Purpose: Identify the benefits of using the endoscope in patients with fractures of the medial wall and floor of the orbit. 
Materials and methods: A retrospective descriptive study is presented in which we reviewed the medical records of all our patients that presented with an orbital fracture of  the posterior third of the medial wall and floor of the orbit, that were taken to surgery between 2006 to 2019. All surgeries were performed through a combined Transorbital and  Endoscopic approach. Ocular motility, presence of enophthalmos and pupillary reflexes were evaluated, both pre-surgical and postoperatively. The study was approved by the local  IRB (approval # 2017/90). 
Results: This study includes seven patients presenting with fractures of the medial wall or floor of the orbit, that were treated with an endoscopically assisted technique. All of  these patients improved their ocular motility and none presented enophthalmos. No postsurgical complications were found in any of the patients. One of our patients presented with  a pre-surgical amaurosis that did not change postoperatively. 
Conclusions: Management of orbital fractures at the posterior third of the medial wall or floor of the orbit through a combined Transorbital and Endoscopic approach is a safe  and effective technique.

Orbital floor fracture

• Orbital medial wall fracture

• Endoscopic surgery

Herrera Vivas AJ, de León Ó, Baquero MM, Roa PF, Rodríguez-Ruiz MT (2020) Benefits of Endoscopically Assisted Orbital Reconstruction of Fractures of the Floor and Medial Wall of the Orbit. Ann Otolaryngol Rhinol 7(4): 1246.

Fractures of the orbital floor were first described by Mackenzie in 1844, but it was only until 1954 that Smith and Regan adopted the term “blow out fracture” for those cases in which the orbital contents protruded through the floor or medial wall [1,2]. In these cases, periorbital and extraocular muscle entrapment frequently occurs leading to diplopia [3-5]. Fractures of the medial wall and or floor of the orbit are quite common in facial trauma, accounting for up to 40% of fractures occurring in the middle third of the face [6].

The treatment of this type of fracture primarily aims to alleviate short- and long-term functional and/or esthetic sequelae such as enophthalmos, hypophthalmos, ophthalmoplegia, dystopia, diplopia, infection, sinusitis, amaurosis, and/ or paresthesia [7,8]. These complications can occur as a consequence of the entrapment of the orbital content in the bony defects resulting from the facial trauma, indicating the need for surgical management to reposition the herniated tissue through the osseous defect, thereby re-establishing the orbital content/container relationship [4]. This treatment approach also re-establishes ocular and periorbital globe stability, thereby restoring the patient’s function and esthetics [9].

The surgical repair of medial wall and orbital floor fractures requires adequate exposure of the osseous surface to allow visualization of the bony defect margins, which enables repositioning of herniated tissues; this is followed by the interposition of alloplastic materials such as titanium or porous high-density polyethylene [10-12].

Traditionally, this type of fracture has been accessed using periorbital approaches such as the transconjunctival or transcaruncular approach [13,14] and in cases of posterior floor or medial orbital wall fractures, endoscopic repair using a transnasal or transmaxillary approach allows direct visualization of the bony defect and follow-up during the reconstruction of the bony defect caused by facial trauma [13].

Endoscopic-assisted techniques have applications in the field of orbital trauma by providing good visibility through high definition images. Direct visualization of the orbital floor or medial wall decreases the risk of malposition of the alloplastic material, particularly in the posterior segment of orbital floor or medial wall fractures, thereby ensuring a more agile and safe surgical procedure [9]. Based on the above considerations, the objective of this study was to identify the benefits of endoscopicassisted orbital reconstruction for medial wall and/or orbital floor fractures, particularly with respect to ocular movement, enophthalmos, and pupillary reflexes.

This study consisted of a review of the clinical records of cases of medial wall or orbital floor fracture that underwent surgery using a combined technique (endoscopic and open) between 2006 and 2019. This study was conducted in Hospital Universitario San Ignacio, a highly specialized care center in Bogota, Colombia.

