Traumatic orbital encephalocele: Presentation and imaging

Objective: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children.

Methods: Retrospective case series from the University of Wisconsin – Madison and Medical College of Wisconsin.

Results: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele.

Conclusion: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.     

Complications of Orbital Roof Fractures

A spectrum of complications of orbital roof fractures is discussed. The authors have had cooperation with the neurosurgical service in treating nine cases. Careful ocular and neurologic examination of the patient is emphasized in an attempt to avoid ocular complications, orbital deformities, ocular muscular imbalance, enophthalmos, blepharoptosis, and intracranial complications. With intracranial involvement, a combined neurosurgical and ophthalmologic approach is indicated. A superior orbitomy is indicated if there is a simple fracture of the orbital roof without involvement of the inner table of the skull.     

眼眶骨折200例临床分析

目的探讨眼眶骨折的病因、伤情和临床治疗方法。方法对200例眼眶骨折病因、损伤部位、伤情和治疗进行分析。认为在软组织裂伤缝合时尽可能早期行眼眶骨折整复。眶上壁骨折若视功能和眼位无明显改变者,不必行骨折整复。视神经孔骨折者,可以经筛窦进路行视神经探查。重度颜面凹陷畸形,需要行颧骨、上颌骨复位后钛板固定。内直肌嵌入筛窦,下直肌嵌入上颌窦,在眶内容还纳复位后分别用天然珊瑚人造骨板修复骨孔。结果眶壁重度粉碎性骨折51例行Ⅱ期骨折整复,其余均在软组织清创缝合时行I期整复,视功能均得到不同程度的恢复。结论眼眶骨折经早期和恰当方法整复,完全可以修复颜面畸形,并恢复眼球运动和视觉功能。     

闭合性前颅脑损伤的眼部病变

目的探讨闭合性前颅脑损伤导致视神经病变的早期诊断与治疗方法。方法回顾性分析我院收治的闭合性前颅脑损伤患者112例,分析视神经损伤的机制、诊断要点及治疗方法。结果本组112例中54例（48．21％）合并视神经损伤,进行了视力、瞳孔、眼底与CT的追踪观察。治疗总有效率为67．86％（76／112）。药物治疗48例,33例有效（68．75％）;手术治疗6例,4例有效（66．67％）。结论缺血缺氧是视神经损伤的重要因素,早期综合药物治疗重要。有视神经管骨折者在药物治疗过程中视力进行性下降时,应考虑手术治疗。视神经管上壁或后端骨折,可采用经额入路手术;视神经管前段骨折可采用经眶筛入路手术。     

Cerebrospinal fluid leakage after dacryocystorhinostomy

The authors have encountered two presumptive cases of cerebrospinal fluid leakage associated with dacryocystorhinostomy. To understand better the pathophysiology, bilateral dacryocystorhinostomies and anatomic dissections were performed on three fresh cadaver specimens. The average distance from the superior bony nasal window to the floor of the anterior cranial fossa was 5.0 mm. The frontal sinus floor overlies the anterior portion of the nasal window, while the thinnest portion of cribriform plate overlies the posterior portion of the nasal window. A bony fracture of the anterior cranial fossa floor and/or cribriform plate resulted from (1) applying a rotational force to the Kerrison ronguer while enlarging the posterior nasal window or (2) fracturing an attenuated superior wall of an ethmoid air cell which has eroded into the orbital roof.     

颅脑损伤后眼眶骨折致眼球突出13例临床分析

目的 探讨颅脑损伤后眼眶骨折致眼球突出的临床特点、螺旋CT重建技术诊断价值、手术适应证和治疗效果。方法对13例（14眼）眼眶骨折致眼球突出的致伤原因、临床表现、骨折类型、手术时机、手术方式及疗效进行回顾性分析。术前行螺旋CT轴位扫描,并颅骨三维重建,根据骨折部位及颅脑损伤情况选择不同的手术入路整复骨折或去除骨折片。术后随访复查螺旋CT。结果病例以颅脑损伤表现为主,13例（14眼）发生眼球突出。术前平均突出度为（2．94±0．47）mm：眼球突出方向8例向外下,5例向前下方。螺旋CT及重建技术能对颅脑损伤、眼眶骨折及眼球突出进行迅速准确的诊断和术后随访复查,眼眶骨折位于眶上壁及内侧壁,均为向眶内骨折。手术均获成功,术后眼部症状迅速消失,无死亡或重度残废病例。结论颅脑损伤后颅内压变化是导致眶壁向眶内骨折的主要原因,进而使眶内容积变小发生眼球突出。螺旋CT检查对其诊断和治疗及随访具有重要意义,早期手术治疗,效果良好。     

