Advanced Ocular Engineering (STANCE), Singapore 639798, Singapore
- School of Chemical and Biological Engineering, Nanyang Technological University, Singapore 637459, Singapore
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
- Institute of Molecular and Clinical Ophthalmology, 4056 Basel, Switzerland
| | - Aurelian M. Ghita
- Department of Ophthalmology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.A.V.)
- Department of Ophthalmology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Diana Ionescu
- Department of ENT, Children’s Clinical Hospital “Dr. V. Gomoiu”, 022102 Bucharest, Romania
| | | | - Roxana M. Piticescu
- Nanostructured Materials Laboratory, National R&D Institute for Nonferrous and Rare Metals, 077145 Pantelimon, Romania
| | - Laura M. Cursaru
- Nanostructured Materials Laboratory, National R&D Institute for Nonferrous and Rare Metals, 077145 Pantelimon, Romania
| | - Alina Popa-Cherecheanu
- Department of Ophthalmology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.A.V.)
- Department of Ophthalmology, Emergency University Hospital, 050098 Bucharest, Romania
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Voss JO, Ziegenrücker P, Doll C, Maier C, Steffen C, Heiland M, Hofmann E, Koerdt S. Diagnostic pitfalls in pediatric orbital entrapment fractures. J Craniomaxillofac Surg 2024; 52:228-233. [PMID: 38142169 DOI: 10.1016/j.jcms.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/11/2023] [Indexed: 12/25/2023] Open
Abstract
Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany. Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009-2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge. Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures.
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Affiliation(s)
- Jan Oliver Voss
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany.
| | - Paula Ziegenrücker
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Christian Doll
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Christoph Maier
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Radiology, Augustenburger Platz 1, 13353, Berlin, Germany; New York University School of Medicine, Dept. of Radiology, Center for Advanced Imaging Innovation and Research (CAI2R), 650 1st Avenue, New York, 10016, NY, USA.
| | - Claudius Steffen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Max Heiland
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Elena Hofmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany.
| | - Steffen Koerdt
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
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Gugliotta Y, Roccia F, Demo PG, Rossi MB. Characteristics and surgical management of pure trapdoor fracture of the orbital floor in adults: a 15-year review. Oral Maxillofac Surg 2023; 27:625-630. [PMID: 35841436 PMCID: PMC10684415 DOI: 10.1007/s10006-022-01099-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This retrospective study aims to define the optimal timing of the surgical treatment of orbital floor trapdoor fractures (OFTFs) in adults according to clinical and radiological findings. METHODS From January 2006 to December 2020, 382 patients with isolated orbital floor fracture were admitted to the Division of Maxillofacial Surgery of Turin, Italy. The criteria for inclusion were age ≥ 16 years, preoperative computed tomography showing a linear (1a) or medial hinge fracture (1b), diplopia, and 6 months of follow-up data. Aetiology and mechanism of injury, presence of post-traumatic enophthalmos and oculocardiac reflex, time between trauma occurrence and surgery [stratified as < 24 h (urgent treatment), 24-96 h (early treatment), and > 96 h (late treatment)], days of hospitalisation, and clinical outcomes were examinated. RESULTS Twenty-four patients (18 males; mean age, 23.2 years) presented with OFTFs. The most common cause was sport injury (50%). Type 1a fracture was observed in eight patients (mean age, 19.5 years), type 1b fracture in 16 patients (mean age, 23.6 years). Urgent, early, and late treatments were performed in eight patients each. The mean time between trauma occurrence and surgery was 3,8 days (range: 0-17 days). Resolution of diplopia was observed 1 week after surgery in 10 patients, 1 month in 12. Diplopia persisted in 2 patient, both treated > 96 h after trauma. CONCLUSION Although the number of patients was too small to define a standard protocol, the authors recommend early treatment of adult OFTFs to promote complete resolution of diplopia.
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Affiliation(s)
- Ylenia Gugliotta
- Division of Maxillofacial Surgery, Surgical Science Department, Città Della Salute E Delle Scienze Hospital, University of Turin, Corso A.M. Dogliotti 14, 10126, Turin, Italy.
| | - Fabio Roccia
- Division of Maxillofacial Surgery, Surgical Science Department, Città Della Salute E Delle Scienze Hospital, University of Turin, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Paolo Garzino Demo
- Division of Maxillofacial Surgery, Surgical Science Department, Città Della Salute E Delle Scienze Hospital, University of Turin, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Maria Beatrice Rossi
- Division of Maxillofacial Surgery, Surgical Science Department, Città Della Salute E Delle Scienze Hospital, University of Turin, Corso A.M. Dogliotti 14, 10126, Turin, Italy
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Hassan B, Liang F, Grant MP. Pediatric Orbital Fractures. Oral Maxillofac Surg Clin North Am 2023; 35:585-596. [PMID: 37302946 DOI: 10.1016/j.coms.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures.
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Affiliation(s)
- Bashar Hassan
- Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 110 South Paca Street, Baltimore, MD, USA; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD, USA
| | - Fan Liang
- Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 110 South Paca Street, Baltimore, MD, USA; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD, USA
| | - Michael P Grant
- Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 110 South Paca Street, Baltimore, MD, USA.
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Soliman L, Sawicki N, Sobti N, Swartz S, Rao V, Woo AS. Re-evaluating the Timing of Surgery after Isolated Orbital Floor Fracture. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4973. [PMID: 37205175 PMCID: PMC10187854 DOI: 10.1097/gox.0000000000004973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/09/2023] [Indexed: 05/21/2023]
Abstract
Orbital floor fractures are among the most common facial injuries. Although urgent surgical repair may be indicated, most patients require interval follow-up to assess for symptom onset and need for definitive operative intervention. This study aimed to evaluate the time to operative indication after these injuries. Methods A retrospective review was conducted of all patients with isolated orbital floor fractures at a tertiary academic medical center from June 2015 to April 2019. Patient demographic and clinical data were recorded from the medical record. Time until operative indication was evaluated by the Kaplan-Meier product limit method. Results Of 307 patients meeting inclusion criteria, 9.8% (30/307) developed indications for repair. Among these, 60% (18/30) were recommended surgery on the day of initial evaluation. Of 137 follow-up patients, 8.8% (12/137) developed operative indications based on clinical evaluation. The median period to decision for surgery was 5 days (range, 1-9). No patients developed symptoms suggesting the need for surgery beyond 9 days after trauma. Conclusions Our investigation demonstrates that only about 10% of patients presenting with isolated orbital floor fracture develop an indication for surgery. For patients undergoing interval clinical follow-up, we found that patients demonstrated symptoms within 9 days of trauma. No patients demonstrated need for surgery beyond 2 weeks of injury. We believe these findings will assist to establish standards of care and inform clinicians on the appropriate length of follow-up for these injuries.
