经睑下缘及内眦切口内镜辅助下眶壁骨折治疗初探

目的 探讨经睑下缘径路内镜辅助下手术治疗眶壁骨折的可行性.方法 对2例外伤所致的眶壁骨折患者,经睑下缘及内眦切口内镜辅助下分离嵌顿的眼肌,于眶下壁及眶内壁置入钛板.结果 1例患者术后复视消失,术后视力1.2,无下降.1例患者术后仍有眼球内陷及复视,术后左眼视力由0.25提高到0.6,右眼仍为1.0.结论 经睑下缘及内眦切口内镜辅助手术治疗眶壁骨折视野清楚,操作准确,无严重的手术并发症发生.     

眶底骨折:早期修复及其结果

累及眼眶的面部骨折可引起严重畸形和眼功能障碍。作者对34例面部骨折累及眶底的病人施行早期修复,其中单纯眼眶粉碎性骨折13例,颧骨及严重眶底骨折9例,眶底及上颌骨、颧骨多数性骨折12例。氏强调在进行眼部、面部感觉、牙咬(牙合)及X线检查确定骨折情况后宜及时手术,手术时间不迟于72小对。本文介绍一种经眶下缘切口与上颌窦柯-陆氏术切口联合进行眶底骨折复位的万法。经眶缘切口剥开眶筋膜可直接检查眶底骨折情况,再通过颊龈切口于上颌窦腔内放一带导管的气囊,注入6～14ml造影剂,可经眶下缘切口在明视下恰当地控制所需造影剂的量,使骨折的眶底回复到正常位置,术后7～14天取出气囊。对眶底严重骨折失去支撑作用的病例,使用0.1mm厚的薄硅板作为移植衬垫,应注意硅板大小要合适,恰好放置在眶下缘后方,避免引起眼球突出。本组中有28例应用硅板接复,其中2例因硅板厚     

经眼下穹窿切开修复眶缘及眶底骨折

作者应用经眼下穹窿切开修复眶缘及眶底骨折获得成功。此法能暴露内、下、外三个眶壁,并可顺利进行骨折的固定和修复。若与上颌窦手术径路合用,可同时处理上颌窦前壁骨折。愈合后局部疤痕轻,外眦切开有利于眼球退缩易暴露术野和减少于术并发症等优点。手术方法:全麻。下直肌缝牵引线。水平剪开眼外眦皮肤约5mm,钝性分离并剪开外眦韧带下臂,沿下穹窿向鼻侧剪开结膜,暴露眶下缘。在眶下缘前面切开骨膜并剥离,牵开骨膜和眼球,即可暴露三个眶壁,检查发现眶     

经鼻内镜柯陆进路自体耳屏软骨修复眶底骨折缺损的方法与疗效

目的:探讨用自体耳屏软骨通过鼻内镜辅助下柯陆进路修复单纯眶底骨折缺损的手术方法及疗效。方法:回顾性分析15例击出性眶底骨折(暴裂性骨折)的治疗过程,取口腔前庭切口直达尖牙窝,凿开上颌窦前壁约2cm×2cm大小,鼻内镜辅助下探查眶底骨折缺损大小,取自体耳屏软骨修复。结果:术后15例均未出现视力下降、复视,无明显眼球下陷;有3例术后出现眼球轻度活动受阻,1个月后基本恢复。随访2年均无假性眼睑下垂、上眼睑陷窝加深、睑裂横径缩短及面部畸形,双眼球位置基本对称,无并发症。结论:经鼻内镜柯陆进路自体耳屏软骨修复眶底骨折缺损疗效满意、微创、操作简单且无眼面部瘢痕。     

