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.     

Transnasal endoscopic surgery for benign orbital tumors

Two cases of orbital tumor are presented, and the surgical technique by means of an endoscopic transnasal approach is discussed. In Case 1, a non-vascular, benign tumor was located inside the orbit, and it was able to be completely removed, without any complications. The tumor in Case 2 was also located inside the orbit, but it was determined to be a hemangioma based on the intraoperative pathology. To avoid eye complications arising from performance of the surgery in the presence of bleeding, it was decided to widely open the orbital lamina papyracea and periosteum, and perform only orbital decompression. The eye symptoms disappeared in both patients. Endoscopic transnasal surgery is indicated for benign orbital tumors that are medially located in the orbit. It can be thought that the eye symptoms can be alleviated by avoiding orbital pressure, regardless of whether-based on the intraoperative pathology-the tumor is completely removed or not.     

Orbital Preservation in Surgical Management of Sinonasal Malignancy

Objective To determine the oncological and functional outcome when applying defined criteria for orbital preservation during surgical treatment of sinonasal malignancy encroaching on the orbital structures. Study Design Retrospective consecutive review of patients in tertiary care center setting. Methods Analysis of 66 patients undergoing surgical treatment for sinonasal malignancy encroaching on the orbit. Orbital preservation was performed in all patients with tumor extension up to and including resectable periorbital involvement. Minimum follow‐up was 2 years. Detailed analysis of oncological and functional outcomes is included. Results Of 66 tumors abutting or invading into the orbit, 54 were amenable for surgical treatment with orbital preservation and the remaining 12 underwent orbital exenteration. Histopathological findings were divided into five subgroups: squamous cell carcinoma, adenomatous carcinomas, sinonasal undifferentiated carcinoma, sarcoma, and other. Squamous cell carcinoma represented the largest subgroup (24 patients), and 5‐year overall actuarial survival was not statistically different (P = 1.4; relative risk, 0.713) between patients treated with orbital preservation (53%) versus those undergoing exenteration (46%). Similarly, no difference in survival was found in the adenomatous carcinoma subgroup. Within the orbital preservation group as a whole, local recurrence occurred in 30% patients (16 of 54) compared with 33% patients (4 of 12) treated with orbital exenteration. Of note, eye‐sparing surgery was associated with local recurrence at the original site of orbital involvement in only 7.8% of cases (4 of 54). Overall eye function was graded as functional without impairment in 54% of patients (29 of 54), functional with impairment in 37% (20 of 54), and nonfunctional in 9% (5 of 54). The most common abnormality was globe malposition (enophthalmos or hypophthalmos) that was seen in 34 patients (63%) and was associated with the lack of adequate rigid reconstruction of subtotal or total orbital floor or multisegment orbital defects. However, enophthalmos was asymptomatic in the majority of cases, and persistent diplopia occurred in only five patients (9%). Various ocular sequelae were present in 20 of the 49 patients (41%) with functional eyes. Radiation therapy increased the risk of ocular complications, in particular, optic atrophy, cataract formation, excessive dryness, and ectropion. Conclusions Selective orbital preservation is oncologically safe and is a worthwhile undertaking in attempting to maintain a functionally useful eye with surgical management of sinonasal malignancy encroaching on the orbit. Consideration should be given to rigid orbital reconstruction in larger defects resulting from subtotal or total orbital floor resection or resections involving two or more orbital walls.     

Orbital exenteration in surgery of malignant neoplasms of the paranasal sinuses. The value of preoperative computed tomography

The extension of paranasal sinus malignant neoplasms into the orbit presents one of the arguments for carrying out orbital exenteration. One method of assessing the extension is computed tomography (CT), but its reliability is still questionable. Therefore, the preoperative CT images were compared with the pathoanatomic features of the surgical specimens in 15 patients who underwent orbital exenteration as part of a procedure for paranasal sinus malignant neoplasm. Ophthalmic symptoms were present in eight patients and in each instance the CT images documented the extension of the tumor accurately. In only four of seven patients without ophthalmic symptoms did CT scanning appear to match the factual situation. Apparently CT scanning is not always reliable in patients without ophthalmic symptoms.     