The study was approved by the local IRB (approval # 2017/90).

The inclusion criteria were as follows: 1. patients with medial wall and/or orbital floor fractures who underwent a combined surgical procedure, and 2. patients who were followed-up at the hospital for a minimum of 2 months.

The exclusion criteria were as follows: 1. patients for which functional results could not be evaluated postoperatively; 2. patients with diminished autonomy; 3. patients with comorbidities affecting surgical management; and 4. patients with fractures of the anterior third of the orbital floor that do not require endoscopic assistance.

All patients or their legal guardians signed a preoperative informed consent that included the acquisition of photographs during the operation. Analysis of the database of the Otolaryngology Unit between January 2006 and June 2019 identified 95 patients diagnosed with medial wall and/or orbital floor fractures, of whom seven underwent surgery using a combined technique. Clinical records were reviewed individually, as well as follow-up records, and none of them met the exclusion criteria. According to the clinical records, the selected patients were evaluated by an otolaryngologist specialized in endoscopic approaches to the paranasal sinuses and skull base. In addition, patients were evaluated by a maxillofacial surgeon, including physical examination and tomographic images, to localize and characterize the orbital fracture.

A Microsoft Office Excel® sheet was used to record the variables of interest, including ocular motility, presence of enophthalmos by clinical appearance, and pupillary reflexes, both pre- and post-operatively.

Data were collected and codified for analysis; categorical variables were described using frequencies and percentages.

Surgical Repair of Orbital Floor Fractures (Figure 1):

Figure 1: Surgical Repair of Orbital Floor Fractures. 1A: Preoperative transnasal endoscopic image obtained through the left middle antrostomy showing herniation of the left orbital floor (PO). PP: posterior wall of the left maxillary sinus; PO: orbital floor; O: herniation of the orbital content. 1B: Intraoperative transnasal endoscopic image through the left middle antrostomy showing the Freer dissector (F) inserted through the external approach to dissect a pocket posterior to the posterior margin of the fracture under endoscopic visualization. 1C: Endoscopic image obtained through the external approach showing the orbital margin (OR). The orbital floor fracture can be observed in the background and is indicated by an arrow. 1D: Endoscopic image obtained through the external approach showing the orbital floor fracture (arrow), the anterior lip of the defect (ALD), and the posterior lip of the defect (PLD). 1E: Endoscopic image obtained through the external approach showing the osteosynthesis plate placed and fixed at the posterior third of the orbit. 1F: Transnasal endoscopic image obtained through the left medial antrostomy showing complete reduction of the orbital content and the wellpositioned osteosynthesis plate.

External Approach

A transconjunctival or subciliary incision is performed according to the characteristics of the defect. In cases with large bony defects, the subciliary incision is preferred because it allows the introduction of a larger mesh with a lower risk of damage to the surrounding soft tissues. The dissection continues across the circular fibers of the orbicularis oculi muscle. Once the infraorbital margin is located, a periosteal incision is performed, followed by subperiosteal dissection of the anterior third of the orbital floor. The dissection then continues with transorbital endoscopic assistance until the defect of the orbital floor is located. The defect is usually located in the middle or posterior third of the orbital floor, and a compromised inferior rectus muscle is normally observed. Transnasal endoscopy is initiated at this time.

Endoscopic Transnasal Approach:

This procedure is performed using a 0-degree endoscope and an optical system equipped with a high-resolution camera. An infiltration of lidocaine 1% and epinephrine is administered to the lateral nasal wall, middle turbinate, and ethmoid bulla to achieve vasoconstriction in the surgical field, which provides adequate visualization during the procedure. The procedure is initiated by performing an uncinectomy using retrograde forceps and a microdebrider. This is followed by a wide middle antrostomy extending from the ascending branch of the superior maxillary bone to the area anterior to the margin of the posterior wall of the maxillary sinus. This provides adequate visualization of the middle and posterior third of the orbital floor. An anterior and posterior ethmoidectomy is then performed in the anterior skull base and lamina papiracea. In these cases, sphenoidectomy and frontal sinusotomy are not necessary.

