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332 PART V ORAL AND MAXILLOFACIAL SURGERY
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A. Fracture reduction without fixation:
Some fractures may prove very stable after simple open reduction without fixation using one
of two approaches: Gillies or Keen. These two approaches are commonly used in patients with
minimal-to-moderately displaced isolated zygomatic arch fracture. Since fixation is not used for
these techniques, relapse rate is relatively high.
B. Open reduction and internal fixation (ORIF):
ORIF of fractured ZMC is indicated when there is comminution or fracture instability to reestablish
adequate three-dimensional anatomies. It is important to know that a greater amount of fixation
will not improve the final results in a fracture that has been poorly reduced in the first place. The
intraoperative Keen approach or a transmalar Carroll-Girard screw can be utilized to reposition
the zygoma before applying the fixations.
15. What are the surgical approaches for treatment of ZMC fractures?
Any or combinations of the following approaches can be used to reduce and fix ZMC fractures,
depending on the patient’s age, location of the fractures, and involvement of other facial bones.
• Gilliesapproach
• Keenapproach
• Intraoralmaxillaryvestibularapproach
• Uppereyelid/blephroplastyapproachincludingtransconjunctival,subciliary,andsubtarsal
• Lateralbroworsupraorbitalbrow
• Extendedlowereyelidapproach
• Coronalaccess
• Transconjunctival
• Subciliary
• Subtarsal
16. What is the sequence for ORIF of ZMC fractures?
A systemic approach is helpful to ensure accurate restoration of facial height, width, and projection.
More complex ZMC fractures usually require exposure of all three anterior buttresses, which include
the zygomaticomaxillary (ZM), zygomaticofrontal (ZF), and inferior orbital rim buttresses. The ZF
fracture may be first stabilized temporarily with an interosseous wire. This is followed by fixation of the
ZM and the infraorbital rim if indicated. A transmalar Carroll-Girard screw offers great three-dimensional
positioning of the zygoma while it is being plated. The temporary wire at the ZF suture line is then
replaced with a plate. The orbital floor can then be reconstructed after the zygoma is restored to its
correct position. Correct alignment of zygomaticosphenoid suture is a good guide for proper threedimensional repositioning of the zygoma.
17. What landmark is most predictable for accurate bony reduction of the ZMC
fracture?
Adequate reduction of the ZMC fracture depends on precise alignment and appreciation of its
ability to be displaced in multiple planes of space. The zygomaticosphenoid suture has often been
proposed as one of the key areas for determining adequate reduction due to its large surface area
and the inherent stability of the greater wing of the sphenoid. In many situations the orbit itself is
not indicated for exploration, due to degree of displacement and integrity of the orbital floor, and in
such situations, the risk of possible negative sequelae being unacceptable, one must focus on other
areas to guide in accurate reduction. In reality it is not the observation of the one best area but the
verification of reduction of multiple areas in concert that will lead to the best results. Checking for
reduction at the zygomaticomaxillary buttress and infraorbital rim (both of which can be observed
through a vestibular incision) coupled with verification at the zygomaticofrontal suture is often
adequate.
18. What are some of the possible complications of surgical treatment of ZMC
fractures?
Although complication rates are very low, the surgeon must recognize them to be able to provide
appropriate care. Some signs and symptoms include infraorbital paresthesia, malunion and facial
asymmetry, infection, enophthalmos, diplopia, traumatic hyphema, traumatic optic neuropathy, superior orbital fissure syndrome, retrobulbar hemorrhage, and trismus.
CHAPTER 31 MANAGEMENT OF ZYGOMATICOMAXILLARY COMPLEX AND ORBITAL FRACTURES 333
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19. Does the masseter muscle play a role in post-reduction instability of zygomatic-
orbital-maxillary complex fractures?
The masseter muscle, having its origin located at the anterior two-thirds of the zygomatic arch, had
historically been implicated as a culprit in the post-reduction displacement of ZOMC fractures. That
assumption led to debates regarding necessary amount and placement of fixation to resist such
forces. Given that the average maximal occlusal bite force approaches 45 kg, it had been proposed
that fixation be to a degree to resist such a force. However, it has been found that the post-injury bite
force and masseteric force are significantly reduced for four or more weeks postoperatively/post-injury.
There is little hard evidence to substantiate claims of masseteric involvement in post-reduction instability; improved results with increased fixation may be explained by the need for increased surgical
access and better direct observation of adequate reduction at multiple locations rather than resistance
to displacement via muscle pull.
20. What is the treatment for ankylosis between the zygomatic arch and coronoid
process?
Coronoidectomy.
21. What is the incidence of permanent diplopia after zygomatic fracture?
Initial transient diplopia is present in up to 10% of patients and is commonly evident on upward,
downward, and lateral gaze. Permanent diplopia, evident on upward gaze, remains in 5% of patients.
