PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 25 no. 2 July – december 2010
42 PhiliPPine Journal of otolaryngology-head and neck Surgery
FEATURED GRAND ROUNDS
Orbital wall fractures result from external impact injuries which cause an abrupt increase
in intraorbital pressure.1 Patients usually present to the emergency room with periorbital
swelling and limited eye movements, with or without changes in vision. Relatively common in
the Philippines, these fractures are frequently caused by violent assault followed by vehicular
accidents involving motorcycles.2 Among 119 maxillofacial trauma cases seen and treated by the
Department of Otorhinolaryngology of the East Avenue Medical Center from 2008-2009, 42 were
diagnosed as cases of orbital fractures with 36% having concomitant involvement of the orbital
floor. Various techniques in diagnosis and treatment developed in the past 20 years, each having
its own strengths and weaknesses. The challenge of choosing which among these methods will
best achieve the goals of function and aesthetics always confronts surgeons particularly in a
developing country setting.
We present a case of bilateral orbital floor fractures with diplopia repaired with conchal
auricular cartilage graft in a 22-year-old female.
CASE REPORT
A 22-year-old female was immediately brought to our emergency room following a head-
on collision with an Asian utility vehicle while driving a motorcycle without a helmet. She was
conscious and coherent with stable vital signs.
On examination, contusion hematomas were noted over both periorbital areas. Visual acuity
was 20/30 OD and 20/40 OS with bilateral limitations of extraocular muscle movement. Bilateral
ocular pressures were measured at 14.6 mmHg. Craniofacial CT Scans revealed linear frontal
bone fractures with subdural hemorrhages and pneumocephalus in the frontal area, fractures
of the calvarial bones, lateral orbital walls, inferior orbital rims and orbital floors (Figure 1). A
mannitol drip was started for the hemorrhage.
She developed a persistent headache and binocular vertical diplopia with monocular
diplopia, OS on left gaze accompanied by pain on lateral left duction. Visual acuity was 20/25
OU. On the 17th hospital day, she underwent open reduction and internal fixation of multiple
facial fractures using titanium plates and screws with reconstruction of both orbital floors using
conchal cartilage autografts. The right eye diplopia resolved on the third postoperative day while
the diplopia on left lateral downward gaze in the left eye resolved from the ninth postoperative
day until the day of discharge.
There was complete resolution of diplopia and improvement in visual acuity to 20/20 OD and
20/25 OS on follow up at one year.
DICUSSION
Orbital floor fractures are relatively common midfacial injuries encountered in urban areas2
and were first described by Smith and Regan in 1957.1 Since then, many articles have been written
about their diagnosis and treatment, including indications and optimal time for surgery as well
as optimal surgical methods.1 Epidemiological studies reveal that despite different settings, the
majority of cases involve the young male population with violent assault as the most prominent
etiology accounting for 37.8% of orbital blowout fractures; motor vehicle accidents came in
at second with 17.6%.; with the remaining fractures resulting from athletics (14.1%).2 To our
Orbital Floor Fracture Reconstruction Using
Conchal Auricular Cartilage Graft
Rubiliza DC. Onofre, MD
Rene Louie C. Gutierrez, MD
Department of Otorhinolaryngology
Head and Neck Surgery
East Avenue Medical Center
Diliman, Quezon CIty, Philippines
Correspondence: Rubiliza DC. Onofre, MD
Department of Otolaryngology Head and Neck Surgery
6th floor East Avenue Medical Center
East Avenue, Quezon City 1100
Philippines
Phone: (632) 928 0611 loc 324
Fax: (632) 435 6988
E-mail: yukito8211@yahoo.com
Reprints will not be available from the author.
