Endoscopic endonasal reduction for blowout fracture of the medial orbital wall

Endoscopic endonasal reductions have been addressed in 63 patients with blowout fracture of the medial orbital wall since 1992. The operations were carried out under general anesthesia with a magnified operative space projected on a television monitor by a charge coupled device video camera attached to the endoscope. The middle nasal turbinate was fractured toward the nasal septum, the uncinate process was cut off, and the bulla was opened. The ethmoidal bony partition and the mucous membrane were removed; however, the fractured bone chips of the medial orbital wall were preserved. The herniated orbital contents were pressed back into the orbital cavity, and the medial wall was set with 2-mm-thick bent silicone plates placed in the ethmoidal sinus. The plates were removed in the outpatient clinic 2 months after the operation. The surgical results of 21 patients treated with endoscopic reduction were compared with those of four patients treated with transfacial reduction with an iliac bone graft. All of the patients had isolated medial wall fracture and became aware of diplopia within 15 degrees in any direction from the primary position (straight gaze) before the operation; the follow-up period covered 6 months. The patients were classified into two categories according to postoperative double vision: "good," indicating no double vision or diplopia of more than 45 degrees, and "poor," diplopia of less than 45 degrees. Improvement of diplopia was observed in all patients without any complication. Of the 21 patients who underwent endoscopic reductions, 17 were classified as "good" and four as "poor." On the other hand, of the four patients who underwent transfacial reductions, three were classified as "good" and one as "poor." Significant differences were not observed between the surgical results of our two methods. Endoscopic endonasal reduction showed greater aesthetic advantages and, moreover, required no grafting. This technique is suggested as one of the most reasonable treatments of medial orbital wall fractures.     

Blowout fracture of the medial orbital wall, with entrapment of the medial rectus muscle.

A case of fracture of the orbital wall, with entrapment of the medial rectus muscle and paresis of the 6th nerve in association with a large fracture of the orbital floor, is presented. The diagnosis was made primarily by the forced duction test.     

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.     

Cell wall invertases from apex and callus tissues of sugar cane

Calluses were obtained from the stalk apex of sugar cane. Boththe stalk apex and callus tissues possessed firmly bound cellwall invertases. The invertases of each tissue were characterizedon the basis of their Km, optimum pH and the action of variousinhibitors. According to this characterization, the two tissuespossess different isoenzymes. Taking into account the presentisoenzymes and the known cell wall invertases from stalk tissue,we postulated a different pattern of isoenzymes for each organof the sugar cane. These differences suggest that the cell wallinvertases might be used as markers in studies of tissue differentiation. (Received May 27, 1980; )     

Cell wall invertases from apex and callus tissues of sugar cane

Calluses were obtained from the stalk apex of sugar cane. Boththe stalk apex and callus tissues possessed firmly bound cellwall invertases. The invertases of each tissue were characterizedon the basis of their Km, optimum pH and the action of variousinhibitors. According to this characterization, the two tissuespossess different isoenzymes. Taking into account the presentisoenzymes and the known cell wall invertases from stalk tissue,we postulated a different pattern of isoenzymes for each organof the sugar cane. These differences suggest that the cell wallinvertases might be used as markers in studies of tissue differentiation. (Received May 27, 1980; )     

Reconstruction of orbital wall fenestrations with polyglactin 910 film

Medial orbital wall fenestrations were created bilaterally in 16 adult cats. The fenestrations were reconstructed with polyglactin 910 film, Dacron-reinforced silicone sheeting, or no implant. Polyglactin 910 was found to be well tolerated in this traumatized area of paranasal sinus bone and soft tissue and was totally absorbed in 4 months. Dacron-reinforced silicone sheeting induced a long-standing acute inflammatory reaction in a similar milieu. Partial osseus replacement of the orbital fenestrations occurred in all animals, but it was accompanied by distortion and erosion in apposition to the silicone sheeting. The study does not answer the question of whether orbital contour will be maintained on a long-term basis adjacent to a pneumatized sinus following reconstruction with a bioabsorbable implant.     

Reconstruction of orbital floor fracture using solvent-preserved bone graft

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.