ORBITAL FRACTURES
†
22. What is the bony anatomy of the orbit?
The orbit is composed of seven bones. The floor is formed by the sphenoid bone, the orbital process
of the palatine bone, and the orbital process of the maxillary bone. The lateral wall is formed by the
greater wing of the sphenoid bone posteriorly and the zygomatic and frontal bones anteriorly. The
medial wall is made of the lesser wing of the sphenoid, the ethmoid bone, the lacrimal bone, and the
frontal process of the maxilla. The roof of the orbit is composed of the frontal and sphenoid bones.
23. What are the dimensions of the orbit?
By age 5 years, orbital growth is 85% complete, and it is finalized between 7 years of age and puberty.
An adult orbit has an average volume of 30 cc with the globe volume being around 7 cc. The height of
the orbit is on average around 35 mm, whereas the width is approximately 40 mm as measured at the
rims. The child’s orbit is rounder, but with age the width increases. From the medial orbital rim to the
apex measures approximately 45 mm in length. From the inferior orbital rim going posteriorly, the floor
dips slightly inferior for about 15 mm; it then gently curves cephalically to the superior orbital fissure.
These measurements and anatomic dimensions and shapes are very important to keep in mind during
orbital reconstructions and restoring orbital volume.
24. What are important foramina, fissures, tubercles, and crests associated with the
orbit?
• Inferior orbital fissure: This is located about 1 cm posterior to the inferolateral oribital rim.
It connects the pterygopalatine fossa with the floor of the orbit. Contents include sensory nerves
V2 (infraorbital and zygomatic nerves), inferior ophthalmic vein and branches to pterygoid plexus,
and parasympathetic branches of the pterygopalatine ganglion. Contents of this fissure are usually
reflected for proper inferior orbital floor exposure during surgery.
• Superior orbital fissure: This is located near the apex of the orbit. It serves as a conduit for cranial
nerves III, IV, and VI and the first division of cranial nerve V (ophthalmic branch). Additionally, it
contains the superior ophthalmic vein and anastomosis of recurrent lacrimal and middle meningeal
arteries. Fractures affecting this structure can lead to ophthalmoplegia, upper eyelid ptosis, pupillary
dilatation, and forehead anesthesia, also known as superior orbital fissure syndrome.
• Optic canal: This is located at the apex of the orbit, just medial to the superior orbital fissure. It is about
5 mm wide and less than 1 cm long. It houses the optic nerve, meninges, sympathetic fibers, and
ophthalmic artery. Fractures involving this canal can lead to blindness. Orbital apex syndrome
usually results from retrobulbar hematoma with compression of the optic canal and superior orbital
fissure. Clinical findings include tense proptosis and periorbital swelling, retroorbital pain, pupillary
†
Written by Siavash Siv Eftekhari and Tuan Bui.
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dilation, ophthalmoplegia, and, most importantly, a change in vision. Fundoscopy reveals a pale
disc with cherry red maculae. Prompt surgical decompression via lateral canthotomy is required to
prevent permanent vision loss.
• Anterior and posterior ethmoid foramen: The anterior ethmoid foramen is located about 25 mm
posterior to the medial orbital rim, and the posterior ethmoid foramin is about 30 to 35 mm posterior to
the medial orbital rim. They contain the anterior and posterior ethmoidal arteries, respectively. These
can be important sources of orbital or nasal bleeds. Nerves within the anterior ethmoid foramen
include the anterior ethmoid branches from the nasociliary nerve from the orbit coursing into the
nasal cavity. The posterior ethmoid foramen contains, variably, a sphenoethmoidal nerve from the
nasociliary nerve. The posterior ethmoid foramen is usually used as a landmark for safe medial
posterior extend of dissection.
• Nasolacrimal canal: This is located at the inferomedial orbital wall and houses the nasolacrimal
duct. Just anterior to the canal is the anterior lacrimal crest that serves as the attachment point
for the anterior portion of the medial canthus. The deeper fibers of the medial canthus along with the
orbicularis oculi muscle attach to the smaller posterior lacrimal crest.
• Whitnall’s tubercle: This is located on the lateral orbital wall just below the frontozygomatic suture
about 1 cm posterior to the lateral rim. It is a point of attachment for the lateral canthus and other
globe suspensory ligaments of significance.
25. What are the layers of the eyelid?
Eyelid layers from superficial to deep include the following: skin, subcutaneous areolar tissue, striated
muscle of orbicularis oculi, submuscular areolar tissue (contains the sensory nerves), tarsal plates
within a fibrous layer, nonstriated smooth muscle, and conjunctiva.