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere, in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each author, and that each
author believes that the manuscript represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest. Philipp J Otolaryngol Head Neck Surg 2010; 25 (2): 42-45 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 25 no. 2 July – december 2010
FEATURED GRAND ROUNDS
PhiliPPine Journal of otolaryngology-head and neck Surgery 43
are those in which the inferior orbital wall is completely separated from
its original position and the periorbital tissue has prolapsed into the
maxillary sinus1 (Figure 2). These fractures can be also be classified by
location: anterior, posterior and anteroposterior1,4 (Figure 3). Our patient
presented with non trapdoor type orbital floor fractures measuring 10 x
4 mm on the right and 10 x 5mm on the left.
Patients with orbital floor fractures often complain of blurred vision
and pain on eye movement. Physical examination also elicits diplopia,
accompanying limitation of eye movement and enophthalmos on
the affected side. These signs and symptoms are due to (1) herniation
of orbital contents with concomitant partial atrophy of extraocular
muscles and to (2) an increase in the volume of the orbital cavity with
possible compression of the optic nerve.4 Because of these features,
orbital floor fractures are classified as both Otorhinolaryngologic
and Ophthalmologic emergencies that warrant immediate surgical
treatment especially if the patient presents with blurred vision.3,5
Confirmatory imaging studies help locate and assess the extent
of orbital floor injury. These include radiographs and computed
tomography of the facial bones. The commonly used radiograph is the
chin-to-nose or Water’s view. This gives a view of the whole orbital area
and may reveal a pathognomonic “tear drop” sign, seen as an elliptical
opacity underneath the inferior orbital rim, that represents orbital
contents, usually orbital fat, that herniated through the fracture.1,3
However, facial computed tomography is still the most useful imaging
tool in assessing orbital floor fractures.1,2,3,4 It is usually requested without
contrast using 3 different cuts: coronal, axial and sagittal. Coronal cuts
reveal discontinuity of the inferior orbital rims with concomitant soft
tissue sublaxation; axial cuts present the extent of areas involved
while sagittal cuts help locate if the fracture is anterior, posterior or
anteroposterior.1,4
A
B
Figure 1 A and B. Craniofacial CT scan, coronal sections, revealing fractures of (A) calvarial
bones and (B) inferior orbital rims and orbital floors
knowledge, local reports have not been published but similarities in
profile can be deduced.
Orbital floor fractures, also known as blowout fractures, imply that
the orbital rims have remained intact, whereas one or more walls of the
orbit, typically the floor has fractured.3 Orbital floor fractures can be
classified into pure and impure according to extent of bone involvement
(Table 1). Pure blowout fractures are fractures of the floor not involving
the rim while impure blowout fractures have rim extension.3 Pure
orbital floor fractures are further classified as trapdoor or non-trapdoor.
Trapdoor fractures are those in which either edge of the inferior orbital
wall is attached to its original position, while non-trapdoor fractures
Table 1. Comparison of Pure Versus Impure Blowout Fractures
Pure Blowout Fractures Impure Blowout Fractures
- Fractures involving the orbital floor without extension
to the inferior orbital rim
- Can be classified as trapdoor or non-trapdoor
- Fractures involving the orbital floor
with extension to the inferior orbital
rimTrapdoor fractures* †
- One edge of the orbital
floor is attached to its
original position
- Periorbital contents may
or may not be prolapsed
into the maxillary sinus
- Common among
anterior orbital floor
fractures
Non-trapdoor fractures* †
- Orbital floor completely
separates from its original
position
- Periorbital contents prolapsed
into the maxillary sinus
- Common among posterior
orbital floor fractures
* Kwon, JH. Kim, JG. Moon, JH. Cho, JH. Clinical analysis of surgical approaches for orbital floor fractures. Arch Facial
Plast Surg. 2008 Jan-Feb;10(1):21-24
† Jin HR, Yeon JY, Shin SO, Choi YS, Lee DW. Endoscopic versus external repair of orbital blowout fractures. Otolaryngol
Head Neck Surg 2007 Jan; 136(1):38-44
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 25 no. 2 July – december 2010
44 PhiliPPine Journal of otolaryngology-head and neck Surgery
FEATURED GRAND ROUNDS
Figure 2. Illustration of fracture classification according to attachment of fragments in
reference to original position; Trapdoor and nontrapdoor fracture
Figure 3. Illustration of fractures classified according to location; anterior and posterior
fractures
advantages over conventional external repair. These include excellent
visualization of the medial and inferior walls of the orbit; easy access
to maxillary bone (avoiding or minimizing use of intraocular alloplastic
implants); virtual elimination of significantly visible facial scarring
and eyelid complications; and performing the procedure under local
anesthesia, making intra-operative evaluation of ocular movements
and diplopia possible.5,6 A transorbital approach has the advantage of
releasing incarcerated orbital tissue, while, in contrast, simply lifting
the orbital tissue upward in a transantral approach may aggravate
the incarceration1 (Table 2). In this patient, the open approach was
used because a mid-facial de-gloving was necessary to access other
fractures.
