Fractures of the upper 1/3 of face Flashcards
What is hypertelorism and how is it classified?
IOD (dacryon to dacryon) >29mm. Tessier classification, by IOD. Mild 30-34, Moderate 35-40 Severe >40
What is telecanthus?
ICD (medial canthus to medial canthus) >35mm. Normal ICD 33-35 or 1/5 width of face
What is ophthalmoplegia?
Paralysis of one or more EOM
What is pseudoptosis?
Excess of upper lid skin but normal lid to pupil distance
Describe the development of the frontal sinus
Absent at birth Forms from lining of ant.ethmoid air cells at 2yo Pneumatization begins at 6yo (visualized on radiograph) Completed development at 10-12yo
What is the venous drainage of the FS?
1- Diploic veins of Breschet (drain into dural veins) 2- Angular facial veins
What is the mucous drainage of FS?
1- into Anterior ethmoid toward middle meatus (75%) 2- into NF duct toward middle ethmoid below the middle meatus (25%) Ostium is in the posteriomedial floor of the FS
Describe the development of the maxillary sinus.
Present and pneumatized at birth Develops until puberty
What teeth roots can penetrate into the maxillary sinus?
1st & 2nd premolars 3rd molar
What is the mucous drainage of the maxillary sinus?
Middle meatus
What are the boundaries of the ethmoid sinuses?
1- Lateral: Lamina Paprycea 2- Midline: Ethmoid plate 3- Posterior: Sphenoid
What are the boundaries of the sphenoid sinus?
Within the body of the sphenoid
What is the shape of the orbit?
Pyramidal The base is lateral and inferior relative to the apex
What bones form each wall of the orbital cavity?
Roof: Frontal, Sphenoid lesser wing Lateral: Frontal, Zygoma, Sphenoid Greater wing Medial: Maxilla, Sphenoid Body, Lacrimal, Ethmoid Floor: Maxilla, Zygoma, Palatine
What forms the posterior shelf of the orbital cavity?
The palatine bone
What is the conus of the orbit?
Musculofascial system containing the EOM and fascia
What is in the intraconal space?
NO muscles!!!
Ophthalmic artery
superior orbital vein
CN 2
CN 3
CN 4
CN 6
CN 5 V1 nasociliary br
What is in the extraconal space?
Lacrimal gland
Lacrimal sac
Fat
Superior ophthalmic vein (posterior br)
(All contents are between the conus and the orbital cavity)
What are the contents of the infraorbital fissure?
CN5 V1 (Zygomaticofacial, Zygomaticomaxillary)
CN5 V2 (Infraorbital)
Infraorbital artery
Inferior ophthalmic vein
What are the contents of the superior orbital fissure?
CN 3
CN 6
Intra conal above - Extra conal below
CN 4
CN 5 V1 lacrimal, frontal branches
Parasympathetic nerves to pupil
Superior ophthalmic vein
What are 3 clinical findings of Enophthalmus
1- Narrowed palpebral fissure
2- Pseudoptosis
3- Deepened Upper lid sulcus
How can you objectively measure enophthalmus (2)?
1- Helter exophthalmometer (measure from lateral orbital rim to anterior cornea)
2- Forward traction test (pull bulbar conjunctiva to try and anteriorly displace globe)
What causes enophthalmus?
1- increased orbital volume
2- decreased orbital contents
3- globe retraction
What is clinically significant orbital volume change?
3.5cc volume change = 3mm displacement
13% volume change = 3mm displacement
How do you manage enophthalmus?
1- Restore VOLUME (reconstruction with alloplast/autologous)
2- Release RETRACTING tissues
Why do we recommend no noseblowing post-op facial fractures involving orbit?
Tension Pneumo-orbit = Orbital compartment syndrome
= compression of CROA
*air enters via maxillary sinus (floor) and anterior ethmoid (medial wall)
Describe anatomy of medial canthal tendon
3 limbs
- anterior: attaches to anterior lacrimal crest
- Posterior: attaches to posterior lacrimal crest
- superior: attaches at frontomaxillary juncture
MCT is continuous with tarsus LCT
Describe anatomy of lateral canthal tendon.