26. What is the importance of the orbital septum?
The orbital septum is a layer continuous with the orbital periosteum and the periosteum of the facial
bones overlying the rims just deep to the orbicularis oculi muscle. It sets the boundary for preseptal
versus postseptal/retrobulbar spaces. It is an important layer to consider when dealing with orbital
infections or hematomas. It converges with the periosteum about 1 to 2 mm below the inferior
orbital rim, forming a periosteal thickening called the arcus marginalis. In the subciliary or preseptal
transconjunctival approaches to the inferior rim and orbital floor, the orbital septum is an important
landmark to keep in mind. Incising below the arcus marginalis prevents orbital contents and fat from
herniating into our surgical field, making our subperiosteal dissection much easier to perform.
27. What are the common patterns of orbital fractures?
There are two types of orbital fractures:
1. Fractures involving the internal orbital wall(s) and orbital rim(s). Examples are naso-orbito-ethmoid
fractures, zygmomatico-orbital fractures, and maxillary Le Fort fractures. These are the most
common types of orbital fractures, with the fractures of the zygomatic complex being the most
common (30% to 55% of all facial fractures).
2. Pure orbital fractures that involve the orbital walls/floor but do not involve the rims. They account
for about 4% to 16% of all facial fractures. Although the bones of the medial orbital wall are the
thinnest, they are strengthened by the perpendicular septa of the ethmoid sinus. Therefore, the
second thinnest wall of the orbit, which is the orbital floor, is most prone to fractures, especially
just medial to the infraorbital canal.
28. What are the clinical findings of orbital fractures?
Common clinical findings in orbital fractures include periorbital edema, subconjunctival ecchymosis,
orbital emphysema, infraorbital nerve paresthesia, bony step deformity around the orbital rim with
point tenderness, and changes in the globe position in more severe fractures including any evidence
of enophthalmous, exophthalmos, or vertical dystopia. A lid retractor such as Desmarres is useful for
separating swollen-tight lids during examination. Generally, orbital fractures have an early presentation of exophthalmus due to swelling. Enophthalmos is present within 1 to 3 weeks if the orbital cavity
is significantly enlarged and appears as the swelling resolves. Any evidence of proptosis or retrobulbar
hematoma should be followed by tonometry examination that indirectly measures intraocular pressure
(normal pressures: 10 to 20 mm Hg). An orbital volume enlargement of more than 5% to 10% will
most likely require open reduction. Orbital apex syndrome usually results from retrobulbar hematoma with compression of the optic canal and superior orbital fissure. Clinical findings include tense
proptosis and periorbital swelling, retroorbital pain, pupillary dilation, ophthalmoplegia, and, most
importantly, a change in vision. Funduscopy reveals a pale disc with cherry red maculae. Prompt
surgical decompression via lateral canthotomy is required to prevent permanent vision loss.
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29. What are the radiographic imaging needed for evaluating orbtial fractures?
CT is the gold standard for assessing the status of the bony orbit. Fine cuts (1 to 2 mm) analyzed through
axial and coronal cuts are needed for diagnosis. Sagittal cuts are useful in evaluating the integrity of
the orbital floor. A soft tissue window can be used for evaluating any radiographic evidence of muscle
entrapment or retrobulbar hematoma. Less optimally, a Waters’ view X-ray can be used to show an
orbital floor fracture. MRI can be useful to assess soft tissues, extraocular muscle entrapment, or optic
nerve damage.
30. What are the etiologies of monocular versus binocular diplopia?
Acute binocular diplopia (double vision) after trauma is usually due to one of three basic mechanisms:
(1) orbital edema or hematoma (most common), (2) restricted motility, or (3) neurogenic injury. Binocular
diplopia is more common in the traumatic setting and may result from an alteration in globe position,
such as proptosis or enophthalmos, or from limitation of globe movement through entrapment of
orbital soft tissues. Monocular diplopia is usually due to lens dislocation or opacification or another
disturbance in the clear media along the visual axis. These physical findings warrant immediate
ophthalmologic consultation. Alternatively, nerve injury may occur intracranially or within the orbit
as a result of compression from hematoma or bone fragments. Surgical repair of the bony orbit and
decompression of affected nerves usually result in correction of diplopia.
31. What is the bowstring test, and in what situations should it be utilized?
The bowstring test is a means of assessing the status of the medial canthal ligament in more severe
orbital fractures involving the Nasoethmoidal (NOE) segments. Commonly, the ligament remains
intact and attached to the lacrimal bone, which may be fractured and displaced. The bowstring test is
performed by placing gentle lateral traction over the lateral canthus while palpating the medial canthal
region to assess mobility. A positive test confirms bony fracture with displacement of the medial
canthal ligament or traumatic telecanthus.
