Soft Tissue Herniation Research Articles

Linear Computed Tomographic Measurement of Soft Tissue Herniation into the Maxillary Sinus as an Indicator for Orbital Floor Fracture Surgery: A Preliminary Study

Linear Computed Tomographic Measurement of Soft Tissue Herniation into the Maxillary Sinus as an Indicator for Orbital Floor Fracture Surgery: A Preliminary Study

How to Reduce Inferomedial Orbital Wall Fracture Using a Navigation System: Tips and Pearls.

The orbit is a confined space with a defined bony structure. Bony protrusion into the ethmoid or maxillary sinuses by the blowout fracture can displace orbital tissues, including rectus muscles and adjacent fascial septae. Especially, reconstructing the orbit's floor and medial wall can be challenging when the inferomedial strut or posterior bony ledge is affected, leading to a loss of critical anatomic landmarks and support. Correctly positioning an implant in the precise anatomic location can be challenging. Recent updates to the navigation system have addressed this issue. Despite its early application, using a navigation system in these orbital fractures advances plastic surgeons in a way that has more confidence and accuracy in surgical planning. The video demonstrates how these 2 can be combined in an operating room. Intraoperatively, the authors check the superior, anterior, and posterior ends of the medial wall fracture and the posterior end of the floor fracture. A single orbital implant was trimmed and reshaped to match defect measurements. The implant placement was meticulously executed to repair the fracture while ensuring the inferior oblique muscle was not injured. After confirming the correct placement of the implant, it was secured to the inferior orbital rim using a single screw. Depending on the medial orbital wall fracture depth or degree of soft tissue herniation, the authors used an artificial dermal matrix or trimmed absorbable mesh plate to cover the uppermost part of the medial wall fracture to prevent postoperative enophthalmos. Finally, a forced duction test was performed. Our study shows that navigation-assisted inferomedial orbital wall reconstruction using materials readily available in the market is safe and effective.

An unusual presentation: temporomandibular tissue herniation through congenital foramen of Huschke.

The herniation of temporomandibular tissue through the foramen of Huschke into the external auditory canal is a rare clinical anomaly. This paper describes one such case and provides an overview of the relevant literature. This paper elaborates upon the aetiology, clinical assessment, management and associated complications. A 54-year-old woman presented with a 3-month history of right ear pain and a polypoid lesion in her right ear canal. This lesion expanded during a Valsalva manoeuvre, and imaging demonstrated a defect in the antero-superior aspect of the canal with herniation of soft tissue. The patient was managed conservatively as the symptoms resided. Ear canal lesions that protrude or change in size with a Valsalva manoeuvre could be due to a persistent foramen of Huschke. In symptomatic cases needing surgical intervention, a variety of materials may be used to close the defect. Titanium mesh, with or without cartilage overlay, appears to be the most popular choice.

Correlation between Orbital Computed Tomography Scan Measurements and Clinical Enophthalmos in Acute Isolated Orbital Floor Fractures

Abstract Purpose: To analyze the correlation between orbital computed tomography (CT) scan measurements including the fracture area (FA), the fracture location, the soft-tissue herniation volume (HV), the fractured orbital volume ratio (OVR) to the normal orbit, and the clinical enophthalmos in acute isolated orbital floor fractures. Methods: We enrolled 100 patients with acute isolated unilateral orbital floor fractures from May 2017 to January 2021. Based on the CT scan findings, we measured the FA, HV, OVR, and fracture site. We assessed enophthalmos using both clinical (CE) and radiographic (RE) measurements. Additionally, we investigated the correlation between CE and the measured parameters, along with the relationship between the pattern of diplopia and the fracture site. Results: We identified enophthalmos in 81% and diplopia in 78% of the patients with an acute blowout orbital floor fracture. CE was moderately correlated with the FA (R 2 = 0.4341, P < 0.001). CE was weakly correlated with the HV (R 2 = 0.2861, P = 0.04). Anterior fractures caused diplopia in both vertical gazes, but posterior fractures were mostly associated with diplopia in the up gaze. OVR was strongly associated with RE (R 2 = 0.663, P < 0.0001) and moderately associated with CE (R 2 = 0.4378, P < 0.0001). The univariate regression analysis also showed that OVR could significantly predict CE and RE. Conclusions: OVR surpasses other CT scan measurements such as FA and HV in the prediction of clinical enophthalmos. Thus, OVR could be utilized to estimate clinical enophthalmos at the time of presentation, especially when the acute clinical setting prohibits the proper clinical evaluation.