2 limbs
- deep STRONG limb: inserts into whitnall’s tubercle (posterior along orbital rim)
- superficial weak limb: inserts onto orbital rim
What is red saturation test
Sensitive test for visual acuity. Show bright red object to each eye and see if different brightness of red
What are signs of globe rupture?
- pupil shape abnormality (tear drop, cat eye)
- Fat herniation from globe
- subconjunctival hemorrhage
- hyphema
- flat anterior chamber
What determines pupil shape?
Sympathetics CN5- pupil constriction
Parasympathetics CN3 - pupil dilation
What is normal IOP?
10-20mmHg
What are principles of corneal protection?
INDICATIONS FOR PROTECTION
- CN7 dysfx
- Chemosis
- lid injury
TREATMENT
- tobramycin or garamycin ointment and occlusive dressing
- tarsorrhaphy
How do you manage a suspected globe rupture
Assessment
- ophtho
- shield eye
- NPO
- do no dilate eye, do not measure IOP
What is a complication of globe rupture?
SYMPATHETIC OPHTHALMIA = BILATERAL GRANULOMATOUS UVEITIS
- purulent uveitis 2’ immune reaction to choroid antigens, leads to immune reaction to contralateral eye => bilateral blindness
What is Traumatic Optic nuropathy (TON)
Loss of visual acuity secondary to trauma
- no evidence of external injury and normal initial ophtho asx.
What are causes of TRaumatic optic neuropathy (TON)
1- Trauma to CN2 (shear force, compression, iatrogenic)
2- Ischemia of CN2 (edema, hemorrhage)
How do you manage Traumatic optic neuropathy?
Methylprednisolone x48hrs
What are indications for operative Tx of TON (with decompression of optic canal)?
1- Drop in VA over 48hrs and <20/800??
2- CN2 sheath hematoma
3- compression of CN2 with bone fragment
4- Post-op TON
What is superior Orbital fissure syndrome?
Compression of contents of SOFissure
CN3 + parasympathetics, CN4, CN6, Cn 5 branches (lacrimal frontal)
Superior orbital vein
Where is the superior orbital fissure?
Sphenoid bone
Where is orbital canal
Sphenoid
What are clinical features of SOFS?
- ophthalmoplegia
- ptosis
- dilatation of pupil
- loss of corneal sensation
- loss of forehead sensation
How do you manage SOFS?
Same as TON
Methylprednisone x48hrs
Operative indications
- post-op
- bone fragment causing compression
- hematoma as cause
What is orbital apex syndrome
SOFS with CN2 involvement:
+ decreased visual acuity
+ RAPD
How to you surgically treat retrobulbar hematoma
1- release sutures
2- lateral cantholysis
3- lateral inferior canthotomy
4- Drainge of hematoma from upper and lower lid sutures
How do you treat post-op RB hematoma compared to post traumatic RB hematoma
Post-op RM hemetoma:
- cantholysis/canthotomy, to OR for decompression
Post- trauma (F#) RB hematoma
- treatment aims to reduc IOP - less likely to benefit because injury has already occured
What is oculocardiac reflex>
ANS drive symptoms secondary to orbital injury and compression of V1
- bradycardia
- syncope
- nausea
How to do treat OCR in kids?
Atropine (block parasympathetics
Urgent orbital exploration and reduction
How to you classify diplopia?
By CAUSE
1- Mechanical
- entrapment of IO/IR, Tenon, Lockwood
- Change in EOM shape/length (enopthalmus/dystopia)
2- NON-MECHANICAL
- nerve injury
- muscle injury
- preexisting phoria
How do you manage diplopia
1- Non-op: prisms corrective wear
2- Operative: strabismus surgery: 6-9m post surgery. resection/recession/transposition
What is progrosis of diplopia if untreated?
50% resolved
25% resolve delayed at 6wks
25% unresolved
How to you manage hyphema
- shield eye!!!!!!!!!!!!!!!!!! (hurts to accomodate pupil)
- HOB up
- bed rest
Where is the canaliculis?
2mm vertical and 8mm horizontal from punctum
How do you treat canaliculi injury?
If both injured, repair one w crawford tube to stent it open
Dacrocystorhinostomy to restore flow from sac to inferior meatus
What are clinical features of Frontal sinus F#?