The repair of orbital floor fractures involves many techniques,
and adequate knowledge and skill is needed to perform any of these
techniques employing careful judgment and analysis in formulating a
plan that will fit the patient’s needs. As a general principle, the orbital
complex is reconstructed by aligning its fractured parts with adjacent
stabilized or intact structures.10 Familiarity with the complex shape
of the orbital walls is important in repair. In the case of the orbital
floor, it gently concaves inferolaterally, turning convex medially to
posteriorly, assuming an S-shape configuration. 1,3 The posterior part
of the floor is farthest from the inferior orbital rim with the infraorbital
nerve coursing thru it makes it vulnerable and weak to the extensive
forces absorbed when applied into the orbital area.1,3,10 This explains
why posterior orbital floor fractures occur as non-trapdoor types and
are difficult to expose. The orbital contents are positioned accurately
and precisely into the orbit making any change in volume affect eye
function. It is important to assess eye function first as it may give the
examiner an idea of the extent of injury to the orbital floor. Indications
for repair include diplopia, nonresolving oculocardiac reflex with
entrapment (bradycardia, heartblock vomiting, nausea and syncope),
fracture involving >50% of the orbital floor, and early enophthalmos
or hypoglobus causing facial asymmetry.11 These signs and symptoms
elicited during physical examination with documentation of the
location of fracture through diagnostic imaging warrant early repair
since herniated soft orbital tissue can atrophy within 2-3 weeks post
trauma.4
The types of grafts/implants used to span the defects of orbital floor
fractures are divided into alloplastic and autogenous implants7 (Table
3). Autogenous grafts include bone, cartilage, and fascia. Alloplastic
implants can be divided into nonabsorbable types, such as those
made of silicone, polytef, hydroxyapatite, tantalum mesh, or titanium,
and absorbable types, including those made of polyglactin or gel film.
Repair of the orbital floor defect is mandatory if the defect measures at
least 50% of the size of the orbital floor bone. The ideal implant must
be nonreactive, provide good structural support, be easily positioned,
and be readily available.1,2,3,4 In this case the surgeon utilized conchal
cartilage grafts. This graft can be used in repairing defects as large as
The goal of surgical repair in orbital floor fractures is two-fold: to
reposition herniated orbital fat and tissue back in the orbit; and to
reconstruct the traumatic defect.4 Approaches are via open surgery
(subciliary or transconjunctival) or endoscopic (transantral), (Table 2).
