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.     

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.     

Functional results following surgical management of isolated orbital floor fractures (blow-out fractures)

Sixty five orbital floor fractures of varying degrees of severity were assessed retrospectively. The operative treatment was performed via the transorbital approach within 14 days of the trauma. Pre-operatively 26 patients had sensory disorders of the infraorbital nerve. Six months later the nerve had recovered fully or partially. Preoperatively 49 patients (74%) were found to have double vision. Six months after the operation 44 patients (90%) were either much better or the double vision could no longer be detected. Only 5 cases showed no improvement. In view of the poor results of non-operative therapy of orbital floor fractures, we recommend early operative treatment for blow out fractures.     

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.     

Orbital floor fractures: early repair and results

In the 5-year period 1978-1982, 34 patients with facial fractures underwent repair of the orbital floor. Reconstruction of the orbital floor by means of an implant was used in 28 of 34 patients (82%). Nineteen patients (56%) had a balloon inflated in the maxillary sinus to stabilize the orbital floor. Radiographic contrast solution was used in the balloon to facilitate the postoperative radiographic control of the balloon and the orbital floor. It was possible to make a follow-up study of 30 of the 34 patients. Nine of the patients had persisting reduced sensitivity in the infraorbital nerve region and 7 patients had slight enophthalmos. Out of the 30 patients, only 2 patients had persisting diplopia of a slight to moderate degree and none found it disturbing enough to need further surgery. This series shows that good results can be expected after early surgery and active management with open reposition, reconstruction and placing of an intral balloon are recommended.     

Persistent sensory disturbances and diplopia following fractures of the zygoma.

In a follow-up study of 124 patients with fractures of the zygoma, 100 of whom had undergone surgery, sensory disturbances of the intraorbital nerve, mostly to a very moderate degree, were found in 46% of those operated on. Slight imperfections of the fracture reduction had no influence on the results, and no substantial difference in outcome was found between the different surgical methods employed. The diplopia that persisted in five patients was due to reduced motility of the globe, without any displacement or sign of loss of orbital contents.     

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.     

Maxillary sinus hypoplasia and superior orbital fissure asymmetry

Misdiagnosis of maxillary sinus hypophasia usually as sinus infection, sometimes as neoplasm, can lead to unnecessary and difficult surgical explorations. Associated anatomical abnormalities, e.g., caudal displacement of the ipsilateral frontal lobe of the brain or central position in the maxilla of the infraorbital nerve may create unexpected surgical hazards. Associated orbital enlargement can lead to diagnostic confusion in the investigation of headache, especially if the superior orbital fissures show marked asymmetry suggesting erosion. Projection of the fissure into the antrum in Waters view can simulate trabeculation of the sinus or fracture of the inferior orbital rim. Radiologic examination of 500 patients without intracranial or intraorbital lesions revealed maxillary sinus hypoplasia in 36 cases (7.2%) and in half the hypoplasia was unilateral (sinus asymmetry); aplasia was not encountered. Fissure asymmetry was present in 30 cases (6%), being present in 3.66% of patients with normally developed sinuses and in 36.1% of the hypoplasia patients. The appearances and measurements of the fissure are presented and examples of marked normal fissure asymmetry are demonstrated. Maxillary sinus hypoplasia is classified in this series as grade I-mild hypoplasia with limited inferolateral expansion (4 cases) and grade II in which there is also a curved orbital floor and lateral displacement of the adjacent nasal wall (32 cases).     

Early treatment of orbital floor fractures with catheter balloon in children

Fifteen pediatric patients with orbital floor fractures were successfully treated early, following injury by a transantrally introduced catheter-balloon technique. The latter stabilizes and supports the torn, but still vascularized periosteum at the edges of the fracture and also serves as a guide for its further proliferation and new bone formation. Apart from a transient anesthesia in the dermatome of the infraorbital nerve in certain patients no complication or sequela was noted in this series. Accordingly early repair with the use of catheter-balloon appears to be a viable alternative in the repair of orbital floor fracture in children.     

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.     

Traumatic ophthalmoplegia: A complication of fractures of the zygomaticomaxillary complex. Review of etiology with report of an unusual case

Ocular muscle imbalance is a common complication in fractures of the zygomaticomaxillary complex. Involvement can be direct; caused by entrapment of either the muscle or tendon in the fracture; or indirect, produced by central or peripheral damage to the cranial nerves supplying the muscles, massive orbital edema or hemorrhage. A case of complete paralysis of the extraocular muscles caused by a critical reduction of the size of the orbit as a result of fracture of the zygomaticomaxillary complex is described.     