The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications

OBJECTIVES: This study compares the use of computed tomography (CT) with magnetic resonance imaging (MRI) and clinical assessment in the diagnosis and surgical management of patients with sinusitis with complications. The common CT findings of patients with intracranial or orbital infection of sinusitis are reviewed. STUDY DESIGN: We reviewed the charts of 82 adult and pediatric patients with the diagnosis of sinusitis with intracranial or orbital infection who were seen at the University of Mississippi Medical Center from January 1985 through December 1999. We assessed the diagnoses and outcomes to determine the most effective use of CT, with or without MRI, in the treatment of these patients. METHODS: Clinical presentations were reviewed, along with the CT and MRI findings, for patients who had sinusitis with complications. Clinical, CT, and MRI findings were compared for accuracy in diagnosing 43 patients with orbital infections and 39 patients with intracranial infections. RESULTS: For patients with orbital complications, most of whom had unilateral ethmoiditis, the diagnostic accuracy was 82% for clinical assessment compared with 91% for CT. For patients with intracranial complications, meningitis was the most common diagnosis, and MRI was more accurate (97%) in determining the diagnosis than CT (87%) or clinical findings (82%). CONCLUSION: CT remains the standard modality for diagnosing sinusitis, but MRI frequently is necessary, especially for patients with intracranial complications. Both diagnostic methods have improved the management and outcomes of patients who have sinusitis with complications.     

鼻窦内窥镜手术眼眶并发症117例分析

目的:探讨鼻窦内窥镜手术眼眶并发症的原因及预防。方法:回顾分析1998年2月至2004年3月行鼻内窥镜手术3?514例的临床资料。结果:117例（侧）发生眶并发症,其中一侧内直肌受损2例,眶内蜂窝织炎12例,眶脂肪疝出14例,眶周瘀斑89例,总发生率为3.33%。结论:熟悉鼻内镜下的解剖结构、标志及定位,术前仔细阅片、术中精确定位判断对预防眶并发症十分重要。     

Preservation of the eye in paranasal sinus cancer surgery

Forty-one patients undergoing surgery between 1977 and 1985 for malignant tumors of the paranasal sinuses abutting or eroding the orbital walls were studied for the need to remove the orbital contents. All patients had preliminary computed tomographic scans to delineate the extent of orbital invasion. All were treated with preoperative radiotherapy. If the tumor mass could be peeled from the periorbita, the eye was saved. Preservation of eyes in the patients without periosteal invasion did not alter survival. Frozen-section control may be used to determine periorbital involvement. If the periorbita was minimally involved, it was locally resected. If invasion of the periorbita was extensive, an orbital exenteration was done. Only five of 41 patients required exenteration. Local recurrence of disease in the orbit has not occurred in these patients.     

Allergic rhinitis as a risk factor for orbital complication of acute rhinosinusitis in children.

The purpose of this article is to determine allergic rhinitis and age as potential risk factors for the development of orbital complications of acute rhinosinusitis in children. One hundred two children presenting with orbital swelling were investigated by computed tomography (CT) of the paranasal sinuses and the orbit as well as for underlying allergic rhinitis. Sixty (58.8%) patients had orbital complications of clinical and radiological acute rhinosinusitis. They were grouped accordingly: preseptal cellulitis (n = 24), periostitis (n = 10), and subperiosteal abscess (n = 26). No abscess within the orbit or cavernous sinus thrombosis was found. Thirty-four (56.7%) of the 60 patients underwent allergy investigation. Allergic rhinitis was found in 9 (64.3%) of 14 children with preseptal cellulitis, in 1 (25%) out of 4 children with periostitis, and in 13 (76.5%) out of 17 children with subperiosteal abscess. The prevalence of allergic rhinitis was significantly higher in patients presenting in pollen season from February to August (17:4) than in patients presenting in the period between September and January (6:7). Thus, allergic rhinitis may be a cofactor in the pathogenesis of orbital complications of acute rhinosinusitis. According to our study population, age only influences the type of orbital complication of acute rhinosinusitis in the sense that older children are more likely to develop subperiosteal abscess, whereas younger children develop preseptal cellulitis.     

