眶壁爆裂性骨折的手术治疗

目的 探讨眼眶壁爆裂性骨折手术治疗的方法和效果.方法 总结我院1998年8月至2007年1月,因眼眶壁爆裂性骨折而行修复手术治疗的患者81例(85只眼).结果 所有患者术后随访6～24个月,52例眼球运动障碍患者中,31例眼动恢复正常,复视消失.其中伤后2周内手术者21只眼,占75.0%(21/28).2周至2个月者8只眼,占44.4%(8/18).超过2个月者2眼,占33.3%(2/6).超过2周以上者眼球内陷的术前均值3.5 mm,术后均值1.5 mm,明显改善.眶内填入材料种类与矫正眼球内陷的效果无明显关系.结论 对于伴有复视、眼球运动障碍的眼眶壁爆裂性骨折应尽早手术治疗.当双眼突出度相差大于2 mm,即应手术矫正.手术应于骨膜下进行,以避免并发症.骨水泥和MEDPOR使用起来安全,效果肯定.     

眶壁爆裂性骨折的手术治疗

目的探讨眼眶壁爆裂性骨折手术治疗的方法和效果。方法总结我院1998年8月至2007年1月，因眼眶壁爆裂性骨折而行修复手术治疗的患者81例（85只眼）。结果所有患者术后随访6～24个月，52例眼球运动障碍患者中，31例眼动恢复正常，复视消失。其中伤后2周内手术者21只眼，占75．0％（21／28）。2周至2个月者8只眼，占44．4％（8／18）。超过2个月者2眼，占33．3％（2／6）。超过2周以上者眼球内陷的术前均值3．5mm，术后均值1．5mm，明显改善。眶内填入材料种类与矫正眼球内陷的效果无明显关系。结论对于伴有复视、眼球运动障碍的眼眶壁爆裂性骨折应尽早手术治疗。当双眼突出度相差大于2mm，即应手术矫正。手术应于骨膜下进行，以避免并发症。骨水泥和MEDPOR使用起来安全，效果肯定。     

Endoscopic approach to medial orbital wall fractures

Repair of medial orbital wall fractures can be challenging with traditional open techniques. This article describes different endoscopic-assisted approaches-transcaruncular and intranasal-which have been used to successfully repair these fractures.     

Blindness following blowout orbital fractures.

Blindness following blowout fractures is an unfortunate complication. The ophthalmologist must be aware of the events and sites of injury to the optic nerve which lead to visual problems. Preventive measures include immediate recognition of the signs of impending optic nerve compression and execution of treatment without delay. The importance of monitoring vision cannot be overstressed. Judicious surgery involves a post-injury delay in cases that are improving daily. The avoidance of additional surgical trauma with implant insertion during that period may help prevent postoperative blowout blindness.     

Endoscopically assisted transconjunctival approach in orbital medial wall fractures

Full exposure of the medial orbital wall for fracture repair poses difficulty with traditional approaches except coronal incision, especially in cases of wide fracture. The endoscopic-assisted approach with limited incision has been introduced. The authors used the endoscopically assisted transconjunctival approach in 21 cases: 15 isolated medial orbital wall fractures and 6 cases of concomitant floor fractures. Through the medial transconjunctival slit incision, repair of the fracture using calvarial bone graft was undertaken with the aid of an endoscope. All patients recovered without any eye symptoms including clinically notable enophthalmos, but one immediate revisional operation was needed because of a displaced bone graft. Otherwise, the desired position of the graft was confirmed via computed tomography. The endoscopically assisted transconjunctival approach to the orbital medial wall provides improved surgical exposure of the most posterior and superior aspects of the fracture site, enabling more accurate reduction of orbital soft tissue and placement of bone grafts.     

