for these lesions, thus radical resection to include cyst capsule should be performed in all patients to avoid tumor recurrence; however, because the cyst capsule can adhere firmly to vital structures and attempts at its radical removal can be dangerous, subtotal resection may be a wise option in selected patients.
REFERENCES
1. Guidetti B, Gagliardi FM. Epidermoid and dermoid cysts. Clinical evaluation and late surgical results. J Neurosurg 1977;47:12–18 2. Lunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg
1991;75:262–266
3. Rubin G, Scienza R, Pasqualin A, et al. A review of 44 cases. Acta Neurochir (Wien) 1989;97:1–16
4. Caldarelli M, Massimi L, Kondageski C, et al. Intracranial midline dermoid and epidermoid cysts in children. J Neurosurg 2004;100(5 Suppl Pediatrics):473–480
5. Ciurea AV, Coman T, Tascu A, et al. Intradural dermoid tumor of the posterior fossa in a child with diastematobulbia. Surg Neurol 2005;63:571–575
6. Lunardi P, Missori P, Gagliardi FM, et al. Dermoid cysts of the posterior cranial fossa in children. Report of nine cases and review of the literature. Surg Neurol 1990;34:39–42
7. MacCarty CS, Leavens ME, Love JG, et al. Dermoid and epidermoid tumors in the central nervous system of adults. Surg Gynecol Obstet 1959;108:191–198
8. Mamata H, Matsumae M, Yanagimachi N, et al. Parasellar dermoid tumor with intra-tumoral hemorrhage. Eur Radiol 1998;8:1594–1597
9. Warakaulle DR, Anslow P. Differential diagnosis of intracranial lesions with high signal on T1 or low signal on T2-weighted MRI. Clin Radiol 2003;58:922–933
10. Akdemir G, Daglioglu E, Ergungor MF. Dermoid lesion of the cavernous sinus: case report and review of the literature. Neurosurg Rev 2004;27:294–298
11. Nakagawa K, Ohno K, Nojiri T, et al. Interdural dermoid cyst of the cavernous sinus presenting with oculomotor palsy: case report. No Shinkei Geka 1997;25:847–851
12. Shehadi JA, Aloraini IA, Johnston KM. Temporal dermoid cyst with a partial dermal sinus tract. Can J Neurol Sci 1999;26: 321–324
13. Yas¸argil M, Abernathey CD, Sarioglu AC. Microneurosurgical treatment of intracranial dermoid and epidermoid tumors.
Neurosurgery 1989;24:561–567
14. Mcardle DJ, Karia SJ. Ruptured intracranial dermoid cyst. Pract Neurol 2016;16:478–479
15. Gormley WB, Tomecek FJ, Qureshi N, et al. Craniocerebral epidermoid and dermoid tumors: a review of 32 cases. Acta Neurochir (Wien) 1994;128:115–121
16. Miller NR, Epstein MH. Giant intracranial dermoid cyst: case report and review of the literature on intracranial dermoids and epidermoids. Can J Neurol Sci 1975;2:127–134.
17. El-Bahy K, Kotb A, Galal A, et al. Ruptured intracranial dermoid cysts. Acta Neurochir (Wien) 2006;148:457–462
18. Stendel R, Pietila TA, Lehmann K, et al. Ruptured intracranial dermoid cysts. Surg Neurol 2002;57:391–398
19. Civit T, Pinelli C, Lescure JP, et al. Stroke related to a dermoid cyst: case report. Neurosurgery 1997;41:1396–1399
20. Nakamura M, Mizuguchi M, Momoi MY, et al. Transient cheiro-oral syndrome due to a ruptured intracranial dermoid cyst. Brain Dev 2001;23:261–263
21. Osborn A, Blaser S, Salzman K, et al. (eds): Diagnostic Imaging: Brain. Vol 17. Amirsys, Inc: Salt Lake City; 2004:12–15
22. Brown JY, Morokoff AP, Mitchell PJ, et al. Unusual imaging appearance of an intracranial dermoid cyst. AJNR Am J Neuroradiol 2001;22: 1970–1972
23. Bucciero A, Del Basso De Caro ML, Carraturo S, et al. Supratentorial dermoid cysts. Presentation and management of five cases. J Neurosurg Sci 1995;39:7–11
24. Caldarelli M, Colosimo C, Di Rocco C. Intra-axial dermoid/ epidermoid tumors of the brainstem in children. Surg Neurol 2001;56:97 – 105.