The open transorbital approach is currently regarded as the mainstream
method for reduction of blowout fractures of the inferior orbital
wall. It is useful for releasing incarcerated soft tissue, as dissecting
all soft tissue around the fracture area is necessary.1 Post operative
complications include ectropion and unsightly scars, but these rarely
occur in the hands of experienced surgeons.5 Endoscopic repair,
usually via a transantral approach, can provide surgeons with several
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 25 no. 2 July – december 2010
FEATURED GRAND ROUNDS
PhiliPPine Journal of otolaryngology-head and neck Surgery 45
* Kwon, JH. Kim, JG. Moon, JH. Cho, JH. Clinical analysis of surgical approaches for orbital floor fractures. Arch Facial
Plast Surg. 2008 Jan-Feb;10(1):21-24
† Jin HR, Yeon JY, Shin SO, Choi YS, Lee DW. Endoscopic versus external repair of orbital blowout fractures. Otolaryngol
Head Neck Surg 2007 Jan; 136(1):38-44
Table 2. Comparison Between Open Versus Endoscopic Approaches in the Repair
of Orbital Floor Fractures
Approach Endoscopic Surgery
Site of surgical incision
Advantages
Disadvantages
Complications
Transorbital or subcillary
- useful in releasing incarcer-
ated inferior orbital wall and
periorbital contents
- can provide better visualization
of anterior fractures
- ideal for anterior, trapdoor
orbital floor fractures *
- need for extensive dissection
of surrounding soft tissues for
proper placement of graft for
reconstruction
- difficulty in identifying and
exposing fractures located
at the posterior region of the
pyramidal shaped-orbit
-excessive dissection for good
exposure of posterior orbital
floor fractures may lead to optic
nerve damage
- can cause injury to posterior
orbital tissue or muscle when
graft place in a poorly exposed
and dissected area
Ectropion, visible scars
Open Surgery
Transantral
- provide excellent visualization of medial
and inferior walls of the orbit enabling
safe removal of bony fragments
- use of endoscope minimizes or eliminates
visible scars
- can be performed under local anesthesia
making intraoperative assessment of
extraocular movements and diplopia
possible †
- easy access to the maxillary bone for
possible graft source for reconstruction
minimizes use of allosteric grafts
- provide better exposure of the posterior
orbital floor fractures
- ideal for posterior non-trapdoor orbital
floor fractures
- use of the approach may not fully release
incarcerated orbital contents
- simply lifting of the orbital tissue upward
with this approach can aggravate
incarceration
- needs to be combined with transorbital
approach for safe implantation of graft
material into the inferior orbital floor
Infection, optic nerve damage *
Table 3. Type of Grafts Used in Recontruction of Orbital Floor Fractures
Autogenous Grafts
Include bone, cartilage, and fascia
Advantages :
-readily available
-cheap
Disadvantages:
- easily undergo resorption except for
cartilage grafts
- need for blood supply for nourishment
- increase morbidity to the patient since
harvesting the graft would produce another
surgical site
Divided into non absorbable (silicone, polytef,
hydroxyapatite, tantalum mesh, or titanium) and
absorbable (polyglactin or gel film)
Advantages:
- do not undergo resorption
- do not need blood supply for nourishment
Disadvantages:
- Costly
- Can cause infection
- Can extrude from the surgical site
Alloplastic Grafts
2 x 2mm. It advantages over other autogenous grafts include having
a shape similar to the orbital floor, ease of harvest, malleability and
limited morbidity at the donor site.4
Autogenous tissue grafts, i.e. bone or cartilage, are preferred over
alloplastic grafts in the repair of isolated orbital fractures similar to this
case.10 Grafts (especially bone) should be secured to avoid displacement
or migration and improve graft survival. Complete dissection of the
fracture is necessary to identify the intact bone on all sides of the
fracture since these will be used for alignment when placing the graft.
In the case of an orbital floor fracture, the posterior portion of the intact
bone will serve as a guide to internal orbital reconstruction. The graft
should be placed in inclined position just behind the inferior orbital
rim to reach the intact posterior bone.3,10 Placing the graft based on
correct anatomic position during reconstruction is of more significance
than using globe position as a basis in volume restoration.10 It is a
must to perform duction tests following graft placement and compare
these to baseline duction tests prior to surgery.9,10 This will help the
surgeon distinguish if the stiff duction test is caused by edema from
impingement of the musculofibrous ligament system by the graft
material.10
ACKNOWLEDGMENT
The authors would like to thank Dr Natividad Almazan and Dr. Felix Nolasco for their
encouragement and support; and the resident doctors of the Department of ORL-HNS for their help
in making this paper.
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