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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
268
CHAP TER9 The cheek andorbit
Figure9.2 Restr iction of upwardgaze.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial
Injuries, ‘Orbi tal Fr actures’, 2014, F igur e9.7a, eds M. Pe rry and S. H olme s, Copy righ t © 2014,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
Management
In all cases it is important to advise the patient not to blow their nose. This is
because if they do, pressur ized air can pass through the nose and antrum
(sinus) into the orbit via the fr acture. This potentially could introduce
bacteria and result in orbital cellulitis. See Figure9.3.
Many hospitals advise prophylactic antibiotics specically. Initial measures include:
• Tell patient not to blow their nose for 3weeks.
• If they have to sneeze, do so with mouthopen.
• Consider antibiotics (co- amoxiclav 375 mg three times daily for
5days).
• Tell the patient to return if they have increasing swelling, pain, or
change in visual acuity.
• Chloramphenicol ointment may be applied to any conjunctival injury.
• Refer to ma xillofacial sur ger y, or specialty that repair s facial
fractures.
• If there are ocular symptoms, refer also to ophthalmology.
Never allow a patient with a suspected blowout fracture to go home if you
have been unable to assess the eye. Inability to open the eyelids is not an
acceptable reason. If you cannot assess the eye, discuss with ophthalmolog y.
Surgical repair of a blowout fracture is not necessary in every case and
is not urgent, except in children where it can be a surgical emergency. The
eye takes priorit y. Where an injury to the globe or associated nerves is
suspected, an ophthalmic opinion should be sought.
ORBITAL FRACTURES (ISOLATED)
Figure9. 3 Surgical emphysema.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘After care and Fol low- up’, 2014, Figu re19.5, ed s M. Perry an d S. Holmes , Copyr ight © 2014,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
Indications for repair of a blowout fracture include:
• Signicant diplopia
• Aretractionsign
• Dystopia (displacement ofglobe)
• Enophthalmos
• A‘large’ blowout on CT— said to predispose to the late development
of enophthalmos.
The aim of repair is to release entrapped soft tissues and restore orbital
geometry and volume. This should release any restrictions on eye movement and restore globe position. Timing of surger y is controversial and
dependent on multiple factors. If the tissues are ver y swollen or there
are minimal signs it is common practice to delay surgery for up to 10 –
14days post- injury. This allows any swelling to settle and gives an idea
of any disability.
In children, the orbits are shallow and there is a greater chance of muscle
entrapment and ischaemic incarceration of the orbital soft tissues or muscles.
Inappropriate pain, blepharospasm, or vomiting may suggest this. Immediate
surgical intervention is indicated.
269
270
CHAP TER9 The cheek andorbit
cZygomatic (malar) fractures
Cheek fractures are common injuries and comprise a spectrum from relatively simple fractures resulting in minimal cosmetic problems, to complex
patterns causing gross disgurement and considerable functional disability.
The terminolog y can also be a little confusing as they often go by a variety
of names (zygoma, malar, zygomaticomaxillary, tripod— to name afew!).
The typical fracture pattern is that of a tetrapod. The ‘feet’ or ‘pods’
relate to the four main sites of fracture displacement, which can be identied either clinically or radiographically. The arch fractures separately
from the remaining sites, which are joined together by a continuous ring
of interlinking fractures. Together this allows separation of the entire
cheek from the rest of the facial skeleton. Although commonly seen ‘en
bloc’, as the energy transfer increases from mild to moderate to severe,
fracture complexity increases correspondingly, with progression to
comminution. Management can therefore vary widely. From a practical
viewpoint fractures can be consideredas:
• Isolated:
•
Zygomaticarch
•
Infraorbital rim (uncommon)
• Minimally displaced
• Signicantly displaced
• Comminuted
• Fractures with associated mid- facial or complex orbital oor/ wall injury.