Invasion of the orbit in paranasal sinus tumours

The extension of paranasal sinus cancer into the orbit is one of arguments for carrying out orbital exenteration. Until the advent of high-resolution computed tomography, en bloc radical resection, including the orbit, was the most effective method of treating a cancer, whose size could not be adequately judged before surgery. Patient evaluation with computed tomography (CT) and magnetic resonance imaging (MR) is described. Different clinical situations relating the orbital content to sinus tumour and their management are discussed. Prosthetic options after orbital exenteration are also presented.     

Residual diplopia after repair of pure orbital blowout fracture: the importance of extraocular muscle injury

BACKGROUND: The aim of this study was to evaluate the incidence of and possible risk factors for residual diplopia after surgical repair of pure blowout fracture (BOF) of the orbit. METHODS: Sixty-three patients with pure orbital BOFs who had preoperative symptomatic diplopia were investigated. In each patient, the relationship of residual diplopia and the following factors were analyzed: (1) timing of surgery, (2) presence of enophthalmos, (3) site of fracture, (4) type of fracture, (5) extraocular muscle swelling, and (6) surgical method. RESULTS: Fifty-five (87.3%) of 63 patients experienced improvement in diplopia and 8 (12.7%) patients had residual symptomatic diplopia after surgery. Of the six factors, only swelling of extraocular muscle on computed tomography (CT) scan was significant for the development of residual diplopia after surgery (p < 0.01). CONCLUSION: In pure BOF of the orbit, patients who have swelling of the extraocular muscles on CT scan are more likely to have residual postoperative diplopia.     

Palliative orbital decompression for metastatic melanoma to the orbit

Although relatively rare, metastatic carcinomas to the orbit are the second most common orbital neoplasm in the adult. There are only ten cases reported in the literature of cutaneous melanoma metastatic to the orbit and, of these, only two had disease involving both orbits. This paper presents the third case of bilateral orbital melanoma; however, in this case, the primary site was the uveal tract in the first eye, with contralateral involvement being a metastasis of the orbital primary. The patient developed severe unilateral proptosis in his only seeing eye with progressive loss of vision. A palliative orbital decompression was performed which successfully restored visual acuity for an extended period of time. A brief discussion of the rationale for this procedure in this type of case is presented.     

Orbital rhabdomyosarcoma presenting as an apparent orbital subperiosteal abscess

We present a patient with acute sinusitis whose CT scan showed a ring-enhancing lesion within the orbit typical of an orbital subperiosteal abscess. On exploration of the orbit, there was no pus present but a tumour was found, which on histological examination was found to be a rhabdomyosarcoma. The clinical signs and CT characteristics of orbital subperiosteal abscesses and rhabdomyosarcomas are discussed. A ring-enhancing lesion within the orbit on CT scan should not be regarded as being pathognomonic for a subperiosteal abscess and the possibility of other diagnoses should be considered.     

Evulsion of the optic nerve, a diagnosis to be recognised!

INTRODUCTION: Evulsion of the optic nerve is a rare but serious injury. It occurs generally after an ocular contusion and may cause blindness. CASE: We report the case of a 53-year-old woman who presented with a blunt ocular trauma after having been punched by her husband. Initial examination of the left eye was impossible due to a major palpebral oedema. A CT scan of the orbit revealed a thickened optic nerve. No improvement was noted. DISCUSSION: Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as its globe entry level. The diagnosis can be confirmed by examination of the ocular fundus or by medical imaging such as CT scan of the orbital cavity as in our case report. The prognosis is usually poor.     

