Indications for repositioning of blow-out fractures of the orbital floor based on new objective criteria - tissue protrusion volumometry

Abstract

a Background and Aim. The otolaryngologist often meets with fractures of the orbital floor. The most serious complication is diplopia, arising as a result of herniation of the orbital contents, with or without fixation of the inferior rectus muscle. The aim of our work was to create a mathematical model to calculate the volume of prolapsed soft tissue of the orbit in blow-out fractures, as a factor in deciding on the need for surgical treatment. Patients and Methods. In a retrospective study (2007)(2008)(2009)(2010)(2011)(2012)(2013), we evaluated 80 patients with blow-out fractures, divided into two equal groups: 40 conservatively treated and 40 surgically treated patients. We created the model by measuring the fracture lines and herniation of the orbital soft tissues in the coronal and sagittal sections from CT images, equivalent to half the volume of a rotating ellipsoid. Results. According to the proposed model, posterior and anterior fractures with a prolapse volume above 500 mm 3 , and anteroposterior fractures with a volume over 1400 mm 3 , are indicated for surgery. Conclusion. The volume of prolapsed soft tissue relative to the location of the fracture is the main indicator for selecting the best treatment procedure immediately after injury.

Treatment of Persistent Post-traumatic Diplopia – An Algorithmic Approach to Patient Stratification and Operative Management

“…First, diplopia is a complex phenomenon involving both anatomic issues of eye position and movement as well as higher order processing in the central nervous system leading to a breakdown in perceptual fusion. 3,18,19,22–26 This interplay between eye and brain in producing diplopia is incompletely understood. Therefore, even excellent anatomic restoration may not lead to resolution of diplopia if central mechanisms cannot adjust.…”

CT parameters in pure orbital wall fractures and their relevance in the choice of treatment and patient outcome: a systematic review

“…Jank et al 23 describe a similar trend in the post-traumatic phase, although no statistical analyses were performed. When focusing more on the exact fracture location, within one or multiple orbital wall surfaces, most articles described a significant relationship with the occurrence of clinical symptoms [25][26][27][28] . Fractures located in the posterior third of the OF, anterior half of the MW, fractures spanning multiple areas, and fractures behind the orbital equator with herniation of orbital tissue were found to be at risk of enophthalmos In multivariate analysis:…”

“…Fracture ratio: in operatively and conservatively treated patients 25,26,28 . Fractures located in the anterior or middle third of the OF were found to be at risk of preoperative, but not postoperative, diplopia 27 .…”

“…The studies on the relationship between either herniated orbital volume or total orbital volume and the clinical outcome were ambiguous [11][12][13][14][26][27][28]34,[37][38][39][40][41][42] . When looking at total orbital volume, absolute values as well as relative values were correlated to the clinical outcome.…”

“…Although the current literature is inconclusive, it is believed that orbital volume measurements can play an important role in the treatment decision and prediction of the clinical outcome, especially enophthalmos. Kovar et al 26,40 suggested >1.4 ml of prolapse in anterior fracture types and >0.5 ml of prolapse in posterior fracture types as indications for surgery in OF fractures, and also applied this in a prospective setting, but no statistical analyses were performed. In their prospective research, Alinasab et al 11 found that herniated volume correlated significantly with the clinical outcome after 1 year of follow-up in a population treated conservatively, with respective cut-off values of 1.0 ml for OF fractures (AUC 0.77) and 0.9 ml for OF + MW fractures (AUC 0.98).…”