Endoscopic endonasal repair of blowout fractures of the orbital floor

Objectives: This study is to show the usefulness of the endoscopic endonasal approach in the surgical treatment of isolated blowout fractures of the orbital floor.Methods: Between 1997 and 2003 we operated on 65 patients complaining of diplopia due to isolated blowout fractures of the orbital floor, including 4 patients accompanied with enophthalmos. In 62 of the 65, only the endonasal approach with endoscope was used, while in the remaining 3 patients, we used the combined endonasal and transantral approach. To do the endonasal repair surgery smoothly under the endoscope, via the middle nasal meatus, septoplasty was supplemented in 13 patients and submucous conchotomy in 57. The bone fragments trapping the orbital content herniated into the maxillary sinus were carefully removed so as to keep the periorbita intact. Tampon gauzes or a balloon catheter for temporal fixation was placed in the maxillary sinus through the middle nasal meatus to support the orbital floor for 2 to 7 days. No permanent supporting material was used. Immediately following the repair and the fixation the eye traction test was respectively performed to confirm that the eyeball was freely moving.Results: Postoperatively diplopia disappeared in 50 of the 57 patients using only the endonasal approach, (87.7%) and enophthalmos improved 3 of 4 followed over 6 months.Conclusions: From this high success rate with respect especially to diplopia we conclude that the endoscopic endonasal approach is alternative to extranasal methods in view of cosmetics and the improvement of eye movement.     

Endoscopic versus external repair of orbital blowout fractures.

OBJECTIVES: This study evaluates the usefulness of endoscopic repair compared to external repair in the treatment of blowout fracture (BOF) of the orbit. STUDY DESIGN AND SETTING: This retrospective study comprised 100 patients who had had surgical repair of orbital BOF since 1992. Forty-eight of the 100 had undergone endoscopic repair, 48 patients had had external repair, and four patients underwent surgery that combined the two approaches. The two basic approaches were evaluated and compared with respect to technique, results and complications. RESULTS: Endoscopically, transnasal and transantral approaches had been used for reduction and support of fractured medial and inferior walls, respectively. In the external approach, various transorbital incisions were made and the fractured wall was repaired with alloplastic or autologous materials. Complete or partial resolution of preoperative diplopia was achieved in 94% of the endoscopic group and 83% of the external group (NS). Enophthalmos was improved in 89% of the endoscopic group and 76% of the external group (NS). Though the endoscopic group had no significant complications, the external group had ectropions, significant facial scars, extrusion of inserted Medpor, and intra-orbital hematoma. CONCLUSIONS: Endoscopic repair appears to be a safe and effective technique for the treatment of BOF of the orbit.     

Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor.

In the repair of orbital blowout fractures through eyelid or conjunctival incision, it is difficult to see the posterior edge of the fracture and the condition of the herniated tissue before reduction of the orbital contents. Prolapsed orbital tissue or infraorbital nerve and vessels may therefore be damaged in the reduction.The recently advocated combination of traditional transconjunctival approach and endoscopic transantral approach allows reduction and reconstruction under clear endoscopic vision without a facial skin incision. We modified this technique to make it less invasive and applied it to the repair of orbital blowout fractures involving the orbital floor. The use of a 70-degree straight endoscope through an enlarged ostium as for functional sinus surgery allowed clear sight of the roof of the antrum. During the repair of the orbital floor through a transconjunctival approach, reduction and reconstruction was assisted from the antrum.Twelve cases of fresh blowout fractures were treated with this approach. There were seven male and five female patients. Mean age was 23.5 years. Causes of injuries were fights, motor vehicle or bicycle accidents, and sports. Patients with concomitant fractures involving the orbital rim were excluded. Persistent diplopia was present in eight cases and enophthalmos of more than 2 mm was detected in five cases preoperatively. The average intervals from injury to surgery was 22.8 days.Exploration, reduction and reconstruction of the orbital floor fractures were precisely performed with this procedure. Large orbital floor defects were reconstructed with silicone sheets, thin iliac bone grafts or nasal septal cartilage. In all eight cases that showed diplopia, ocular movement recovered and symptomatic diplopia disappeared after surgery. Enophthalmos of more than 2 mm was also improved in all five cases. One early case showed temporary entropion. Transient numbness of the cheek appeared in five cases and temporary maxillary sinusitis recovered in one case. Postoperative infection was not observed.This method provides visualisation of posterior edge of the fracture and the condition of herniated orbital contents before initiation of reduction. Dual manipulation by two surgeons is also possible in reduction and reconstruction of the orbital floor.     