32. How can entrapment of orbital contents be diagnosed in an unconscious patient?
Diagnosis of orbital content entrapment is made by performing a forced duction test. The test involves
grasping the insertion of a rectus muscle onto the ocular globe with a forceps approximately 7 mm
from the limbus. The globe is then gently rotated in all four directions, and any restriction is noted. The
inferior rectus muscle is the most commonly tested muscle, although the superior, medial, or lateral
recti muscles may be used as well.
33. What is a Marcus Gunn pupil?
It is an afferent pupillary defect resulting from lesions involving the retina or optic nerve back to the
chiasm. With this defect, a light shone in the unaffected eye produces normal constriction of the pupils
of both eyes (consensual response), but a light shone in the affected eye produces a paradoxical dilation rather than constriction of the affected pupil.
34. What is the most common site of an isolated intraorbital fracture?
The most frequent intraorbital fracture involves the orbital floor just medial to the infraorbital canal
and is usually confined to the medial portion of the floor and the lower portion of the medial orbital
wall. Depressed fractures of these regions may cause the orbital soft tissue to be displaced into the
maxillary and ethmoid sinuses, leading to an increase in orbital volume.
35. What is the incidence of hypoesthesia or anesthesia in the distribution of infraor-
bital floor associated with orbital floor fractures?
The incidence is 90% to 95%.
36. What are the indications for operative management of orbital fractures?
Indications for surgery can be functional or cosmetic.
The functional indications include continued diplopia and decreased visual acuity are the most
important indications. Any evidence of inferior rectus muscle entrapment, which is most commonly
seen in the pediatric population due to the elasticity of their bones, warrants early intervention to free
up the tissue and prevent ischemic necrosis or scar contracture.
The cosmetic deformity indications include enophthalmos or hypo-ophthalmos and result
from bony orbital volume increase and/or fat herniation into maxillary sinus in case of orbital floor
fractures. Studies show that most patients will notice globe asymmetry once there is 2 to 4 mm of
globe malposition. Orbital floor defects of greater than half of the surface area with concomitant CT
evidence of orbital content herniation into maxillary sinus generally should be repaired. With minimal
floor disturbance (usually less than 50%) and no muscle entrapment or minimal to no orbital content
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herniation, observation for 2 weeks is recommended. If a patient develops any functional problems or
enophthalmous is greater than 2 mm, then surgery can be offered.
37. What are the surgical approaches for treating orbital fractures?
• Subciliarylowereyelidincision
• Subtarsalincision
• Infraorbitalapproach
• Transconjunctivalincision
• Lateralbrowincisionandupperblepharoplastyincision
• Intraoralmaxillaryvestibularapproach
• Bicoronalapproach
38. What are important considerations when exposing an orbital floor fracture?
Orbital rim fractures need to be adequately reduced prior to repairing any of the orbital walls. No
matter which surgical approach is used, the orbital floor dissection is similar in all cases. Pertinent
landmarks are the inferior orbital fissure and the infraorbital nerve and its canal. Dissection begins
subperiosteally from the inferior orbital rim exposing the orbital floor defect. Medially, the dissection
can be carried safely to the level of the posterior ethmoid foramen. At all times, the surgeon needs
to keep in mind that the orbital floor ascends at a 30-degree slope from the midaxial plane. The
tendency is to dissect into the maxillary sinus unless the surgeon is always ascending as he/she is
dissecting posteriorly. The periosteum should be completely dissected off sound bone around the
defect. The infraorbital nerve can serve as a guide for the surgeon’s path of dissection on the orbital
floor. Finally, the most important structure to locate is the posterior ledge of bone on which our reconstruction material can rest. Once we have adequate dissection and exposure, a suitable reconstructive
material can be used to span the defect.
39. What materials are used to reconstruct the orbital floor?
Restoring the correct anatomy of the orbit and orbital volume are more important than the material
used for restoration as long as the material provides adequate rigidity. The following are some of the
materials that have been used for this purpose:
• Inorganicalloplasticmaterials(e.g.,Medpor,Silastic,Vitallium,stainlesssteel,Teon,
Supramid, or titanium implants)
• Autogenousbonegrafts(splitcalvarial,iliac,orsplitrib)
• Allogenicbonegrafts
Ideal materials should be thin and rigid, minimal size needed to span the wall defect, properly shaped
to restore orbital volume, and placed tension-free and adequately stabilized. Additionally, adequacy of
reconstruction should be verified. This can be done by intraoperative versus postoperative CT or use of
an intraoperative navigation system.
