Abstract

Purpose: Orbital fractures continue to be a prevalent and common problem encountered in maxillofacial trauma. The surgical management of orbital floor fractures has traditionally involved repairing the orbital floor through either a transcutaneous or a transconjunctival approach. These approaches have been fraught with lower lid complications such as ectropion, entropion and lower lid shortening. The purpose of this study was to evaluate a relatively new surgical approach to the repair of orbital floor fracture by avoiding incisions in the lower lid. This procedure involves repairing the floor through an intra oral incision via the maxillary sinus. With this transantral endoscopic approach the floor integrity is restored from below. Following the proper bony reduction, a biodegradable lactic acid polymer plate is inserted from below to maintain the floor reduction until bone healing has occurred.

Method: Transantral endoscopic repair of orbital floor blowout fractures was performed on twenty patients that presented to our Level I trauma center after sustaining direct trauma to the periorbital area. The patients were mostly male, all over the age of 18, and all presented with large isolated orbital floor blowout fractures. Patients were diagnosed through initial evaluation with history and physical exam and preoperative high resolution CT scans. All patients were repaired endoscopically through a transmaxillary sinus approach with placement of an absorbable polymer implant. All patients received follow-up with clinical exams and CT scans at one month, three months, and six months.

Results: Throughout the last two years, our technique has been modified to ensure reproducible, safe results. The floor defect in our patient population measured on average 25mm by 10mm as calculated from coronal and sagittal CT scans. Pre-operative orbital volumes on the fractured orbit were found to be greater than on the contralateral normal orbits. Postoperative CT scans revealed that the orbital volumes on the fractured orbit were restored and closely equaled the volumes of the normal orbits. Enophthalmus was corrected in all patients. Complications reported include transient anesthesia in the infraorbital nerve dermatome and plate malposition requiring re-operation. We converted one endoscopic approach to an open approach due to the extraordinarily large size of the fracture involving the entire floor.

Conclusion: Endoscopic transantral repair of large pure orbital floor fractures is safe and effective. There are several advantages of endoscopic repair over the traditional approaches. This minimally invasive technique allows the restoration of proper orbital volumes avoiding under correction and the possibility of residual postoperative enophthalmos without injury to the lower lid.