- post-nasal drip
- forehead pain, swelling, bruising
- periorbital swelling, bruising, subconj hemorrhage
- paresthesias V1
How do you classify FSF#?
1- Location : anterior or posterior table
2- Displacement: displaced by >1width of table, comminution
3- CSF leak: presence of absence
4- NFD involvement: yes or no
WHat are indictions for operative treatment of Frontal sinus F#
1- NFD injury (usually associated with NOE)
2- Persistent CSF leak >72hrs
3- Displacement of posterior table
4- Displacement of anterior table and contour deformity
5- Open F#
What are indications for non-operative tx of frontal sinus F#?
1- medically unfit
2- anterior and posterior table displaced but no csf leak
3- minimally displaced anterior table
4- Option for secondary recon for contour
What are the operative treatment options for FSF# if NFD is involved vs. not?
1- FSF with no NF duct involved - ORIF frontal bone
2- FSF with NF duct involved - obliteration of FS (mucosal exenteration, NFD obliteration) and ORIF frontal bone
What are indications for cranialization?
FS# with CSF leak 2’ posterior wall involvement
Describe the steps of cranialization
1- Neurosurgery consult and OR presence
2- ORIF anterior table
3- FS obliteration (mucuosal exenteration, NFD ostium obliteration)
4- Removal of posterior table and repair of dural tears
What materials can be used for obliteration of NFD ostium?
1- Autgenous:
Vascularized: pericranial flap
Graft: fat, fascia(TPF), cancellous bone ,muscle (temporalis)
2- Alloplastic
Bone cement, PMMA with titanium mesh?
What are complications of a FSF#?
EARLY
- BONE: contour deformity, lose hardware, resorption)
- INFECTION: OM, encephalo/meningitis, sinusitis, wound infection
- NERVE: injury to SON, anosmia
- CSF leak
LATE
- INFECTION: mucocele (closed mucosa), mucopyrocele (infected), chronic frontal sinusitis, frontal OM (potts puffy tumor)
What is management of a mucopyrocele
Emergent Evacuation
Antibiotics
removal of hardware
Reconstruction to seperate nasal cavity and orbital cavity/crnaial cavity
Why is mucopyrocele an emergency?
Can lead to abscess of brain/subdural/epidural/meningeal
What are signs and symptoms of CSF rhinorrhea
- clear leak when SITTING FORWARD
- POSTURAL HEADACHE
- ANOSMIA
what are investigations for determining presence of CSF leak?
- positive Beta trasnferrin
- halo sign (blood centrally and clear fluid ring around)
How do you manage CSF leak?
Non-operative
Conservative for 72hrs
- HOB at 30’, prevent nausea, hypertension
If no resolution at 3-5days, lumbar drain
Operative
- dural patch
Indications for operative repair of CSF leak
- failure conservative management
- large displaced fragment of bone. penetrating injury
- large pneumocephalus
- meningitis despite abx
What is the pathophysiology of orbital compartment syndrome?
1- SOL (retrobulbar hematoma) or other lesion (abscess) increasing pressure in closed spcae (orbital septum and canthal tendons)
2- compensatory proptosis
3- RESULT - CRA compression
What are clinical features of orbital compartment syndrome?
- PAIN
- proptosis
- decrease function of CN2 (VA, visual field, APD)
- IOP>30mmHg
Managmeent of a RB hematoma
Acetazolimide 500mg IV x1 then 250mg IV q6h
Timilol 0.5% 1gtt affected eye BID
Methylprednisone 1000mg IV x1
Mannitol 1-2g/kg IV over 30-60mins
analgesics
+/- canthotomy
What are operative indications for RB hematoma?
- in awake patient: acute VA loss
- if not awake: proptosis, IOP>40mmHg +/- RAPD
How do you classify obital floor f#
Blow out: pure (rim intact) vs impure (rim injured)
Blow in
Why do all orbital F# require ophtho consult?
30% or orbital fracture have ocluar injury
Describe OR sequence for Orbital floor f# repair
1- optho pre-op consult
2- forced duction pre-post
3- temp tarsorrhaphy then confirmer
4- release and elevation of periorbital tissue
5- ORIF rim
6- Recon orbital cavity
What are options for recon of orbital floor
Alloplastic
- titanium mesh
- pmma
- MEDPOR TITAN (high density porous polyethylene with titanium mesh - malleable, visible on imaging, minimal ingrowth on superior surface given density)
- polygalactin (absorbable)
Autogenous
- bone graft
What are surgical approaches to the lower lid?