Upon completion of this procedure, the herniated orbital tissue in the maxillary sinus is reduced, which is achieved using a Freer elevator through the transorbital dissection under endoscopic visualization mediated by the middle antrostomy. In general, it is useful to combine the dissection maneuvers through transorbital and transnasal approaches simultaneously until complete reduction of the herniated tissues in the orbital cavity is achieved. During these procedures, it is important to dissect the posterior distal margin of the defect to enable stable positioning of the osteosynthesis mesh, which should be anchored to the posterior margin of the bony defect. At this time, the external approach is closed in layers, and a nasal tamponade is left in place at the level of the middle metal plate.

Surgical Repair of Medial Wall Fractures (Figure 2):

Figure 2: Surgical Repair of Medial Wall Fractures: 2A: Transnasal endoscopic image obtained through the left nostril showing the herniated orbital content (O). CoM: middle turbinate; Et: ethmoid bone; Esf: sphenoid bone; O: orbit; PLN: lateral nasal wall. 2B: Transnasal endoscopic image obtained through the left nostril showing the osteosynthesis plate placed in an anatomical position and anchored to a pocket posterior to the posterior margin of the fracture. Esf: sphenoid bone; O: orbit; M: titanium mesh

These fractures are managed using the same external approach through a transconjunctival or subciliary incision, and a subperiosteal dissection of the orbital floor and medial wall is performed until the defect is exposed. At this time, the transnasal endoscopic approach is introduced, which in addition to the procedures mentioned above, facilitates sphenoidotomy and wide frontal sinusotomy. Upon identification of the orbital content herniated through the middle orbital wall, fat and the medial rectus muscle are reduced using joint procedures through both approaches with the aim of bypassing the herniated content until dissection of the posterior margin of the defect is achieved. Completion of this step is followed by placement of a custom mesh constructed according to the size of the orbit, which should be anchored to the posterior margin of the defect. Once of the advantages of the endoscopic technique in these cases is that it facilitates the identification of anterior and posterior ethmoid arteries, thereby with or without involvement of the orbital margin presented for orbital reconstruction using a combined approach (external and endoscopic) 2 weeks after the traumatic event. The cohort included two women and five men with a median age of 31.14 years (range, 19–48 years). All patients underwent surgery between January 2006 and June 2019. Regarding the type of fracture, one patient (14.2%) had medial wall involvement, three patients (42.8%) had inferior wall (floor) involvement, and three patients (42.8%) had medial wall and inferior wall (floor) involvement.

Preoperative Findings

The clinical characteristics of the patients are shown in Table 1.

Table 1: Pre and postoperative characteristics.

Abbreviations: F, female; M, m

Of seven patients, five (71.42%) showed ocular motility alterations. Four patients (57.1%) had enophthalmos, one patient (14.2%) had amaurosis, and the remaining patients had no alterations of pupillary reflexes or optical nerve involvement.

Postoperative Findings

The clinical characteristics of the patients are shown in Table 1. During the postoperative period, ocular motility improved in all patients (100%). All patients with preoperative enophthalmos showed improvement. None of the patients showed alterations of pupillary reflexes, and the patient with preoperative amaurosis showed no changes in visual acuity. Postoperative complications such as hemorrhage or granuloma formation were not reported in any of the patients (0%).

In the context of orbital fractures, enophthalmos either isolated or together with hypophthalmos can have functional implications and cause alterations in the facial appearance of the patients; it is associated with an increase in the orbital content/ container relationship resulting from displacement of facial fractures. Other causes of enophthalmos include fat atrophy, necrosis, and scar contraction in the retrobulbar region, which leads to a posterior and inferior shift of the ocular globe [4,5,7].