A Rare Entity in Emergency Department: Trapdoor Fracture

Trapdoor fracture also known as, ‘White-eyed blowout fracture’’ is generally seen among pediatric patients with orbital floor blowout fracture. It is presented as ‘’open door fracture’’ in adults because of the mineralized, fragile orbital bones. An 11-year-old boy was admitted to the emergency department (ED) because of falling and hitting his on the occipital region. His main complaint was diplopia. He did not have nausea or pain. No visible lesion detected on his head. When the orbital CT scan was examined carefully, a fracture of the right orbital floor and herniation of orbital soft tissue was noticed. The patient was transferred to the plastic surgery department for surgical intervention. Even though there is no direct trauma, or visible pathology around orbital region, emergency physiscians should keep in mind trapdoor fracture, especially in pediatric patients with head trauma.

Orbital floor fractures—a comparison between CT images and findings at surgery

PurposeThe present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia.MethodsIn this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery.ResultsIn the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. “Rounding” significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue.ConclusionsThe results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time.

Pediatric Orbital Entrapment: Radiographic Findings and Their Predictive Values.

Although orbital fractures are less common in children than adults, the literature suggests that orbital entrapment occurs more frequently in the pediatric population. Orbital entrapment is an emergency, and early diagnosis and prompt management are critical. Specific radiographic manifestations such as herniation of extraocular muscles (EOMs) through orbital fractures have led to increased suspicion and overdiagnosis of orbital entrapment. This study evaluated the value of specific radiographic findings in predicting clinical findings after pediatric orbital floor fractures. A retrospective review at a pediatric level 1 trauma center was performed. ICD-9 and ICD-10, codes identified patients with orbital fractures. Computed tomography (CT) reports were queried for the following terms: "herniation," "herniated," "entrapped," and "entrapment." Patients 16 years and older were excluded, as were all patients who were unable to undergo EOM evaluation on presentation. Electronic medical records were reviewed for fracture type, mechanism of injury, clinical and radiographic findings, surgical interventions, and demographic information. Medical diagnosis tests, including positive and negative predictive values, sensitivity, as well as specificity, were calculated to identify the relationship between radiographic findings and specific symptomology. One hundred fifty-three patients with 265 orbital fractures were included. "Entrapment" was mentioned in 34.6% of CT reports, whereas the incidence of clinical entrapment was 12.4% (19/153). Radiographic fat herniation, EOM herniation, and EOM irregularity had positive predictive values of 25%, 31%, and 10%, respectively, for clinical entrapment diagnosis at the initial examination. Overall, 32.7% (50/153) of patients with orbital fractures required surgery. Although the radiographic description of soft tissue herniation has become interchangeable with entrapment, these CT findings alone are poorly predictive. Orbital entrapment should be diagnosed preoperatively by physical examination, with radiographs as an adjunct only. Radiographic statements without clinical correlation may lead to the improper management of pediatric facial trauma patients.

FORAMEN TYMPANICUM- AN EMBRYOLOGICAL DEFECT IN TYMPANIC PLATE

Foramen tympanicum or Foramen Huschke is a bony defect in the tympanic part of temporal bone that persists after 5 years of age. Due to this, there is a chance of discharge in the ear leading to perisistent otitis externa , herniation of soft tissue into auditory canal and due to the communication there is higher chances of parotid infections to be transmitted into the EAC . The present study was conducted on 40 dried human crania .The tympanic part of temporal bone that forms the inferior wall of external auditory canal was studied to find any developmental defect - foramen tympanicum . Out of all crania studied , foramen tympanicum was observed on right side in two crania and on both sides in one cranium .The persistant foramen can produce clinical complications like fistula formation or herniation of tissues into external auditary canal.. Knowledge of this embryological defect is useful for ENT and Maxillofacial surgeons to avoid complications during operative procedures of this region and also to diagnose rare clinical presentations like persistent or chronic pain in the region of Temporomandibular joint.