All zygomaticomaxillary fractures, by denition, have a fracture line running
through the orbit. Patients should therefore be assessed for ocular injury,
diplopia, and entrapment. The eye takes priority. Associated ocular prob-
lems include:
• Globe/ muscleinjury
• RBH
• Superior orbital ssure syndrome
• Orbital apex syndrome.
Clinical features
These vary depending on the force of impact and degree of displacement
of the cheek. They include:
• Signs of injur y:
•
Pain
•
Swelling/ bruising
•
Subconjunctival haemorrhage
•
Surgical emphysema
• Signs of orbital involvement:
•
Double vision/ limitation of eye movement
•
Enophthalmos
•
Proptosis (exophthalmos)
• Signs of fracture displacement:
•
Flattening of the malar prominence (of ten masked by swelling
immediately after injury)
•
Palpable infraorbitalstep
•
Antimongoloidslant
•
Hypoglobus (vertical ocular dystopia)
•
Altered sensation of cheek/ upperlip
ZYGOMATIC (MALAR) FRACTURES
•
Restricted jaw movements
•
Malocclusion (premature contact of the molar teeth on the side of
injury).
A well- dened ‘black eye’ or a subconjunctival haematoma with no posterior limit,
are reliable signs of a fracture involving the orbit. Assess these patients carefully.
Investigations
• Visual acuity/ orthoptic assessment.
• Occipitoment al, lateral face. Look carefully, sometimes the only clue
is a uid level in the antrum.
• CTscan.
• Ultrasound scan and maxillary sinus endoscopy for orbital oor
fractures have been reported as useful techniques but usually have no
role in an emergency department setting. They are rarely undertaken.
Interpreting occipitomentalviews
To the inexperienced, interpreting occipitomental images can be tricky. This
is probably due to a combination of complex anatomy, superimposition of
the skull (notably va scular markings and sutures), and the relatively oddly
angled views compared with images taken elsewhere in the body. The best
way to learn is to see plenty of examples. Anumber of useful approaches
have been described to help in interpretation. See Figures 9.4 and9.5.
271
Figure9.4 Campbell’slines.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Fra ctur es of th e Chee k:Zygom aticomax illa ry Com plex’, 2014, Figu re8.11b, eds M . Perr y and
S. Hol mes, C opyri ght © 2014, Spri nger - Verla g Londo n. With per missi on of Sp ringe r Nature.
272
CHAP TER9 The cheek andorbit
Figure9.5 Occipitome ntal view of f ractured zygo ma.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Fra ctur es of th e Chee k:Zygom aticomax illa ry Com plex’, 2014, Figu re8.13, eds M. Perr y and
S. Hol mes, C opyri ght © 2014, Spri nger - Verla g Londo n. With per missi on of Sp ringe r Nature.
Knowledge of a ‘tetrapod’ frac ture conguration enables one to
inspect the key areas (or ‘pods’) on an occipitomental view. These are
the sites where displacement is most noticeable. Alternatively the ‘baby
elephant’ interpretation involves checking the sites shown (one infraorbital rim, two frontozygomatic sutures, and three zygomaticomaxillary
buttress) and looking for a broken ‘trunk’!
Management
In all cases it is important to advise the patient not to blow their nose. This is
because if they do, pressur ized air can pass through the nose and antrum
into the orbit via the fracture. This potentially could introduce bacter ia
and result in orbital cellulitis. Many hospitals advise prophylactic antibiotics specically. Initial measures include:
• Tell patient not to blow their nose for 3weeks.
• If they have to sneeze, do so with mouthopen.
• Consider antibiotics (co- amoxiclav 375 mg three times daily for
5days).
THE BULGING EYE (PROPTOSIS/EXOPHTHALMOS)
• Tell the patient to return if they have increasing swelling, pain, or
change in visual acuity.
• Chloramphenicol ointment may be applied to any conjunctival injury.
• Refer to ma xillofacial sur ger y, or specialty that repair s facial fractures
• If there are ocular symptoms, refer also to ophthalmology.