Endoscopic approach to orbital blowout fracture repair.

OBJECTIVES: Transconjunctival and subciliary approaches to orbital floor blowout fractures (OBF) have known risks of postoperative eyelid malposition. This study evaluates the endoscopic transmaxillary repair of OBFs in a cadaveric model and clinical setting. METHODS: Sixteen cadaveric and 10 clinical OBFs were repaired endoscopically. A Caldwell-Luc approach and modified sinus surgery instrumentation were used to repair each fracture. Variations in fracture pattern, instrumentation, and surgical technique were evaluated. RESULTS: Endoscopic repair was achieved in all 16 cadaveric orbits and in 9 of 10 patients. Fracture patterns were classified as either medial or lateral to the infraorbital nerve. Average clinical operating time was 1:38. Of 9 postoperative CT scans, 5 were rated as excellent, 3 as good, and 1 as poor. CONCLUSIONS: The endoscopic transmaxillary approach is a safe, viable technique for OBF repair. It offers improved visualization, anatomic fracture repair, no risk of postoperative eyelid complications, and good clinical results. EBM rating: C.     

Computed tomography of orbital medial wall fractures

Increasing experience with computed tomographic evaluation of head trauma reveals this radiologic modality to be superior to conventional polytomography in the assessment of certain areas of maxillofacial injury. A comparison of hypocycloidal polytomography and computed tomography in nine patients with fractures of the medial wall of the orbit reveals CT to be superior in localization of the fracture site, delineation of displaced bone fragments, and recognition of herniation of intraorbital contents into the ethmoid labyrinth. Information regarding damage to the nasolacrimal duct and associated intraorbital abnormalities such as the presence and location of hemorrhage and foreign bodies is also available from the CT scan.     

Endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor.

The indications for and timing of surgical treatment of blowout fractures of the orbital floor remain controversial. We report good results with the endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor in the early stage after trauma in a consecutive series of 29 patients treated over the last 3 years, based on the following criteria: 1) diplopia observed by ophthalmological examination, 2) entrapment of intraorbital tissue at the fracture site on diagnostic imaging, mainly using CT scans, and 3) no improvement of diplopia during the acute phase (within one week of injury). Even in the presence of eyelid swelling, this method allows reduction and fixation of the fracture and impacted tissues simply and in a short time. Disappearance of diplopia was reported by 27 patients (93 %) within three months after surgery, and all 20 patients with enophthalmos were cured. There were only 4 cases with transient minor operative complications. Re-entrapment at the fracture site or relapse of symptoms was not seen during follow-up for 5 to 39 months (mean: 23.4 months). The combination of endoscopic transmaxillary reduction and the balloon technique for blowout fractures of the orbital floor is an effective and minimally invasive treatment with a high rate of improvement, not just for disturbances of ocular movement, but also for enophthalmos, which is often a problem in the long term.     

Intranasal endoscopy-assisted repair of medial orbital wall fractures

The repair of medial orbital blow-out fractures remains a challenging surgical procedure for most surgeons. Endoscopic intranasal visualization of the medial orbital wall or lamina papyracea is a technique familiar to most otolaryngologists. This endoscopic view would allow for confirmation of orbital content reduction and bimanual manipulation of an orbital implant. To determine the effectiveness of a new surgical technique, a cadaveric study was performed to evaluate the ability to (1) reduce the herniated orbital contents and (2) restore the normal anatomic orbital configuration and volume with the addition of an orbital implant. Excellent visualization of the fracture was achieved in all cadaveric specimens. In addition, endoscopic intranasal visualization of the medial orbital wall greatly facilitated the anatomic reduction of orbital contents and proper placement of the orbital implant. The surgical technique is described and a clinical case is reported in which this endoscopic technique was effectively used. Arch Facial Plast Surg. 2000;2:269-273     

Endoscopic transnasal approach for the treatment of isolated medial orbital blow-out fractures: a prospective study of preoperative and postoperative orbital volume change