Sports Femoral Hernia in a Young Female Weightlifter - The First Reported Case in the World

A sports hernia is an increasingly recognized cause of chronic groin pain among many professional and non-professional athlete. It is a misnomer as there is no classic herniation of soft tissue. However, small occult inguinal hernias are documented during surgical exploration. It is more commonly seen in young male than female athletes. Diagnosis is usually challenging as most this pain has an insidious onset. It requires a high index of suspicious as clinically visible sports hernia has not yet been reported in the English literature. Similarly, a visible incarcerated femoral hernia in a young weightlifter has yet to be reported. We report the case of 27 years young professional female weightlifter who presented with having an aching pain in her left groin for one year. She had visited many GP’s and her pain temporary subsided with the use of NSAIDs. A Computerized Tomography of abdomen and pelvis revealed a left femoral hernia. Emergency femoral hernia repair was performed. The patient’s had an uneventful post-op recovery. At 36 months follow up the patient is doing well, participating in her professional weightlifting without any further complaints. This case highlights the typical presentation of the sports hernia i.e chronic groin pain and also illustrates how the diagnosis of this hernia is missed or delayed. We hereby report the world first case of incarcerated visible femoral hernia in a young professional weightlifter and a literature search was performed to highlight its management options.

Pediatric Orbital Medial Wall Trapdoor Fracture with Normal Computed Tomography Findings.

With advances in diagnostic technology, radiologic diagnostic methods have been used more frequently, and physical examination may be neglected. The authors report a case of pediatric medial orbital trapdoor fracture in which the surgery was delayed because computed tomography (CT) findings did not indicate bone displacement, incarceration of rectus muscle, or soft tissue herniation. A healthy 6-year-old boy was admitted to the emergency room for right eyebrow laceration. We could not check eyeball movement or diplopia, because the patient was irritable. Thus, we performed facial CT under sedation, but there was normal CT finding. Seven days later, the patient visited our hospital due to persistent nausea and dizziness. We were able to perform a physical examination this time. Lateral gaze of right eye was limited. CT still did not show any findings suggestive of fracture, but we decided to perform exploratory surgery. We performed exploration, and found no bone displacement, but discovered entrapped soft tissue. We returned the soft tissue to its original position. The patient fully recovered six weeks later. To enable early detection and treatment, thorough physical examination and CT reading are especially needed when the patient shows poor compliance, and frequent follow-up observations are also necessary.

Identification of Foramen of Huschke with Reversible Herniation of Temporomandibular Joint Soft Tissue Into the External Auditory Canal on Multidetector Computed Tomography

The foramen of Huschke, or foramen tympanicum, is a developmental defect in the bony part of the external auditory canal (EAC) due to a defect in ossification of normal bone in the first 5 years of life. Seen in the anteroinferior part of the EAC, it can be asymptomatic or present with salivary discharge into the EAC during mastication or as soft tissue swelling in the EAC in the absence of any inflammation, tumor, or trauma. We present a case of a man who presented with herniation of soft tissues of the temporomandibular joint into the EAC through a persistent foramen tympanicum.

Multidetector computed tomography depiction of foramen of huschke with reversible herniation of temporomandibular joint soft tissue into external auditory canal

We present a case of an adult male who presented with herniation of soft tissues of temporomandibular joint into the external auditory canal (EAC) through a persistent foramen tympanicum. The patient was referred for computed tomography (CT) for suspicious mass in the left EAC. Multidetector CT helped in correctly characterizing the lesion with retraction of the soft tissue mass in open mouth biopsy and thereby avoiding unnecessary biopsy.

Influence of the volume of soft tissue herniation on clinical symptoms of patients with orbital floor fractures.