40. What is the transantral approach for repairing the orbital floor?
The transantral endoscopic approach provides direct access to the orbital floor without any unsightly
skin incisions. The approach involves exposing the anterior maxillary sinus wall through an intraoral
maxillary vestibular incision and creating a bony window through the anterior portion of maxillary
sinus. Through this antrostomy, a 0-degree and 30-degree endoscope can be inserted to evaluate
the roof of the sinus that is the orbital floor. Orbital floor blowout fractures can then be reduced. If a
trapdoor defect exists, the fracture’s bony ledge should be elevated back to the anatomic position
with overlap of its edges on the native orbital floor. This may or may not need fixation. Alternatively, a
reconstruction plate/mesh can be properly shaped and introduced through the maxillary antral wall
defect with adequate curve to support the bony defect back into its proper position with inset into the
posterior ledge. Anterior extension of the plate is then brought through the antral window, and the
plate is stabilized with two small screws on the anterior maxillary wall.
41. Which incision has the greatest propensity for ectropion?
Scleral show and ectropion are frequent sequelae of the subciliary incision after lower lid surgery
and are often due to lid retraction. These conditions improve with time in many patients but may be
permanent deformities that result from permanent scarring within the lower eyelid.
42. What are the most frequent complications of inadequately treated or untreated
fractures of the orbital floor?
Diplopia and enophthalmos.
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43. What complications are associated with fractures of the orbital roof?
Fractures of the orbital roof usually involve the supraorbital ridge, frontal bone, and frontal sinus. The
trochlea of the superior oblique muscle is often damaged because of its proximity to the surface of the
roof, resulting in transitory diplopia. Another sign is globe displacement that occurs in an inferolateral
direction and may result in proptosis. Cranial nerve (CN) VI may be traumatized with orbital roof fractures, resulting in paralysis of the lateral rectus muscle and limitation of ocular abduction. Additional
complications include dural tears, anterior cranial base injuries, CSF leaks, cerebral herniation, and
pulsatile exophthalmos.
44. What is the mechanism of posttraumatic enophthalmos?
Enophthalmos results mostly from displacement of a relatively constant volume of orbital soft tissue
contents into an enlarged bony orbital volume caused by disruption and displacement of one or more
of the orbital walls. Enophthalmos in excess of 5 mm results in a noticeable deformity.
Diplopia is double vision, which is often transient and present only at the extremes of gaze rather
than within a functional field of vision. It is commonly attributed to hematoma or edema that causes
muscular imbalance by elevating the ocular globe or to injury of the extraocular musculature and
temporary effects on the oculorotary mechanism. Diplopia in itself is rarely an indication for surgery.
45. What is a blowout fracture of the orbit?
A blowout fracture of the orbit results from direct trauma to the globe resulting in distortion of the
globe and increased intraorbital pressure. The orbital rim generally stays intact, and the force is
transmitted to the interior area of the orbital cavity. The force is dissipated by outward fracture of the
weaker bones of the orbital floor and medial wall. As force increases, the fractures may extend both
posteriorly and circumferentially. A thorough physical exam and diagnostic imaging, specifically CT
scanning, are required to evaluate the size of the defect and possible entrapment of orbital structures.
Significant defects require operative repair to prevent posttraumatic enophthalmos.
46. What are the differences between superior orbital fissure syndrome and orbital
apex syndrome?
Superior orbital fissure syndrome results from compression of the contents found in the superior
orbital fissure by hematoma or bony fragment. Clinical findings include:
• PupillarydilationthroughdysfunctionofCNIIIinnervationofpupillaryconstrictormuscles
• OphthalmoplegiasecondarytopalsyofCNsIII,IV,andVI
• Uppereyelidptosisfromlevatorpalpebraeparesis
• Anesthesiaoftheforeheadandlossofcornealreexfromophthalmicdivisionofthetrigeminal
nerve compression
• Proptosissecondarytoedemafromobstructionoftheophthalmicveinandlymphaticsystem.
47. What is the relationship between orbital volume changes as they relate to orbital
The normal volume of the bony orbit is approximately 30 cc. Fractures of orbital bones may increase
48. What is hyphema, and how is it managed?
Hyphema is the layering of blood in the anterior chamber of the globe, usually from the tearing of
Orbital apex syndrome usually results from retrobulbar hematoma with compression of the optic
canal and superior orbital fissure. Clinical findings include tense proptosis and periorbital swelling,
retroorbital pain, pupillary dilation, ophthalmoplegia, and, most importantly, a change in vision.
Funduscopy reveals a pale disc with cherry red maculae. Prompt surgical decompression via lateral
canthotomy is required to prevent permanent vision loss.
trauma?
or decrease this volume, with resultant changes in the position of the orbital contents. Fractures that
decrease orbital volume compress the orbital contents and may create exophthalmos. Increases in
orbital volume provide more room for the globe and may result in dystopia or a change in the vertical
position of the globe. Enophthalmos is a change in the anterior-posterior position of the globe. Alterations
in globe position as a function of orbital volume change are dependent on two factors: disruption of
Lockwood’s suspensory ligament and the relationship of the change in volume relative to the axis of the
globe. The axis is defined as a line connecting the lateral orbital rim to an area just in front of the lacrimal
bone. Volume changes behind this line can produce significant alterations in globe position. It is estimated that 1 mL of volume loss behind the axis produces 1.5 mm of enophthalmos. Anterior orbital floor
and medial wall fractures are usually in front of the axis and produce minimal changes in globe position.
blood vessels at the root of the iris. It may present with pain, blurred vision, and photophobia.
