Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures

Purpose

To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures.

Methods

A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6–10 days, decision for surgical repair, and presence of diplopia were recorded.

Results

Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07).

Conclusion

Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia.     

Digital design of functional surgery for odontogenic cyst intruding into maxillary sinus

Introduction

Traditional Caldwell-Luc approach needs modifications for odontogenic cysts intruding into the maxillary sinus, to preserve sinus mucosa and bony contour. Recently, digital technology has been widely applied to the field of maxillofacial surgery, guiding the surgical plan and improving its accuracy.

Experimental evaluation of relapse-risks in operated zygoma fractures

Objectives

Prevention of relapse, or postoperative dislocation, of the fixed zygoma is necessary to achieve optimal results in the treatment of zygoma fractures. Assuming that the occurrence of intensified stresses on mastication at the screw–bone interface (SBI) constitutes the essential cause of the relapse, we evaluated the stresses for three different fixation methods—fixation at the frontal process (FP), inferior orbital rim (IOR), and zygomatico-maxillary buttress (ZMB).

Methods

We used 10 computer-aided design (CAD) models simulating zygoma fractures in the experiment. For each CAD model, we fixed the fractured zygoma with four screws and one mini-plate at the FP, IOR, or ZMB. After applying a 5.5 kg force simulating mastication, we calculated the intensity and distribution patterns of the stresses occurring at the SBIs of the fixation screws using the finite element method. Thereby, we evaluated dynamic stability of the fixed zygoma for each of the three fixation methods.

Results

Greater stresses occur at the SBIs with IOR fixation than at those with FP and ZMB fixation. Although the stresses occurring at the SBIs on mastication demonstrated evenly distributed patterns with the FP and ZMB fixation, the stresses demonstrated concentration on one screw with the IOR fixation.

Conclusions

The fixed zygoma is more likely to cause relapse with the IOR fixation than with the FP or ZMB fixation. Hence, in performing zygoma fixation at the IOR, care should be taken to minimize the likelihood of postoperative relapse that is caused by skewed distribution of the stresses on the fixation screws.     

Usefulness of partial uncinectomy in patients with localized maxillary sinus pathology

Purpose

Conventional total uncinectomy may be unnecessary in localized maxillary sinus lesion. Partial removal of the uncinate process and middle meatal antrostomy would be sufficient to eradicate the pathological condition. Therefore, we aimed to evaluate the efficacy of partial uncinectomy versus total removal of the uncinate process in patients with localized maxillary sinus disease.

Methods

In total, 25 patients were assigned randomly to partial and total uncinectomy groups. Preoperative computed tomography established that all patients had localized pathology in the maxillary sinus. The lower half of the uncinate process was removed in the partial uncinectomy group, while the total uncinectomy group underwent the conventional surgery. Time required for the uncinectomy, healing period for the uncinectomy site, incidence of lamina papyracea or nasolacrimal duct injury, obstruction or stenosis of the frontal recess, and incidence of synechia formation in the middle meatus were compared between the groups.

Results

All patients completed the follow-up and were included in the analysis. Surgical indications included chronic maxillary sinusitis, fungal sinusitis, antrochoanal polyp, and odontogenic sinusitis. Operation durations and healing periods were significantly shorter in the partial uncinectomy group. One patient had a minor injury to the lamina papyracea and two patients showed partial synechia formations in the total uncinectomy group. However, other parameters did not differ significantly between the groups.

Conclusions

Partial uncinectomy may be useful in patients with pathological conditions confined to the maxillary sinus. Shorter operation duration, more rapid healing, and lower incidence of complications are advantages over a conventional total uncinectomy.     