Orbital Fracture: Significance of lateral wall

The lateral orbital wall is the strongest among other orbital walls. However, it is commonly fractured in the setting of severe facial trauma. The fracture usually occurs at the sphenozygomatic suture line. In general, patients with lateral wall fractures are commonly young male who may present with mid facial swelling and some degree of deformity. In some cases, lateral orbital wall fracture may be associated with visual loss or change in mental status due to associated intracranial injury. Imaging studies with computed tomography is important in the proper diagnosis and planning of the surgical intervention. Management of intracranial or eye injuries should be undertaken on emergent basis. Thereafter, significantly displaced lateral wall fractures need to be repaired on timely basis. Proper realignment of the plane of the lateral orbital wall at the sphenozygomatic suture along with the other complex articulations of the zygomatic bone is necessary for proper functional and aesthetic outcome.     

儿童眼眶爆裂性骨折36例临床分析

目的 总结儿童眼眶爆裂性骨折的临床特点及治疗方法,提高对本病的认识.方法 对36例眼眶爆裂性骨折的儿童的致伤原因、就诊时间、手术时间、骨折类型、手术方式及预后情况进行回顾性分析.结果 36例眼眶骨折的患者中受伤原因依次为撞伤、摔伤、车祸;超过7岁的眼眶骨折患者26例,占72.3%;就诊时间1d至7个月,平均为28d;伤后至接受手术治疗时间,最短4d,最长60d,平均18天;发生于眶下壁19例,占52.7%;眶内壁6例,占16.7%;眶内下壁复合型骨折11例,占30.6%.保守治疗17例,复视消失15例;手术治疗19例,6个月内复视消失15例.结论 儿童眼眶爆裂性骨折多发生于眶底,好发年龄为大于7岁.保守治疗对儿童某些线性骨折有效.发生活板门样爆裂性骨折时,越早手术,效果越好.     

眶底爆裂性骨折致眼球运动障碍的上颌窦手术进路治疗

目的 观察上颌窦进路手术治疗眶下壁爆裂性骨折所致眼球运动障碍的临床效果.方法 对12例12只眼眶下壁爆裂性骨折伴复视及眼球运动障碍者,眼眶CT显示:眼外肌眶内软组织嵌顿于眶下壁骨折区,伤后观察2周,复视及眼球运动障碍无明显改善,采用上颌窦进路行眶下壁骨折复位术.术后随诊3～6个月.结果 12例患者术中开放上颌窦后可清晰观察到眶下壁骨折区各个边界及眶内软组织嵌顿情况,术中均将嵌顿在眶底骨折处的眶内组织推送回眶内,眶底骨折复位.术后12例患者中10例各方向眼球运动不受限,无复视,2例正前方及下方无复视,向上方运动轻度受限.术后1例并发上颌窦炎,经上颌窦冲洗治愈.结论 上颌窦进路早期治疗单纯眶下壁爆裂性骨折所致眼球运动障碍是有效的.     

枪击或弹药爆炸所致的眶下壁骨折手术治疗的临床研究

目的:探讨在现代战争中快速恢复颅面部骨折患者正常面容及生理功能的有效治疗方法。方法:对不同部位、不同病变的骨折采取不同的治疗方案:对不同部位的颅面部骨折在鼻内窥镜引导下采取不同的手术微创及美容切口和钛板钛网等固定方法;应用医用耳脑胶(EC)对于颅颌面碎骨片进行复位和固定等。结果:颅面部骨折术后患者能较快恢复正常面容和生理功能。结论:在鼻内窥镜引导下采取不同的手术微创及美容切口和钛板钛网等固定方法是非常有效的手术方法;应用EC对于颅颌面碎骨片进行复位和固定能促进骨质较早愈合,加速骨折修复。     

Neuro-Ophthalmic Manifestations of Hypertrophic Cranial Pachymeningitis Associated With Antineutrophil Cytoplasmic Antibody for Myeloperoxidase

