PÁGINA DEL RESIDENTE

What is the diagnosis and how would you manage the surgical complication?

¿Cuál sería su diagnóstico y el manejo de la complicación quirúrgica?

After trauma to the left face, a 23-year-old patient presented a subpalpebral wound that was sutured in the emergency room, fracture and collapse of the zygomatic arch, and orbito-malar fracture without displacement. With the permission of the patient, we decided to schedule treatment of the zygomatic arch fracture by closed reduction with a bone hook.

Two days after the fracture and under general anesthesia, an incision was made by cryocautery in the fracture area. The bone hook was introduced and, when it was positioned under the fracture of the arch, traction was applied to the zygomatic arch to reduce the fracture. After several maneuvers, acute proptosis occurred, which was difficult to reduce, together with left conjunctival herniation (Figs. 1 and 2).

Orbital hematoma drained through the maxillary sinus

Hematoma orbitario drenado a través del seno maxilar

K. Arbulú Tarazona¹, M.Á. Bada García², J. Garatea Crelgo², A. Riaño Argüelles², I. Quílez Sardá²

1 Médico Residente.
2 Médico Adjunto.
Servicio de Cirugía Oral y Maxilofacial.
Hospital Virgen del Camino. Pamplona. España

Dirección para correspondencia

Orbital hematoma appeared as a complication of the surgical maneuvers and/or mobility of the fracture foci. We decided on emergency drainage in the same surgical act by an incision in the oral vestibule, removal of the periosteum, and opening of the maxillary sinus by puncture with a Crile type clamp without waiting for the assembly and startup of a surgical micromotor. An aspiration cannula was inserted into the bone opening, and blood aspiration was quickly apparent, resulting in resolution of the hematoma with reduction of the proptosis and conjunctival herniation. An intraoral drainage tube was left in place (Figs. 3 and 4).

We chose the intraoral tract because we thought that it would provide rapid access to the hematoma and was facilitated in this case by a fracture of the orbital floor, without displacement, that would facilitate drainage. We decided not to open the wound on the orbital rim because it had been sutured by another professional and we did not know its extension.

Discussion

Closed reduction of fractures of the zygomatic arch by means of a bone hook does not satisfy some of the general principles accepted for the treatment of facial fractures (exposure of fracture foci, anatomic reduction, rigid internal fixation), but it is one of the techniques admitted for restoring the lateral projection of the middle third of the face. However, and guarantee of precision and stability that it provides may be difficult to evaluate intraoperatively: the precision depends mainly on the surgeon’s subjective assessment and stability depends on the integrity of the periosteal fixation. If we add the lack of visual control of a closed reduction with a bone hook to the complicated zygomatic-malar zone, it is understandable that injury to facial structures or potential complications may occur (Fig. 5).

When orbital hemorrhage occurs during the repair of a fracture, we have to ask ourselves what caused the hemorrhage, the fracture itself or our surgical maneuvers? However, we will not often reach an answer that is one hundred percent validated. In this case, it is impossible to know whether intraorbital bleeding occurred as a result of the mobility of the fracture foci or direct injury of a vascular structure with the hook.

Knowing the anatomy of the orbit, we understand its lack of flexibility and how small hematomas can create a «compartment syndrome» with an increase in intraorbital pressure, exophthalmos, vascular compression and/or compression of the optic nerve, with dramatic consequences. We almost can affirm that there is some degree of fracture of the orbital floor in any orbito-malar fracture. Therefore, intraorbital hematomas appear more frequently in fractures without orbital displacement. If clear lines of fracture exist, there usually is natural drainage into ethmoidal cells or maxillary sinus, followed by epistaxis and spontaneous decompression.

The signs that warn us during surgery of an orbital hematoma are: acute proptosis that is hard to reduce, periorbital inflammation/ hematoma, and pupil dilation. This complication has to be treated immediately because the functional recovery on the eye and prevention of vision loss or blindness depend on the speed of diagnosis and prompt decision to perform emergency surgical drainage.

Surgical decompression can be performed by different routes, i.e., opening local wounds that may exist after the traumatism, incision at the tail of the eyebrow or on the eyebrow for access to the orbital floor (transconjunctival, subciliary, and along palpebral folds or the infraorbital rim), lateral canthotomy with cantholysis, endonasal endoscopy, Caldwell-Luc approach).

Once the orbit is reached, the problem will be solved if the collection is between the orbital wall and periorbit (orbital periosteum), or if the periorbit is perforated. However, if the hematoma is above an intact periorbit, we will have to make an incision to evacuate it. Intraconal dissection may even be necessary, generally between the inferior and lateral rectus muscles. Treatment is completed with medical therapy, consisting of high doses of corticoids and even diuretics. Later evaluation by the ophthalmologist is fundamental, who will studyi the ocular fundus, optic nerve function, and intraocular pressure.

Dirección para correspondencia:
Karen Arbulú Tarazona
Servicio de Cirugía Oral y Maxilofacial. Hospital Virgen del Camino
C/ Irunlarrea, 4.
31008-Pamplona. España
karbulut@navarra.es

References

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4. Ellis E. Fractures of the zygomatic complex and arch. En: Fonseca R, Walker R, editors. Oral and maxillofacial trauma. Philadelphia: Saunders 1991;435-514.        [ Links ]

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