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Affiliation(s)
- Luke Soliman
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
| | - Nicholas Sawicki
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
| | - Nikhil Sobti
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
| | - Solomon Swartz
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
| | - Vinay Rao
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
| | - Albert S. Woo
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, R.I
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Takabayashi K, Maeda Y, Kataoka N, Kagokawa H, Nagamine M, Ota I, Fujita T. Algorithm for pediatric orbital blowout fractures: a 20-year retrospective cohort study. Braz J Otorhinolaryngol 2023; 89:447-455. [PMID: 36754674 PMCID: PMC10164772 DOI: 10.1016/j.bjorl.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/02/2022] [Accepted: 01/19/2023] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Pediatric orbital blowout fractures can include pathologies that seem mild but require urgent release; serious sequelae can occur with standby surgery or conservative treatment. We sought to validate an algorithm for the treatment of pediatric orbital blowout fractures. METHODS This retrospective cohort study included 61 pediatric patients, aged 18 years or younger, treated for pure orbital blowout fractures according to the algorithm from April 1, 2000, to August 31, 2020, at the Japanese Red Cross Asahikawa Hospital. RESULTS There were 52 males (85%). Median age was 14 years (range, 5-18 years). There were 9 patients categorized as needing urgent release, 16 as needing repair, and 36 as needing conservative treatment. Mean follow-up ocular movement was 98.0 (95% Confidence Interval [95% CI], 96.8-99.2). Postoperative diplopia was not observed in 96% (79.6%-99.9%) of patients, better than in previous studies. A higher proportion of patients aged 0-12 years needed urgent repair than those aged 13-18 years (Odds Ratio [OR] = 14.2; 95% CI 1.6-683.4; p = 0.0046). There were no differences in Hess area ratio by age group. CONCLUSION Clinical results with the algorithm were satisfactory. The algorithm is suitable for treatment of pediatric orbital blowout fractures. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Kosuke Takabayashi
- Japanese Red Cross Asahikawa Hospital, Department of Otorhinolaryngology, Asahikawa City, Hokkaido, Japan
| | - Yohei Maeda
- Osaka University Graduate School of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Suita City, Osaka, Japan; Japan Community Health Care Organization Osaka Hospital, Department of Otorhinolaryngology, Osaka City, Osaka, Japan.
| | - Nobuya Kataoka
- Japanese Red Cross Asahikawa Hospital, Department of Ophthalmology, Asahikawa City, Hokkaido, Japan
| | - Hiroyuki Kagokawa
- Japanese Red Cross Asahikawa Hospital, Department of Otorhinolaryngology, Asahikawa City, Hokkaido, Japan
| | - Masayoshi Nagamine
- Japanese Red Cross Asahikawa Hospital, Department of Ophthalmology, Asahikawa City, Hokkaido, Japan
| | - Isao Ota
- Japanese Red Cross Asahikawa Hospital, Department of Otorhinolaryngology, Asahikawa City, Hokkaido, Japan
| | - Taketoshi Fujita
- Japanese Red Cross Asahikawa Hospital, Department of Otorhinolaryngology, Asahikawa City, Hokkaido, Japan
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Pediatric Orbital Fractures: Outcomes in Relation to Time of Surgery. J Craniofac Surg 2023; 34:976-978. [PMID: 36728445 DOI: 10.1097/scs.0000000000009163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 10/02/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Orbital trapdoor fractures in children and adolescents can cause persistent problems with vision and appearance. Early surgery is recommended, although, because of the rarity of these fractures, there is a lack of evidence regarding the optimal timing of surgery.The objective of this study was to examine the effect of the time from trauma to surgery on the recovery time and severity of diplopia in children and adolescents with orbital trapdoor fractures. MATERIALS AND METHODS A retrospective cohort study was performed of all orbital fractures in children and adolescents aged 0 to 20 years, treated at a tertiary referral center in 2005-2017. Data relating to demographics, cause of injury, surgery, time of follow-up, and final outcomes were extracted. The cases of trapdoor fracture were specifically examined with regard to the time from trauma to surgery and diplopia at last follow-up, which was the primary outcome. RESULTS One hundred thirty-five patients, aged 2.4 to 20 years (mean 17.0), were treated for orbital fractures during the period; 37 (27%) had an isolated orbital floor fracture and 12 (9%) had a trapdoor fracture. All patients with trapdoor fractures underwent surgery; the mean time to surgery was 11.9 days in 2007-2011 and 1.1 days in 2012-2017. Although statistical significance cannot be proven in this small and retrospective study, a shorter time from trauma to surgery seems to lead to fewer problems with diplopia and 2 patient cases that highlight this are presented. CONCLUSIONS Delayed surgical intervention in pediatric orbital trapdoor fractures increases the risk of delayed recovery and persistent diplopia. Other factors, such as the degree of muscle incarceration and necrosis and the surgeon's experience and skill, may, however, also influence the outcomes.
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Abdullah MF, Phoon K, Phyelgye R, Majid MNA. A delayed endoscopic assisted elevation of pediatric white-eyed blow out fracture: An immediate recovery. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Asystole Due to Oculocardiac Reflex during Surgical Repair of an Orbital Blowout Fracture. Plast Reconstr Surg Glob Open 2022; 10:e4544. [PMID: 36187280 PMCID: PMC9521747 DOI: 10.1097/gox.0000000000004544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/25/2022]
Abstract
Bradycardia and asystole due to oculocardiac reflex (OCR) are potential intraoperative complications of periocular surgery. We report a case of asystole due to OCR that occurred during surgical repair performed 40 hours after an orbital blowout fracture. The patient had vomiting, bradycardia, and ocular motility disorder before the operation. During the operation, asystole occurred when the entrapped tissue was grasped with forceps. After administration of anticholinergic drugs, the heart promptly resumed beating, and no sequelae due to asystole were observed after surgery. Before and during periocular surgery, it is important for the surgeon to maintain a protective surgical procedure and communicate appropriately with the anesthesiologist, including discussion of risks and emergency measures. In addition, prolonged entrapment of the extraocular muscles is likely to cause irreversible damage, so it is important to make a diagnosis and perform surgery as soon as possible.
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Amarath-Madav R, Adamkiewicz D, Bigler D, Yu JC, Lima MH. White-Eyed Orbital Blowout Fracture With Oculocardiac Reflex Secondary to Extraocular Entrapment in a Pediatric Patient. J Craniofac Surg 2022; 33:e767-e771. [PMID: 36109010 DOI: 10.1097/scs.0000000000008713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/18/2022] [Indexed: 11/25/2022] Open
Abstract
White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited.
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Affiliation(s)
| | | | - Diana Bigler
- Medical College of Georgia, Department of Otolaryngology
| | - Jack C Yu
- Medical College of Georgia, Department of Plastic Surgery, Augusta, GA
| | - Maria Helena Lima
- Medical College of Georgia, Department of Plastic Surgery, Augusta, GA
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12
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South Texas orbital fracture protocol for emergency department evaluation of orbital fractures. Am J Emerg Med 2022; 57:42-46. [DOI: 10.1016/j.ajem.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/22/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022] Open
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Kotecha S, Ferro A, Harrison P, Fan K. Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants. Oral Maxillofac Surg 2022:10.1007/s10006-022-01074-x. [PMID: 35589881 DOI: 10.1007/s10006-022-01074-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/09/2022] [Indexed: 01/15/2023]
Abstract
The purpose of this study is to execute an evidence-based review answering the following question (PICO): "Do patient-specific implants (PSI), manufactured or designed using computer-assisted technology, improve outcomes (orbital volume change, enophthalmos, diplopia, and operative duration) compared to conventional methods in orbital reconstruction following traumatic orbital injury in the adult patient population?" We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. Inclusion criteria included any comparative paper whereby computer-assisted technology was used in the prefabrication or design process of implants for use in post-traumatic orbital reconstruction. Paediatric patient populations were excluded. Eight databases were systematically searched for relevant studies. Risk of bias was assessed through the NOS and RoB2 tools. Random-effects models were used to identify differences in outcomes between groups where possible. Analysis was performed using R 4.0.0. Eleven of 4784 identified studies were included, comprising 628 adult patients, with 302 and 326 patients in the patient-specific and conventional groups, respectively. Weighted mean difference between unaffected and post-operative orbital volume was 0.32 ml (SD 0.75) and 0.95 ml (SD 1.03) for patient-specific and conventional groups, respectively. Significant improvement was identified in post-operative orbital volume reconstitution with the use of PSI, compared to conventional implants, in 3 of the 5 reporting studies. Equally, post-operative enophthalmos trended towards lower severity in the patient-specific group, with 11.2% of patients affected in the patient-specific group and 19.2% in the conventional group, and operative duration was significantly reduced with the use of PSI in 3 of the 6 reporting studies. Despite a tendency to favour PSI, no statistically significant differences in key outcomes were identified on meta-analysis. Although there is some encouraging data to support improved outcomes with the use of patient-specific orbital implants in post-traumatic reconstruction, there is, at present, no statistically significant evidence to objectively support their use over conventional implants based on the currently available comparative studies. Based on the results of this study, the choice of implant used should, thus, be left to the discretion of the surgeon.