眉弓切口鼻内镜下眶内壁骨折整复术

爆裂性眶壁骨折中儿童以眶下壁骨折多见,成人以眶内壁骨折多见。传统的眶内壁骨折整复术自内眦皮肤切口进路,不仅皮肤切口大(至少2．5cm)、面部遗留疤痕,而且并发症多,易损伤内眦韧带及泪囊。我院自2000年5月～2002年8月对经CT扫描诊断为眶内壁骨折且存在复视或眼球内陷的病人18例应用眉弓改良切口鼻内镜辅助下眶内壁骨折整复术取得了良好的临床治疗效果,现报告如下。     

上颌窦前壁自体骨移植治疗眶底暴折

我科于2003年5月～2005年7月对9例单纯眶下壁击出性骨折患者,采用自体上颌窦前壁骨片修复眶底,下睑下和柯-陆手术联合进路在鼻内镜下行眶内容物复位固定术9例,取得良好疗效,现报道如下。1资料与方1.1临床资料。9例患者均为外伤所致眶下壁骨折,眶内容物脱入上颌窦内,男性6例,女性3例;年龄17～62岁;病程2～30天。临床表现:眼睑和面部皮下淤血、肿胀,球结膜充血或结膜下出血,眼球活动障碍,3例患者有同侧眶下神经分布区面部麻木感。CT扫描示右侧眶下壁骨质不连续,并可见眶内容物向下突入上颌窦内(图1)。经1周以上保守治疗,复视无好转或出现眼球…     

眶底骨折继发脑梗塞1例

患者 ,男 ,2 0岁。 1996年 4月 4日上午右面部撞在通电管上 ,无昏迷 ,右眼视物模糊不清 ,面部出血 ,头痛头昏 ,非喷射状呕吐 3次。入院体检 :右眶下缘有一不规则的“△”状伤口 ,最长边约 5ｃｍ ,并右眼球下陷 ,球结膜下出血 ,睑结膜水肿 ,触诊探及眶下缘塌陷。Ｘ线片 :右眶底粉碎性骨折。局麻下行眶底骨折复位术 ,术日当晚患者躁动不安 ,神智恍惚 ,言语不清 ,饮水呛咳 ;血压 90 / 6 0ｍｍＨｇ (1ｍｍＨｇ =0 .133ｋＰａ) ;头颅ＣＴ未见异常。此后患者一直嗜睡 ,出现不完全性运动性失语。右眼球活动良好 ,双瞳孔等大等圆 ,对光反射存在 ;右…     

粉碎性眶内壁骨折和软组织凹陷

粉碎性骨折是眶骨最常见的损伤,占面骨骨折的第三位,仅次于鼻骨和上颌骨骨折。本文报告2例的治疗经过。例1,男性11岁,左眼因被扫帚柄撞伤,眼眶瘀斑、肿胀、鼻衄,眼球向上向外运动受限,视力正常。平片和断层片发现眶底至眶内壁粉碎性骨折。病人伤后10天取内眦眶下缘切口进行探查,发现眶底骨折向内侧,致使眶内壁下份凹下,纸板薄而活动,有几处骨折并有软组织陷入筛窦,切除纸板及邻近筛房以减少眶组织凹陷和减压,从后筛房到鼻腔开一个1cm的孔以利引流。出院随访6个月眼球运动渐恢复,但在向最外侧注视时有复视。例2,男性20岁,右眼被拳击伤,眼眶瘀斑,外侧结膜下出血,疼痛,向内、外侧平视时有复视,内直肌运动受限,视力正常。平片发现右筛窦轻度模糊,CT扫描发现眶内壁骨折及软组织陷入筛窦。伤     

内镜下中鼻道联合泪前隐窝入路治疗眶壁骨折

目的:探讨内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁双壁骨折的手术方法和疗效。方法:回顾性分析我科收治的3例实施鼻内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁骨折患者的临床资料,分析其疗效和手术并发症的发生情况。结果:术后随访6个月~1年,3例患者复视症状消失,眼球内陷完全矫正,无手术并发症。结论:采用内镜下中鼻道联合泪前隐窝入路治疗眶底壁和眶内壁的眼眶双壁骨折,具有组织损伤小、费用低、并发症少等优点,疗效满意,值得临床推广。     