One of the most important complications of orbital floor fractures is diplopia and restricted ocular movement. The role of the volume of soft tissue herniation on these clinical symptoms after orbital floor fractures is unclear and potentially may predict development of persistent clinical symptoms. Therefore the aim of this study was to assess pre- and postoperative complications associated to the volume of soft tissue herniation, with special interest to diplopia and bulbus motility impairment. 204 untreated patients with orbital floor fractures from 2009 to 2011 were included in this retrospective study. Contingency tables and χ2-test were performed to analyze associations between two qualitative variables. p-Values p<0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the software "ITK-Snap". The volume of soft tissue herniation correlated significantly with pre- and postoperative diplopia (p=0.003; p=0.002), persistent diplopia (p=0.009) as well as pre- and postoperative bulbus motility impairment (both p<0.001). Furthermore we found out significant associations between the volume of soft tissue herniation and pre- and postoperative complications depending on fracture type and reconstruction technique. Volume measurement of soft tissue herniation may help to predict postoperative complications, particularly bulbus motility restriction and persistent diplopia. The risk for these symptoms rises with increasing volume of soft tissue herniation after orbital floor fractures. Therefore we recommend for these patients within indication an early repair and/or closer observation.

Efficacy of Titanium Mesh in various Maxillofacial Surgeries

Maxillofacial injuries make up to 48 of all forms of injuries of which road traffic accidents and assaults contribute to 34. In which 52.5 are mandibular fractures. Tumors cysts osteomyelitis injuries post traumatic defects and multiple surgeries in maxillofacial region can lead to extensive bone loss. These large bony defects can result in soft tissue herniation into the defect affecting the facial contour. Due to functional and esthetic reasons large defects on the face should be reconstructed to preserve the facial contour. True dentofacial deformities of the midface in persons who have retrusive protmsive hypoplastic hyperplastic short face and long face without cranial vault deformities can be surgically corrected. The treatment of complex cases such as fractures of highly atrophic edentulous mandibles discontinuity defects and comminuted fractures with the use of mini plates is often difficult and unsatisfactory. Hence in such cases Titanium mesh has been successfully used.nbsp

Delayed Superior Orbital Fissure Syndrome After Reconstruction of Blowout Fracture

The superior orbital fissure syndrome (SOFS) has been known to be a condition caused by impairment of the nerves that cross the superior orbital fissure. Traumatic SOFS is an uncommon complication which occurs usually within 48 hours after a facial injury. A 25-year-old male sustained facial trauma following an altercation. Clinical findings on presentation included swelling, ecchymosis, hyphema, subretinal hemorrhage, and mild extraocular movement limitation upon lateral gaze on his right eyelids. Facial computed tomography scan confirmed fractures of the medial walls of the right orbit and herniation of orbital soft tissue without the incarceration of medial rectus muscle. Ten days after the trauma, the operation was performed. On postoperative day 16, the patient showed ptosis of the right upper eyelid with a fixed pupil, and there was a hypoesthesia over the distribution of the right supraorbital and supratrochlear nerves. The authors diagnosed as a delayed SOFS and prescribed 4 mg of methylprednisolone q.i.d. for 30 days. After steroid therapy, extraocular movement limitations improved progressively. After 8 months, movement was completely restored. The authors experienced delayed SOFS on posttrauma day 27, and it was treated by steroid therapy. Surgical intervention is required when there is an evident etiology such as underlying hematoma or plate migration. If the reason is not clear like our case, steroid therapy can be considered as one of the options. Particularly, the authors should give special attention to the patient who has congenitally narrow superior orbital fissure, like Fujiwara et al suggested.

The use of reformatted Cone Beam CT images in assessing mid-face trauma, with a focus on the orbital floor fractures.

Background and aimThis study aims at evaluating the reliability on specific multi-planar cone beam computer tomography (CBCT) reconstruction in the orbital floor fractures.MethodsCBCT examination of the mid-face fractures area involving the floor of the orbit was performed in a number of 93 trauma patients by two independent radiologists. Both radiologists assessed the axial, coronal and sagittal sections and also the oblique coronal and sagittal extracted sections evaluating the location of the orbital fractures, its size and displacement, the involvement of the infra-orbital foramen, herniation of fat or muscle within the maxillary sinus, the overall type of the fracture and the implication of lateral or medial orbital wall. We also registered the section that provided better confidence of both examiners in visualizing the fracture of the orbit floor and the presence of herniated soft tissue, on different reformatted sectioning.ResultsThe presence of pure fracture of the orbital floor was detected in 11% of patients. The association of the orbital fractures with the zygomatic fractures was identified in the majority of the patients. In 86% of patients the displacement of the floor of the orbit was visualized, and in almost 30% of cases more than 50% of the orbital floor was involved in the fracture. Regarding the confidence between examiners, they were more confident using the oblique sagittal CBCT reformatted images for fracture detection and bone displacement evaluation, as for the soft tissue herniation the oblique coronal sections provided the highest level of confidence.ConclusionMid-face trauma involves the orbital floor in the majority of situations. CBCT allows to obtain oblique images extracted from the three dimensional (3D) data that provide high confidence level in assessing pure orbital floor fractures.

