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

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1 The British Association of Plastic Surgeons (2004) 57, Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor q M. Kakibuchi*, K. Fukazawa, K. Fukuda, N. Yamada, K. Matsuda, K. Kawai, S. Tomofuji, M. Sakagami Division of Plastic Surgery, Department of Otolaryngology, Hyogo College of Medicine 1-1, Mukogawa-cho, Nishinomiya, Hyogo , Japan Received 4 February 2003; accepted 21 October 2003 KEYWORDS Blowout fracture; Endoscopic repair; Orbital floor Summary 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 q This paper was partly presented at the 12th Congress of the International Confederation for Plastic, Reconstructive and Aesthetic Surgery, in San Francisco, California, on June 27 through July 2, 1999 and at the 4th Asian Pacific Craniofacial Association Conference, in Tokyo, Japan, on October 21 through 23, *Corresponding author. Tel.: þ ; fax: þ address: mkaki@hyo-med.ac.jp S /$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 38 M. Kakibuchi et al. 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. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Introduction Orbital blowout fractures are commonly encountered in the fields of ophthalmology, plastic surgery and otolaryngology. The aims of treatment are reduction of prolapsed orbital tissue and reconstruction of the orbital walls to improve symptoms such as diplopia and enophthalmos with minimal postoperative complications. Although a variety of approaches to orbital floor fractures have been proposed, 1 6 satisfactory postoperative results have not been obtained in all cases. One of the important problems in the repair of orbital blowout fractures is the difficulty of seeing clearly the posterior edge of the fracture before reduction of the orbital contents. Surgical approaches to the orbital floor are classified in three categories: trans-orbital, transantral and a dual approach. The traditional eyelid skin incision exposes the orbital floor with the best exposure. However, confirmation of atraumatic and complete reduction of the prolapsed orbital tissue is improved with a view from the antrum. Endoscopic exploration, which was advocated for diagnosis and repair of medial orbital wall fractures, 7 has recently been applied to orbital floor fractures. 5 Observation from the maxillary sinus is helpful for accurate reduction of the orbital contents and reconstruction of orbital floor. Endoscopically assisted repair of orbital floor fractures 8 and endoscopic endonasal repair of orbital floor fractures without maxillary fenestration 9 has also been reported. However, approaches from the orbital side are necessary in many cases when reconstruction of the orbital wall with implant or bone graft is required. A combination of approaches from the orbit and maxillary sinus seems to be a solution that facilitates more accurate treatment of this type of fracture. Temporal removal of the inferior orbital rim 2 is one method of dual approach to the orbital floor. However, extended palpebral scarring is an inevitable disadvantage of this procedure. A combination of the traditional transconjunctival approach and the endoscopic transantral approach achieves and confirms complete reduction and reconstruction without a facial skin incision. 8 Recently, endonasal transconjunctival orbital floor repair was advocated in the ophthalmic literature. 10 One of the drawbacks of the technique seems to be wide removal of the lateral nasal wall to insert a 25 or 30-degree endoscope through an enlarged ostium. We modified their technique to make it less invasive and applied it to pure orbital fractures involving the orbital floor. Use of a 70- degree straight endoscope allowed visualisation and assisted reduction and reconstruction of the orbital floor via limited enlargement of the ostium as for functional sinus surgery. Under endoscopic assistance, complete reduction and reconstruction of the orbital floor was achieved. Patients and methods Twelve cases of fresh blowout fractures involving the orbital floor were treated with combined transconjunctival and endonasal-transantral approach from May 1997 to December 2000 (Table 1). Our indications for surgical treatment were (1) incomplete resolution of diplopia 2 weeks after injury or (2) enophthalmos of more than 2 mm at any time within the first 6 weeks following the injury. There were seven male and five female patients. The average age was 23.5 years old and the range was 7 46 years old. The causes of injury were fights, motor vehicle or bicycle accidents, and sports. Patients with concomitant fractures involving the orbital rim were excluded. Other concomitant fractures were nasal fractures in two patients. Persistent diplopia was observed in eight cases and enophthalmos of more than 2 mm was detected in five cases preoperatively. Infraorbital nerve sensory loss was observed in three cases. A forced duction test was positive in two cases. Average intervals from injury to surgery were 22.8 days, ranging 9 41 days. Surgical procedure The patient was placed in the supine position with the head slightly elevated for ease of endoscopic