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Retinal hemorrhage is also found in more than 50% of hyphemas. Management of hyphema is
directed toward prevention of rebleeding, which occurs in 3% to 30% of cases. Rebleeds generally occur 3 to 5 days after injury, are usually more severe than the original injury, and may result in
impaired vision, corneal staining, and glaucoma formation. Patients are usually admitted for bed rest
and daily ophthalmologic evaluation. An eye patch is applied, and increased intraocular pressure is
treated with topical beta blockers and carbonic anhydrase inhibitors or mannitol if necessary. Aspirin
is absolutely contraindicated in these patients.
49. What are the possible etiologies of extraocular movement disorders following
trauma?
Extraocular movements are controlled by the six extraocular muscles. The inferior, superior, medial
rectus, and inferior oblique muscles are all innervated by CN III (oculomotor). The superior oblique
muscle is innervated by the trochlear nerve (CN IV), and the lateral rectus muscle is supplied by the
abducens nerve (CN VI). Traumatic disruption of either muscle or nerve continuity would likely result in
a movement disorder manifested by limited gaze in the direction of affected muscle pull and binocular
diplopia. Entrapment of muscle in traumatic bony defects (e.g., orbital floor blowout fracture) also may
lead to restricted gaze.
50. What are the causes of traumatic ptosis?
Ptosis refers to the drooping of the upper eyelid. Normal resting eyelid position is mediated by
the sympathetic nervous system by the superior cervical ganglion. The muscle end point of these
nerves is Mueller’s muscle, a smooth muscle that inserts on the upper tarsal plate. Disruption of the
sympathetic fibers (e.g., in Horner’s syndrome) leads to ptosis. The levator palpebrae superioris is
responsible for voluntary eye opening and is innervated by CN III. Injury to this nerve or muscle also
results in ptosis. Alteration in globe position may result in the appearance of ptosis despite full function of related nerves and muscles.
BiBliography
Zygomaticomaxillary Complex and Orbital Fractures
Abubaker AO, Ziccardi VB, McDonald I: Midfacial fractures: fractures of the nose, zygoma, orbit and maxilla. In Abubaker AO,
Benson KJ, editors: Oral and maxillofacial surgery knowledge update, vol 3:TRA80-90. 2001, AAOMS.
Carter TG, Bagheri S, Dierks EJ: Towel clip reduction of the depressed zygomatic arch fracture, J Oral Maxillofac Surg
63(8):1244–1246, 2005.
Dal Santo F, Ellis III E, et al.: The effects of zygomatic complex fracture on masseteric muscle force, J Oral Maxillofac Surg
50:791–799, 1992.
Ellis III E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures, J Oral Maxillofac Surg
54:386–400, 1996.
Ellis III E, Reddy L: Status of the internal orbit after reduction of zygomaticomaxillary complex fractures, J Oral Maxillofac
Surg 62:275–283, 2004.
Haug RH, Bradrick JP, Morgan JP: Complications in the treatment of midface fractures. In Kaban LB, Pogrel MA, Perrott DH,
editors: Complications in oral and maxillofacial surgery, Philadelphia, 1997, W.B. Saunders, p 153.
Jamal BT, Pfahler SM, et al.: Opthalmic injuries in patients with zygomaticomaxillary complex fractures requiring surgical
repair, J Oral Maxillofac Surg 67:986–989, 2009.
Knight JS, North JF: The classification of malar fractures: an analysis of displacement as a guide to treatment, British
Journal of Plastic Surg 13:325–339, 1961.
Kontio R, Lindqvist C: Management of orbital fractures, Oral Maxillofac Surg Clin NA 21(2):209–220, 2009.
Lee EI, Mohan K, Koshy JC, Hollier LH: Optimizing the surgical management of zygomaticomaxillary complex fractures,
Semin Plast Surg 24(4):389–397, 2010.
Long JA, Gutta R: Oribital, periorbital, and ocular reconstruction, Oral Maxillofac Surg Clin NA 25:151–166, 2013.
Markiewicz MR, Bell BR: Traditional and contemporary surgical approaches to the orbit, Oral Maxillofac Surg Clin NA
24:573–607, 2012.
Markiewicz MR, Gelesko S, Bell BR: Zygoma reconstruction, Oral Maxillofac Surg Clin NA 25(2):167–201, 2013.
