Infraorbital Region Research Articles

A Rare Cause of Penetrating Head Trauma; Shovel Handle in Brain

The most severe and fatal causes of traumatic brain injuries are penetrating head injuries. In this report, we describe a rare case of a 37-year-old male who presented with brain injury caused by a shovel handle which penetrated the infra orbital region, passed through the right hemisphere and exited from the occipital region. Our aim in reporting this rare case was to underline the importance of early imaging studies and to remind the emergency physicians of management of patients with head trauma. (JAEM 2014; 13: 33-5)

Lacrimal Sac Rhinosporidiosis: An Unusual Case Report

Rhinosporidiosis is a granulomatous disease that is a disease caused by Rhinosporidium seeberi. Though it occurs universally, the disease is widely prevalent in the tropics, especially in southern India and Sri Lanka. It usually affects the nasal mucosa and nasopharynx and rarely the conjunctiva, lacrimal sac, tonsils and skin. We present a case study of an isolated lacrimal sac rhinosporidiosis in a 15-year-old boy who was a resident of Terai. He presented with a diffuse left medial infraorbital swelling for a period of 14 months. He also complained of intermittent epiphora. External examination of the left eye revealed a diffuse, soft, and nontender swelling in the medial infraorbital region. Fine needle aspiration report was inconclusive. A computed tomography scan of the paranasal sinuses revealed an isodense lesion with mild enhancement within the preseptal compartment along the inferior aspect of the left orbit. A dacryocystectomy was performed and histopathology report confirmed rhinosporidiosis. There is no recurrence after 2 years of follow up.

A study on variability of quantitative sensory testing in healthy participants and painful temporomandibular disorder patients

Objectives: Quantitative sensory testing has mainly used thresholds to evaluate somatosensory sensitivity so far. The variability of different measures from session to session has also been investigated, but the variability of the single individual measures of a threshold or subject-based reports has not been considered. This study aimed to investigate the potential value of threshold variability in one session as a measure of internal consistency in somatosensory function.Methods: The standardized quantitative sensory testing battery developed by the German Research Network on Neuropathic Pain was performed bilaterally over the infraorbital, mental, and hand regions in 70 healthy and 22 temporomandibular disorder pain participants. Somatosensory variability was investigated by calculating the Coefficient of Variation of three to five repeated measures in one threshold determination. The influences of side, gender, site, age, and presence of pain on the somatosensory variability were evaluated.Results: In the healthy participants, somatosensory variability was region dependent: hand > mental and/or infraorbital for CDT, WDT, HPT, MDT-N, MPT-Y, MPT-N, WUR, and MPS (p ≤ 0.043), infraorbital > hand for VDT (p = 0.001), mental > infraorbital for HPT and WUR (p ≤ 0.001); and age dependent for WDT, TSL, CPT, HPT, MDT-Y, MDT-N, MPT-N, and WUR (p ≤ 0.017). Gender and side had no main effect on variability (p ≥ 0.136). The pain patients presented higher variability compared with healthy participants for TSL, MDT-N, MPT-Y, WUR, and PPT (p ≤ 0.033).Discussion: The somatosensory variability along with the threshold would be a more complete method to investigate the somatosensory disorders and underlying pain mechanisms. The correlation between pain duration and somatosensory variability should be studied further with different pain conditions.