Long-term efficacy of inferior meatal antrostomy for treatment of postoperative maxillary mucoceles

PurposeTransnasal endoscopic marsupialization has replaced the conventional Caldwell-Luc operation for managing postoperative maxillary mucoceles. Inferior meatal antrostomy (IMA) may be an easier and more effective method than middle meatal antrostomy (MMA) because of anatomical and structural changes of the maxillary sinus. We evaluated the long-term efficacy and technical simplicity of both methods.MethodsThis study included 21 and 32 patients who underwent MMA and IMA, respectively. They were diagnosed with a unilateral postoperative maxillary mucocele, and medical records were reviewed for history, clinical presentation, radiographic findings, surgical intervention, complications, and outcomes. During follow-up, the size of the opening and stenosis or obstruction of the antrostomy site were evaluated.ResultsPreoperative symptoms and mean follow-up period were similar in both groups. All patients in the IMA group received the operation as planned, whereas in four MMA patients, the attempt to create an opening failed because of thick bones and anatomical changes from the previous operation; in these patients, IMA was performed. The opening remained large enough for ventilation and drainage between the mucocele and the nasal cavity in both groups. There were no major complications, such as profuse bleeding, wound infection, or orbital or nasolacrimal duct injury.ConclusionsAlthough both surgical procedures seem to be effective for managing postoperative maxillary mucoceles, IMA is easier to perform, and no instances of failure to create antrostomy openings occurred. We recommend IMA as the surgical technique of choice, but providing an opening of sufficient size is necessary to ensure long-term efficacy.     

Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium

Objective

To evaluate the use of wide middle meatal antrostomy in recurrent antrochoanal polyp (ACP) in children as regard technical difficulty, efficacy, and safety in children.

Study design

Retrospective study.

Patients and methods

In a retrospective study, 12 children with unilateral recurrent ACP (5 left-sided, 7 right-sided). All the ACPs were documented by preoperative endoscopy and computer tomographic (CT) scans. All cases were treated using endoscopic wide middle meatal antrostomy. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6-15 years).

Results

Postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications or recurrence during the follow up period.

Conclusions

Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal 3 polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 70°) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum.     

Clinical characteristics and outcome in patients with isolated sphenoid sinus aspergilloma

Objective

Isolated sphenoid sinus aspergilloma (ISSA) is a rare disorder that is difficult to diagnose in a timely manner. These lesions can also extend to adjacent structures and thereby cause severe complications. ISSA patients with orbital complications typically have a poor prognosis even when surgical interventions have been successful. We here reviewed 30 ISSA cases with respect to clinical characteristics and treatment outcomes.

Methods

A group of 30 patients diagnosed with ISSA between January 1990 and October 2010 were retrospectively reviewed in terms of clinical manifestations, endoscopic findings, radiologic imaging data, and treatment results. We also compared the clinical manifestations and treatment results between patients with and without orbital complications.

Results

Old age (median, 55 years) and a female predominance (23 women in the study) were noted. The most commonly reported symptom was headache (80%) and the average duration of the symptoms before diagnosis was 8.1 months. On radiologic examination, including CT and MRI scans, 13 patients showed bony wall erosions and five patients demonstrated orbital complications including diplopia and visual loss. The appearance of a bony wall erosion on a CT scan and the acute onset of ISSA symptoms were found to be significant factors in the onset of orbital complications (P = 0.003 in each case). Endoscopic sphenoidotomy was performed in all 30 cases. Most of the preoperative symptoms among the patients, including headache, facial pain, and postnasal drip, were improved after surgery. Among the five patients in the study group with orbital complications, diplopia was completely resolved after surgery in each case but there was no improvement in visual loss.

Conclusions

An early diagnosis of ISSA, although not easy, is important to prevent complications arising from extensions of these lesions beyond the sphenoid sinus. Our present study demonstrates that ISSA could be effectively treated with an endoscopic sphenoidotomy, and that timely intervention is needed in patients with a sinus bony wall to prevent irreversible complications such as visual loss.     