25. Canbaz B, Kemerdere R, Ocal E, et al. Intracranial dermoid cyst mimicking a giant thrombosed aneurysm. Neurol India 2004;52: 524–525
Reconstruction of Orbital Floor
With Auricular Concha
Ergin Seven, MD,Ali Teoman Tellioglu, MD,y Emre Inozu, MD,Hulda Rifat Ozakpinar, MD, Ugur Horoz, MD,zAvni Tolga Eryilmaz, MD,§ and Sebat Karamursel, MD
Abstract:Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious com-plications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital frac-tures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors’ clinical experiences of reconstruc-tion of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.
Key Words:Blow-out fracture, conchal graft, orbital floor, reconstruction
T
he orbit is a bony pyramid that protects the visual apparatus comprising the 7 bone structures.1,2 Orbital floor fractures involving any part of the internal orbital wall within the orbitalFrom thePlastic Reconstructive and Aesthetic Surgery Clinic, Diskapi Yildirim Beyazit Training and Research Hospital; yPlastic Reconstruc-tive and Aesthetic Surgery Department, Yildirim Beyazit University, Ankara; zPlastic Reconstructive and Aesthetic Surgery Clinic, Dr Ersin Arslan Training and Research Hospital, Gaziantep; and §Plastic Recon-structive and Aesthetic Surgery Department, Ufuk University, Ankara, Turkey.
Received October 31, 2016.
Accepted for publication April 17, 2017.
Address correspondence and reprint requests to Ugur Horoz, MD, Plastic Reconstructive and Aesthetic Surgery Clinic, Dr Ersin Arslan Training and Research Hospital, 27010 Gaziantep, Turkey;
E-mail: ugur_horoz@hotmail.com The authors report no conflicts of interest. Copyright#2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
soft tissues entrapped in the maxillary sinuses are called blow-out fractures; in these fractures the most frequently injured part of the orbit is its floor, which is extremely thin.1 – 41Blow-out fractures occur due to blunt trauma to the periorbital region, usually associ-ated with traffic accidents, industrial accidents, physical assaults, and social activities.4 – 6,23,26,33 – 35More rarely, gunshot or fall may be the cause of these fractures.5,6,23 Thus, cultural background, demographics, and social characteristics are the main associated factors.11 Orbital floor fractures are classified as follows: pure blow-out fractures, which are usually caused by low-energy mech-anisms; and impure blow-out fractures, in which the orbital floor fracture occurs with an infraorbital rim fracture due to high-energy mechanisms involving the contiguous 4 bones (maxillary, zygo-matic, nasoethmoidal, and frontal).1 – 9,33Orbital floor fractures that retain a degree of continuity with an intact orbital floor, resulting in a periorbital ‘‘hinge’’ allowing the fractured bony segment to pivot are called trapdoor or hinged fractures, also known as white-eyed blow out fractures with neither conjunctival hemorrhage nor peri-orbital ecchymosis.2,3,9Orbital floor fractures were first recognized and described by Mackenzie in 1844, and then pure orbital floor fractures were described by Long in 1889.1,3 Most commonly entrapped muscles are inferior oblique and rectus muscles, whose entrapment may lead to restriction of upward look and diplopia.1 Diplopia, periorbital ecchymosis, eyelid edema, infraorbital nerve sensory deficits, local pain, blurred vision, and subconjunctival hemorrhage are the main clinical findings of orbital fractures.1 – 38 Hypoglobus may occur when the entire globe is depressed infer-iorly.1,9,10More than 5% increase in globe volume, 0.9 mm or more herniation of orbital tissues, or 0.7 cm3 increase in total orbital
volume is enough to cause clinically significant enopthalmos.1,9,10
The most useful radiographic evaluation method is the coronal computed tomography (CT), which informs us about the defect size, status of the globe, evidence of entrapment, and status of extrao-cular muscles. If multiple orbital walls are involved, reconstruction of the orbital defect becomes even more difficult because of the increased shape variability of the defect. Subciliary approaches have the highest rate of complications such as cicatricial ectropion and scleral show.1,22Lyophilized durameter and banked deminer-alized bone are the most commonly used allografts; these resorb faster than autografts and are associated with slow virus infections such as transmission of prion diseases, originated from human, animal, or alloplastic sources. Homologous cartilage grafts undergo ossification and calcification and have a greater tendency for resorption when compared with autogenous cartilage grafts. Xeno-grafts obtained from porcine collagen are useful for linear fractures less than 5 mm; however, their use is not widely reported yet. Allogenic materials are no longer in use since reports of slow virus infections reported due to these materials. There also are reports of implant-associated complications such as migration of implant, infection, dacrocystitis, palpability, extrusion, loss of vision, enopthalmos, and diplopia. In this study, we aimed to submit our clinical experiences about reconstruction of blow-out fractures with auricular conchal graft.