Hypertrophic cranial pachymeningitis is a rare inflammatory disease characterised by localised or diffuse thickening of the dura mater. We report a 68-year-old woman with hypertrophic cranial pachymeningitis presenting with subacute progressive bilateral visual loss and left abducens nerve palsy. On repeat fundoscopy, no remarkable findings were found, the patient was referred to our hospital 2 months after the onset of the ocular manifestations. Magnetic resonance imaging revealed thickening of the dura mater in the middle and anterior cranial fossae, which extended bilaterally to the vicinity of the optic canals and the superior orbital fissures. On immunological testing, elevated titres for antineutrophil cytoplasmic antibody for myeloperoxidase were found. The patient was immediately treated with high-dose methylprednisolone. After treatment, visual loss in the right eye and the left abducens nerve palsy improved significantly, but visual loss in the left eye remained unchanged. Careful systemic and radiological observations may be required when ophthalmic manifestations are seen in patients with positive antineutrophil cytoplasmic antibody for myeloperoxidase. The early initiation of treatment could prevent permanent damage to the optic nerve.     

Orbital cholesterol granuloma with destruction of the lateral orbital roof

PURPOSE: Orbital cholesterol granuloma in a 51-year-old man is described. METHODS: Computed tomography (CT) and magnetic resonance imaging (MRI) were done. RESULTS: Both studies showed a mass in the left orbit, with evidence of orbital roof destruction in the CT scan. On the basis of clinical and imaging findings, a diagnosis was made of malignant orbital tumor with destruction of the lateral orbital roof. Surgical exploration revealed a thickly encapsulated mass densely adherent to the left superior orbital bone and periosteum. Although the dura mater was intact, bone destruction in the lateral orbital roof was seen. The entire mass was successfully excised and histopathological evaluation was performed. Histopathology showed numerous inflammatory cells, blood degradation products, and cholesterol clefts. The absence of epithelial elements led to the diagnosis of cholesterol granuloma. CONCLUSIONS: Care must be taken to differentiate cholesterol granuloma from malignant orbital tumor. CT scan and MRI imaging seem well-suited to detecting the characteristic findings of cholesterol granuloma.     

Adult Medial Orbital Wall Trapdoor Fracture with Missing Medial Rectus Muscle

We report the case of a 28-year-old man presenting with a medial orbital wall trapdoor fracture with a missing medial rectus muscle. We believe this to be the first case report of an adult medial orbital wall trapdoor fracture. Trapdoor fractures most commonly occur in the pediatric population, and those involving the medial orbital wall generally occur in areas with less developed ethmoid air cells. Since the present case followed neither pattern, a different injury mechanism was considered. The ethmoid air cells in this case were well developed, which may have played an important role in the pathogenesis of this adult medial orbital wall trapdoor fracture. Based on our findings, we propose a possible mechanism for a medial orbital wall trapdoor fracture in an adult. The cellular frames enable the medial bone to shift just minimally, regardless of the high orbital pressure during a blow. The excess volume of the orbital content escapes into the cells through narrow cracks; therefore, after a blow, it cannot move back completely into the orbit. Consequently, it pushes the shifted bone towards the orbit, becoming trapped in a manner similar to that of a check-valve mechanism.     

Progressive bilateral enophthalmos associated with cerebrospinal shunting

A 22-year-old woman was examined for a complaint of bilateral progressive enophthalmos that had begun after the cerebrospinal fluid shunting procedure 9 years ago. Photographs and CT scans taken before surgery proved that the position of her eyes was normal before surgery. The enophthalmos was so severe that it induced a poor eyelid-globe apposition with trichiasis and superficial keratopathy. CT of the orbits showed that both orbital roofs were arched and displaced toward the anterior cranial fossa. The placement of porous polyethylene sheets on the orbital roofs through a coronal approach corrected the eye position. A literature review indicated that cerebrospinal shuntings are plagued by a variety of complications including bone changes and craniosynostosis. We believe that enophthalmos associated with cerebrospinal fluid shunting results from a rare acquired bony orbital anomaly.     

Naso-orbital Fractures,Complications, and Treatment

Naso-orbital fractures designate a backward displacement of the bones of the nasoskeletal framework into the interorbital space. This anatomical disruption results in deformities, lacrimal dysfunction, medial canthal deformities, ptosis, blow-out fractures, ocular complications, and most severely, penetration of bony fragments into the anterior cranial fossa. Early and late treatment methods are considered. Restoration of the bony contour of the nose and medial canthoplasty procedures are discussed.     