Endoscopic intranasal reduction of the orbit in isolated blowout fractures

CONCLUSION: Endoscopic intranasal reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel packing, provided good functional results and definite advantages. We suggest that these techniques are another surgical alternative for isolated orbital floor or medial wall blowout fractures that do not accompany any associated fractures of the orbital rim. OBJECTIVES: Extended applications of endoscopic sinus surgery have reported endoscopic intranasal reduction or reconstruction of the orbital wall with good functional and cosmetic results. We present our experience with endoscopic intranasal reduction of the orbit in isolated orbital floor and/or medial wall blowout fractures, treated by reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel packing. SUBJECTS AND METHODS: Floor reduction: After creating a wide middle meatal antrostomy, herniated orbital contents and fracture-displaced floor are mobilized and reduced. The orbital floor is supported by a saline filled balloon, which is connected with an infant feeding catheter and passed through the middle meatal antrostoma. After confirming the reduction of the orbital floor by postoperative CT, the catheter is ligated and cut in short to keep it in the nasal cavity. Medial wall reduction: After completing an intranasal ethmoidectomy, herniated orbital contents and fractured lamina papyracea are mobilized and reduced. The shape of the medial orbital wall is fixed by a silastic sheet and Merocel packing saturated with an antibiotic solution. Surgery was performed when the eye function could be accurately assessed, usually at 7 to 10 days following the injury. Temporary supporting of the orbital wall with a detachable temporary balloon, or a silastic sheet and Merocel packing was removed 4 weeks after surgery in the out-patient clinic. RESULTS: We have experienced 40 cases of endoscopic intranasal reduction of the orbit in blowout fractures. CT scan confirmed isolated orbital floor fracture in 11 patients, isolated medial wall fracture in 17 patients, and combined fractures of the orbital floor and the medial wall in 12 patients. Twenty five patients had diplopia, 20 patients had limitation of eye movement, and 14 patients developed enophthalmos. Thirty three of the 40 patients recovered completely without any residual eye symptoms or complications.     

Uszkodzenia ścian kostnych ucha środkowego u chorych operowanych z powodu schorzeń ucha w Klinice Otolaryngologii CM UJ w latach 2008–2012

Background

We perform the middle ear operation to remove pathological tissue and in the next step present ossicular chain reconstruction. Otosurgeon has to also identify bone dehiscences, as a potential way to develop otogenic intracranial and intratemporal complications.

Aim

We analyzed the patients with bone defects in the middle and/or posterior cranial fossa who present also defects of the bony wall of the facial nerve canal and lateral semicircular canal.

Material and methods

We observed 537 patients who were operated on middle ear for the first time in the Department of Otolaryngology at the Jagiellonian University of Cracow from 2008 to 2012. We used a special questionnaire that includes diagnostics of the ear's disease, method of the operation and short- and long-term effects.

Results

We discuss 45 patients with the skull base defects in the middle and/or posterior cranial fossa. Dehiscence of the bony wall of the facial nerve canal was present in 7 patients. In 4 cases semicircular canal fistula coexisted.The most common cause of bone dehiscence was granulation tissue, less frequently cholesteatoma.

Conclusions

1.

Apart from skull base defects in the middle and/or posterior cranial fossa, frequency of bony dehiscence of the facial nerve and semicircular canal fistula is the same as in all population operated on ear.

2.

Defects of the bony wall of the facial nerve and semicircular canal fistula are observed more frequently in granulomatous chronic otitis media than in cholesteatoma chronic otitis media.

3.

We observe the same frequency of intracranial complication in population of patients with defects of the bony wall of the facial nerve canal and horizontal semicircular canal than in all groups with skull base defects.

     

Spatial anatomy of the nasofrontal recess on the CT using multiplanar reconstruction technique

Objective

To clarify the spatial orientation relevant to the endoscopic sinus surgery (ESS) for the frontal sinus.