Never allow a patient with a suspected zygomatic fracture to go home if you
have been unable to assess the eye. Inability to open the eyelids is not an
acceptable reason. If you cannot assess the eye, discuss with ophthalmolog y.
Surgery is usually carried out either immediately or about 5– 6 days
following injury. Many fractures are treated by open reduc tion and internal xation (OR IF) with titanium miniplates. Surgical access for reduction
and xation is commonly through the mouth to avoid facial scars. Access
to the frontoz ygomatic suture and infr aorbital rim may also be necessary
to assist reduction and xation.
cThe bulging eye (proptosis/
exophthalmos)
Proptosis, or exophthalmos, is the forward displacement of the eye in
the orbit. Since the orbit is essentially a closed cavity, any enlargement
of structures located within it will cause this. It can be unilateral or bilateral, acute or longstanding. When unilateral and non- traumatic, consider
an orbital tumour or orbital cellulitis. Some degree of proptosis, usually
minor, is common following trauma to the eye or orbit. Complete or
partial dislocation of the globe from the orbit is possible but is very rare.
In the vast majority of cases proptosis is not vision threatening despite
its obvious cosmetic eects. Never theless, many patients complain of
symptoms related to a dry eye and if the cor nea remains unprotected
serious complications canoccur.
All cases of proptosis should be investigated for underlying or associ-
ated pathology (notably thyroid disea se or orbital tumour).
Causes
• Periorbital trauma (from retrobulbar swelling, bleeding, displaced
bones/ air)
• Graves’ ophthalmopathy (hyperthyroidism). This can also cause
unilateral proptosis
• Orbital cellulitis
• Dacryoadenitis
• Mucormycosis
• Orbital pseudotumour
• High- altitude cerebraloedema
• Wegener’s granulomatosis
• Tumours (leukaemia, lymphoma, meningioma, sarcoma,etc.)
• Haemangioma
• Dermoidcyst
• Carotid- cavernous stula (look for pulsation)
• High myopia (short- sightedness).
273
274
CHAP TER9 The cheek andorbit
eTrauma- related proptosis
Proptosis following trauma occurs in approximately 3% of craniofacial
injuries. However, vision- threatening proptosis is a much rarer event.
Never theless, when it occur s urgent intervention is required if loss of
vision is to be prevented. Usually proptosis is apparent by the time the
patient arrives in the emergency department, but delayed presentation
of up to several days can alsooccur.
The orbit is essentially a rigid box, except anteriorly. It is therefore at risk
of a compartment syndrome following trauma. Bleeding or swelling quickly
results in a r apid r ise in interstitial pressure, decreased perfusion pressure, and, if untreated, ischaemia and infarction. Re- est ablishment of
perfusion is therefore essential if sight is to be saved. The two most common causes of sight- threatening proptosis following trauma are gross
swelling behind the eye (orbital compartment syndrome (OCS)) and
bleeding behind the eye(RBH).
fRetrobulbar haemorrhage/ orbital compartment
syndrome
RBH is usually a clinical diagnosis and needs to be treated as soon as
possible. It is eectively an acute compartment syndrome within the orbit
and should be managed with the same degree of urgency as compartment
syndromes elsewhere in the body. Raised intra- orbital pressure is caused
by bleeding and oedema. This is contained within the bony orbit, behind
the relatively unyielding orbital septum. Bleeding can occur within or
outside the muscle ‘cone’, formed by the recti muscles, intra- conal
bleeding being more severe. As the pressure rises, it compresses the
ophthalmic and retinal vessels, resulting in retinal and optic ischaemia . In
many cases there is no bleeding but oedema. When severe enough, this
presents in exactly the same way. This is termed orbital compar tment
syndrome(OCS).
Clinical features
Consider retrobulbar haemorrhage if thereis:
• Severe eyepain
• Acute proptosis
• Visual loss/ RAPD
• Severely decreased eye movements in all directions
(ophthalmoplegia).
