Preliminary Results of 10 Cases of Endoscopic Orbital Floor Repair

Problem: Orbital floor fracture repair via peri-lid approaches have known risks, but patients with isolated orbital floor defects may benefit from Endoscopic Trans-antral Repair of orbital floor fractures to eliminate the potential facial scars and scleral show.  

Materials and Methods: 10 patients with orbital floor fractures with defect >2cm, hypoglobus, pain on lateral gaze, restricted extraocular movements were taken to OR for transantral repair of orbital floor fractures.  Sample size: 10 patients.  Duration of Study from September 2015 - September 2016.  Patients were taken to the OR under general anesthesia underwent transantral orbital floor repair as described by Ducic et. al with traditional gingivobuccal sulcular incision to expose the anterior maxilary sinus wall.  Then a caldwell luc window 1.5cm x1.5cm was made into the anterior maxillary sinus wall while using caution to prevent injury to the Infraorbital nerve and roots of the teeth.  Then a 0 to 30 degree 4mm Rigid scope was placed into the window and the defect was explored, the herniating peri-orbital contents were visualized and reduced.  An PTFE alloplastic material (Medpore) was placed to repair the orbital floor defect.  Forced duction tests were performed after reduction of peri-orbital contents.   

Methods of Data Analysis: Post-reduction endoscopic visualization confimed adequate reduction and restoration of orbital volume.  Also, all patients underwent follow-up evaluation to check for diplopia, enopthamos, pain or restriction on lateral gaze up to 3 months.

Results: There were no cases of blindness, evidence of lid complications (Ectropion, Entropion) or new permanent diplopia, or new infraorbital anesthesia.

Outcomes Data: One patient developed sinusitis requiring removal of anterior maxillary sinus wall fixation and debridement via antrostomy.  One patient required removal of Medpore mesh after the alloplastic material was not adequately adapted to remaining walls around the floor defect.  Sagital view of allograft PTFE implant on CT scan with poor adaption due to implant staying rolled up and flexing.  All patients who had binocular diplopia post trauma had resolution of binocular diplopia.  Intraoperative photographs and video demonstrating the periorbital fat herniating into the maxillary antrum, extent of the orbital floor defect and placement of orbital floor mesh.

Conclusions: Endoscopic trans-antral repair of isolated orbital floor fractures can completely eliminate the risk of complications associated with traditional peri-lid incisions including facial scarring and ectropion.  As with any endoscopic procedure there is always a learning curve, but the caldwell luc window through the anterior maxillary sinus wall provides almost straight line access to most isolated orbital floor fractures.  This direct visuailzation is beneficial in orbital floor fractures to ensure proper adaptation of the alloplast to remaining walls especially in larger posterior defects.  This is essential in restoring the proper orbital volume. 

References:  Ducic Y, Verret DJ. Endoscopic transantral repair of orbital floor fractures. Otolaryngol Head Neck Surg. 2009;140(6):849–854  

Cheung K, Voineskos SH, Avram R, Sommer DD. A systematic review of the endoscopic management of orbital floor fractures. JAMA Facial Plast Surg. 2013;15(2):126–130.