Endoscopic endonasal repair for orbital fracture

Abstract

Indications, techniques, outcomes, advantages, and disadvantages of endoscopic endonasal or transmaxillary repair of orbital fracture are reported. The goal of this surgery is 1)to completely free intra-orbital tissues from entrapment and/or adhesion by fractured bone fragments and to restore smooth ocular movement, and 2)to reconstruct the orbital wall by returning orbital tissue from the sinus into the orbit and fixing it there. Fracture of the medial orbital wall is repaired endonasally and fixed with gauze packing for a week. Orbital floor fracture is repaired endonasally or transmaxillary and fixed with a urinary bladder catheter for a week. These techniques of repair have a wider operative field and allow easier forceps manipulation than does conventional microscopic transorbital repair, especially in the posterior part of the orbital floor. By virtue of the clear and magnified field of view in various directions and angles provided by the 0- and 70-degree rigid endoscopes, various tissues, such as the sinus mucosa, bone fragments, periostium, and periorbital adipose tissue, can easily be distinguished, decreasing the risk of injury of intra-orbital tissue. On the other hand, possible disadvantages of the endonasal approach include the difficulty of reinserting bone fragments after removal of fractured bone fragments to reconstruct the orbital floor. We believe that during the one-week period of fixation, regenerating sinus mucosa and connective tissue completely cover the wound and form new supporting tissue that covers the bone defect. Long-term follow-up is, however, necessary to determine whether enophthalmos will develop or not in the future. Endoscopic repair is considered an appropriate and less-invasive method for orbital fractures. Diplopia resolved postoperatively in 80.7% of our patients. However, in several patients with trapdoor fractures, the orbital tissues became fibrotic and diplopia persisted after surgery. When trapdoor fractures are suspected, repair should be performed as soon as possible.