Methods

Various dimensions of structures around the frontal recess were measured on 256 CT images of 128 Japanese patients using the multiplanar reconstruction technique. Measurements done in this study were: the distance from the nostril to the narrowest point of the frontal recess (D1), and the distance from the narrowest point of the frontal recess to the bony wall of the anterior skull base on an extension of the same line (D2). The smallest anterior–posterior (D3) and right–left (D4) diameters of the “route to the frontal sinus,” a site containing the narrowest airspace in the frontal recess, being surrounded by the posterior edge of maxillary bone anteriorly, by the bony wall of the anterior skull base posteriorly, by the middle turbinate medially, and by the medial orbital bony wall laterally, respectively, on the parasagittal and coronal planes. The angle between the line connecting the nostril to the lowest portion of the frontal process of the maxilla and frontal bone, and the line connecting the lowest portion of the frontal process to the narrowest portion of the frontal recess (A1).

Results

The mean values D1–D4 were 55.9, 9.4, 6.9 and 8.2 mm. In 154 of 256 sides, A1 ranged from 129.5° to 175.7°.

Conclusion

The present study provides important information about the spatial anatomy of the nasofrontal recess, which is essential for avoiding complications of an ESS for the frontal sinus.     

Submucous inferior turbinotomy cooperating with combined antrostomies for endonasal eradication of severe and intractable sinusitis

Objective

This paper aims to prove the usefulness of submucous inferior turbinotomy cooperating with the combined middle and the inferior antrostomies in endoscopic endonasal sinus surgery (ESS), enabling the eradication of severe maxillary sinusitis without extranasal approaches. The long-term surgical outcomes of 22 adult patients are presented together with details of this procedure.

Methods

Subjects comprised 22 adult patients with severe unilateral maxillary sinusitis, showing total opacification on computed tomography and failure of medical treatments preoperatively. Patients who could be managed using conventional ESS methods were excluded. Endoscopic submucous resection of the inferior turbinate bone including the uncinate process was first performed. The procedure aimed to make both the middle and the inferior nasal meatus wide enough to eradicate the sinus disease, cooperating with combined antrostomies.

Results

Pathology comprised multiple massive polyposis including antrochoanal polyps in 6 and fungal ball in 16 patients. Neither surgical complications nor recurrent disease was seen postoperatively in any patient. Postoperative endoscopic management via both openings was easy and facilitated the restoration of mucosal lining in the sinus.

Conclusion

We proved our new surgical procedure was useful in ESS without any extranasal approaches, although applied to unilateral lesions in the current study. Postoperative management via the middle and the inferior meatal openings helped to facilitate postoperative mucosal healing.     

Canal wall reconstruction and preservation in the surgical management of cholesteatoma in children with Down's syndrome

Introduction

Down's syndrome is associated with poor Eustachian tube function, and an increased incidence of cholesteatoma. The only previously published case series suggests that ‘canal wall preserving’ procedures are only rarely suitable for the management of cholesteatoma in this population.

Methods

We conducted a retrospective review of the hospital's clinical records database to identify patients with Down's syndrome and cholesteatoma. These patients’ notes were then reviewed.

Results

We identified nine patients with Down's syndrome who had undergone surgical management of cholesteatoma over a twelve year period. Three patients had bilateral disease, meaning twelve ears were treated. Seven ears were initially treated with ‘canal wall down’ procedures. Four out of five of the remaining ears were successfully treated using ‘canal wall preservation’ or ‘canal wall reconstruction’, with one ear requiring subsequent conversion to a ‘canal wall down’ approach.

Conclusion

Canal wall preservation/reconstruction is feasible in patients with Down's syndrome, even when cholesteatoma extends into the mastoid.     

Endoscopic partial medial maxillectomy with mucosal flap for maxillary sinus mucoceles

Purpose

To describe a technique of endoscopic medial maxillectomy with mucosal flap for postoperative maxillary sinus mucoceles and to present a case series of subjects who underwent this procedure.

Materials and methods

This case series includes four subjects with postoperative maxillary sinus mucoceles who underwent resection via endoscopic partial medial maxillectomy with a mucosal flap. We will discuss the clinical presentation, imaging characteristics, operative details, and outcomes.