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Affiliation(s)
- Sanjeev Kotecha
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, London, UK. .,Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, UK.
| | - Ashley Ferro
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, London, UK.,Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, UK
| | - Patrick Harrison
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, London, UK.,Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, UK
| | - Kathleen Fan
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, London, UK.,Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, UK
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Isolated paediatric orbital fractures: a case series and review of management at a major trauma centre in the UK. Oral Maxillofac Surg 2022:10.1007/s10006-022-01056-z. [PMID: 35312892 PMCID: PMC8936037 DOI: 10.1007/s10006-022-01056-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/06/2022] [Indexed: 11/08/2022]
Abstract
Purpose Paediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis. Methods This retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020. Results Thirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department. Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24–48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months. Conclusion Paediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.
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Hsieh PJ, Liao HT. Outcome Analysis of Surgical Timing in Pediatric Orbital Trapdoor Fracture with Different Entrapment Contents: A Retrospective Study. CHILDREN 2022; 9:children9030398. [PMID: 35327770 PMCID: PMC8947637 DOI: 10.3390/children9030398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Orbital trapdoor fracture occurs more commonly in pediatric patients, and previous studies suggested early intervention for a better outcome. However, there is no consensus on the appropriate timing of emergent intervention due to the insufficient cases reported. In the current retrospective study, we compared the outcomes of patient groups with different time intervals from injury to surgical intervention and entrapment content. Twenty-three patients who underwent surgery for trapdoor fracture between January 2001 and September 2018 at Chang Gung Memorial Hospital were enrolled. There was no significant difference in diplopia and extraocular muscle (EOM) movement recovery rate in patients who underwent surgery within three days and those over three days. However, among the patients with an interval to surgery of over three days, those with muscle entrapment required a longer period of time to recover from EOM movement restriction (p = 0.03) and diplopia (p = 0.03) than those with soft tissue entrapment. Regardless of time interval to surgery, patients with muscle entrapment took longer time to recover from EOM movement restriction (p = 0.036) and diplopia (p = 0.042) and had the trend of a worse EOM recovery rate compared to patients with soft tissue entrapment. Hence, we suggested that orbital trapdoor fractures with rectus muscle entrapment should be promptly managed for faster recovery.
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Affiliation(s)
- Pei-Ju Hsieh
- Division of Traumatic Plastic Surgery, Department of Plastic and Reconstructive Surgery, Craniofacial Research Center, Chang Gung Memorial Hospital at LinKou, Chang Gung University College of Medicine, Taoyuan City 333, Taiwan;
| | - Han-Tsung Liao
- Division of Traumatic Plastic Surgery, Department of Plastic and Reconstructive Surgery, Craniofacial Research Center, Chang Gung Memorial Hospital at LinKou, Chang Gung University College of Medicine, Taoyuan City 333, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Department of Plastic Surgery, Xiamen Chang Gung Hospital, Xiamen 361000, China
- Correspondence: ; Tel.: +886-3-328-1200 (ext. 2946); Fax: +886-3-328-9582
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Does Early Treatment of Paediatric Orbital Fracture Offer Any Advantage in Terms of Post-Operative Clinical Outcomes. J Maxillofac Oral Surg 2022; 21:25-33. [PMID: 35400913 PMCID: PMC8934817 DOI: 10.1007/s12663-021-01543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/24/2021] [Indexed: 10/21/2022] Open
Abstract
Background Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex. Methods A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies. Results A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h. Discussion Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.
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Mehmood N, Hasan A. Oculocardiac Reflex: An Underrecognized But Important Association With Orbital Trap Door Fractures. Pediatr Emerg Care 2021; 37:e1731-e1732. [PMID: 31389903 DOI: 10.1097/pec.0000000000001884] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Blowout fractures of the floor of the orbit can serve as a "trap door" for extraocular muscles. Presentation of inferior orbital muscle entrapment classically involves an upward gaze restriction. Diplopia and exophthalmos can also be present. Rarely, orbital fractures can result in an oculocardiac reflex, which is a triad of bradycardia, syncope, and nausea. The purpose of this study was to describe a patient who had orbital floor fracture with symptoms highly suggestive for oculocardiac reflex after a traumatic injury. Although entrapment of extraocular muscles does require early intervention to prevent ischemia and tissue necrosis, the presence of oculocardiac reflex warrants emergent evaluation and management by an ophthalmologist due to the risk of developing arrhythmias. Frequently, there may be none or very subtle clinical findings present, and abnormal motility may be the only apparent clinical sign, which can be difficult to assess in very young and uncooperative children; therefore, a high index of suspicion must be maintained for early identification and management as well as a reduction of complications.
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Affiliation(s)
- Noormah Mehmood
- From the GY-3 Driscoll Children's Hospital, Corpus Christi, Texas
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Abstract
Orbital fractures are common in facial trauma and can be a challenge to treat. Understanding anatomy of the orbit, the clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative are essential in providing appropriate treatment for patients who have sustained orbital fractures. In this article, the authors review the diagnostic evaluation, acute management, treatment options, and common complications of orbital fractures, as well as recent advancements in orbital fracture repairs.
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Affiliation(s)
- Peiran Zhou
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington
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TABAKAN İ, KOKAÇYA Ö, ESER C, GENCEL E. Epidemiologic analysis of pediatric maxillofacial trauma. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.920560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Kakeue K, Kanazawa M, Yunoki T, Mihara M, Hayashi A. Evaluation of saccadic velocity in patients with orbital floor fracture before and after surgery. Semin Ophthalmol 2021; 37:491-495. [PMID: 34586972 DOI: 10.1080/08820538.2021.1985528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Saccadic eye movement plays an important role in the rapid movement of the eyes to visual targets; however, it has not been fully investigated in patients with an orbital floor fracture. Thus, this study investigated saccadic eye movement before and after surgery in patients with an orbital floor fracture. The saccadic peak velocity (PV) was recorded using an eye-tracking device before and after surgery in nine eyes of nine patients with an orbital floor fracture. The type of fracture was a depressed fragment fracture in all cases, and there was no trap-door fracture. Ocular motility and diplopia were evaluated by the Hess area ratio (HAR%) and the scoring of binocular single vision (BSV). The preoperative HAR% and those at 1 month post-surgery and the final post-surgery observation were 62 ± 6%, 83 ± 11%, and 91 ± 8%, respectively. The preoperative, 1 month post-surgery, and final observation post-surgery BSV scores were 34 ± 18, 46 ± 8, and 50 ± 8 points, respectively. The postoperative HAR% and BSV were significantly improved at the final post-surgery observation (p < .05 each). The saccadic PVs of adduction, abduction, and downgaze before and after surgery were not significantly different in both the non-injured eyes and the injured eyes. However, the upgaze saccadic PVs at 1 month and the final post-surgery observation in the injured eyes were significantly increased (p < .05 each). The saccadic PV may be useful to evaluate detailed and precise extraocular muscle function before and after surgery for orbital floor fractures.