Miloro M, Ghali GE, Larsen P, Waite P: Peterson’s principles of oral and maxillofacial surgery, ed 3, Shelton, CT, 2011,
PMPH.
Moreira Marinho RO, Freire-Maia B: Management of fractures of the zygomaticomaxillary complex, Oral Maxillofac Surg
Clin NA 25(4):617–636, 2013.
Ogden GR: The Gillies method for fractured zygomas, J Oral Maxillofac Surg 49:23–25, 1991.
Palmieri CF, Ghali GE: Late correction of orbital deformities, Oral Maxillofac Surg Clin NA 24:649–663, 2012.
Rhea JT, Noveline RA: How to simplify the CT diagnosis of Lefort fractures, Am J Roentgenol 184:1700–1705, 2005.
Turvey TA, Golden BA: Orbital anatomy for the surgeon, Oral Maxillofac Surg Clin NA 24(4):525–536, 2012.
Zingg M, Laedrach K, Chen J, et al.: Classification and treatment of zygomatic fractures: a review of 1025 cases, J Oral
Maxillofac Surg 50:779–790, 1992.
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Orbital Fractures
Ellis III E: Orbital trauma, Oral Maxillofac Surg Clin NA 24(4):629–648, 2012.
Holmes S: Reoperative orbital trauma: management of posttraumatic enophthalmos and aberrant eye position, Oral Maxil-
lofac Surg Clin NA 23(1):17–29, 2011.
Joseph JM, Glavas LP: Orbital fractures: a review, Clin Opththalmol 5:95–100, 2011.
Kawamoto HK: Late posttraumatic enophthalmos: a correctable deformity? Plast Reconstr Surg 69:423–432, 1992.
Kontio R, Lindqvist C: Management of orbital fractures, Oral Maxillofac Surg Clin NA 21(2):209–220, 2009.
Long JA, Gutta R: Oribital, periorbital, and ocular reconstruction, Oral Maxillofac Surg Clin NA 25:151–166, 2013.
Manson PN, Iliff N: Management of blow-out fractures of the orbital floor. II. Early repair for selected injuries, Surv Ophthal-
mol 35:280–292, 1991.
Markiewicz MR, Bell BR: Traditional and contemporary surgical approaches to the orbit, Oral Maxillofac Surg Clin NA
24:573–607, 2012.
Nguyen PN, Sullivan P: Advances in the management of orbital fractures, Clin Plast Surg 19:87–98, 1992.
Palmieri CF, Ghali GE: Late correction of orbital deformities, Oral Maxillofac Surg Clin NA 24:649–663, 2012.
Turvey TA, Golden BA: Orbital anatomy for the surgeon, Oral Maxillofac Surg Clin NA 24(4):525–536, 2012.
MIDFACIAL FRACTURES:
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NASAL, NASOETHMOIDAL,
AND LE FORT FRACTURES
CHAPTER 32
A. Omar Abubaker, Deepak G. Krishnan, Michael J. Grau Jr.
NASAL FRACTURES*
1. Where are the most common sites for nasal bones to fracture?
Fractures of the nasal bones occur most commonly in the distal nasal bones, which are broad and
thin. Direct frontal blows to the nasal dorsum usually result in fracture of the thin lower half of the
nasal bones. The proximal nasal bones are stronger and thicker and relatively resistant to fracture.
However, when the force of the blow is more severe, the fracture may involve the more proximal nasal
bones, the frontal process of the maxilla, and the frontal bone.
2. What is the role of radiographs in the diagnosis and treatment of nasal fractures?
Standard facial radiographs are of limited diagnostic and therapeutic value in the treatment of nasal
fractures. However, radiographs can serve as a physical record of a nasal fracture, and computed
tomography (CT) scans can accurately determine the degree of displacement of nasal fractures
and fractures of the orbitoethmoidal region. Therefore, although radiographic documentation is
recommended for medical-legal reasons, physical exam of the nose should provide the basis for
whether surgical intervention is indicated.
3. When is nasal packing indicated after treatment of nasal fractures?
After successful reduction of a nasal fracture, intranasal packing is often used to serve the following
purposes:
• Tocontrolbleedingandpreventpostoperativeseptalhematoma
• Tosplintthenasalseptumintopositionandkeeptheseptalmucosaadaptedtotheseptalcartilage
and to provide internal support for reduced bone fragments
• Topreventsynechiaeiflargeareasofmucosaareabraded
4. What are the indications for posterior nasal packing?
A posterior pack is indicated for posterior nasal bleeds. This type of bleeding is often diagnosed when
the patient’s chief complaint is bleeding into the throat or if a posterior nosebleed is visualized and the
bleeding cannot be controlled with a well-placed anterior pack.
