Successful treatment of a rare subcutaneous emphysema after a blow-out fracture surgery using needle aspiration: A case report

BACKGROUND

Many cases of emphysema associated with blow-out fractures occur before surgery due to trauma. However, emphysema can occur even after surgery, and most of such cases are managed conservatively and allowed to resolve. Swelling in the periorbital area due to emphysema that occurs after surgery can make early recovery difficult.

CASE SUMMARY

Herein, we describe a case of postoperative subcutaneous emphysema that was treated using a simple needle aspiration method. A 48-year-old male patient visited the hospital with a blow-out fracture of the left medial orbital wall and nasal bone fracture. One day postoperatively, swelling and crepitus in the left periorbital area were observed, and follow-up computed tomography showed emphysema in the left periorbital subcutaneous area. Needle aspiration using an 18-gauge needle and syringe was used to relieve the emphysema. The symptoms of sudden swelling improved immediately, and no recurrence was observed.

CONCLUSION

We conclude that needle aspiration is a useful method that could help in relieving symptom, resolving discomfort, and enabling early return to daily life in patients with postoperative subcutaneous emphysema.

Orbital floor fractures-a comparison between CT images and findings at surgery

PURPOSE

The present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia.

METHODS

In this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery.

RESULTS

In the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. "Rounding" significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue.

CONCLUSIONS

The results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time.

Xanthogranuloma formation after endoscopic sinus surgery: A case report

Introduction

Although xanthogranuloma is known to be related to trauma or mucosa, possibly developing around a periorbital or oral lesion, xanthogranuloma related to sinusitis urgery has not been reported. We present a case of xanthogranuloma formation after endoscopic sinus surgery (ESS).

Presentaion of case

A 54-year-old man with pain and swelling in the right periorbital area presented to our clinic. He had had a blowout fracture treated by ESS 2 years prior. Physical examination and computed tomography revealed an ∼1-cm × 0.7-cm cystic mass on the right lower eyelid. Subciliary exploration found a fat-like mass that we completely excised. A histological examination revealed xanthogranuloma. No recurrence was observed for 1 year.

Discussion

If the wall between the sinuses and the orbit and the mucosa of the maxillary sinus are injured during ESS, infectious material and hematoma could develop into chronic granulomatous inflammation. In addition, a large antrostomy and/or a damaged nasolacrimal duct are risk factors for xanthogranuloma. Antibiotics can treat the disease and prevent infection. Progressive growth of the lesion and its infiltration into surrounding tissues may result in surgical resection.

Conclusion

Because many masses are idiopathic, the development of xanthogranuloma after simple ESS or a nondisplaced blowout fracture is possible. Although xanthogranuloma progression usually is benign and without specific complications, it may be sight- or life-threatening. Antibiotics and surgical resection are the treatments of choice and the latter can be a diagnostic tool. Physicians should be aware of the possibility of granuloma formation in patients who have undergone ESS.

Application of the three-dimensionally printed biodegradable polycaprolactone (PCL) mesh in repair of orbital wall fractures

PURPOSE

The present study aims to investigate the surface characteristics and biomechanical properties of 3D-printed polycaprolactone (PCL) mesh and present the clinical outcomes of this implant in the treatment of orbital wall fractures.

PATIENTS AND METHOD

A retrospective review of patients who underwent surgery for medial, inferior and inferomedial orbital wall fractures using PCL mesh was performed between April 2017 and June 2018. Two clinical outcomes were investigated: functional recovery and anatomical accuracy of reduction detected in image. Furthermore, scanning electron microscopy was used to evaluate the microscopic morphology, surface characteristics, and porosity of the PCL mesh.

RESULTS

Among a total of 22 patients with a mean age of 41.3 years, the most common cause of injury was assault (54.5%). Fourteen patients (63.6%) had isolated orbital floor fractures. At postoperative 1-week follow-up, three patients (13.6%) exhibited diplopia and a further three patients (13.6%) showed restriction in ocular motility, but these patients had completely recovered by their 6-month postoperative follow-up. Ideal repair of orbital fracture was almost achieved in 21 patients (95.4%) and there were no cases of implant infection, inflammatory response, migration of implant, or hemorrhage. Microscopic imaging of PCL mesh surface revealed fully interconnected micropores with 50% porosity.

CONCLUSIONS

The repair of orbital wall fracture using PCL mesh offers reliable stabilization of orbital wall defects with a low complication rate, leading to outstanding functional and aesthetic outcomes. Therefore, PCL mesh is a good alternative for bioresorbable implants in the treatment of orbital wall fractures.

Transient Anisocoria during Medial Blowout Fracture Surgery

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.

Oculocardiac reflex elicited by orbital floor fracture and inferior globe displacement

Purpose

To review the physiology, presentation and management of the oculocardiac reflex (OCR) by describing a case of the OCR associated with an orbital foreign body and complete ocular prolapse through a large orbital floor fracture in a 40-year-old male following a motor vehicle accident.

Observations

The patient demonstrated marked bradycardia and hypotension necessitating intubation and medical therapy for autonomic shock. A computed tomography (CT) showed a total blow out floor fracture and complete dislocation of a radiographically intact globe with uninterrupted rectus muscle attachments into the left maxillary sinus. He was taken to the operating room for urgent repair resulting in subsequent termination of severe OCR.

Conclusions and importance

The oculocardiac reflex can precipitate marked bradycardia and hypotension in the setting of trauma with significant orbital and maxillofacial injury. Prompt identification and management with vagolytic agents or definitive surgical intervention may prevent morbidity or mortality.

A case of isolated abducens nerve paralysis in maxillofacial trauma

Nervus abducens is a pure motor nerve located in the pons. It retracts the eyeball laterally by stimulating rectus lateralis muscle. In case of their paralysis, diplopia and restriction in the eye movements while looking sideways, are seen. Since the same signs are seen due to the muscle entrapment in blowout fractures, its differential diagnosis has importance in terms of the treatment protocol and avoiding unnecessary operations. In this article, we present a 22-year-old male patient who was referred to our department due to the prediagnosis of blowout fracture following maxillofacial trauma. However, he was diagnosed with abducens nerve paralysis after the consultations and analysis and his restriction of movement was resolved via systemic steroid treatment instead of unnecessary operation.

Customized orbital floor soft tissue retractor

For the correction of blow out fractures of the orbit, the retraction of orbital floor contents are necessary. We are here in presenting a customized orbital floor soft tissue retractor to overcome the disadvantages of the conventional Rows orbital floor retractor.