Marked lid oedema may make proptosis dicult to recognize. Inability
to open the eyelids with any one of these features is highly suspicious for RBH/ OCS. Failure to recognize this may result in blindness.
Irreversible damage has been estimated to occur following only 90
minutes of ischaemia. Raised IOP can be assessed with a Tono- Pen®,
however many emergency departments will not have this equipment
available. Therefore if suspected it is bet ter to err on the side of caution
and assume it is present. Time is of the essence in any patient with dete-
riorating vision and increasing pain— these are the ones in whom treatment
is most likely to be successful. If you can, per form an immediate lateral
TRAUMA-RELATED PROPTOSIS
canthotomy and cantholysis. If you cannot, get immediate help and learn
how to do this. As for a surgical airway, this needs to be done immediately and any delay waiting for a ‘specialist’ to arrive will worsen the
prognosis. Urgent referral to ophthalmolog y and maxillofacial surger y
is also required (depending on local referral pathways). The canthotomy
just buys time. For mal decompression may be required, depending on
the clinical picture.
Lateral canthotomy/ cantholysis
Late ral canth otomy with l ateral ca nthal ten don divisi on can be per formed
under local anaesthesia in the emergency department . Lignocaine 1%
with adrenaline (epinephrine) (1 in 200,000) is injected into the lateral
canthal area of the aected eye and the lateral canthus is incised to the
orbital rim and the identied canthal tendon cut. The tendon is identied
by ‘strumming’ the tissues, while the eyelid is pulled medially and out.
Great care must be taken to avoid damage to the globe. The lower lid
attachment is always divided and some authorities recommend division
of the upper lid attachment as well. This allows the globe to translate
forward, partially relieving the pressure by eectively increasing the retrobulbar volume. The steps for thisare:
• Clean the site with sterile saline.
• Inject local anaesthetic into the lateral canthus.
• Cr ush the lateral canthus with a straight haemostat, advancing the
jaws of the clip into the later al fornix until the rim of the bony orbit
isfelt .
• Clamp for 30– 60 seconds.
• Using straight scissors, make a 1cm long horizontal incision of the
lateral canthal tendon, in the middle of the crushmark .
• Grasp the lower eyelid with toothed forceps, pulling the eyelid away
from the face. This pulls the inferior crus (the band of the lateral
canthal tendon) tight so it can be easily cut loose from the orbit al rim.
It will have a ‘banjo str ing’ feel against the tip of the scissor s.
• Continue to pull the lower eyelid outwards and downwards away
from theeye.
• Use blunt- tipped scissors to cut the inferiorcrus.
• Keep the scissor s parallel (at) to the face with the tips pointed
towards the chin. Place the inner blade just anterior to the
conjunctiva and the outer blade just deep to theskin.
• The globe should pull freely away. It may also ‘pop’ for ward, relieving
the pressure. Cut any residual lateral attachments of the lower eyelid
if it does not move freely.
• Do not worr y about cutting ½ cm of conjunctiva or sk in. The lower
eyelid is cut, relieving orbital pressure.
• If the int act cornea is exposed apply ointment or lubr icant to prevent
corneal desiccation and infection.
• Do not apply absorbent gauze dressing to the exposed cornea.
See Figure9.6.
275
276
CHAP TER9 The cheek andorbit
Figure9.6 Lateral canthotomy and cantholysis.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Ini tial Co nsiderat ions:High - vs. Low - En ergy Inj urie s and th e Impl icati ons of Co exis ting
Mult iple I njur ies’, 2014, Fig ure1.51d, eds M. Pe rry and S. H olmes, Copy right © 2014, Sp ringerVerlag L ondon. Wit h perm ission of Spr inger.
Medical decompression
This should be commenced in addition to the canthotomy.
• Mannitol (osmotic diuretic) 20% 2 g/ kg IV over 5 minutes.
• Dexamethasone 8mgIV.