Surgical implications of an unusual anomaly of the infraorbital nerve

The infraorbital nerve is a direct extension of the maxillary division of the Vth cranial nerve. It typically courses anteriorly through a canal within the bone of the orbital floor. We describe an unusual anatomic variation of this canal that to our knowledge has not been previously described in the literature. This anomaly may have significant implications during surgery on the paranasal sinuses and maxillofacial skeleton. Careful preoperative assessment of the course of the infraorbital nerve is necessary to prevent iatrogenic hypoesthesia, paresthesia, or neuralgia.     

Long-term follow-up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopathy

Dysthyroid exophthalmopathy (orbitopathy) results from an enlargement of extraglobal orbital structures, producing ocular proptosis, optic nerve compression, and corneal exposure. Treatment with corticosteroids and radiation may be beneficial; refractory cases require surgical decompression of the orbit. Transantral orbital decompression was described by Walsh and Ogura and has been performed in over 350 patients at this institution. A review of 305 patients with long-term follow-up was performed. Visual acuity improved or was maintained at preoperative levels in over 95% of the patients, with ocular recession ranging from 1 to 12 mm (average: 4 mm). Postoperative ocular balance of relative exophthalmos was to within 1 mm in 76% of the patients and to within 2 mm in approximately 90% of the patients. Normal postoperative extraocular muscle balance was present in 99 patients. Immediate postoperative diplopia was noted in 206 patients. Long-term follow-up revealed that in 137 of these patients, diplopia resolved or responded to conservative management. Extraocular muscle surgery was required for correction in 69 patients. Twenty-seven patients had postoperative complications. These included 16 patients with hypesthesia of the infraorbital nerve, 5 patients with sinusitis, 3 patients who had incomplete decompression, 2 patients with oral antral fistulae, and 1 patient who had CSF rhinorrhea. Five patients, despite surgery, radiation, and steroid therapy progressed to blindness. We conclude that this procedure is effective and carries few complications. Orbital imaging, using computed tomography or magnetic resonance sequence with reconstructive capabilities, permits early diagnosis and treatment of dysthyroid compression optic neuropathy.     

管内段视神经损伤的诊断和疗效分析

目的分析管内段视神经损伤所致视力障碍的诊断要点、疗效及影响愈后的因素。方法对２６例（２７侧）管内段视神经损伤继发视力障碍的患者,经眶部ＣＴ检查后,在药物治疗的同时,采用鼻外开筛进路视神经减压术治疗。结果该病的眶部ＣＴ检查总阳性率为６６７％,其中视神经管骨折阳性率为８１３％,视神经水肿阳性率为５５．６％。伤后立即出现视力障碍者有效率为５７．１％,非伤后立即出现视力障碍者有效率为８３３％。术中明确发现有视神经管骨折者有效率为５６．３％,仅见视神经水肿者有效率为６６．７％。手术时机愈晚,疗效愈差。结论眶部ＣＴ检查对管内段视神经损伤具有重要诊断价值,ＣＴ检查阴性不能除外该病;疗效与视神经损伤程度和手术时机等因素有关。     

管内段视神经损伤的诊断和疗效分析

目的 分析管内段视神经损伤所致视力障碍的诊断要点、疗效及影响愈后的因素。方法对２６例（２７例）管内段视神经损伤继发视力障碍的患者,经眶部ＣＴ检查后,在药物治疗的同时,采用鼻外开筛进路神经减压术治疗。结果 该的眶部ＣＴ检查总阳性率为６６．７％,其中视神经管骨折阳性率为８１．３％,视神经水肿阳性率为５５．６％。伤后立即出现视力障碍者有效率为５７．１％,非伤后立即出现视力障碍者有效率为８３．３％,术中明     

Transparotidean approach to surgical management of condylar neck fractures. A prospective study]