3 Combination of transconjunctival and endonasal-transantral approach 39 Table 1 Summary of the patients Case Age/sex Location of the orbital fracture Procedure of orbital floor reconstruction 1 19/M Right floor and medial wall Silastic sheet þ antral ballooning 2 8/M Left floor Silastic sheet þ antral ballooning 3 29/F Left floor and medial wall Silastic sheet þ antral ballooning 4 20/F Left floor and medial wall Periosteal repair þ antral ballooning 5 23/F Right floor Silastic sheet þ antral ballooning 6 23/F Left floor and medial wall Antral ballooning 7 46/M Left floor and medial wall Iliac bone graft 8 26/M Right floor Iliac bone graft 9 28/M Left floor Iliac bone graft þ antral ballooning 10 35/M Left floor Iliac bone graft 11 7/M Right floor Periosteal repair þ antral ballooning 12 18/F Left floor and medial wall Periosteal repair þ antral ballooning exploration. After packing the nasal cavity on the affected side with cotton soaked with 4% cocaine hydrochloride for 5 min before surgery, 1% epinephrine with 1% lidocaine hydrochloride was infiltrated in the lateral nasal wall. A 0-degree, 4 mm straight endoscope was introduced into the middle nasal meatus under the middle turbinate. The uncinate process was removed, and the ethmoidal bulla and basal lamella were removed to perform an anterior ethmoidectomy. After completing a partial posterior ethmoidectomy, the condition of the medial orbital wall was examined to confirm bulging orbital tissue. Gentle push upon the eyeball and traction on the medial rectus muscle helped identify the herniated orbital contents. If the forced duction test was positive, the entrapment of the medial rectus muscle was released under endoscopic visualisation. Then, the maxillary ostium was identified and enlarged posteriorly by standard straight biting nasal forceps and anteriorly by backward biting nasal forceps, whereas its extent was limited as in standard functional sinus surgery for maxillary sinusitis. The middle turbinate was left intact during this maneuver. A 70-degree, 4 mm straight endoscope was inserted into the middle meatus and the whole roof of the maxillary sinus was examined through the enlarged ostium. If prolapsed orbital tissue and the infraorbital nerve were observed in the roof of the maxillary sinus, an incision in the palpebral conjunctiva was made just below the lower border of the tarsal plate. A preseptal dissection plane was pursued downward to the inferior orbital rim. The periosteum was incised at the orbital rim and elevated to expose the orbital floor. Dislocated prolapsed orbital tissue and the orbital floor were reduced by dual approach. Reduction was performed from the orbit under illumination and assistance from the antrum. Pushing and propping the prolapsed orbital tissue under 70-degree endoscope visualisation helped in accurate reduction and reconstruction of the orbital floor. The orbital floor was reconstructed if the defect was larger than 2 cm 2. The medial wall was reconstructed to treat the enophthalmos. To avoid postoperative complications such as infection or migration of implant materials, we have recently preferred thin iliac bone grafts for reconstruction of the orbital walls. If reconstruction is not required, placing a urinary balloon catheter in the antrum or a gauze-containing rubber sac in the ethmoid for three weeks after surgery supports reduced orbital tissue. Case report A 28-year-old male suffered a blunt orbital injury due to a traffic accident. Restriction of upward movement of the left eyeball was accompanied by double vision. The patient also had a 2 mm of enophthalmos (Fig. 1). Computed tomography indicated herniated orbital tissue through a fractured orbital floor. The medial orbital wall of this patient was intact (Fig. 2, left). Endoscopic examination during the operation demonstrated massive dislocation of orbital tissue bulging into the maxillary sinus (Fig. 3). The fracture of the orbital floor was also examined through a transconjunctival approach (Fig. 4). The orbital contents were reduced by dual approach from the orbit and the antrum (Fig. 5). Reduction was confirmed by endoscopy (Fig. 6). The orbital floor was reconstructed with a thin iliac bone graft (Fig. 2, right). A urinary catheter was inserted into the maxillary sinus and the balloon at the tip