Results

Four subjects are included in this study. The average age at the time of medial maxillectomy was 52 years (range 35–65 years). Three subjects (75%) were female. One subject (25%) had bilateral postoperative maxillary sinus mucoceles. Two subjects (50%) had unilateral right sided mucoceles, and the remaining subject had a unilateral left sided mucocele.All subjects had a history of multiple sinus procedures for chronic sinusitis including Caldwell–Luc procedures ipsilateral to the postoperative mucocele. All subjects underwent endoscopic medial maxillectomy without complication and were symptom free at the last follow up appointment, average 24 months (range 3–71 months) after medial maxillectomy.

Conclusions

For postoperative maxillary sinus mucoceles in locations that are difficult to access via the middle meatus antrostomy, we recommend endoscopic medial maxillectomy with mucosal flap. Our preliminary experience with four subjects demonstrates complete resolution of symptoms after this procedure.     

Alkaline pH in middle meatus in cases of chronic rhinosinusitis

Study type

Prospective and observational study.

Methods

The study group was divided in two groups consisted of 50 normal subjects (100 meati) and 50 patients (100 meati) of chronic rhinosinusitis (CRS). All subjects underwent nasal endoscopy along with measurement of the pH of the middle meatus using a portable pH monitoring device. Statistical analysis was done to compare mean pH of normal middle meatus with the diseased one.

Results

The mean pH of normal 100 middle meati was measured to be 7.35(± 0.82). The mean pH of 100 middle meatii in CRS patients was higher 7.81(± 0.83) and was found to be statistically significant (p = 0.00011).

Conclusion

Alkaline pH (7.81) was observed in the middle meatus of CRS patients.     

Transantral Orbital Floor Fracture Repair Using a Folded Silastic Tube

Objectives

The purpose of this study was to evaluate the advantages and limitations of using a silicon tube to support the fractured orbital floor by a transantral approach.

Methods

A retrospective study was conducted from January 2000 to December. 2011 in 51 patients with pure orbital floor fractures. The patients underwent reduction surgery via a transantral approach for inserting a folded silastic tube to support the fractured orbital floor in the maxillary sinus. A chart review of preoperative and postoperative ocular symptoms, operation records, and complications was maintained.

Results

In 18 out of 25 patients with diplopia, postoperative improvement was seen. In 13 out of 15 patients with extraocular muscle limitation, postoperative improvement was seen. Enophthalmos resolved postoperatively in four of five patients. Postsurgical complications occurred in three patients: an overcorrection, an infection in the maxillary sinus, and an implant extrusion, all of which were resolved by revision surgeries.

Conclusion

During the course of the study, we sensed reduction using a folded silastic tube via a transantral approach as an easy and effective technique with good postoperative results, and minimal implant related complications. This novel procedure is recommended as a surgical option for the reduction of orbital floor fractures.     

Traumatic dislocation of intact mandibular condyle into middle cranial fossa

Introduction

A 10-year-old girl presented to the Emergency Department with temporomandibular joint pain, malocclusion, and trismus after a bicycle accident.

Methods

CT of the temporal bones showed displacement of the right mandibular condyle into the middle cranial fossa with small intraparenchymal hemorrhage. The condyle was reduced using closed reduction technique and the patient was placed in maxillomandibular fixation.

Results

Complete reduction of the displaced condyle with resultant normal occlusion and persistent bony defect in the temporal bone.

Conclusion

In early follow-up assessments the patient has had complete resolution of symptoms with residual bony defect from the site of fracture in the temporal bone.     

Rekonstruktive Orbitachirurgie

Background

In complex orbital reconstructions ideal positioning of the bony buttress and surrounding soft tissue is a prerequisite for an aesthetic and functional result. The use of computer-assisted surgery can support the surgeon before and during the reconstruction procedure and facilitate quality control processes. This is illustrated using three clinical examples.