鼻内镜下鼻中隔软骨移植修复眶内壁缺损

随着鼻眼相关外科学的不断发展,我们从1996年起开展了经鼻内镜筛窦进路利用自体鼻中隔软骨修复因外伤而致的眶内壁缺损手术54例,现报道如下。1资料与方法1.1一般资料。1996年5月～2008年6月我院因爆裂性眶内壁骨折而行鼻内镜筛窦进路利用自体鼻中隔软骨修复眶内壁缺损手术54例,男45例,女9例     

Treatment of 813 zygoma-lateral orbital complex fractures. New aspects

A 10-year experience with surgical treatment of 813 zygomalateral orbital complex fractures is reviewed. Regardless of the type or severity of the fracture pattern, concomitant fractures of the orbital floor and rim were approached exclusively through the transconjunctival approach without a lateral canthotomy. The advantages of this approach compared with the subciliary access are the avoidance of a visible scar and markedly reduced incidence of postoperative lower eyelid complications such as ectropion and edema. Implants of lyophilized dura or cartilage and autogenous bone were used to reconstruct orbital floor defects. Malar asymmetry is a frequent complication of zygoma fractures resulting from inadequate three-dimensional reduction. Methods for accurate reduction and stabilization, indications for closed and open reduction, and management of the fractured infraorbital rim are emphasized. The indications for miniplates vs wire ligatures for the infraorbital rim are discussed. Long-term follow up and evaluation of the results with regard to the fracture pattern, complications, maxillary sinus dysfunction, and facial and orbital symmetry are presented.     

Preseptal transconjunctival approach for orbital floor fracture repair: ophthalmologic results in 209 patients

CONCLUSIONS: The transconjunctival approach to orbital floor fractures permits excellent exposure of the inferior orbit and provides a good surgical outcome, especially with regard to ocular motility. OBJECTIVE: Surgical access to orbital floor fractures can be accomplished via the transconjunctival approach. The majority of studies on this subject deal with surgical aspects and complications. The purpose of this study was to report the ophthalmologic outcome after transconjunctival orbital floor fracture repositioning in a significant number of patients. MATERIAL AND METHODS: In a retrospective study, the data of 209 patients with orbital floor fractures treated via the transconjunctival approach with (n=181) and without (n=28) lateral canthotomy were analyzed. RESULTS: The commonest cause of injury was forms of violence (32%). An isolated fracture of the orbital floor had occurred in 62 cases, while concomitant facial fractures were present in the remaining 147. A total of 24 patients (11%) had an exophthalmos and 13 (9%) an enophthalmos. Most patients (69%) complained of infraorbital dysesthesia. When elevating the eyeball, the majority of patients showed a marked or severe disturbance of ocular motility (53% in abduction; 51% in adduction) and diplopia (37% in abduction; 36% in adduction). Thirteen patients required repeat surgery. After a follow-up period of 2 years, infraorbital dysesthesia was observed in only three patients, one of whom presented with a considerable persistent enophthalmos of 4 mm, and only four patients had persistent reduced motility and diplopia.     

Preseptal transconjunctival approach for orbital floor fracture repair: ophthalmologic results in 209 patients

Conclusions. The transconjunctival approach to orbital floor fractures permits excellent exposure of the inferior orbit and provides a good surgical outcome, especially with regard to ocular motility.

Objective. Surgical access to orbital floor fractures can be accomplished via the transconjunctival approach. The majority of studies on this subject deal with surgical aspects and complications. The purpose of this study was to report the ophthalmologic outcome after transconjunctival orbital floor fracture repositioning in a significant number of patients.

Material and methods. In a retrospective study, the data of 209 patients with orbital floor factures treated via the transconjunctival approach with (n=181) and without (n=28) lateral canthotomy were analyzed.