• Acetazolamide (carbonic anhydrase inhibitor, reduces production of
aqueous humour), 500 mg IV then 250 mg 6- hourly for 24hours.
Visual acuity is the key to urgenc y. If the vision is normal, patients can be
investigated urgently to nd the precise cause. But if the vision is rapidly
deteriorating, or already signicantly aected, time is of the essence. Think of
the vision as the ‘GCS of theeye’.
Assessment ofproptosis inthe unconscious patient
Comprehensive assessment of proptosis in the emergency department,
ICU, or operating theatre is usually not possible in the early stages of
management. What is possible is often limited, even more so if the
patient is confused, agitated, or unresponsive. Dierentiation between
RBH and OCS on clinical grounds alone is not always possible since both
share similar features.
In awake patients, clinical urgency can be determined by deterioration in visual acuit y. However, in the unconscious or agit ated patient,
this is not possible. Pain and ophthalmoplegia, two fur ther indicators
of vision- threatening proptosis, also cannot be determined. It is also
worth remembering that a well- made prosthetic eye can fool all but the
most astute of clinicians. In unconscious patients, initial assessment of
any proptosis is therefore signicantly restricted to a relatively crude
examination. This includes assessment of the eyelids, pupils, careful palpation of the globes, and, if possible, fundoscopy (or portable slit lamp
ORBITAL CELLULITIS
examination). Each has its limitations. In many patients, the only readily
identiable signs of RBH/ OCS will be a ‘tense’, proptosed globe with an
abnormally reacting pupil and swollen disc. The main issue is to maintain
a high index of suspicion and to seek adviceearly.
If the patient requires a CT scan of part of their body and their condition
allows, request a CT of the orbits (or head). The additional time required to
obtain these scans is now relatively small and you may identify a treatable
cause of proptosis.
Remember that proptosis following trauma has several causes:
• Blood(RBH)
• Oedema(OCS)
• Air (surgical emphysema)
• Bone (fractures displaced into theorbit)
• Brain (craniofacial fractures)
• Contra st material (interventional radiology), a rarecause.
eOrbital cellulitis
This is a severe infection deep to the orbital septum, involving the orbital
contents. The commonest source of infection is from infected periorbital
sinuses (especially the ethmoid), or from spread of a preseptal cellulitis.
The orbital septum is therefore a key anatomical landmar k, which acts as
a barrier to spread of infection during the initial stages. Tooth abscesses
and organisms introduced by trauma are other, less common causes.
Patients with orbital cellulitis are of ten unwell with a high fever and a
painful, swollen eye. There is a quick onset of rapidly worsening symptoms often with a history of sinus disease, periorbital infection, or injury.
There is marked proptosis, chemosis, and lid oedema, which is red,
hot, and tender to touch. Visual acuity and colour vision are reduced,
together with an R APD, if the optic ner ve is involved. Eye movements
are reduced and painful. Fundoscopy may show swollen optic ner ve head
and ar ter y or vein occlusions.
The main dierential diagnosis is pre- sept al cellulitis, which is less
severe and represents an infection anterior to the septum. This generally follows an eyelid infection. If there is blurred vision, or the conjunc tiva
is injected, even without other signs of posterior involvement, assume orbital
cellulitis until proven otherwise.
Management
• Patients should be urgently admitted. Refer to ophthalmology.
• FBC, biochemistry, and blood cultures should be performed.
• CT of the or bit and brain is necessary to look for intracranial
involvement, pus, and to assess the sinuses.
• Commonly associated pathogens are Staphylococcus aureus,
Streptococcus pneumoniae and pyogenes, and (in children) Hamophilus
inuenzae. High- dose, broad- spectrum IV antibiotics that cover both
anaerobic and aerobic organisms should be administered after the
blood cultures have been taken. Metronidazole and ceftazidime is
one such combination.
• Urgent surgical drainage of orbital, sinus, tooth, and brain abscesses
is usually required.
277