Material and methods

The areas of interest (bony defect areas, surrounding tissues) are segmented in a 3D image series. In most cases, the contralateral non-affected side can serve as the reference in virtual reconstruction. The virtual model obtained can now be used for the manufacturing of patient specific models and implants, as well as for intraoperative navigation or direct quality control with the use of intraoperative cone beam computed tomography (CBCT).

Results

For the reconstruction of primary and secondary traumatic defects as well as for congenital malformations or neoplastic diseases, the presented workflow can be used. Preoperative virtual visualization, patient specific reconstruction and direct quality control using intraoperative CBCT ensure that the preoperatively planned result can be achieved. Together with the interplay of hard and soft tissue the best possible results can be achieved.

Conclusion

Computer-assisted surgery has been continuously further developed over the last two decades and is currently used in the clinical routine. Patient specific implants in combination with the use of direct intraoperative quality control facilitate the reconstruction of complex orbital injuries and defects and enable the ideal reconstruction from both aesthetic and functional aspects.

     

Posterior canal wall reposition for management of cholesteatoma: Technique and results

Objective

The main goal of surgery in acquired middle ear cholesteatomas is the complete eradication of the disease with an ear free of discharge. This can be performed either by open or closed techniques with their benefits and drawbacks. We present the technique of reposition of the posterior canal wall for the management of cholesteatoma cases and its results and outcome.

Is orbital floor a reliable and useful surgical landmark in endoscopic endonasal surgery?: a systematic review

Background

The orbital floor is considered as an important intraoperative reference point in endoscopic sinonasal surgery. The aim of this review is to evaluate its reliability and usefulness as a surgical landmark in endoscopic endonasal surgery.

Methods

A literature search was performed on electronic databases, namely PUBMED. The following keywords were used either individually or in combination: orbital floor; maxillary sinus roof; endoscopic skull base surgery; endoscopic sinus surgery. Studies that used orbital floor as a landmark for endoscopic endonasal surgery were included in the analysis. In addition, relevant articles were identified from the references of articles that had been retrieved. The search was conducted over a period of 6 months between 1st June 2017 and 16th December 2017.

Results

One thousand seven hundred forty-three articles were retrieved from the electronic databases. Only 5 articles that met the review criteria were selected. Five studies of the orbital floor (or the maxillary sinus roof) were reviewed, one was a cadaveric study while another 4 were computed tomographic study of the paranasal sinuses. All studies were of level III evidence and consists of a total number of 948 nostrils. All studies showed the orbital floor was below the anterior skull base irrespective of the populations. The orbital floor serves as a guide for safe entry into posterior ethmoids and sphenoid sinus.

Conclusions

The orbital floor is a reliable and useful surgical landmark in endoscopic endonasal surgery. In revision cases or advanced disease, the normal landmarks can be distorted or absent and the orbital floor serves as a reference point for surgeons to avoid any unintentional injury to the skull base, the internal carotid artery and other critical structures.

     

Atelectasis of the maxillary sinus: report of a case of acute onset

INTRODUCTION: Maxillary sinus atelectasis is a rare pathology, characterized by a retraction of the maxillary sinus walls associated with tenacious mucus secretions filling the antrum. The disease usually develops in a chronic fashion, leading progressively to enophthalmos. This is sometimes associated with diplopia and midfacial depression. In these typical forms, maxillary sinus ventilation (via a middle meatal antrostomy) stops progression to retraction, but usually cannot reverse the phenomenon, resulting in a specific surgical procedure on the orbital floor or on the anterior wall of the sinus. MATERIALS & METHODS: We describe a case of maxillary sinus atelectasis with enophthalmos and midfacial depression, which appeared suddenly in one week, without nasal or sinus related symptoms. A middle meatal antrostomy performed rapidly enabled us to observe a reversal of the atelectatic process with recovery of the sinus volume, correction of the enophthalmos and disappearance of the associated diplopia, without the necessity for an additional surgical procedure. It is, to our knowledge, the first case described with such a rapid evolution.