Results. The commonest cause of injury was forms of violence (32%). An isolated fracture of the orbital floor had occurred in 62 cases, while concomitant facial fractures were present in the remaining 147. A total of 24 patients (11%) had an exophthalmos and 13 (9%) an enophthalmos. Most patients (69%) complained of infraorbital dysesthesia. When elevating the eyeball, the majority of patients showed a marked or severe disturbance of ocular motility (53% in abduction; 51% in adduction) and diplopia (37% in abduction; 36% in adduction). Thirteen patients required repeat surgery. After a follow-up period of 2 years, infraorbital dysesthesia was observed in only three patients, one of whom presented with a considerable persistent enophthalmos of 4 mm, and only four patients had persistent reduced motility and diplopia.     

The expanded transconjunctival approach with lateral canthotomy to the orbital margin, floor and infraorbital nerve

The range of indications for and the surgical technique of the extended transconjunctival approach to the inferior and lateral orbital margin, the floor of the orbit, the upper part of the facial wall of the maxillary sinus and the medial part of the zygomatic bone are described. We present 64 patients with mid-face fractures: 9 with fractures of the orbital margin, 48 with isolated blow-out fractures, and 7 with zygomaticomaxillary fractures. All have been operated on in the last 5 years. The transconjunctival approach extended by a lateral canthotomy is better than infraorbital or subciliary access. Exposure and cosmesis are excellent. None of the complications that follow other methods were seen after our surgical treatment.     

Fractures of the zygoma. A geometric, biomechanical, and surgical analysis.

We present a four-part study of the cosmetic results of common zygomatic fracture reduction techniques: (1) a geometric analysis of an idealized paper and clay model; (2) a topographic analysis of zygomatic fractures in the dry skull; (3) a biomechanical analysis of fixation techniques in the fresh cadaver; and (4) a retrospective and prospective review of our clinical experience. The following are concluded: Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Masseteric contraction may cause late displacement in poorly fixed fractures. Two-point interosseous fixation at the "buttress" fracture and the frontozygomatic fracture is suitable for routine surgery. The infraorbital rim may be aligned through the gingivobuccal sulcus incision. Transcutaneous incisions may be limited to the brow incision. The transconjunctival approach is suitable for orbital floor repair.     

Interobserver variation of the sonographic diagnosis of orbital floor fractures and fractures of the infraorbital margin]

PURPOSE: The aim of the study was to evaluate the interobserver variation of the ultrasound diagnosis of orbital floor fractures and fractures of the infraorbital rim. MATERIAL AND METHODS: A total of 25 patients with a clinical diagnosis of an orbital trauma were investigated prospectively by computed tomography (CT) and ultrasonography (US). Inter-observer variation was calculated using the lambda coefficient (lambda). The US images were reassessed by two inexperienced investigators. RESULTS: The lambda value for the US investigation of the orbital floor showed poor reliability comparing the US findings with the results of the re-investigators. The comparison between the two re-investigators showed a good reliability for the US evaluation of the orbital floor. The lambda for the US investigation of the infraorbital margin showed a good reliability comparing the US findings with the results of the both re-investigators. The comparison of the two re-investigators showed a good reliability as well. CONCLUSION: Ultrasound is not yet an alternative method for the evaluation of orbital floor fractures and fractures of the infraorbital margin. To replace CT which is accepted as the current gold standard, further studies have to be done to reach a better diagnostic quality of the method and to achieve a better calibration of the investigations.     

Endoscopic repair of orbital floor fractures: computed tomographic analysis using a cadaveric model

OBJECTIVE: To determine the efficiency (and accuracy) of endoscopic repair versus transconjunctival repair for orbital floor fractures in a cadaveric model. METHODS: In nine fresh cadavers, a standardized technique created orbital floor fractures. One orbit was repaired using an endoscopic transantral approach, whereas the other was repaired using a standard transconjunctival approach. Commercially available implants were used for floor reconstruction. A validated computed tomographic volumetric analysis of the orbits was performed at three time points: prefracture, postfracture, and postrepair. Student's t-test analyzed the percentage of volume change in the prefracture and postrepair stages for each approach. RESULTS: The percentage of change between the prefracture and postrepair states was not statistically significant for transconjunctival (p = .834) or endoscopic (p = .366) repair. The average differences between transconjunctival repair and endoscopic repair were not statistically significant (p = .732). CONCLUSIONS: This study objectively confirms the efficiency of the endoscopic repair of orbital floor fractures when compared with traditional techniques in the cadaveric model.     