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Affiliation(s)
- Ken Kakeue
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Masanobu Kanazawa
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Tatsuya Yunoki
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Miharu Mihara
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Atsushi Hayashi
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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Combined Subciliary/Transantral Approach for Reconstruction of Orbital Floor Fracture. JOURNAL OF OTORHINOLARYNGOLOGY, HEARING AND BALANCE MEDICINE 2021. [DOI: 10.3390/ohbm2030007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Orbital floor fracture, especially with constriction of orbital soft tissue, should be reconstructed surgically. Although various approaches to treat the orbital floor have been reported, procedures have not been unified among hospitals or surgeons. Since 2009, we have adopted a procedure combining a transorbital approach via subciliary incision with a transantral approach through upper gingival incision. The combined approach compensates for the shortcomings of each approach, leading to successful reconstruction. It is applicable safely for trapdoor fracture of the orbital floor in children, which more frequently constricts orbital soft tissue and which leaves permanent diplopia. This report retrospectively assessed clinical preoperative findings and postoperative outcomes of patients who received reconstruction of orbital floor fracture with the combined approach in our department from August 2009 through March 2021. Data of 21 patients with orbital floor fracture were analyzed, only one (4.8%) of whom had postoperative diplopia. Specifically, we describe children with trapdoor fracture treated with the combined approach, resulting in complete recovery. The combined approach stands as an excellent procedure for reconstruction of orbital floor fracture in adults and even in children.
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Chen YH, Tsai YJ, Tzeng IS. Factors influencing surgical outcomes in orbital trapdoor fracture. Sci Rep 2021; 11:17547. [PMID: 34475434 PMCID: PMC8413308 DOI: 10.1038/s41598-021-96920-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/18/2021] [Indexed: 11/12/2022] Open
Abstract
This study is aimed to determine the appropriate timing of performing surgical reduction on trapdoor fractures for bringing out better visual outcomes and the factors influencing surgical outcomes in this special subgroup of fracture victims. Data for 72 patients of orbital trapdoor fracture were analyzed retrospectively. Post-operative diplopia is the main posttreatment outcome of orbital bone fracture reduction. The receiver-operating characteristic (ROC) analysis indicated the cut-off point of surgical reduction timing at day 10 post-fracture. The rate of postoperative diplopia showed a significant difference between patients who underwent surgical reduction within 10 days and those who did after 10 days of injury (5.3% vs. 38.2%). Multivariate analysis revealed that preoperative infra-duction limitation (p = 0.02), muscle incarceration (p = 0.01), duration from injury to surgical reduction (p = 0.004), and postoperative supra-duction limitation (p = 0.004) were independent factors for poor surgical outcomes. In younger patients with head injury, the diagnosis of orbital trapdoor fracture should be kept in mind. Timely recognition and surgical reduction, especially within 10 days, can result in better visual outcomes without the occurrence of postoperative diplopia.
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Affiliation(s)
- Yi-Hua Chen
- Department of Ophthalmology, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing St., Guishan Dist., Taoyuan City, 33375, Taiwan.,College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan city, 33302, Taiwan
| | - Yueh-Ju Tsai
- Department of Ophthalmology, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing St., Guishan Dist., Taoyuan City, 33375, Taiwan. .,College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan city, 33302, Taiwan.
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, No.289, Jiang-Kuo Rd., Xindian Dist., New Taipei City, 231, Taiwan
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Resorbable Versus Titanium Hardware for Rigid Fixation of Pediatric Upper and Midfacial Fractures: Which Carries a Lower Risk Profile? J Oral Maxillofac Surg 2021; 79:2103-2114. [PMID: 34171220 DOI: 10.1016/j.joms.2021.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Titanium associated risks have led to interest in resorbable hardware for open reduction and internal fixation (ORIF) of pediatric facial fractures. This study aims to systematically review and compare the outcomes of titanium/resorbable hardware used for ORIF of upper/midfacial fractures to determine which hardware carries a higher complication rate in the pediatric patient. METHODS Studies published between 1990 and 2020 on the ORIF of pediatric upper/midfacial fractures were systematically reviewed. A retrospective institutional review was also conducted, and both arms were compiled for final analysis. The primary predictor value was the type of hardware used and the primary outcome was the presence of a complication. Fisher's exact test and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value < .05. The low quality of published evidence precluded meta-analysis. RESULTS Systematic review of 23 studies identified 659 patients, and 77 patients were identified in the institutional review. A total of 736 patients (299 resorbable, 437 titanium) were included in the final analysis. Total complication rate was 22.8%. The titanium group had a higher complication rate (27 vs 16.7%; P < .01), and more often underwent elective hardware removal (87.3 vs 0%, P < .01). In each hardware subgroup, the incidence of complications was analyzed by fracture site. In the titanium group, complication incidence was higher when treating maxillary fractures (32.8 vs 22.9%, P = .03). When comparing the 2 hardware groups by fracture site, maxillary fractures had a higher rate of complications when treated by titanium hardware compared with resorbable hardware (32.8 vs 18%, P < .01). CONCLUSIONS Upper/midfacial pediatric fractures requiring ORIF, especially maxillary fractures, may be best treated with resorbable hardware. Additional hardware-specific outcomes data is encouraged.
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"Trap Door" Orbital Floor Fractures in Adults: Are They Different from Pediatric Fractures? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3537. [PMID: 33868879 PMCID: PMC8049158 DOI: 10.1097/gox.0000000000003537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/14/2021] [Indexed: 11/25/2022]
Abstract
Background: “Trap door” orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital tissue to prolapse into the fracture site during fracture formation. The bony fragments of the fracture then return to their original position, entrapping the prolapsed orbital tissue. In the hinged fracture type, the fractured part of the floor is minimally displaced into the maxillary sinus and acts as the hinge of a “swinging door” entrapping the orbital tissue. Methods: We report on a series of 10 adult patients with hinged orbital floor fractures. Results: The mean patient age was 35 years. Seven patients had a pure orbital floor fracture and the remaining 3 patients had fractures of both the orbital floor and the inferior orbital rim. All 10 patients had diplopia in the upgaze. None of the patients had signs of the oculocardiac reflex. None of the CT scans showed a “tear-drop” sign. However, the sagittal CT scans showed evidence of entrapment of the inferior rectus. All patients had a small area of a slightly depressed orbital floor at the site of entrapment, without a bony defect. All patients underwent surgery through an infraorbital incision and a titanium mesh was used in all patients. There were no postoperative complications. All patients regained full range of motion of the globe. Conclusion: This is the first series in the literature that reports on the characteristics and outcome of trap door orbital floor fractures in adults.