Nasal Sinus Tract Associated with Dental Infection

Dear Editor: Sinus tracts of odontogenic origin are usually intraoral. However, extraoral sinus tracts associated with odontogenic infections have been reported1 and they often represent a diagnostic challenge. The occurrence of nasal sinus tract of dental origin is very rare2. We observed a case of a 58-year-old female patient who complained of a nodule in the right nostril since approximately the last 2 months. The physical examination revealed an erythematous painless nodule in the right nostril with a purulent discharge (Fig. 1A). On intraoral examination, the right maxillary incisor crown was dark in color, and there was extensive restoration due to secondary caries. The pulp vitality test for assessing the response to cold was negative, indicating pulp necrosis. Radiographically, there was a diffuse radiolucent image in the periapical region of this tooth, with disruption of the lamina dura (Fig. 1B). A nasal sinus tract associated with an odontogenic infection was the main diagnosis. Hence, nonsurgical endodontic treatment was performed for the involved tooth. After 1 week, the purulent discharge stopped completely, confirming the initial clinical diagnosis (Fig. 2). Fig. 1 (A) An erythematous painless nodule in the right nostril. (B) A diffuse radiolucent image in the periapical region of the right maxillary central incisor, with disruption of the lamina dura (cortical alveolar bone) (arrows). Fig. 2 Complete healing of the nasal lesion after the nonsurgical endodontic treatment. A sinus tract of dental origin is caused by pulp necrosis associated with bacterial infection, which causes an inflammatory lesion in the periapical region of the involved tooth1-3. This inflammatory reaction may spread to the alveolar bone, following the path of least resistance, and externalize on the oral mucosa or skin1,3. Although a nasal sinus tract of dental origin is very uncommon, this condition may occur in periapical infections from maxillary central incisors2,3. The evaluation of cutaneous fistulas must begin with thorough history taking and awareness that any cutaneous lesion on the face and neck could be of dental origin4. In maxillary teeth, the cheek is the most common site of an extraoral sinus tract originating from molars and premolars; and the nasolabial fold, upper lip, and infraorbital region are common sites of an extraoral sinus tract originating from incisors and canines. In the mandible, the submandibular region and the neck are the extraoral sites of a sinus tract originating from molars and premolars, whereas the chin and submental region are the most common extraoral sites of a sinus tract originating from incisors and canines3. Eventually, the patient's history may reveal dental pain2, but clinicians should keep in mind that most of the teeth progress to pulp necrosis without causing any discomfort to the patient5. A chronic, purulent drainage via the sinus tract also reduces the pressure and swelling and consequently, the pain3. The differential diagnosis of an extraoral sinus tract of odontogenic origin includes the other dermatoses, such as folliculitis, actinomycosis, tuberculosis, pyogenic granulomas, foreign bodies, osteomyelitis, congenital fistulas, and squamous and basal cell carcinomas1,4. Nevertheless, these cases have been misdiagnosed and treated inappropriately, mainly with recurrent unnecessary surgical procedures and antibiotic therapy1. In the present case, the initial diagnosis was an odontogenic nasal sinus tract after adequate clinical and radiographic exams. Appropriate treatment results in predictable and rapid healing of these lesions3. If there is an extra-oral sinus tract associated with dental infection, the elimination of infection through effective endodontic treatment will lead to resolution of the lesion1. Dental extraction is indicated in nonrestorable teeth3.

Anatomic variation of the facial artery and its implications for facial surgery: a case report

Abstract Introduction: Vascular variations are congenital morphological differences that arise in the human body. Although, for the most part, do not cause injury to the individual, may be important in cases where it is necessary a specific access to the vascular system. The anatomic understanding of the facial artery and its branches are especially important in the practice of medical and dental care, in the surgeries of neck and face; and also for the radiologist to understand and interpret facial artery imaging when undertaking head angiography. The variations found in the formation and trajectories of the facial artery are described, however in the case studied, we described a morphological aspect until then not documented. In this sense, the objective of this study was to report a variation of the facial artery and to analyze it in relation to the literature state of the art. Case Report: During a head dissection of an adult male human cadaver fixed in 10% formaldehyde we identified a variation of the facial artery branches. We reported, in the right hemiface, a supernumerary branch of the facial artery emerged between the origins of submentual and inferior lip arteries, close to the bottom edge of the mandible body, going towards the infra-orbital region. Discussion: The report of a considerable caliber atypical branching of the facial artery deserves attention because of the large number of interventions in this region, not only in cases of trauma, but also in cases of elective surgeries of face pathologies.

A Case of Adenomatoid Odontogenic Tumor

The patient was a girl in her teens. A panoramic radiograph revealed an impacted canine and a mixture of radiolucency and radiopacity in the right sinus. The patient was referred to the Dental Clinical Division, Hokkaido University Hospital. She had no subjective symptoms. A slight bone expansion from the base of the right ala of the nose to the infraorbital region was palpable, but no tenderness or paresthesia was noted. A CT image indicated a tumor mass shadow with fine-grained sand radiopacity contained in the impacted canine in the right sinus.The patient was pathologically diagnosed as having an adenomatoid odontogenic tumor by biopsy and underwent tumor resection. The 40 × 28 mm tumor had a capsule and contained the canine and sand granule-like hard materials. The tumor cavity was washed out with a saline solution through the bone defect formed after tumor extirpation in the anterior wall of the maxillary sinus, and the cavity was closed 1 year later. Approximately 5 years since the operation, neither relapse of the tumor nor deformation of the maxilla has been observed.