- transconjunctiva (retroseptal, preseptal)
- subciliary
- midlid
Describe subciliary approach and compx
- 2mm below lash line
- Sq dissection above tarsus until past tarsus
- cut through O.ocli and septum to rim
+/- lateral extension
Complications
- 20% rate of compx, 14% ectropion
Describe mild lid approach and compx
- in lower crease below tarsus
- thgough subq and O.oculi
- dissect along septum to rim and through arcus marginalis
Complication 10%
Describe transconjunctival
- below tarsus but above arcade
- trhough lower lid retractors
preseptal - thgouth septum, trace along deep surface of o.oculi to rim
retroseptal - alonf fat to rim - avoid septum and CPF confluence disruption.
complication - ectropion 1.5%
What is white-eyed blow-out?
Trapdoor f# in child
entrapment with restricted EOM
Nausea/vomiting
No periorb ecchymosis (white eye)
What are clinical features of an orbital fracture?
diplopia
enophthalmus
infraorbital nerve paresthesia
What is best imaging for orbital fractures
CT coronal - to view size of floor defect and for rounding of IR
CT sagittal to view floor inclination
3D recon for orbital volume
Indicaitions for non-operative treatment of orbital f#
no defect/displacement
monocular patient
medically unstable
* need to review patient in 5-7days to re-examine for enophthamus, diplopia, ocular injury
Indiciations for operative treatment of orbital f#
entrapment
enophthalmus
(only two according to JF)
relative:
RB hematoma
hypoglobus
defect >1cm2
diplopia in functional fields of gaze unresolved in two weeks
What are early complications post-op of orbital fracture ORIF?
- worse/new diplopia
- retrobulbar hematoma 3%
- optic nerve injury w visual loss 1%
- compression to parasympathetic nerve w pupil dilatation
- SOFS, OAS
- V2 numbness
What are late complications of orbital f# ORIF
ENOPHTHALMUS 20%
DIPLOPIA
Ectropion 10%
Damage of canaliculi, lacrimal system, lid elevator
Sinusitis
How do you classify orbital roof f#? (sullivan)
undisplaced
displaced with orbit involvement
displaced with brain involvement
What are operative indications for orbital roof f#
Need for decompression of SOF contents of optic canal
Repair of associated injuries (dural tear)
Prevent herniation of cranial contents into orbit
What is an NOE fracture
Fracture of lower /3 of medial orbital rim allowing for segment displacing the MCT
What defines an NOE fracture
Fracture of four regions
1- orbital rim
2- medial orbital wall
3- superior nasomaxillary buttress (maxilla at jx w frontal bone)
4- inferior nasomaxillary buttress (at piriform)
What are clinical features of NOE
- telecanthus >35mm
- short palpebral fissure
- epiphora (in 100% of cases)
- epistaxis/CSF rhinorrhea
- loss of nasal projection, height
How do you classify NOE fracture
Manson - Markowitz classification
Type 1 - single central fragment bearing MCT
Type 2 - Comminuted central fragment external to insertion of MCT
Type 3- Comminuted central fragment extending into MCT (avulsion in 5% only)
Indications for NOn-operative tx of NOE
no displcaement on CT or physical exam
Indication for opeative tx of NOE
Displaced fragment
Mobility of canthal bearing segment
CSF leak with extended cranial fractures
epiphora NOT ADDRESSED at 1’ surgery
Treatment of NOE fractures according to type
Type 1: ORIF with plates and screws
Type 2: ORIF with plates, screws adn trasnasal wires
Type 3: ORIF with 1’ BG, ORIF plates and screws and trasnansal wires
What is a normal medial wall distance?
25mm
Describe transnasal wiring
- place wire posterosuperior to lacrimal fossa, just below NFsuture. if too anterior, get rotation of segment posterirly which actually causes telecanthus
ALL NOE neeed MANSON splint
What is the resulting deformity of untreated Lefot 1?