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Management of Pediatric Orbital Fractures. J Craniofac Surg 2021; 32:224-227. [PMID: 33273204 DOI: 10.1097/scs.0000000000006915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Although uncommon in children, orbital fractures can be devastating to both vision and appearance. Due to the scarce information in the literature, the authors here present our experience and management with all pediatric orbital fracture patients. MATERIAL AND METHODS A 6-years retrospective study was conducted on pediatric patients presented with orbital wall fracture (OFx). All patients (n = 43) were grouped for comparison based on the treatment method. The cohorts were analyzed for demographics data, location of fracture, type of material used for reconstruction, complication rate and follow up length. Data was analyzed utilizing SPSS for χ2 test. RESULTS The majority of patients were male (86%) and the mean age of patients was 12.09 ± 4 years. Mean follow-up time was 237 ± 72 days. Most of Patients 31 (72%) underwent surgical intervention. A higher rate of complications was observed in the surgically treated group (32%) compared to the conservative group (8%) regardless to the defect size. Subgroup analysis of the surgery treated group revealed that large size defect had inferior outcome compared to small size defect. CONCLUSION The consequences of treatment on long-term growth and development must be a cornerstone when choosing the optimal therapeutic method. Conservative management should be considered first in the absence of significant clinical pathologies. In addition, when surgery is indicated the least invasive procedure should be applied. The use of autogenous bone graft is preferable over alloplastic materials, however, when there is insufficient bone quantity the use of alloplastic materials is not contraindicated for reconstruction.
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Chai G, Zhang D, Hua W, Yin J, Jin Y, Chen M. Theoretical model of pediatric orbital trapdoor fractures and provisional personalized 3D printing-assisted surgical solution. Bioact Mater 2020; 6:559-567. [PMID: 33005822 PMCID: PMC7501422 DOI: 10.1016/j.bioactmat.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/09/2020] [Accepted: 08/31/2020] [Indexed: 01/06/2023] Open
Abstract
Pediatric orbital trapdoor fractures are common in children and adolescents and usually require emergency surgical intervention. Herein, a personalized 3D printing-assisted approach to surgical treatment is proposed, serving to accurately and effectively repair pediatric orbital trapdoor fractures. We first investigated stress distribution in external force-induced orbital blowout fractures via numerical simulation, determining that maximum stresses on inferior and medial walls exceed those on superior and lateral walls and thus confer higher probability of fracture. We also examined 36 pediatric patients treated for orbital trapdoor fractures between 2014 and 2019 to verify our theoretical construct. Using 3D printing technique, we then created orbital models based on computed tomography (CT) studies of these patients. Absorbable implants were tailor-made, replicating those of 3D-printed models during surgical repairs of fractured orbital bones. As follow-up, we compared CT images and clinical parameters (extraocular movements, diplopia, enophthalmos) before and 12 months after operative procedures. There were only two patients with diplopia and six with enophthalmos >2 mm at 12 months, attesting to the efficacy of our novel 3D printing-assisted strategy. Numerical simulation is used to theoretically investigate the mechanism of external force-induced orbital blowout fractures. 3D printing--assisted surgical treatment is proposed to effectively repair pediatric orbital trapdoor fractures. Clinical studies are performed by repairing fractured orbital bones via 3D printed customized absorbable implants.
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Affiliation(s)
- Guangrui Chai
- Department of Ophthalmology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
| | - Deming Zhang
- Department of Mechanical and Aerospace Engineering, University of Florida, Gainesville, FL 32611, USA.,The State Key Laboratory of Fluid Power and Mechatronic Systems, School of Mechanical Engineering, Zhejiang University, Hangzhou, Zhejiang 310027, China
| | - Weijian Hua
- Department of Mechanical Engineering, University of Nevada Reno, Reno, NV, 89557, USA
| | - Jun Yin
- The State Key Laboratory of Fluid Power and Mechatronic Systems, School of Mechanical Engineering, Zhejiang University, Hangzhou, Zhejiang 310027, China
| | - Yifei Jin
- Department of Mechanical Engineering, University of Nevada Reno, Reno, NV, 89557, USA
| | - Ming Chen
- Department of Ophthalmology, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, China
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Amin D, Al-Mulki K, Henriquez OA, Cheng A, Roser S, Abramowicz S. Review of Orbital Fractures in an Urban Level I Trauma Center. Craniomaxillofac Trauma Reconstr 2020; 13:174-179. [PMID: 33456683 DOI: 10.1177/1943387520924515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To perform a comprehensive review and analysis of surgically treated orbital fractures. Study Design Retrospective cohort chart review study for surgically treated orbital fractures during 5 years. Results A total of 173 patients (average age 41.6 years) were diagnosed with orbital fractures. Most were male with a ratio of 3.3:1. Most fractures were caused by assault (39.3%); 22.5% of the cases were bilateral. The left orbit (40.5%) was fractured more than the right. The orbital floor (97.1%) was the most common anatomic location and the maxilla (65.3%) was the most commonly involved bone. The average time from trauma to surgical intervention was 8.7 ± 14.6 days and the average time from surgical intervention to discharge was 5.1 ± 9.0 days. The transconjunctival incision (63%) was the most commonly used incision, and nonresorbable implant (92.7%) was the most commonly used implant. Finally, the length of stay for the repair of a simple orbital fracture was less than for complex orbital fracture (1.5 days and 5.9 days, respectively). Conclusion Understanding the patterns and mechanisms of injury associated with orbital fractures can assist in developing standardized treatment protocols across all surgical specialties. This would ultimately allow for a uniform high quality of surgical care for patients with maxillofacial fractures.
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Affiliation(s)
- Dina Amin
- Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Kareem Al-Mulki
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Oswaldo A Henriquez
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Angela Cheng
- Division of Plastic Surgery, Department of General Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Roser
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Shelly Abramowicz
- Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2020; 78:568-577. [DOI: 10.1016/j.joms.2019.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 11/20/2022]
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Intraoperative Findings of Extraocular Muscle Necrosis in Linear Orbital Trapdoor Fractures. J Oral Maxillofac Surg 2019; 77:1229.e1-1229.e8. [DOI: 10.1016/j.joms.2019.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 11/17/2022]
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Saggese NP, Mohammadi E, Cardo VA. The 'White-eyed' Orbital Blowout Fracture: An Easily Overlooked Injury in Maxillofacial Trauma. Cureus 2019; 11:e4412. [PMID: 31245200 PMCID: PMC6559398 DOI: 10.7759/cureus.4412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The ‘white-eyed’ blowout fracture (WEBOF) is an injury that is often overlooked in head trauma patients, as it often has few overt clinical and radiographic features. Although benign in appearance, it can lead to significant patient morbidity. Here, we intend to increase the awareness of WEBOF and provide general principles for its diagnosis. WEBOF should be recognized early to ensure timely management and a successful outcome.