眼眶骨折的CT与临床（附62例分析）

作者分析６２例眼眶骨折的ＣＴ与临床资料。根据眼眶骨折的受力情况和骨壁特点将其分为５型：１．单眶壁直接骨折；２．多眶壁直接骨折；３．单眶壁爆裂骨折；４．多眶壁爆裂骨折；５．混合型骨折。眼眶骨折的ＣＴ征象为：骨连续性中断、骨质粉碎、骨质凹陷及眶壁曲度失常。爆裂骨折好发眶内侧壁和底壁，直接骨折以眶外侧壁较多受累。眼眶骨折的ＣＴ诊断具有重要的临床价值。此外，作者还对ＣＴ扫描技术和临床有关问题进行了讨论。     

Intracranial foreign body in a globe-perforating injury

CASE REPORT: To report a case with an intracranial foreign body in the setting of a globe-perforating injury. A 53-year-old man experienced a sudden pain in his right eye while he was breaking a stone with a sledgehammer. Upon examination, a 1.5 mm superomedial corneoscleral perforation site was noted. Cranial sections of axial orbital computed tomography (CT) revealed a foreign body at the middle cranial fossa. COMMENTS: A high index of suspicion is required to detect an intracranial foreign body in ocular injuries. Orbital CT must be included in preoperative evaluation of these patients and cranial sections must also be examined carefully.     

An analysis of orbital fracture in open-clinic practice of Department of Ophthalmology Medical University of Gdansk 1990-1991 and 2000-2001 years

Orbital fractures are common in midface trauma. The aim of our study was the retrospective analysis of patients with eye injuries. According to a prospective protocol we studied 82% adults and 18% children with orbital fractures. Men compared 72% of the patients. Men aged 21-35 years the most affected (mean age 29 years). These patients were divided into two groups: these who was treated in Emergency Department of our Clinic in 1990-1991 years (group I) and these who was treated in 2000-2001 (group II). Patients were analysed for age, sex, cause of injury and types of orbital fracture. In a patient with orbital trauma and orbital fractures visual acuity and ocular muscle motility are two most important ophthalmologic functions to be evaluated emeregently. Inclusion criteria were clinically suspected orbital injuries defined by reduced bulbus motility or diplopia We determined visual function: visual acuity, intraocular pressure, biomicroscopy and ophthalmoscopy, X- ray and CT examination. X- ray and CT has come to play a major role in the orbital examination of trauma patients with orbital fractures. Our cases of the orbital margin fractures classified into: blow-out (orbital floor fracture), Le Fort III (orbital- zygomatic fracture), roof fracture (fracture of the inferior orbital rim) and complex orbital fracture. The blow-out orbital fracture was the most common fracture type and orbital roof was the least common site of fracture of the orbital bony covering of the eye. In whole orbital fractures there were single wall fracture in 43% of cases in group I and 41% of cases in group II., two-wall fracture in 31% of cases in group I and 30% of cases in group II, Three wall-fracture in 15% of cases in group I and 17% of cases in group II. and four wall-fracture in 11% of cases in group I and 12% of cases in group II. Of whole orbital fractures had an associated eye injury. Common mechanisms included assaults (37% of cases in group I and 46% of cases in group II) and car or motor vehicle accidents (43% of cases in group I and 44% of cases in group II). We believe that further studies on this subject are necessary because the mechanism which produces the orbital fractures is subject to debate, they are acknowledged to be difficult to diagnose solely through clinical means.     

Myoepithelioma of the Orbital Apex and Middle Cranial Fossa: Case Report and Review of the Literature

Myoepitheliomas are rare tumours that originate from glandular tissues such as the parotid or salivary glands, and less commonly from soft tissues of the head, neck, and other parts of the body. Intraorbital myoepitheliomas generally arise from the lacrimal gland. Intracranial myoepitheliomas are rare. We report a myoepithelioma of the orbital apex that did not originate from the lacrimal gland. It extended to the middle cranial fossa from the orbital apex and involved the dura and adjacent bone. A diagnostic biopsy via a lateral orbitotomy preceded resection. We review the natural course and histopathology of myoepithelial neoplasms, the surgical nuances of approaching an orbital apex tumour with maximal functional preservation, and the optimal management practices of these rare lesions.