Pre- and postseptal orbital rhinosinusogenic complications

The authors present examination and surgical data on 78 patients with different forms of orbital rhinosinusogenic complication. One of the major factors for the course and therapeutic policy in such complications is pre- or postseptal location of the process in the orbit. Such local signs as exophthalmos, chemosis, dislocation, reduced motility of the eye ball and, later on, sight disorders indicate the lesion focus location behind the orbital septum. Clinical comparisons of the pre- and postseptal orbital complications evidence for more severe and prognostically unfavorable course of the inflammation in the posterior part of the orbit. This urges early active combined therapy and cleansing of the affected paranasal sinuses in such patients.     

自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术的回顾性分析

目的本文旨在通过回顾性分析观察自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术患者的疗效。方法回顾性分析2017年9月至2020年9月30例眼内容物剜除术后选择自体巩膜双层覆盖义眼台一期植入的临床数据。连续随访6~12个月,观察了该项手术的疗效及术后相关并发症。结果所有病例均伤口痊愈良好,义眼台无任何暴露或外力移位,眼眶饱满,眼球运动程度适中,患者美容满意,并发症少。结论自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术对比其他手术方法更简便,术后义眼台不易暴露,眼球运动程度好,这是一种比较成熟的手术治疗方式。     

Simultaneous intracranial and orbital complications of acute rhinosinusitis in children

OBJECTIVE: To evaluate the frequency of intracranial and orbital complications occurring as simultaneous but separate complications of acute rhinosinusitis in the pediatric population. METHODS: Records of children admitted to St. Louis Children's Hospital between 1 January 1990 and 31 December 2002 were reviewed. Relevant literature was reviewed with the assistance of Medline. RESULTS: We identified 74 patients with orbital complications related to acute rhinosinusitis. A bimodal age distribution was identified with one group above and one group below the age of 7 years. The frequency of intracranial complications in pediatric patients already admitted for orbital complications of acute rhinosinusitis was 0% for those less than 7 years of age and 9.3% (4/43) for patients 7 years and older. If surgery was required for orbital disease, these risks were 0 and 24% (4/17), respectively. The review found that patients with dual complications had a mean age of 15 years, 11 months, were male (100%), had subperiosteal abscesses located superiorly or superolaterally within the orbit, and presented with significant frontal sinus disease. All intraoperative cultures were polymicrobial. MRI was superior to CT for identification of intracranial extension. CONCLUSIONS: Simultaneous intracranial and orbital complications are rare but significant occurrences in acute pediatric rhinosinusitis. Because of the high incidence of intracranial findings, we recommend MRI in addition to CT scan along with aggressive management in children older than 7 years of age admitted with orbital complications of acute rhinosinusitis who also demonstrate risk factors for intracranial disease. These risk factors are discussed.     

鼻腔鼻窦骨良性病变累及眼眶的鼻内镜手术

目的探讨累及眼眶的鼻腔鼻窦骨良性病变鼻内镜下手术处理方法,分析手术运用特点、手术并发症及疗效。方法回顾性分析南京大学医学院附属鼓楼医院耳鼻咽喉科2014年1月—2018年7月收治的13例累及眼眶的骨良性病变,其中骨瘤7例,骨纤维异常增殖症4例,骨化纤维瘤2例。2例筛窦骨瘤突入眶内,其余11例均有眶壁不同程度受累。所有患者均经鼻内镜手术,部分患者结合运用影像导航技术、鼻中隔开窗及泪前隐窝入路手术,术中准确定位病变界限,对突入眶内病变及受累的眶组织予以彻底切除。所有手术操作均以保护并不突破眶筋膜为原则,除1例突入眶内巨大筛骨骨瘤外,其余术毕均未予眶壁重建处理。结果所有患者均经鼻内镜完成手术,受累眶壁及眶内骨性病变均切除彻底。5例患者术后第1天出现眶周轻度肿胀,取出鼻腔填充物后消除,无眼球功能障碍。术后复查CT显示眶内解剖结构及位置正常。随访11～65个月,所有患者均无复发。相关鼻窦引流通畅、上皮化良好,无远期并发症。结论彻底切除骨良性病变的眶受累解剖结构有利于减少术后复发,鼻眼相关解剖及手术视野和操作角度是手术成功的要点,经鼻内镜手术处理累及眼眶的骨性病变具有微创和疗效好等优势。     