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Affiliation(s)
- Nicholas P Saggese
- Oral and Maxillofacial Surgery, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Ebrahim Mohammadi
- Oral and Maxillofacial Surgery, Babol University of Medical Science, Babol, IRN
| | - Vito A Cardo
- Oral and Maxillofacial Surgery, Brookdale University Hospital and Medical Center, Brooklyn, USA
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Dunphy L, Anand P. Paediatric orbital trapdoor fracture misdiagnosed as a head injury: a cautionary tale! BMJ Case Rep 2019; 12:12/4/e228739. [PMID: 30948403 DOI: 10.1136/bcr-2018-228739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Trapdoor fractures, otherwise known as 'white-eyed blowout' fractures, occur predominantly in the paediatric cohort and have a male predilection. Patients commonly present with acute fractures to the emergency department, and delayed diagnosis can result in significant morbidity. A lack of external signs, such as oedema or ecchymosis, often misleads physicians into underestimating the seriousness of the injury. It can be initially misdiagnosed as a head injury due to the oculocardiac reflex, nausea, vomiting, poor patient compliance and a failure to examine the eye appropriately. The incarcerated muscles may become necrotic because of ischaemia, resulting in ocular motility problems. Immediate surgery is recommended for symptomatic persistent diplopia or clinical evidence of muscle entrapment. The authors present the case of a 16-year-old male adolescent initially diagnosed with a head injury due to his nausea and vomiting following trauma to his orbit. This resulted in a delay to surgery. This article highlights the importance of performing an ophthalmic assessment to detect other features of a trapdoor fracture in children presenting with orbital trauma. It also reinforces the importance of knowledge of the oculocardiac reflex as its association with orbital injuries is well documented.
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Affiliation(s)
- Louise Dunphy
- Department of Surgery, Milton Keynes University Hospital, Milton Keynes, UK
| | - Pradeep Anand
- Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, UK
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Park J, Baek S. Management of pediatric orbital wall fractures. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2018.1560266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jinhwan Park
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea
| | - Sehyun Baek
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea
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Bony Orbital Decompression Following Lateral Canthotomy and Cantholysis for Traumatic Orbital Compartment Syndrome. J Craniofac Surg 2019; 30:231-234. [DOI: 10.1097/scs.0000000000004902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kulenkamp JE, Farooq AV, Abbasian J, Shah H. Trapdoor orbital floor fracture and inferior rectus entrapment with minimal infraduction deficit and hypertropia. Can J Ophthalmol 2018; 53:e252-e254. [PMID: 30503008 DOI: 10.1016/j.jcjo.2018.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/13/2018] [Accepted: 01/16/2018] [Indexed: 10/17/2022]
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Effect of Time to Operative Intervention on Motility Outcomes Following Orbital Floor Fracture Repair in Children. Ophthalmic Plast Reconstr Surg 2018; 34:351-354. [DOI: 10.1097/iop.0000000000000993] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
INTRODUCTION The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction. METHODS A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material. RESULTS A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials. CONCLUSION Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.
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Su Y, Shen Q, Bi X, Lin M, Fan X. Delayed surgical treatment of orbital trapdoor fracture in paediatric patients. Br J Ophthalmol 2018; 103:523-526. [PMID: 29858184 DOI: 10.1136/bjophthalmol-2018-311954] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/14/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Trapdoor fracture is a special type of orbital blowout fracture. Although early surgery is recommended, there still remain some patients delayed by various reasons. In this study, we analysed the clinical characteristics of delayed paediatric patients, especially those with different levels of ocular motility restriction before surgery. METHODS Thirty patients (3 to 14 years old) who underwent delayed surgery for trapdoor fractures between January 2008 and September 2016 were enrolled. Their demographics, causes of injury and delay, clinical features, imaging data and follow-up information were collected. RESULTS Muscular entrapment was found in 17 patients (group A) and soft-tissue entrapment in 13 patients (group B). 12 (7 in group A) presented with severe motility restriction and 18 (10 in group A) with mild restriction before surgery. 41.7% with severe restriction recovered after surgery, compared with 83.3% with mild restriction. Four (23.7%) in group A (all with severe restriction) and six (46.2%) in group B (half with severe restriction) presented with persistent diplopia. CONCLUSIONS Long recovery time and a high percentage of persistent diplopia are the main problems of delayed trapdoor fracture in children. A prompt surgery within 48 hours is strongly recommended in patients with muscular entrapment even if an urgent treatment is hard to achieve. So are patients with soft-tissue entrapment and significant motility restriction. In the other patients without such indications, even though some recovery might be possible in the long term, a prompt surgery right after diagnosis is still preferable regardless of the entrapped contents.
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Affiliation(s)
- Yun Su
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Qin Shen
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Xiaoping Bi
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Ming Lin
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China .,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Xianqun Fan
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China .,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
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Papadiochos I, Petsinis V, Tasoulas J, Goutzanis L. Pure Orbital Trapdoor Fractures in Adults: Tight Entrapment of Perimuscular Tissue Mimicking True Muscle Incarceration with Successful Results from Early Intervention. Craniomaxillofac Trauma Reconstr 2018; 12:54-61. [PMID: 30815216 DOI: 10.1055/s-0038-1625965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 07/28/2017] [Indexed: 10/18/2022] Open
Abstract
Orbital trapdoor fractures (OTFs) entail entrapment of intraorbital soft tissues with minimal or no displacement of the affected bones and are almost exclusively seen in children. This article aimed to report the diagnosis and treatment of an OTF of the floor in an adult patient and to critically review the literature regarding the management aspects of this specific subset of orbital blowout fractures in adults. A 29-year-old man presented with limitations of vertical right eye movements owing to blunt orbital trauma. The patient mainly complained of double vision in upper gazes and some episodes of nausea. Neither floor defect nor significant bone displacement found on orbital computed tomography, while edema of inferior rectus muscle was apparent. The patient underwent surgical repair 5 days later; a linear minimally displaced fracture of the floor was recognized and complete release of the entrapped perimuscular tissues was followed. Within the first week postoperatively, full range of ocular motility was restored, without residual diplopia. This case was the only identified pure OTF over a 6-year period in our department (0.6% of 159 orbital fractures in patients >18 years). By reviewing the literature indexed in PubMed, a very limited number of either of isolated case reports or retrospective case series of pure OTFs has been reported in adults. Contrary to the typical white-eyed blowout fractures, the literature indicates that OTFs in adults seem to not always constitute absolute emergency conditions. Although such fractures need to be emergently/ immediately treated in children, in the absence of true muscle incarceration, adults may undergo successful treatment within a wider but either early or urgent frame of time. Adults frequently exhibit vagal manifestations and marked signs of local soft tissues injury.