Maxillary distraction osteogenesis at Le Fort-I level induces bone apposition at infraorbital rim

The aim of this study is to evaluate whether there is any remodeling of bone at infraorbital rim following maxillary distraction osteogenesis (DO) at Le Fort-I level. Twelve adult subjects in the age range of 17-21 years with complete unilateral cleft lip and palate underwent advancement of the maxilla by DO. The effect of maxillary DO on the infraorbital rim remodeling was evaluated from lateral cephalograms recorded prior to the DO (T0), at the end of DO (T1), and at least 2-years after the DO (T2) by Walker's analysis. The ANOVA and two-tailed t test were used and probability value (P value) 0.05 was considered as statistically significant level. There was anterior movement of maxilla by 9.22 ± 3.27 mm and 7.67 ± 3.99 mm at the end of immediate (T1) and long-term (T2) follow-up of maxillary DO, respectively. The Walker's analysis showed 1.49 ± 1.22 mm and 2.31 ± 1.81 mm anterior movement of the infraorbital margin (Orbitale point) at the end of T1 and T2, respectively (P < 0.01). This apposition of bone at the infraorbital rim region further improved the facial profile of these patients. The advancement of maxilla by distraction osteogenesis at Le Fort-I level induced significant bone apposition at infraorbital rim. Patients with mild midface hypoplasia who would otherwise may be candidates for osteotomy at Le Fort-II or Le Fort-III level may benefit from maxillary distraction at Le Fort-I level.

Ethnic differences in oro‐facial somatosensory profiles—quantitative sensory testing in Chinese and Danes

Ethnic differences in pain experiences have been widely assessed in various pathological and experimental conditions. However, limited sensory modalities have been described in previous research, and the affective-motivational factors have so far been estimated to be the main mediator for the ethnic differences. This study aimed to detect the ethnic differences of oro-facial somatosensory profiles related to the sensory-discriminative dimension in healthy volunteers. The standardised quantitative sensory testing battery developed by the German Research Network on Neuropathic Pain was performed bilaterally in the infraorbital and mental regions on age- and gender-matched healthy Chinese and Danes, 29 participants each group. The influences of ethnicity, gender and test site on the somatosensory profile were evaluated by three-way anova. The ethnic disparities were also presented by Z-scores. Compared to Danes, Chinese were more sensitive to thermal detection, thermal pain, mechanical deep pain and mechanical pain rating parameters (P<0·002) related to small fibre functions. However, the inverse results were observed for mechanical tactile modality related to large fibre function (P<0·001) and wind-up ratio (P=0·006). Women presented higher sensitivity compared to men. The mean Z-scores of all the parameters from Chinese group were in the normal zone created by Danish Caucasians' means and SDs. The ethnic disparities in somatosensory profile illustrated the necessity of establishing the reference data for different ethnic groups and possibly individual pain management strategies for the different ethnic groups.

Late intracranial haemorrhage and subsequent carotid-cavernous sinus fistula after fracture of the facial bones

Carotid-cavernous sinus fistula is an arteriovenous fistula between the internal carotid artery and the cavernous sinus, and is usually caused by a traumatic tear or a ruptured aneurysm of the cavernous segment of the internal carotid artery. We describe a rare case of delayed intracranial haemorrhage and carotid-cavernous sinus fistula that presented 3 weeks after fracture of the facial bones. The patient developed orbital apex syndrome including ptosis of upper eyelid, pulsatile exophthalmos, chemosis, loss of ocular motility, monocular blindness on the right, and numbness of the right infraorbital region. After transcatheter intra-arterial embolisation, the ptosis and chemosis improved.

Cheek rotation flap reconstruction—an anthropometric appraisal of surgical outcomes

Cheek rotation flaps are an established surgical procedure for coverage of facial skin defects especially of the cheek and infraorbital region. A comparison of pre- and postoperative anthropometric measurements may help to objectify intraoperative estimations with regards to postoperative appearance. We present an evaluation of 31 patients undergoing periorbital reconstruction by a cheek rotation flap on standardized photographs based on reference anthropometric data. Analysis included intercanthal, binocular and eye fissure width, eye fissure, lid sulcus and upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, scleral show, ectropion, and canthal tilt. Furthermore, it was clearly differentiated whether the defect to cover included eyelid skin or not. Ectropion showed a significant association to surgery (p = 0.03) and time (p = 0.03). If the defect to cover included lower eyelid skin, lower iris coverage values decreased significantly (p = 0.02), meanwhile the rate of scleral show increased significantly (p < 0.01), indicating pre- to postoperative lower eyelid retraction. In all patients analyzed, indices were reproducible and reliable. An association between surgery and ectropion was detectable. Whenever lower eyelid skin is involved in the defect to be covered, the significantly decreased lower iris coverage and increased rate of scleral show indicate an increased risk of lower lid retraction. Whenever eyelid skin is involved in a defect to be covered by a cheek rotation flap, there is an increased risk of postoperative lower lid distortion. Special care has to be taken to perform techniques preventing lower lid retraction.