Clinical implications of orbital cellulitis

Periorbital and orbital cellulitis are clearly two distinct disorders with different etiologies. Periorbital cellulitis is well-documented as a more common infectious process limited to the eyelids in the preseptal region. In contrast, orbital cellulitis represents a more severe, but less common, infection of the orbit posterior to the septum with or without subperiosteal abscess, orbital abscess, or cavernous sinus thrombosis. A retrospective review of the clinical and laboratory data of 137 cases of orbital and periorbital cellulitis was performed. Periorbital cellulitis was documented in 98 cases (71%), in contrast to orbital cellulitis which was noted in 39 (28%) patients. All patients with orbital cellulitis received intravenous antibiotics, however, surgical therapy was necessary for progression of orbital cellulitis in 49% of patients. The majority of patients underwent incision and drainage of an abscess in the orbit. Complications as a result of orbital cellulitis occurred in nine (23%) of the patients. A distinction is made between the clinical entity of periorbital cellulitis and orbital cellulitis. Separating these clinical entities on the basis of physical examination and radiographic studies is important because the medical and surgical management of these two disease processes is different.     

Effect of endoscopic marsupialization of paranasal sinus mucoceles involving the orbit: a review of 27 cases

Paranasal sinus mucoceles (PSMs) can involve the orbit because the topographic anatomies of the paranasal sinuses and orbit are interrelated. We encountered 27 patients with PSMs involving the orbit that caused orbital symptoms. In this study, we evaluated the frequent symptoms and signs of PSMs involving the orbit, and report postoperative changes of orbital symptoms including the effects on visual acuity. A retrospective chart review, radiologic evaluation, and interviews were conducted after Institutional Review Board approval was obtained. Over the past 11 years, we encountered 27 patients with PSMs involving the orbit. We classified the patients according to orbital symptoms and PSM origin, and evaluated the surgical outcomes. A total of 27 patients (17 males and 10 females) with PSMs involving the orbit were included in the present study. The mean patient age was 51.0 ± 9.7 years (range 32–90) and the mean follow-up period was 20.5 months (range 2–84). Proptosis (15/27, 56 %) was the most common symptom. Other common symptoms included orbital pain (9/27, 33 %), decreased visual acuity or vision loss (9/27, 33 %), and diplopia (7/27, 26 %). All symptoms except for vision loss were improved by endoscopic marsupialization regardless of the disease period. Four out of five patients with decreased visual acuity experienced complete recovery. The remaining patient showed partial improvement after surgery. Four patients who were blind when they initially visited the hospital did not show any improvement after surgery. For PSM patients with decreased visual acuity, we can predict that vision will improve after surgery regardless of the disease duration. However, blindness will probably not resolve after endoscopic marsupialization. Even if the orbital symptoms (except for blindness) have persisted for a long time, surgery could still produce positive outcomes.     

35例鼻眼相关疾病的诊治分析

目的：回顾分析鼻眼相关疾病的诊治结果,提高鼻眼相关疾病的诊治水平。方法:回顾分析35例鼻眼相关疾病患者的临床资料。结果:35例中, 鼻源性眼眶蜂窝织炎6例,外伤性鼻眶骨折、视神经管骨折4例,鼻窦黏液囊肿11例,内翻性乳头状瘤3例,鼻窦恶性肿瘤11例。鼻眼病变特征：炎性病变以眶壁破坏吸收为主,良性肿瘤则表现为眶壁受压移位,恶性肿瘤以眶壁破坏为主。结论:鼻窦与眼眶关系密切, CT扫描有助于此区域病变的早期诊断、指导治疗及观察预后;良性肿瘤以手术切除为主,恶性肿瘤需采用手术加放疗等综合治疗。