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Affiliation(s)
- Ioannis Papadiochos
- Clinic of Oral and Maxillofacial Surgery, Geniko Nosokomeio Evangelismou, Athens, Greece
| | - Vasilis Petsinis
- Clinic of Oral and Maxillofacial Surgery, Dental School, University of Athens, Athens, Greece
| | | | - Lampros Goutzanis
- Clinic of Oral and Maxillofacial Surgery, Dental School, University of Athens, Athens, Greece
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Yoo YJ, Yang HK, Kim N, Hwang JM. Pediatric orbital wall fractures: Prognostic factors of diplopia and ocular motility limitation. PLoS One 2017; 12:e0184945. [PMID: 29095826 PMCID: PMC5667750 DOI: 10.1371/journal.pone.0184945] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/02/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To investigate the factors affecting recovery of diplopia and limited ocular motility in pediatric patients who underwent surgery for orbital wall fracture. DESIGN Retrospective observational case series. METHODS In this retrospective observational case series, 150 pediatric patients (1-18 years old) who were diagnosed with orbital medial wall or floor fracture and underwent corrective surgery between 2004 and 2016 at Seoul National University Bundang Hospital were included. The medical records of patients with orbital medial wall or floor fracture were reviewed, including sex, age, diplopia, ocular motility, preoperative computed tomographic finding, and surgical outcomes. Factors affecting recovery of diplopia and ocular motility limitation were analyzed. RESULTS Of the 150 patients (134 boys; mean age, 14.4 years) who underwent corrective surgery for orbital wall fracture, preoperative binocular diplopia was found in 76 (50.7%) patients and limited ocular motility in 81 (54.0%). Presence of muscle incarceration or severe supraduction limitation delayed the recovery of diplopia. In case of ocular motility limitation, presence of muscle incarceration and retrobulbar hemorrhage were related with the delayed resolution. Multivariate analysis revealed supraduction limitation (Hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.19-2.55), larger horizontal orbital floor defects (HR = 1.22, 95% CI = 1.07-1.38), and shorter time interval to first visit (HR = 0.73) as negative prognostic factors for the recovery of diplopia. In addition, muscle incarceration (HR = 3.53, 95% CI = 1.54-8.07) and retrobulbar hemorrhage (HR = 3.77, 95% CI = 1.45-9.82) were found as negative prognostic factors for the recovery of motility limitation. CONCLUSIONS Presence of muscle incarceration and retrobulbar hemorrhage, horizontal length of floor fracture, supraduction limitation, and time interval from trauma to first visit were correlated with the surgical outcomes in pediatric orbital wall fracture patients. These results strengthen that the soft tissue damage associated with bony fracture affects the orbital functional unit. When managing children with orbital wall fracture, meticulous physical examination and thorough preoperative computed tomography based evaluation will help physicians to identify damage of orbital functional unit.
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Affiliation(s)
- Yung Ju Yoo
- Department of Ophthalmology, Kangwon National University Hospital, Kangwon National University Graduate School of Medicine, Chuncheon, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Namju Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes. J Craniofac Surg 2017; 28:1966-1971. [PMID: 28953154 DOI: 10.1097/scs.0000000000004017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors' study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors' study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.
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Prospective study on ocular motility limitation due to orbital muscle entrapment or impingement associated with orbital wall fracture. Injury 2017; 48:1408-1416. [PMID: 28499464 DOI: 10.1016/j.injury.2017.04.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/18/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The recommended urgent surgical management of ocular motility restriction due to orbital muscle entrapment or impingement associated with orbital wall fracture needs to be elucidated. AIM To evaluate the importance of the time from injury to surgery for the outcome in ocular motility and diplopia, the time lapse of ocular motility, diplopia and hypesthesia recovery. MATERIAL AND METHODS Patients with entrapment or impingement of orbital contents due to orbital wall fracture were followed up prospectively over 1year regarding ocular motility, diplopia, hypesthesia and cosmetic deformity. RESULTS 21 patients (10 entrapments and 11 impingements) were included and treated surgically. The median time from injury to surgery was 36 (8-413)h for the entrapment group and 168 (48-326)h for the impingement group. The median time from study inclusion to surgery was 0 (0-1) days for the entrapment group and 1.0 (0.2-4.8) days for the impingement group. All the patients had ocular motility limitation and diplopia at the inclusion. Ocular motility improved gradually and was normal at final visit. Diplopia resolved gradually in all patients except in two with non-disturbing diplopia, at the final visit. Forced duction test was positive in 90% of the patients in the entrapment group and 70% in impingement group. At final visit, hypesthesia was found in none of the patients in the entrapment group but in 4 patients in the impingement group. CONCLUSIONS In this, the first prospective long term follow up of orbital wall fractures with ocular motility restriction, we did not find any significant correlation between the time from injury to surgery and the outcomes in ocular motility and diplopia. An entrapment requires surgery as soon as possible; however, the surgical reduction is at least as important as surgical timing. Surgery should be delayed until it can be performed by an experienced surgeon. Ocular motility restriction causing diplopia due to impingement is not an ophthalmologic emergency and surgery is recommended if the diplopia and ocular motility has not improved over time. Clinical examination of ocular motility and not CT scan findings is crucial to determine whether a limitation of ocular motility exists or not.
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Yang DJ, Kim YJ, Seo DW, Lee HJ, Park IJ, Sohn CH, Ryoo JM, Lee JS, Kim WY, Lim KS. Characteristics of orbital wall fractures in preschool and school-aged children. Clin Exp Emerg Med 2017; 4:32-37. [PMID: 28435900 PMCID: PMC5385511 DOI: 10.15441/ceem.16.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/28/2016] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to evaluate the injury patterns in pediatric patients with an orbital wall fracture (OWF) and to identify the differences in injury patterns between preschool and school-aged patients with OWF who presented to the emergency department. Methods We performed a retrospective observational study in the emergency department of a tertiary hospital between January 2004 and March 2014. A total of 177 pediatric patients (<18 years) with OWF who underwent facial bone computed tomography scans with specific discharge codes were included. Patients were categorized into preschool (≤7 years) and school-aged (>7 years) pediatric groups. Results The inferior wall was the most common fracture site in both the preschool and school-aged pediatric groups (50.0% vs. 64.4%, P=0.15). The male-to-female ratio and the mechanism of injury showed significant differences between the two age groups. Violence was the most common mechanism of injury in the school-aged pediatric group (49.3%), whereas falls from a height caused OWF in approximately half of the patients in the preschool pediatric group (42.9%). Concomitant injuries and facial fractures had a tendency to occur more frequently in the school-aged pediatric group. Conclusion Significant differences according to the sex and mechanisms of injury were identified in preschool and school-aged pediatric patients with OWF.
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Affiliation(s)
- Dong Jin Yang
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung-Joo Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-June Park
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Min Ryoo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Summers SM, Wood RM, Costello JE, Carlson CL. Orbital Trapdoor Fracture: An Open-and-shut Case? Clin Pract Cases Emerg Med 2017; 1:67-68. [PMID: 29849426 PMCID: PMC5965448 DOI: 10.5811/cpcem.2016.11.32397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Shane M Summers
- San Antonio Military Medical Center, Department of Emergency Medicine, JBSA Fort Sam Houston, Texas
| | - Richard M Wood
- San Antonio Military Medical Center, Department of Emergency Medicine, JBSA Fort Sam Houston, Texas
| | - Justin E Costello
- San Antonio Military Medical Center, Department of Emergency Medicine, JBSA Fort Sam Houston, Texas
| | - Christian L Carlson
- San Antonio Military Medical Center, Department of Emergency Medicine, JBSA Fort Sam Houston, Texas
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Li Y, Song X, Li L, Fan X, Lin M. Forced duction training: A potential key point for recovery in pediatric patients with trapdoor fracture. Medicine (Baltimore) 2016; 95:e5121. [PMID: 27858844 PMCID: PMC5591092 DOI: 10.1097/md.0000000000005121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trapdoor fracture is a type of orbital fracture frequently observed in pediatric patients after facial trauma. The treatment options and surgical outcomes associated with this fracture are controversial.This study investigated the surgery principles and strategies as well as the functional training for the recovery and prognosis of pediatric patients with trapdoor fracture.A retrospective study was conducted on 21 pediatric patients with orbital trapdoor fracture who received the transconjunctival approach for orbital defect reconstruction surgery between 2009 and 2014 at the Department of Ophthalmology, Shanghai Ninth People's Hospital. The minimum follow-up period was 1 year, and the average follow-up time was 2.5 years. These data included surgery principles and strategies, functional training for recovery, and patient prognosis.Of all the numerical variables, interval to surgery was the only parameter that affected the recovery of ocular movement and diplopia grades [ΔLEMSG (6 m:pre) = -2.689 + 0.015 • interval to surgery, P = 0.018; ΔLEMSG (last:pre) = -3.171 + 0.026 • interval to surgery, P = 0.033; Δdiplopia (6 m:pre) = -3.266 + 0.026 • interval to surgery, P = 0.047; Δdiplopia (last:pre) = -2.518 + 0.019 • interval to surgery, P = 0.031], whereas recovery was not affected by age or preoperative ocular movement or diplopia grades (P > 0.05). According to the categorical variable analysis, patient prognosis grouped by coordination to forced duction training varied across the different groups (P < 0.05); however, male and female patients did not differ with regard to prognosis (P > 0.05).To judge the prognosis of pediatric patients with trapdoor fracture, cooperation to forced duction training and interval to surgery are most likely key points. Correct surgical approaches and functional training are of great importance for faster recovery.