4 40 M. Kakibuchi et al. of it was inflated to support the repaired orbital floor. The position and movement of the eyeball were improved and the double vision disappeared (Fig. 7). Results Figure 1 Preoperative view of the patient. (Above) Restriction of upward movement of the left eyeball is found. (Below) Worm s eye view: 2 mm of enophthalmus is presented. Exploration, reduction and reconstruction of orbital floor fractures was accurately performed with this procedure in all 12 cases. Orbital floor defects larger than 2 cm 2 were initially reconstructed with silicone sheeting in five early cases. Subsequently, thin iliac bone was used in four later cases and nasal septal cartilage was used in one case. In all eight cases that showed diplopia preoperatively, ocular movement recovered and symptomatic diplopia disappeared within a few months after surgery. Enophthalmos also was improved to less than 2 mm in all five cases immediately. One early case showed temporary entropion, which was cured within a week after surgery. The follow-up period was from 113 to 419 days (mean 329 days). Transient numbness of the cheek appeared in five cases and recovered within 3 months. Temporary maxillary sinusitis occurred in one case and was cured immediately. Postoperative infection was not observed. Discussion The principles of the treatment for orbital blowout fracture are to regain normal position and movement Figure 2 Findings of computed tomography. (Left, preoperative) Orbital tissue was bulging into the antrum. (Right, postoperative) Orbital floor is reconstructed with iliac bone graft.

5 Combination of transconjunctival and endonasal-transantral approach 41 Figure 3 Endoscopic findings of the roof of the antrum. Prolapsed orbital contents are presented. of the eyeball with minimal postoperative complications. However, achieving excellent results is challenging in some cases. Even in this era of sophisticated computerised tomography and magnetic resonance imaging, insufficient preoperative information about the condition of the damaged orbital floor and herniated orbital contents compels surgeons to make intraoperative assessments. Through traditional approaches to the orbit such as the subciliary incision or the conjunctival incision with or without lateral canthotomy, the fracture lines except of the posterior edge is well visualised before reduction of the prolapsed orbital contents. However, detecting the condition of the posterior edge and the orbital contents in detail is difficult. High-resolution endoscopes that have been used in functional endoscopic sinus surgery by otolaryngologists provide clear visualisation and access to the orbital walls. They clearly demonstrate the posterior border of the orbital floor fractures and infraorbital nerve accurately. Endoscopy also provides the possibility of dual examination and manipulation by two surgeons for the orbital floor if it is combined with a traditional approach from the eyelid. Temporally removing the inferior orbital rim provides dual vision from orbit and sinus, and is another choice. However, it requires a longer skin incision and wide dissection around the orbital rim and infraorbital nerve to perform osteotomy and plate fixation. Transantral endoscopic orbital floor exploration Figure 4 Findings from the orbit. Fracture of the orbital floor is presented through transconjunctival approach.

6 42 M. Kakibuchi et al. Figure 5 Endoscopic findings of the roof of the antrum. Reduction of the orbital contents is assisted with clump through the ostium. may avoid eyelid skin incision in the reconstruction of small orbital floor defects. 5 There has been another report on reconstruction of the orbital floor using endoscopes through a larger maxillary antrostomy. 8 However, accurate reduction and reconstruction without information and manipulation from the orbital approach seems to be difficult, even for experienced surgeons. Generally, an incision in the eyelid skin or conjunctiva is necessary when reconstruction of the orbital wall is required. One of the inevitable problems of maxillary antrotomy is numbness of the alveolus after surgery. Application of this technique in children, who have small antrum and tooth buds in the anterior wall of the maxilla, is not possible. Endonasal approaches to the antrum without maxillary antrotomy is another good solution. In 1998, Woog et al. advocated the combination of an endonasal approach and a transconjunctival orbital floor repair. 10 However, the area seen from the antrum with a 20- or 30-degree endoscope is limited to the posterior portion of the orbital floor, and their technique seems to be more invasive than standard functional endoscopic sinus surgery because extended enlargement of the ostium is required to obtain complete visualisation of the orbital floor with a Figure 6 orbit. Endoscopic findings of the roof of the antrum. Orbital contents are reduced with elevatrium through the