Cutaneous Rosai-Dorfman Disease Recurrence in Infraorbital Region

Rosai-Dorfman disease (RDD), also named sinus histiocytosis with massive lymphadenopathy, is a rare, idiopathic, and benign disorder that classically presents as a painless massive bilateral cervical lymphadenopathy. In cases of extranodal presentations, such as cutaneous RDD, it may not involve the classic manifestation. The diagnosis is usually made by histopathologic analysis. Surgery is suggested in the cases of significant cosmetic deformity or when there is fatal or functional obstruction. We reported a case of extranodal RDD that recurred in the infraorbital region postoperatively.

Dacryo salivary fistula. Unusual case of salivary fistula draining into the inferior fornix of the eye

Salivary fistula after a traumatic injury in the buccal region is not common. It is most commonly encountered in injuries involving the pre auricular region or soft tissues along the course of the parotid duct. It is more frequent in the parotid because its anatomical location is superficial; traumatic salivary fistulae of the other two major salivary glands are rare. This report presents an unusual case of a salivary fistula that occurred following trauma to the infraorbital region and drained into the inferior fornix of the left eye. A review of cases reported in the literature is presented. This is the only case of such a presentation the authors have found after a thorough search of the relevant English language literature.

Foreign body in the mid-face – An unusual case report

A 58 year old male patient visited to dental clinic with complains of inability to open mouth for the past two months. Patient had a history of accidental blast in a laboratory set up. He was treated in a hospital by general surgeons and all glass splinters were supposed to be removed at that time. The patient reported of pain in the same region from which the splinters had been removed. After thorough investigations a glass splinter was found to be lodged in infra-orbital region. This was operated and removed from the site. Clinical relevanceIt is of vital importance for professional knowledge about the possible foreign body existence on the patient's head and neck segment in order to decrease the delayed foreign body's removal due to several common misdiagnosis errors, reducing the complications that are likely to occur when foreign bodies are retained in the organism. ObjectiveForeign bodies are often encountered by dental surgeons and may present a diagnostic challenge, due to many factors such as misleading history, the difficult access and a close anatomical relationship of the foreign body to vital structures.

New radiographic sign for orbital floor fractures

Examination and comparison of OM radiographs and CT for the diagnosis of isolated orbital floor fractures in the hope of finding a new radiographic sign on plain films indicative of fracture. In a previous study there was an increased thickness in the infraorbital region on the fractured side when compared to the non injured side on plain radiographs noted. The pre-operative plain and CT films of patients who underwent orbital floor repair between January 2004 and September 2008 at JCUH were reviewed by a consultant neuroradiologist.

Distinct time courses of microglial and astrocytic hyperactivation and the glial contribution to pain hypersensitivity in a facial cancer model

Although recent evidence suggests that central glial hyperactivation is involved in cancer-induced persistent pain, the time course of this hyperactivation and the glial contribution to pain hypersensitivity remain unclear. The present study investigated the time-dependent spatial changes of microglial and astrocytic hyperactivation in the trigeminocervical complex, which consists of the medullary (MDH) and upper cervical (UCDH) dorsal horns, and pain-related behaviors in a rat facial cancer model in which Walker 256B-cells are inoculated into the vibrissal pad. In this model, the tumors grew within the vibrissal pad, from which sensory nerve fibers project into the MDH, but did not expand into the infraorbital region, from which fibers project into the UCDH. Nevertheless, mechanical allodynia and thermal hyperalgesia were observed not only in the vibrissal pad but also in the infraorbital region. Western blotting and immunofluorescence studies indicated that microglia were widely activated in the trigeminocervical complex on day 4 and gradually inactivated by day 11. In contrast, astrocytes were only activated in the MDH on day 4; the hyperactivation later expanded into the UCDH. Daily administration of the glial hyperactivation inhibitor propentofylline beginning on day 4 suppressed the glial hyperactivation on later days. Propentofylline treatment largely prevented allodynia/hyperalgesia in the infraorbital region beginning on day 5, although established allodynia/hyperalgesia in the vibrissal pad was less sensitive to the treatment. These results suggest that central glial hyperactivation, transient microglial hyperactivation and persistent astrocytic hyperactivation, contributes to the development of pain hypersensitivity but not to the maintenance of pain in this model.

