Pediatric orbital blowout fractures

Pediatric Head and Neck Trauma

The pediatric patient population has unique anatomic characteristics that bring challenges and increased risk to management. The purpose of this article is to guide the head and neck trauma surgeon in decision making for the treatment of pediatric head and neck trauma with an emphasis on facial fracture management.

Trigeminocardiac Reflex: A Review and Key Implications to Dermatologic Surgery

BACKGROUND

The trigeminocardiac reflex is a common but underreported occurrence that can vary from benign to life threatening. This reflex can be elicited by placing direct pressure on the globe of the eye or from traction of the extraocular muscles, stimulating the trigeminal nerve.

OBJECTIVE

To provide a review of potential stimuli for the trigeminocardiac reflex within dermatologic surgery and to discuss management options for the treatment of the trigeminocardiac reflex.

METHODS

PubMed and Cochrane were used to identify articles and case reports that established scenarios in which the trigeminocardiac reflex was provoked and subsequently how the reflex was managed.

RESULTS

Within the field of dermatologic surgery, the trigeminocardiac reflex can be stimulated during biopsies, cryoablations, injections, laser treatments, Mohs micrographic surgery, and oculoplastic interventions, most often occurring in an office setting. The most common presentations include significant bradycardia, hypotension, gastric hypermobility, and lightheadedness. The most definitive treatment is cessation of the inciting stimulus, monitoring, and symptomatic management. Glycopyrrolate and atropine are common treatments for severe, intractable cases of the trigeminocardiac reflex.

CONCLUSION

The trigeminocardiac reflex, while underreported and underrepresented in dermatologic literature and dermatologic surgery settings, should be considered in the setting of bradycardia and hypotension during dermatologic procedures.

Algorithm for pediatric orbital blowout fractures: a 20-year retrospective cohort study

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

Pediatric Orbital Fractures: Outcomes in Relation to Time of Surgery

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.

Personalized Medicine Workflow in Post-Traumatic Orbital Reconstruction

Restoration of the orbit is the first and most predictable step in the surgical treatment of orbital fractures. Orbital reconstruction is keyhole surgery performed in a confined space. A technology-supported workflow called computer-assisted surgery (CAS) has become the standard for complex orbital traumatology in many hospitals. CAS technology has catalyzed the incorporation of personalized medicine in orbital reconstruction. The complete workflow consists of diagnostics, planning, surgery and evaluation. Advanced diagnostics and virtual surgical planning are techniques utilized in the preoperative phase to optimally prepare for surgery and adapt the treatment to the patient. Further personalization of the treatment is possible if reconstruction is performed with a patient-specific implant and several design options are available to tailor the implant to individual needs. Intraoperatively, visual appraisal is used to assess the obtained implant position. Surgical navigation, intraoperative imaging, and specific PSI design options are able to enhance feedback in the CAS workflow. Evaluation of the surgical result can be performed both qualitatively and quantitatively. Throughout the entire workflow, the concepts of CAS and personalized medicine are intertwined. A combination of the techniques may be applied in order to achieve the most optimal clinical outcome. The goal of this article is to provide a complete overview of the workflow for post-traumatic orbital reconstruction, with an in-depth description of the available personalization and CAS options.

Critical appraisal of patient-specific implants for secondary post-traumatic orbital reconstruction

In orbital reconstruction, a patient-specific implant (PSI) may provide accurate reconstruction in complex cases, since the design can be tailored to the anatomy. Several design options may be embedded, for ease of positioning and precision of reconstruction. This study describes a cohort of 22 patients treated for secondary orbital reconstruction with a PSI; one patient received two PSI. The preoperative clinical characteristics and implant design options used are presented. When compared to preoperative characteristics, the postoperative clinical outcomes showed significant improvements in terms of enophthalmos (P < 0.001), diplopia (P < 0.001), and hypoglobus (P = 0.002). The implant position in all previous reconstructions was considered inadequate. Quantitative analysis after PSI reconstruction showed accurate positioning of the implant, with small median and 90th percentile deviations (roll: median 1.3°, 90th percentile 4.6°; pitch: median 1.4°, 90th percentile 3.9°; yaw: median 1.0°, 90th percentile 4.4°; translation: median 1.4 mm, 90th percentile 2.7 mm). Rim support proved to be a significant predictor of roll and rim extension for yaw. No significant relationship between design options or PSI position and clinical outcomes could be established. The results of this study show the benefits of PSI for the clinical outcomes in a large cohort of secondary post-traumatic orbital reconstructions.

Combined Subciliary/Transantral Approach for Reconstruction of Orbital Floor Fracture

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.

Surgical treatment of enophthalmos in children and adolescents with pure orbital blowout fracture

PURPOSE

This study evaluated outcomes of surgical treatment for enophthalmos after pediatric orbital blowout fracture. Associations of fracture type, fracture site, time from injury to treatment, and type of surgical procedure with treatment outcomes were assessed.

METHODS

The medical records of 200 children and adolescents (38 girls and 162 boys) with orbital fractures treated in the authors' department from 1975 to 2015 were reviewed retrospectively. The main causes of injury were accidental blows to the orbit and sports injuries. This study included only patients with fracture of the floor and/or medial wall of the orbit, which is referred to in the English literature as pure, or internal, blowout fracture. Patients with fracture of the orbital rim, lateral wall, or roof were excluded. Surgical treatment was performed for 178 patients; the other 22 children were treated conservatively.

RESULTS

In the surgically treated group, treatment outcomes did not differ in relation to the severity of post-traumatic enophthalmos. The setting of the eyeball improved in 83% of patients.

CONCLUSION

The severity of post-traumatic enophthalmos was not associated with surgical outcome in children.

Resorbable Material for Pediatric Orbital Floor Reconstruction

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.

Delayed surgical treatment of orbital trapdoor fracture in paediatric patients

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.