5. How long should a posterior pack be left in place?
For 3 to 5 days.
6. What is the treatment of a severely comminuted nasal fracture?
Severely comminuted nasal fractures usually can be reduced primarily and supported with intranasal
packing and externally applied splints. Packing is placed underneath the nasal bones so that formation of the bone fragments is sandwiched between and supported by internal and external support
mechanisms. The combination of internal and external splinting helps prevent hematoma, compresses
and narrows the splayed nasal dorsum, and conserves nasal height. Open reduction of a comminuted
nasal fracture early after injury risks loss of bone fragments with little soft tissue attachment and
should be used with caution or avoided completely.
* Written by A. Omar Abubaker, Vincent B. Ziccardi, and Ian McDonald.
340
CHAPTER 32 MIDFACIAL FRACTURES 341
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7. What are the indications for secondary treatment of nasal fractures?
Even with adequate reduction, postoperative nasal deformity may still occur, and patients should be
informed of such a possibility. Late deformities may include a nasal hump or deviation, loss of dorsal
height, septal deviation, and nasal obstruction. Secondary treatment of nasal fractures is indicated
when any of these deformities is present, especially in the presence of either functional or cosmetic
problems.
8. How are acute septal hematomas treated?
Septal hematomas are treated with an incision along the base or most inferior portion of the hema-
toma to allow dependent drainage and prevent refilling of the cavity with blood or serum. Bilateral
hematomas can be treated with bilateral incisions, maintaining an intact septal cartilage, or with a
unilateral incision and resection of a window of cartilage to allow a bilateral communication with the
incision. A light nasal packing and prophylactic antibiotics are recommended.
9. How soon after injury should a nasal fracture be reduced?
Nasal fractures should be reduced within the first few hours after injury, if at all possible. If this is not
done within this period, edema makes accurate judgment of the degree of deformity and the decision
to operate difficult. The next window of opportunity occurs 3 to 14 days after injury, after the edema
has resolved but before bony union of the fractured fragments occurs.
10. What are the late complications of nasal fractures?
The following complications may be seen following nasal fractures with and without treatment:
• Airwayobstruction
• Nasaldeformitysecondarytosaddledeformityordorsalhump
• Nasaldeviationandseptalperforation
• Theformationofsynechiaebetweentheseptumandturbinates
• Recurrentepistaxisandrecurrentsinusitisandheadaches
11. What is a nasal septal hematoma, and how is it treated?
A nasal septal hematoma usually presents as a boggy, blue elevation of the septal mucosa. This
finding is significant because it requires drainage to prevent secondary infection and necrosis of
the septal cartilage leading to perforation and possible saddle nose deformity. Drainage can be
accomplished by either needle aspiration or small mucosal incision. Transseptal resorbable sutures
and nasal packing can be placed to prevent re-accumulation of blood.
Septal hematomas are treated with an incision along the base or its most inferior point to
allow dependent drainage and prevent its refilling with blood or serum. Bilateral hematomas can be
treated with bilateral incisions, maintaining an intact septal cartilage, or with a unilateral incision and
resection of a window of cartilage. Nasal packing and prophylactic antibiotics are recommended.
12. What is saddle nose deformity?
Saddle nose deformity is the concave appearance of the nasal dorsum that sometimes follows
significant nasal trauma. It results from fracture and inferior displacement of the nasal bones, resulting in buckling of the cartilaginous septum and disruption of the upper lateral cartilage position. Late
effects of the injury that amplify the deformity include septal collapse, which may result from septal
hematoma formation, asymmetric septal growth, and scar contractures.
13. How is epistaxis managed in the emergency department?
Anterior nasal epistaxis usually involves Kiesselbach’s plexus, which is the confluence of the
terminal ends of the superior labial, anterior ethmoid, and sphenopalatine arteries. Packing of this
area with phenylephrine-soaked cotton pledgets is frequently successful. Direct visualization with
a nasal speculum may allow direct cauterization with either electrocautery or silver nitrate sticks
to be performed. Excessive cauterization should be avoided, however, to prevent subsequent septal
perforation. Most commonly, sterile petrolatum-impregnated gauze is carefully packed in a layered
manner and left in place for 2 to 5 days. Broad-spectrum antibiotic coverage should be initiated to
prevent maxillary sinus infections caused by blockage of the middle meatus.
Posterior nosebleeds are more difficult to manage due to inability to provide adequate pressure
with nasal packing. This frequently is managed by placing a Foley urinary catheter into the affected
nares, inflating the balloon with saline, and pulling the balloon back to seal the nasopharynx and to
allow packing to be placed around the Foley. Tension is maintained on the catheter by placing an
umbilical clip on it at the entrance of the nose. Commercially available posterior nasal balloons are
also available.
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