Endoscopic, endonasal management of fractures of the medial orbital wall
It is well known that fractures of the orbital floor are more frequent than those of the medial wall. The reason is that the most delicate part of the orbit is the lamina papyracea. High resolution CT has helped make this diagnosis more precise and permit
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Endoscopic, endonasal management of fractures of the medial orbital wall
It is well known that fractures of the orbital floor are more frequent than those of the medial wall. The reason is that the most delicate part of the orbit is the lamina papyracea. High resolution CT has helped make this diagnosis more precise and permits us visualize the region surrounding the lamina papyracea with greater detail. Conventionally, fractures of the medial orbital wall have been corrected with transorbital techniques through an external incision and a maxiloethmoidal approach. An orbital fracture with lesions of the delicate intraorbital structures can be a complication of endoscopic paranasal sinus surgery when previous procedures have changed the patient's anatomy, or when the surgeon is not adequately trained and fails to realize he has entered the orbit. The use of motor driven instruments may also cause complications with devastating damage to this area. Endoscopic, endonasal approaches for the reconstruction of the medial orbital wall and the orbital floor using a computer assisted imaging navigational system is a great help, and it eliminates the external skin incision.
Objective To reduce the anatomical and functional defect of the orbital content caused by the trauma, and if necessary, to free any extraocular muscles that are trapped among the bone fragments.
Indications Limitations of ocular movement secondary to entrapment, or hernia of intraorbital soft tissue (fat, muscles and periorbital tissue), displaced bone fragments within the orbit that compress delicate structures, enophthalmus greater than 2 mm, blow-out structures of the medial wall and orbital floor (Fig. 1-4).
Fig. 1. Fracture of the medial orbital wall. Three dimensional model created by computer generated images of a patient with a fracture of the medial orbital wall after Functional Endoscopic Sinus Surgery (FESS). Note the asymmetry of the orbit and the left enophthalmus
C. Yañez, Endoscopic Sinus Surgery © Springer-Verlag/Wien 2003
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Endoscopic, endonasal management of fractures of the medial orbital wall
Instruments 0° and 30° 4 mm endoscopes. Double ended 190 mm (7.5") 2.6 mm ballpoint probe with a 90° angle (for the maxillary sinus) with a cutting end on one of its borders, and a 195 mm (7.625") probe with a 90° end (for the frontal sinus), retrograde cutting forceps, straight Weil-Blakesley clamp, 3 mm curved aspiration cannula, Freer elevator, and a Hoz knife. An XPSTM 2000 Microdebrider with a Straightshot™ Magnum™ with a 3.5 mm Tricut™ blade and a 4 mm curved RAD 40™ blade at 1500-3000 RPM (Xomed, Jacksonville Fla. USA).
Procedure Realize an infundibulectomy, ostiumplasty and ethmoidectomy according to the previously described techniques until reaching the lamina papyracea where the fracture is located. Remove the fragments, the lamina papyracea, as well as any adhered, fibrous tissue very carefully; pushing the orbital content laterally into the orbit with a blunt instrument (Fig. 5). Once the defect has been reduced, place a Si
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