The treatment of enophthalmos and hypophthalmos is straightforward: the aim is to restore the correct position of the ocular globe in both vertical and anteroposterior directions [14]. A common objective of treatment is to provide continuity to the orbital bony container by repositioning the fractured segments in combination with the use of a mesh of titanium or other materials such as porous high-density polyethylene [9,15].

Preoperative evaluation should include computed tomography studies of the medial wall and/or orbital floor defect, its size, and periorbital and extraorbital muscle herniation, which is associated with selective ophthalmoplegia. Following evaluation of the size of the bony defect, the orbital floor should be assessed from a sagittal view to attempt to restore the anterior portion to a concave form that changes to convex with the progression to the posterior region of the floor towards an angle of 30 degrees; this change is located posterior to the axis of the ocular globe. The return of this “S” shaped aspect during the orbital reconstruction enables the correct projection of the ocular globe [13,16].

The timing of the surgical management of orbital fractures should be individualized according to age, type of fracture, and clinical and radiographic findings. In some cases, the process should be delayed until a precise diagnosis is obtained. Burstine et al. [17], recommend intervention at 2 weeks after the facial trauma. Matteini et al [18]. Recommend that cases showing diplopia with extrinsic ophthalmoplegia should be treated at a maximum of 1 week after trauma, whereas children should be treated after a few days because of the risk of muscle fibrosis [7,18-20]. In the present cohort, patients underwent surgery at 2 weeks after the injury with good postoperative results regarding ocular motility and the absence of complications.

In cases of open reduction with internal fixation of the orbital fracture, correct dissection and identification of the posterior margin of the bony defect previously detected by computed tomography is important to ensure the correct positioning of the alloplastic material, thereby restoring the continuity of the medial wall and orbital floor. Residual postoperative enophthalmos greater than 2 mm is associated with incorrect positioning of the alloplastic material resulting from inadequate reduction of the orbital volume [9,12,21].

One alternative is the use of porous high-density polyethylene, which is applied in layers until an adequate orbital volume is reached [19]. Literature propose the insertion of thin sheets of porous high-density polyethylene of 0.2 mm or 0.4 mm, which is a relatively easy technique because the smaller material allows better control during the re-establishment of the adequate projection of the ocular globe without causing its excessive elevation [19].

In the present study, the combined intervention (external and transnasal endoscopic approaches) in four patients presenting with enophthalmos resulted in an improvement in the position of the ocular globe with complete correction of enophthalmos.

As mentioned above, fat necrosis or wound contraction in the retrobulbar tissue is associated with the presence of enophthalmos. Park et al. [15], claim that reduction and anatomical orbital reconstruction are not sufficient, proposing instead the generation of an exophthalmos of approximately 3 mm, in which 1 mm of the over-correction are lost in the 3 months after surgery. Together with previous findings, this suggests that enophthalmos following orbital reconstruction can be prevented by overcorrecting the projection of the ocular globe [9,13,10].

Endoscopic-assisted treatment of facial trauma has been applied for more than 30 years; it has served as a complement to traditional or external approaches, and its use in clinical practice has increased in the last two decades [11,22]. In cases of defects in the medial wall or orbital floor, it is considered a fundamental technique that allows the adequate direct visualization of bony defects, thereby facilitating the correct positioning of the orbital reconstruction material and ensuring a more effective and safe procedure. This is supported by the present results showing complete success in the correction of enophthalmos and ocular motility restriction, and the preservation of pupillary reflexes in all patients.

The simultaneous application of external and endoscopic approaches can increase the success rate of the correction of enophthalmos and ocular motility defects, thus converting the open reduction of orbital fractures with or without reconstruction into an efficient procedure. In addition, endoscopic surgery enables the localization and identification of anatomical structures such as the optic nerve, ethmoid arteries, and orbital clefts, thereby improving the safety of surgery.

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