7 Combination of transconjunctival and endonasal-transantral approach 43 enhances accuracy in reduction of the orbital contents and reconstruction of the orbital floor. For example, illumination from the antrum is a great help during reduction and reconstruction from the conjunctival incision. The transconjunctival approach to the orbital floor is not easy for inexperienced physicians. Orbital floor injury with extraocular muscle entrapment following functional endoscopic sinus surgery has also been reported 14 and another report cites two medial rectus injuries, five orbital hemorrhages, and one nasolacrimal duct injury in the review of 616 endoscopic sinus procedures. 15 So our technique is recommended only for experienced physicians familiar with surgery of the orbit and the sinuses with the support of high quality instruments and skilled staff. In adequate situations this technique may help in obtaining excellent aesthetic and functional results in management of orbital blowout fractures. References Figure 7 Postoperative view of the patient. (Above) Restriction of upward movement of the left eyeball disappeared. (Below) Worm s eye view: enophthalmus is cured. 20- or 30-degree endoscope. Another report of the endonasal approach without eyelid or conjunctival incision showed poor results. 4 They supported the orbital floor with a urinary catheter after reduction and two patients in only 11 cases needed postoperative prism-glass management for persistent diplopia after surgery. Accurate reduction and reconstruction from an orbital approach seems to be necessary in most cases of orbital blowout fractures. Tessier 11 advocated a transconjunctival approach for surgery of craniofacial dysostoses and Converse 1 applied this incision for orbital fractures. Temporary entropion and laceration of the tarsal plate are possible complications of the transconjunctival approach. However, this method has been applied to a variety of orbital surgeries with a low complication rate. 12,13 Our endonasal endoscopic repair of the orbital floor combined with a conjunctival incision appears to be a safe and effective technique for the treatment of blowout fractures involving the orbital floor. Its dual examination and manipulation from the orbit and the antrum 1. Converse JM, Firmin F, Wood-Smith D, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg 1973;52: Tessier P. Inferior orbitotomy. A new approach to the orbital floor. Clin Plast Surg 1982;9: Sachs ME. Orbital floor fractures: the maxillary approach. Adv Ophthalmic Plast Reconstr Surg 1987;6: Hayasaka S, Aikawa Y, Wada M, Kodama T, Noda S. Transconjunctival and transantral approaches are combined with antral wall bone graft to repair orbital floor blow-out fractures. Ophthalmologica 1994;208: Saunders CJ, Whetzel TP, Stokes RB, Wong GB, Stevenson TR. Transantral endoscopic orbital floor exploration: a cadaver and clinical study. Plast Reconstr Surg 1997;100: O Regan MB, Macleod SPR. Miniantrostomy for the reduction of fractures of the orbital floor. Br J Oral Maxillofac Surg 2000;38: Jin HR, Shin SO, Choo MJ, Choi YS. Endonasal endoscopic reduction of blowout fractures of the medial orbital wall. J Oral Maxillofac Surg 2000;58: Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108: Ikeda K, Suzuki H, Oshima T, Takasaka T. Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg 1999;125: Woog JJ, Hartstein ME, Gliklich R. Paranasal sinus endoscopy and orbital fracture repair. Arch Ophthalmol 1998;116: Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1973;1: Baumann A, Ewers R. Use of the preseptal transconjunctival approach in orbit reconstruction surgery. J Oral Maxillofac Surg 2001;59: discussion Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach: a review of 400 cases. Arch Otolaryngol Head Neck Surg 1997;123:385.

8 44 M. Kakibuchi et al. 14. Carton A, Hislop S. Orbital floor injury with extraocular muscle entrapment following functional endoscopic sinus surgery. Br J Oral Maxillofac Surg 2000;38: Corey JP, Bumsted R, Panje W, Namon A. Orbital complications in functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 1993;109: