Management Of Orbital Blowout Fractures Research Articles

Contemporary management of orbital blowout fractures

Orbital floor blowout fractures may lead to significant morbidity, including debilitating double vision and globe malposition. Thorough evaluation and timely surgical intervention may prevent long-term sequelae. New studies have demonstrated certain patients with orbital floor fractures to do well when managed conservatively. In those necessitating operative repair, precise surgical dissection and adequate fracture reduction are essential to restoring orbital anatomy and function. Novel surgical techniques and orbital floor reconstruction materials, described in this review, will further optimize patient outcomes. A knowledgeable evaluation, thoughtful management strategy and modernized surgical technique can prevent long-term disability in patients with orbital floor blowout fractures.

New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study.

Despite extensive debate and publications in the management of blowout fracture (BOF), there are still considerable differences in the surgeons' management of BOF due to a lack of reliable evidence-based studies. This article aimed to evaluate which BOF patients require surgical treatment due to functional and/or cosmetic deformities; evaluate which computed tomography (CT) scan findings predict these problems; and provide an algorithm in the management of BOF. Seventy-nine patients with BOF were treated conservatively and followed up prospectively regarding functional and cosmetic deformities for at least 1 year. The patients' CT scans were analyzed and several measurements were performed. Patients' symptoms and the clinical findings were correlated to the CT scan measurements. We found visible deformity in 37% of the patients, but only 10% chose to proceed to surgery due to cosmetic deformities. In patients with inferior BOF and a herniation < 1.0 mL, a visible deformity was found when the ratio between fracture and the fractured orbital wall areas was ≥42%, or the total area of the fracture was ≥ 2.3 cm 2 . In patients with inferior BOF and a herniation ≥ 1.0 mL, a visible deformity was found when the distance from the inferior orbital rim to the posterior edge of the fracture was ≥ 3.0 cm. In patients with inferomedial fracture, a visible deformity was found when the herniation was ≥ 0.9 mL. Diplopia improved significantly and remained in only 3% of the patients in nonoperated group. Hypoesthesia of the infraorbital nerve improved significantly, but 23% of the nonoperated and 50% of the operated patients still experienced loss of sensation at final control. In this prospective study, we found that not only herniated orbital volume but also other CT scan findings in BOF were crucial to predict late visible deformities. Based on these findings, we propose an algorithm for the prediction of late visible deformity with 83% accuracy. There are indications that diplopia without ocular motility disorder is due to edema and we recommend observation as long as the diplopia improves gradually.

The role of computed tomography (CT) in predicting diplopia in orbital blowout fractures (BOFs).

The management of orbital blowout fractures (BOFs) is controversial: the evaluation of diplopia is the most important criterion for planning whether to undertake surgery. Our aim was to determine CT findings that may suggest the presence of diplopia when patients with BOFs cannot be adequately examined to plan an orbital repair. We retrospectively evaluated CT of all patients presented to our Emergency Department for blunt craniofacial trauma (N=3334) from January 2014 to March 2016, selecting patients with CT-demonstrated BOFs. The following CT variables were assessed: fracture location, fracture multifocality, bone fragments displacement, extraocular muscles (EOM) thickening, EOM entrapment, EOM displacement, EOM hooking, intraconal and extraconal emphysema, intraconal and extraconal hematoma, and fat herniation. All patients underwent Hess-Lancaster test, to establish the presence of diplopia. After performing group comparison with Pearson χ2 test, we derived our prediction model by using logistic regression, with diplopia as the prediction and CT variables as predictors. We observed 299 patients with BOFs, 46 (15.4%) with a Hess Lancaster test-proven diplopia. The CT variables with statistically significant difference between the group with diplopia and the group without diplopia were as follows: floor fracture (p=.014), bone fragments displacement (p=.001), multifocality (p=.005), EOM thickening (p=.001), EOM entrapment (p<.001), EOM displacement (p<.001), fat herniation (p=.003). The CT variables with significance as predictors of diplopia at multivariate analysis were as follows: orbital floor fracture (p value 0.015; odds ratio 2.871, 95% confidence interval of odds ratio 0.223-6.738), EOM displacement (p value 0.001; odds ratio 10.693, 95% confidence interval of odds ratio 3.761-30.401), EOM entrapment (p value 0.001; odds ratio 11.510, 95% confidence interval of odds ratio 3.059-43.306). The presence of diplopia can be suggested on the basis of CT findings after an orbital trauma.

Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns.

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively (p = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.

Linear trapdoor or “white-eye” blowout fracture of the orbit: not restricted to children

The management of orbital blowout fractures remains controversial, particularly in patients with a white-eye or trapdoor-type injury. We report our experience with 10 such cases (mean age 19.6 years, range 4–53) and show, unlike previous reports, that this pattern of injury is not restricted to children. Although most patients had a white eye (70%), the presence of subconjunctival haemorrhage and periorbital bruising did not exclude this injury, and the patients often (60%) had serious autonomic symptoms such as nausea and vomiting. A high index of suspicion and cross-sectional imaging is required to confirm the diagnosis. Early intervention (less than 7 days) seems to be associated with better outcome, but patients benefitted from intervention up to 41 days after injury. The mechanism underlying this pattern of injury and the rationale behind early intervention is also discussed.

Management of orbital blow-out fractures

Two main patterns of orbital fractures are encountered: zygomaticomaxillary complex (ZMC) fractures and isolated orbital fractures. ZMC fractures, also known as tripod fractures, are frequently caused by a direct trauma to the zygomatic bone (e.g., with a fist, or a baseball bat) and are characterized by multiple fractures involving the inferior orbital rim, the zygomatic arch, the frontozygomatic suture and the zygomaticomaxillary suture; the orbital floor is frequently involved during ZMC fractures. The management of a tripod fracture is complex, requires a multidisciplinary approach and it is not the goal of this perspective. Isolated orbital fractures, also known as blow-out fractures, are internal fractures of the orbital floor and/or medial wall, with displacement of orbital soft tissues (fat and/or muscle) in the adjacent sinuses. This paper will focus on the pathophysiology, diagnosis and management of orbital blow-out fractures.

Late correction of complications of orbital trauma

Koornneef L: Current concepts on the management of orbital blowout fractures. Ann Plast Surg 9:185, 1982 Bartkowski SB, Krzystkowa KM: Blow-out fracture of the orbit. Diagnostic and therapeutic considerations and results in 90 patients treated. J Oral Maxillofac Surg 10:155, 1982 Putterman AM, Stevens T, Uris TMG: Non-surgical management of blow-out fractures of the orbital floor. Am J Ophthmal 76:232, 1974

Isolated orbital blowout fractures: survey and review

The management of orbital blowout fractures is controversial. The continuing debate includes the use of antibiotics and steroids, imaging, the surgical approach, and the choice of implant material for repair of the bony defect.A cross-sectional study was undertaken to assess current practice in treating orbital blowout fractures in the UK, in the form of a tick-box questionnaire. The questionnaire contained 9 closed and 2 open questions, and was forwarded to 256 practising fellows of the British Association of Oral and Maxillofacial Surgery. The response rate to the questionnaire was 73% (187/256).There was no consensus about the use of prophylactic antibiotics. However, 91% prescribed post-operative antibiotics and over half the respondents prescribed steroids. The most common imaging techniques used were computed tomography (CT, 88%) and plain radiograph (83%), 60% routinely sought an ophthalmic opinion and 65% assessed visual acuity. The most common surgical approaches were the subciliary (41%) and the infraorbital (37%), over half the respondents preferred to operate 6–10 days after the injury, and silicone elastomer was the preferred implant material of 66%.

Current concepts on the management of orbital blow-out fractures

Current concepts on the management of orbital blow-out fractures

Current concepts on the management of orbital blow-out fractures.

Surgical versus nonsurgical treatment of orbital blow-out fractures has been controversial in the past. In the 1950s it was advocated that all blow-out fractures be treated surgically based on the conception that extraocular muscles were blown out and trapped in the fracture hole, causing double vision and enophthalmos. Gradually, however, a shift to a more conservative approach occurred, probably because of the complications of surgery, the disappointing results in improvement of motility and enophthalmos, and the growing evidence of spontaneous improvement of double vision. This article analyzes the literature chronologically and blends this analysis with the results of a new anatomical approach to the human orbit. New theories on the mechanism of blow-out fractures are postulated. No longer is entrapment of muslces in a blow-out fracture held responsible for the severe motility problems; rather it is viewed as caused by a dysfunction of the entire motility apparatus in the fracture region. Consequently, conventional surgical treatment, repairing the orbital floor only, seems to have lost its theoretical foundation and a conservative approach is advocated until microsurgical techniques become more readily avaliable to treat the sequelae of blow-out fractures at their origin.