Endoscopic transnasal reduction is a safe and effective technique for the treatment of blow-out fractures of the medial orbital wall. However, because this approach does not use rigid permanent material for reconstruction of the fractured medial orbital wall, some degree of herniation of the orbital contents may occur after the intraethmoidal packing material is removed. The purpose of this study was to evaluate the change in orbital volume in patients with medial orbital wall fractures treated through an endoscopic transnasal approach. This study was a prospective analysis that includes 20 patients who underwent endoscopic transnasal reduction of medial orbital wall fractures between April 2007 and December 2008. Computer-assisted orbital volume measurements were made using axial computed tomography. The mean (standard deviation [SD]) volume increase was 2.00 (0.92) cm(3) and the mean (SD) dimension of the fractured orbital wall was 2.76 (0.83) cm(2). After endoscopic surgery, an average (SD) volume decrease of 2.15 (0.91) cm(3) was achieved with ethmoid sinus packing. After removal of the packing materials, 1.14 (0.78) cm(3) increase of the orbital volume was observed. The dimension of the orbital wall fracture significantly correlated with the increased preoperative orbital volume (P = 0.002, r = 0.609); the preoperative increase in the orbital volume also significantly correlated with volume relapse after removal of the packing (P = 0.023, r = 0.452). These findings suggest that in broad orbital wall fractures, reconstruction of the orbital wall by rigid materials or prolongation of the packing period should be considered, because orbital volume can increase again after packing removal, and may thus lead to postoperative complications.     

单纯型眶壁爆裂骨折晚期畸形的诊断及整复

目的：探讨眶壁爆裂骨折所致眶壁畸形、眼球内陷的发生机制及其整复手术。方法：应用三维CT影像学技术及计算机三维诊断系统，观察眶壁畸形特征，测量眶腔容积变化，分析眼球内陷和复视的发生机制。并采用自体骨或羟基磷灰石人工骨植人恢复眶腔容积的方法进行整复。结果本组11例，未出现植人骨感染、外露等并发症。其中10例眼球突出度、眼球运动功能恢复，复视得以矫正，眶、眼睑外形良好；1例复视未得到矫正，眼球运动功能恢复欠佳。结论：眶壁爆裂骨折眼球内陷的原因主要是眶腔容积增大、眶内容疝出，还纳眶内容后植骨恢复眶腔容积，是治疗此类畸形的有效方法。     

Clinical analysis of orbital blowout fractures caused by a globe-to-wall contact mechanism

Computed tomograms of blowout fractures of the pure medial and inferomedial wall that showed that the size of the orbital displacement exactly fitted the shape of the globe in many cases were investigated. To examine the veracity of a "globe-to-wall contact mechanism", we have analysed our own cases of medial or inferomedial blowout fractures (and also the charts of presumptive cases in which this mechanism was suspected), for the clinical information. The size of the displacement of the orbital wall exactly fitted the globe in 20/45 patients (44%). All fractures occurred in the inferomedial area of the orbital wall. In our study, serious complications such as corneal laceration, global rupture, paralysis of the cranial nerve, and ophthalmic nerve neuropathy were seen more often than in other studies.     

Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction

The reconstruction of the anterio-posterior inclination of the medial aspect of the orbital floor, despite a wide 360 degrees exposure, including coronal and conjunctival incisions, is a challenging task in severe injuries of the orbit with massive comminution and complete displacement of the medial orbital wall and orbital floor. Out of a total of 20 patients with orbital fractures, five underwent a surgical intervention of repositioning the medial aspect of the orbital floor and especially the transition area between the orbital floor and medial orbital wall, using navigation-aided procedures. Using the mirroring tool of the Stryker-Leibinger STN-system, post-operative CTs indicated an average difference of the globe position of -4.9% between the operated side and the unaffected side, depending on the position of the medial aspect of the orbital floor. Navigation-aided procedures proved to be an essential precondition for achieving precise and predictable results in orbital reconstruction. In such cases, unlike those with an intact medial orbital wall remnant as a surgical target, bone grafts for reconstruction of the orbital floor cannot be implanted as onlay grafts.