Schwannoma originating from the infraorbital nerve: a case report

A 16-year-old female admitted to otolaryngology outpatient clinic with the complaints of pain and replacement of her left eyeball upwards. Radiological imaging demonstrated a solid mass inferior to the left globe. The anterior wall of the maxilla was thinned and the mass pushed the orbital floor inferiorly. Following subciliary incision, the bone over the mass was removed from the orbital rim and the mass was exposed. The mass originated from the infraorbital nerve. The mass was excised and the orbital rim, malar region and the orbital floor were reconstructed by a titanium mesh. The histopathological report was "schwannoma". Seven cases of schwannomas arising from the infraorbital nerve reported in English literature. In this paper we report a case of infraorbital schwannoma and review the literature.     

Bewertung einer wenig invasiven Therapie von Jochbeinfrakturen mit einem Klassifikationsvorschlag

The pre- and postoperative symptoms of zygomatic bone fractures were examined in a follow-up study to prepare a classification proposal. A differential indication for minimally invasive therapy modes was looked for with respect to this proposal. Therapy of isolated zygomatic bone fractures consisted in repositioning with a hook and miniplate fixation across the frontozygomatic suture. The aims of this study were clinical and radiological assessment of the repositioning result in terms of aesthetics and stability and quantification of the postoperative remission of disturbances of sensitivity of the infraorbital nerve. A total of 52 patients were examined. After the operation (on average after 3.5 days following the trauma) they were followed-up postoperatively for 12 months according to a strict schedule. Preoperatively, 49 patients reported disturbances of sensitivity of the infraorbital nerve. Other symptoms, such as periorbital haematoma and flattening of the zygomatic prominence, were observed in 49 patients and 45 patients, respectively. All fractures were repositioned well as assessed clinically and radiologically. The aesthetic result was evaluated as symmetric and durable in all cases. Six months postoperatively 41 patients reported normal sensitivity in the area of the infraorbital nerve. In only five patients (10.2%) was the sensitivity loss persistent throughout the entire follow-up period. Patients with primarily lacking diplopia developed neither eye motility disturbances nor postoperative enophthalmus in the following period. It can be concluded that the treatment of an isolated zygomatic bone fracture which satisfies aesthetic and functional requirements is possible by reposition and fixation with one miniplate at the lateral orbital rim. An additional osteosynthesis at the infraorbital rim or at the zygomaticomaxillary crista is not necessary. A routine revision of the orbital floor is only indicated in cases of preoperative diplopia. A zygomatic bone fracture connected with diplopia should be classified as combined zygomatic-/orbital floor fracture.     

Endoscopic repair of orbital floor fractures

Significant orbital trauma can result in orbital floor fractures with subsequent prolapse of the orbital contents into the paranasal sinuses. Prolapse of the periorbita can result in extraocular muscle entrapment, diplopia, enophthalmos, and even visual loss. Management of orbital floor fractures traditionally has been accomplished through transconjunctival and subciliary incisions. These approaches provide adequate visualization and cosmetically acceptable scars. Unfortunately, post-operative lid malposition can occur in a small percentage of cases. Another limitation is easy visibility of the posterior orbit, which often is obscured by prolapsed orbital fat. In light of these limitations, some surgeons have begun to evaluate an endoscopic approach to orbital floor fractures. The endoscopic approach offers a hidden incision, improved fracture visualization, and avoidance of post-operative eyelid malposition. This article reviews the indications, technique, and potential complications of endoscopic orbital blow-out fracture repair.