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Abstract SUMMARY AND CONCLUSIION Head and neck trauma contributes significantly to mortality and morbidity. Most of these injuries are due to vehicle accidents. Other etiological factors include personal assaults, falls, sport injuries and industrial injuries. The orbits are paired bony structures in the midface separated in the midline by the inter-orbital space. They are limited above by the floor of the anterior cranial fossa and below by the maxillary sinuses. Orbital fractures result from severe injuries in the midfacial area. The concept of orbital blowout fracture was advocated by Lang in 1889. Smith and Regan, 1957, defined it as a fracture of the orbital floor caused by sudden increase in the intra orbital or hydraulic pressure. They may occur as isolated fractures or in association with fracture of the maxilla, zygoma, nasoorbital or frontoethmoidal areas. Orbital blowout fractures are classified into pure and impure blowout fractures. Impure blowout fractures are associated with fracture of the adjacent facial bones including the thick orbital rim. All patients with orbital fractures require ophthalmologic examination, radiological evaluation. Visual acuity must be documented. Pupil reactivity, eye mobility, visual field, intraocular pressure, and fundus examination are essential Summary and Conclusion components of the evaluation. Loss of sensation in the cheek, the ala of the nose and the upper lip is suggestive of a blowout fracture involving the infraorbital canal or groove in the floor of the orbit. Normal infraorbital nerve conduction implies that the fracture site is lateral or medial to the infraorbital canal.Diplopia and cosmetically unacceptable enophthalmos are the major complications of blowout fractures. A number of methods have been advocated for the treatment of blowout fractures. The surgical approaches may be open, endoscopic or combined. The trans-maxillary endoscopic approach for repair of OBFs offers better visualization of the posterior orbital shelf, accurate implant placement, and reduced postoperative periorbital edema, It also eliminates the need for eyelid incisions and the potential for postoperative malposition when compared to the other methods, but on the other hand, it tends to consume additional operating room time, add its own morbidities as transient postoperative infraorbital paresthesia, maxillary sinusitis, persistent diplopia, or residual enophthalmos. This technique can also be used for intraopertive assessment of orbital floor disruption after reduction of zygomaticomaxiallary complex fractures. Surgeons learning this technique can use transmaxillary endoscopy to assist with the dissection and confirm implant placement during traditional Summary and Conclusion - 148 - eyelid approaches. Orbital floor blowout fractures can be endoscopically catagorized into 3 types: medial trapdoor, medial blowout, and lateral blowout fractures. Medial trapdoor fractures can be repaired without the need for an orbital implant. Medial and lateral blowout fractures require implant placement for reconstruction of the orbital floor. Critical steps in endoscopic fracture repair include a conservative mucosal dissection to clearly visualize the bony defect (without injury to infra-orbital nerve or the maxillary sinus ostia), complete removal of all bone fragments that could be pushed back into the orbital cavity, and meticulous reconstruction of the orbital floor with native bone (MTD fractures) or an implant (MBO and LBO fractures). The orbital floor is reconstructed if the defect was larger than 2 cm². Classically, by calverial bone graft, Recently thin iliac bone grafts, rib graft, conchal cartilage graft, nasal septal cartilage, silicone sheets, titanium mesh or high-density porous polyethylene are preferred for reconstruction of the orbital walls. If reconstruction is not required, placing a urinary balloon catheter in the antrum for one week after surgery supports reduced orbital tissue. Pure Endoscopic repair was successful in 6 of 15 OBFs eliminating the need for eyelid incisions and combined Summary and Conclusion - 149 - approaches were done in the other 9 cases of OBFs, transient postoperative infraorbital paresthesia, maxillary sinusitis were documented as complications of trans-maxillary endoscopic approach. Endoscopic surgery is technically demanding and requires expertise in traditional repair of orbital floor fractures. The surgical technique, patient selection, instrumentation, and postoperative results will continue to evolve as more surgeons attempt this technique. As more data are obtained, it will be important to compare the results with the traditional open approach. The endoscopic approach appears to be a promising new technique for isolated trap door and medial orbital floor fractures. |