AIM: Different surgical approaches for the open treatment of mandibular condylar fractures are described in the literature. We evaluated the morbidity of the transparotidean approach in a prospective study over 5 1/2 years. PATIENTS AND METHODS: A total of 48 patients with 52 condylar neck fractures class II and IV according to the Spiessl and Schroll classification were treated by a transparotidean approach. Rigid internal fixation was performed by means of miniplate fixation. After surgery, no mandibulomaxillary fixation was performed. The occurrence of surgical and functional complications was documented both during hospitalization and 1, 3, 6 and >9 months after surgery. RESULTS: In none of our patients were major problems in wound healing such as infection of the fracture site observed. At the beginning of the study, in four cases a fistula of the parotid gland was seen within the initial days after surgery; after careful wound closure of the parotid capsula in the following operations, no further complications involving fistulas were observed. Signs of temporary palsy of the facial nerve caused by the hooks occurred in ten (19.6%) of all patients but was completely reversible within the first 6 months after the procedure. One patient suffered temporarily from a minimal malocclusion and two patients from symptoms of the temporomandibular joint 6 months postoperatively. In three patients we observed miniplate fractures without consecutive dysfunction of the TMJ or malocclusion. CONCLUSION: Open reduction and rigid internal fixation of condylar neck fractures by transparotidean approach is a recommendable procedure in class II and IV fractures. With the advantages of minimal tissue alteration and rare complications on the one hand and sufficient exposure of the fracture site on the other hand, this technique has been established as a standard procedure in treating condylar neck fractures by open reduction.     

Three-point alignment of zygoma fractures with miniplate fixation

Over the years, depression of the malar eminence has been one of the most persistent complications of zygoma fractures, regardless of the fixation technique used. The use of a sublabial incision for direct visualization and alignment of the fracture lines at the infraorbital rim and lateral maxillary buttress is described. When coupled with single miniplate fixation of the zygoma across the frontozygomatic suture, the sublabial approach results in improved reduction of the fractures with rigid stabilization. Our experience with this approach, as well as with two-point wire fixation and with miniplate fixation without sublabial exposure, is reviewed.     

Endoscopic treatment of subcondylar fractures

Objectives/Hypothesis: To evaluate the effectiveness of endoscopic treatment of subcondylar fractures, highlighting an improved technique of repair that facilitates ease of repair. Study Design: A retrospective review. Methods: All subcondylar fractures treated by the author with the improved endoscopic technique from 2001 to 2007 were reviewed. Results: A total 34 subcondylar fractures were initially treated with the outlined technique. Thirty‐three of 34 were successfully managed with the endoscopic technique alone. There were no instances of facial nerve paralysis or palsy noted. There were two instances of malocclusion that were believed to be minor in the 27 of 34 patients who made themselves available for 6 week follow‐up. Both of these patients had associated multiple maxillofacial fractures repaired. Average operative time from ramus incision start to completion of plate fixation for the subcondylar fracture was 32 (range, 21–49) minutes. Conclusions: The outlined technique results in improved ease of rigid endoscopic fixation of subcondylar fractures in the majority of patients.     

眶上颌颧骨复合骨折35例临床分析

目的：探讨眶上颌骨复合骨折复位固定的治疗效果。方法：开放性骨折患者行清创术同时予复位固定,闭合性骨折则应用发际切口及唇龈切口径路或两种径路并行复位固定。结果：３５例术后有２例咬合不定,１例面部畸形,２例张口受限,其余治疗效果满意。结论：熟悉局部解剖,及早复位,进行坚固内固定是治疗本病的关键。     

Intraoperative nerve monitoring reduces recurrent laryngeal nerve injury in geriatric patients undergoing thyroid surgery

Objective: This research was aimed to investigate whether the intraoperative nerve monitoring (IONM) can reduce the incidence of recurrent laryngeal nerve (RLN) injury in geriatric patients undergoing thyroid surgery.

Methods: This retrospective cohort study included 522 geriatric patients undergoing thyroid surgery between January 2013 and June 2016 in the Sun Yat-sen Memorial Hospital. Patients with IONM during the surgery (n?=?340) were compared with patients without IONM (n?=?212). RLN injury was verified by direct or indirect laryngoscope and relative factors for injury would be retrospectively analyzed.

Results: The use of IONM group showed significant reduction in both total and transient RLN injury incidence, when compared with that in control group (1.76 versus 4.72%, p?=?.01 and 1.32 versus 3.67%, p?=?.03, respectively). However, the permanent RLN injury incidence did not show difference between the two groups (p?=?.3).

Conclusions: Our finding showed the use of IONM resulted in significantly reduction in RLN injury incidence. The technology of IONM is safe and convenient to detect, track and monitor the complete function of RLN and to provide the guidance for the surgeons during the thyroid surgery in geriatric patients, who are at high risk of RLN injury.