Quantitative Assessment of Orbital Volume and Intraocular Pressure after Two-Wall Decompression in Thyroid Ophthalmopathy.

BackgroundSurgical outcomes after orbital wall decompression have focused on the degree of exophthalmos and intraocular pressure. The aim of this research was to evaluate intraorbital volume using computed tomography (CT) images following two-wall decompression using a combined subcilliary and endoscopic approaches.MethodsA retrospective review was performed for all patients who had undergone the two-wall decompression method. The pre/postoperative CT images were used to evaluate changes in intraocular volume. Intraocular pressure was evaluated using applanation tonometry. Surgical details are discussed within the body of text.ResultsTwo-wall decompression thru the medial wall and floor was associated with an average intraorbital volume change of 7.3 cm3, with maximal accommodation up to 13 cm3. Changes in intraocular pressures were not statistically significant.ConclusionTwo-wall decompression was effective in accommodation of up to 13 cm3 of soft tissue herniation. There was no statistically significant association between changes in volume to pressure.

Reply

Sir: We thank Dr. Shinder for his thoughtful letter regarding our article.1 We agree with the assessment that there is a scarcity of literature describing strict indications for repair of medial wall fractures. In our institution, we use the following criteria for surgical repair: a defect size larger than 2cm2 along the medial wall with evidence of soft-tissue herniation into the defect, medial rectus entrapment with associated diplopia, or enophthalmos greater than 2mm. In addition, in subjects with medial wall fractures and concomitant large orbital floor defects, wherein the medial aspect of the floor was compromised, the medial wall repair was undertaken to reconstitute the inferomedial aspect of the orbital anatomy. In contrast, nonoperative management was used in cases where the defects were small (<2cm2), those without associated soft-tissue entrapment, those that demonstrated no significant enophthalmos, and those in which ipsilateral orbital floor or midfacial fractures did not meet criteria for surgical repair. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Chad R. Gordon, D.O. The Johns Hopkins University School of Medicine Baltimore, Md. Srinivas M. Susarla, D.M.D., M.D., M.P.H. Michael J. Yaremchuk, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Massachusetts General Hospital Boston, Mass.

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

PurposeTo 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. MethodsA 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 6–10days, decision for surgical repair, and presence of diplopia were recorded. ResultsFifty-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). ConclusionTransverse 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.

Sports hernia: a clinical update

Chronic groin pain in young athletic patients poses a difficult diagnostic and therapeutic challenge, especially with such a wide variety of potential causes. Sports hernias were first described in the early 1980s, and are an increasingly recognised cause of chronic groin pain. Injury to a number of high profile athletes has raised the public awareness of this condition. Typically occurring in young athletic males, sports hernias usually present with insidious onset exercise-related groin pain. It is often disabling and results in cessation of participation in sport. The diagnosis often goes unrecognised for several months or even years. Many patients with sports hernias will have made several visits to their GP and physiotherapist with the pain that often gets branded as a ‘groin strain’. However, early detection and instigation of the correct treatment is essential in the management of sports hernia. The diagnosis and appropriate treatment requires a high index of suspicion and a multiprofessional approach, consisting of GPs, surgeons, physiotherapists, and radiologists. The term sports hernia is in fact a misnomer as there is no classical herniation of soft tissue.1 However, ‘sports hernia’ has been so widely popularised by the media that it is now commonly used by the medical profession, media, and public alike. It is also referred to, and synonymous with, sportsman’s hernia, athletic pubalgia, and Gilmore’s groin, as well as others. Sports hernia is in fact a poorly understood phenomenon, and as such the exact definition, aetiology, and pathophysiology vary widely …