Management of Delayed Infection After Insertion of Bioresorbable Plates at the Infraorbital Rim

Delayed infections after use of absorbable plates in the infraorbital region have been documented in various reports. We report 2 cases of infections at the infraorbital rim after fixation with absorbable plates: one was managed with surgical removal and one was managed with conservative treatment. We recommend that, before treatment, computed tomographic scans and cultures be obtained whenever possible. The presence of maxillary sinusitis is the single most important factor in choosing surgical removal of the plates, but the patient should be fully informed about the possibility of postoperative ectropion.

Surgical and Prosthetic Considerations to Rehabilitate an Ocular Defect Using Extraoral Implants: A Clinical Report

This clinical report shows the use of extraoral implants to rehabilitate an ocular defect, focusing the surgical and prosthetic procedures. Using local anesthesia and a surgical template obtained from the diagnostic wax ocular pattern, two cylinder dental implants were strategically placed in the lateral aspect of the right infraorbital region. Four months later, an acrylic framework including two spherical magnets was made using plastic UCLA abutments. After casting laboratory steps, a customized silicon prosthetic appliance was fabricated from the diagnostic wax ocular pattern and attached to the Co-Cr framework, observing its profile and seating aspects. The patient was satisfied with the treatment result, due to the retention, esthetics, and adhesive-free method to anchor his ocular prostheses.

The “reading man” flap in facial reconstruction: Report of 12 cases

Reconstruction of defects in the infraorbital, malar, and temporal areas after tumor resection may present problems such as distortion of anatomic points and extra normal skin removal. The "reading man" flap is a recent local flap procedure, which has been used to solve those problems. We report our experience with this procedure, which has been used for the closure of circular defects in 12 patients (7 men and 5 women), aged 68 to 86 years (mean age: 77 years), who had undergone surgical excisions of basal cell carcinomas of the temporal, malar, and infraorbital regions. The functional and aesthetical results were satisfactory in all cases. In our experience, the "reading man" flap is a useful option for the reconstruction of circular defects in these facial areas.

The versatility of lower eyelid blepharoplasty incision: In open reduction and fixation of zygomatic complex injuries

Introduction:A zygomatic complex fracture includes disruption of the four articulating sutures: zygomaticofrontal, zygomaticotemporal, zygomaticomaxillary and zygomaticosphenoidal sutures. All zygomatic complex fractures involve the orbital floor and therefore an understanding of orbital anatomic features is essential for those treating these injuries.Aims and Objectives:To analyze the efficacy and shortcomings of this approach. To evaluate the adequacy, role of tarsorrhaphy, difficulties, role of steroid in postoperative edema control in lower lid blepharoplasty approach.Materials and Methods:A total number of six patients were included in this study and all the patients were treated surgically under general anesthesia. All the patients were approached through lower eyelid blepharoplasty incision. The first skin crease in the lower eyelid region is selected for this incision.Results:All patients were administered with steroid injection. Frost sutures were placed in four cases and tarsorrhaphy was done in two patients. Three cases encountered immediate mild edema and immediate scar formation. Late scar was present only in two patients with a follow up of three months.Conclusion:Lower eyelid blepharoplasty incision is an excellent, non complicated, simple procedure in the management of fractures in the infraorbital region, orbital floor, which occurs as a part of zygomatic complex fractures.

Favre-Racouchot syndrome associated with eyelid papilloma: a case report

A 55-year-old Chinese man presented with an asymptomatic pedunculated elevation on his left lower eyelid which had been gradually increasing in size during the past three years. The patient was diagnosed with eyelid papilloma by pathological examination. Concomitantly, the patient developed open comedones with a bilateral linear distribution, along with oblique wrinkle lines in his infraorbital regions. These lesions were noninflammatory and remained unchanged for two years. To the best of our knowledge, this distribution of open comedones, especially in combination with eyelid papilloma, has not been reported previously in Favre-Racouchot syndrome.