Malocclusion
Anterior open bite
elongated posterior midface
What is the resulting deformity of untreated zygoma?
enophthalmus, increased facial width, decreased projection
What is the resulting deformity of untreated NOE?
Telecanthus
canthal dystopia
Why is timing 2wks for facial fractures?
b/ soft tissue contracts, fracture heals
Scarring in each lamella of the lower eyelid will cause what deformity
what and where is the carumcle
confluence of periosteum, deep tarsal fascia and CPF. Need to be infront of lacrimal fossa (at caruncle) and dissect behind lacrimal crest, leaving the sac down, dissecting above or superficial to lacrimal sac. Limited by mct
Describe steps of ORIF zygoma
Need 3 pts of fixation per f# sgement, but not all three if low evergy.
Will expose orb floor w midlid if high energy and expect injury
If low E, start w UBS and lateral wall
When do you need a coronal for zygoma?
so comminuted there is no bony continuity
Where is the optic canal, and what are its contents?
- within lesser sphenoid
- 45-55mm superomedial from oribtial rim
- optic nerve & ophthalmic artery
where is the superior orbital fissure and what are it’s contents
- superior orbital fissue is between the greater and lesser sphenoid bone
- contents include:
- CN III, IV, VI
- CN V1 - lacrimal, nasociliary, frontal
- parasympathetic nerve to pupil (v1)
- superior ophthalmic vein
what is the inferior orbital fissure bounded by, and what are its contents?
- Bounded by:
- superiorly: greater wing of sphenoid
- inferiorly: maxilla and orbital process of palatine bone
- laterally: zyoma
- CN V2: infraorbital, zygomaticofacial, nasofrontal
- inferior orbital artery, inferior ophthalmic vein
what are the components of the medial canthus
- medial canthal ligament
- medial check rein ligament (fascial extension of medial rectus)
- Whitnall & Lockwood ligament
- Levator superioris aponeurosis
- septum
- deep head of pretarsal OO
what are the insertion points of the medial canthal ligament?
- 3:
- anterior to lacrimal fossa (maxilla)
- posterior to lacrimal fossa (lacrimal bone)
- superiorly near NF suture
what comprises the lateral canthus?
4L’s
- lateral canthal ligament
- lockwood (and whitnall) ligament
- lateral rectus check rein ligament
- levator aponeurosis
what are clinical features associated w/ globe rupture
- extruding eye contects
- subconj hemorrhage
- oblonge / cat eye pupil
- hyphema
what is sympathetic ophthalmia?
- autoimmune reaction that can occur after a globe rupture
- mechanism: globe rupture +/- subsequent necrotic globe releases choroidal pigment systemically
- this induces an autoimmune response to uvea and can result in ipsilateral purulent uveitis
- bc systemic, a contralateral purulent uveitis autoimmune reaction can occur, causing bilateral blindness
what are bad prognostic features of traumatic optic neuropathy?
- associated orbital fracture
- sudden onset
- no light perception at presentation
- penetrating injury
(not, good prognostic features are exact opposite of above)
A patient has post-operative hypertension and vomiting after orbital floor repair. This is followed by extreme pain of ipsilateral globe, proptosis, diminished EOM.
What is your suspected diagnosis?
What will you do immediately?
What will you plan urgently within 2 hours?
Will anything be different if there is a sudden change to visual acuity,
- Post-operative retrobulbar hematoma
- Immediately will put patient on 95% O2 and elevate HOB
- Call ophthalmology for stat assessment +/- bedside tonometer to measure IOP
- Initiate medical treatment w IV mannitol, diamox (CA inhibitor) +/- oral steroid +/- topical beta-blocker
- Consider stat CT scan
- with a sudden change to VA consider adding
- suture removal
- lateral canthotomy / cantholysis
- urgent (WI 2 hrs) trip back to the OR for exploration / evacuation of hematoma (consider interval imaging after cantholysis)
why would a patient have diplopia after orbital floor fracture?
- mechanical causes
- entrapment of periorbital tissue
- muscle
- fat
- suspensory ligamentous strutures
- enopthalmos
- dystopia
- entrapment of periorbital tissue
- non-mechanical causes
- nerve injury
- muscle injury: acute - hematoma; late - fibrosis
- CNS injury
- pre-existing phoria or tropia