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Affiliation(s)
| | | | | | | | - Ming Lin
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai, China
- Correspondence: Ming Lin and Xianqun Fan, Department of Ophthalmology, Shanghai Ninth People's Hospital, Zhizaoju Rd 639, Shanghai 200011, China (e-mail: ; )
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Postoperative Improvement of Diplopia and Extraocular Muscle Movement in Patients With Reconstructive Surgeries for Orbital Floor Fractures. J Craniofac Surg 2016; 27:2043-2049. [DOI: 10.1097/scs.0000000000003192] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Vazquez MP, Kadlub N, Soupre V, Galliani E, Neiva-Vaz C, Pavlov I, Picard A. [Facial trauma and injury in children]. ANN CHIR PLAST ESTH 2016; 61:543-559. [PMID: 27614719 DOI: 10.1016/j.anplas.2016.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 07/27/2016] [Indexed: 11/25/2022]
Abstract
Facial traumas are common in children but often unconsidered. Facial injury is responsible of impressive bleeding because of the rich vascularization of the face; this bleeding is often underestimated because of the immediate arterial vasoconstriction that is very strong for children. The blood volume is 80ml/kg for a newborn, with a total of 250ml, reaching 70ml/kg at one year of age. The evaluation must be rigorously performed due to the risk of a sudden decompensation. Regarding the wounds, the primary repair must be performed directly neat or optimal in case of damaged tissues. The rule is to keep maximum of the integrity and to limit debridement. Careful repair often requires general anesthesia, especially in young children, to facilitate a perfect joining of the edges and of the mucocutaneous lines. Losses of substance should be treated by directed cicatrization. Flaps are never performed in children as a first intention for reasons developed below. Given the elasticity of the facial skeleton, fractures require a brutal shock to occur, but the clinical signs can be misleading. For instance, too specific and sometimes ignored, fractures can show weakly symptomatic signs : the fractures of the condylar and the orbital floor, with their respective complication that are temporomandibular bone ankylosis and definitive diplopia. Possible children abuse should be suspected in case of different age lesions and discrepancies between the told story and types of injuries. Once the vital urgency is eliminated, the orbital emergency should be first considered in facial traumas within the ophthalmology specialty because wounds and contusions of the globe are often under-evaluated and threaten the vision. The second emergency is the orbital floor fracture in its 'trapdoor' type, specific to the child. Combined with a motionless eye and uncontrollable vomiting, this is the second true urgency because it involves the prognosis of the oculomotricity and requires emergency surgery. Finally, dental trauma should not be overlooked because of their functional and aesthetic consequences. Primary cicatrization is usually rapid but scars remain inflammatory during a long time. The risk of hypertrophy exists in case of contusions and lacerations associated with wounds but also during puberty and in some locations. Age interfere with the result because growth will either improve or worsen the initial result, depending on the location and mechanism. The secondary specialized and prolonged managing and monitoring is capital on the functional, aesthetic and psychological points of view.
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Affiliation(s)
- M-P Vazquez
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France.
| | - N Kadlub
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - V Soupre
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - E Galliani
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - C Neiva-Vaz
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - I Pavlov
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - A Picard
- Service de chirurgie maxillo-faciale et chirurgie plastique pédiatrique, hôpital Necker, faculté de médecine Paris Descartes, Paris 5, AP-HP, 149, rue de Sèvres, 75015 Paris, France
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Resorbable Materials for Reconstruction of the Orbital Floor in Children. J Craniofac Surg 2016; 27:1826-1829. [DOI: 10.1097/scs.0000000000002908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Su Y, Shen Q, Lin M, Fan X. Predictive factors for residual diplopia after surgical repair in pediatric patients with orbital blowout fracture. J Craniomaxillofac Surg 2016; 44:1463-8. [DOI: 10.1016/j.jcms.2016.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/16/2016] [Accepted: 06/13/2016] [Indexed: 11/28/2022] Open
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DeParis SW, Grumbine FL, Vagefi MR, Kersten RC. Persistent Upgaze Restriction after Orbital Floor Fracture Repair. Craniomaxillofac Trauma Reconstr 2016; 9:268-70. [PMID: 27516846 DOI: 10.1055/s-0035-1570076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 07/28/2015] [Indexed: 10/22/2022] Open
Abstract
Here we present two cases of marked postoperative upgaze restriction after successful repair of orbital floor fracture and release of inferior rectus entrapment. In both cases, follow-up imaging showed enlargement of the inferior rectus, and gradual resolution of gaze limitation was observed over several months of conservative management. Thus, in patients with postoperative findings suggestive of residual inferior rectus entrapment, follow-up imaging is indicated prior to returning to the operating room. With a markedly swollen inferior rectus muscle but no radiographic evidence of residual muscle entrapment in the fracture, a trial of conservative management may be warranted.
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Affiliation(s)
| | - F Lawson Grumbine
- Department of Ophthalmology, University of California, San Francisco, California
| | - M Reza Vagefi
- Department of Ophthalmology, University of California, San Francisco, California
| | - Robert C Kersten
- Department of Ophthalmology, University of California, San Francisco, California
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Merali FI, Grant MP, Mahoney NR. Orbital Floor Fracture with Atypical Extraocular Muscle Entrapment Pattern and Intraoperative Asystole in an Adult. Craniomaxillofac Trauma Reconstr 2015; 8:370-4. [PMID: 26576246 DOI: 10.1055/s-0035-1556052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/31/2015] [Indexed: 10/23/2022] Open
Abstract
Extraocular muscle entrapment in a nondisplaced orbital fracture, although a well-known entity in pediatric trauma, is atypical in adults. It can present with a triad of bradycardia, nausea, and in rare cases, syncope, and result in severe fibrosis of damaged and incarcerated muscle. We present a case of muscle entrapment in a partially nondisplaced two-wall orbital fracture with accompanying preoperative bradycardia and intraoperative asystole in an adult.
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Affiliation(s)
- Farhan I Merali
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
| | - Michael P Grant
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
| | - Nicholas R Mahoney
- Johns Hopkins University, Wilmer Ophthalmological Institute, Baltimore, Maryland
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