PATIENTS AND METHODS
In this retrospective study, we reviewed the records of 55 patients who were diagnosed with blow-out fractures and surgically treated from 2008 to 2014 in our hospital. Data collected included age, gender, mechanism of injury, etiology, clinical findings, ocular injury, treatment, time from injury to surgery, implant material, incision type, length of hospital stay, follow-up period, and com-plications. Forward distance of the lateral orbital rim to the front of the cornea was measured after 1 week from the trauma before the operation and after 1 month from the operation in the postoperative
period. All the operations were performed under general anesthesia 1 week after initial trauma, that is, when the facial edema had resolved. The surgical procedure is described in brief here. The orbital floor was approached via a subciliary incision in all cases (22 stepped and 33 nonstepped subciliary). In the nonstepped approach, skin and orbicularis oculi muscle were cut in the same incision, whereas in the stepped approach, the muscle was transversed approximately 3 mm below the skin incision. A blunt dissection was performed to the infraorbital rim, the periost was elevated, herniated soft tissues were removed from the maxillary sinus to the orbital cavity, and a conchal cartilage graft was adapted to the orbital floor defect area.
After the injection of the local anesthetic solution that either reduces bleeding or facilitates dissection the markings for the skin incision planned on the posterior ear. Conchal cartilage graft dissection starts from the lateral border of antihelix and superior aspect of the inferior crus. It is important to leave a gap of 2 mm from each edge of the concha to prevent degradation of the natural structure. Besides observing the shape of the defect and shaping the graft is one of the other important steps. But care must be taken during shaping of the graft with soft movements as it may be more fragile in some patients which was independent of age and gender. After the bleeding was controlled, the incision was sutured with 5.0 absorbable suture, and a tie-over bolster dressing was applied for the donor ear (Fig. 1).
RESULTS
During the 5-year study period, 55 patients with orbital floor fractures were surgically treated. Patients (42 men and 13 women) underwent conchal cartilage graft reconstruction of orbital blow-out fracture. The duration of the conchal cartilage removal time was 20 5 minutes. We did not observe significant difference about structure of the grafts which taken from older patients. The most common cause of injury was trauma; 25 fractures were on the right side, 19 fractures were on the left side, and 11 fractures were on both sides. The mean age at the time of surgery was 30 (17–54) years. The mean postoperative hospital stay was 6 (4–7) days. Location of the orbital wall fractures was confirmed by CT (Fig. 2). We did not find any difference in technique between stepped and nonstepped subciliary incisions. Limitations in extraocular movement and diplopia were determined by ophthalmologists and plastic surgeons. Forward distance of the lateral orbital rim to the front of the cornea was between 9 and 17 mL before the operations and between 15 and
FIGURE 1. (A) Intraoperative view removal of the conchal cartilage graft. (B) Intraoperative view of the conchal cartilage graft. (C) Intraoperative view of the blow-out defect of 20-year-old girl. (D) Intraoperative view of the concha of 41-year-old man. (E) Intraoperative view of excised conchal graft. (F) Intraoperative view of the reconstructed blow-out defect with concha graft.
18 mL after the operation. Mean duration follow-up time was noted as 31 months. Neither persistent diplopia nor enophthalmus was noted at postoperative follow-up visits. (Diplopia and forward distance from lateral orbital rim was appreciated in the postopera-tive 1th, 2nd, 3rd, 6th, and 12th months period.) Seven patients had anesthesia and 8 had hypoesthesia of the area innervated by the infraorbital nerve.
DISCUSSION
Orbital floor fractures vary widely, from simple nonsurgical fractures to complicated injuries.1 – 11 Treatment failure of blow-out fractures may result in significant functional or cosmetic issues. Fractures most commonly occur due to violent assault in men, traffic accidents in women, and falling or slipping in the elderly.6In 1957, Smith and Regan described the possible mech-anisms underlying orbital floor fractures, namely, hydraulic, and buckling mechanisms.1 – 3,5,18,21 According to the hydraulic mechanism, the fracture occurs because the kinetic energy of the blow forces the incompressible orbital soft tissues into the floor of the orbit. The buckling theory states that fracture occurs because of the transfer of the trauma forces directly to the orbital floor through the orbital rim. Piombino et al5 classified the fractures with bony defects as either small defects of less than 3 cm2and large defects of more than 3 cm2. Orbital wall defects are also classified into 5 groups according to size and extending tissues.7,10 Most commonly recognized ocular symptoms are diplopia, extraocular movement limitation (muscle dysfunction due to entrapment, ischemia, hemorrhage, or nerve injury),
infraorbital nerve anesthesia, and enopthalmus.1 – 21The occur-rence of enopthalmus and diplopia usually depends on the pro-lapse of orbital bone structures, fat atrophy, loss of ligament support, and/or orbital bone structure enlargement.8Diplopia was usually associated with medial wall fractures, whereas hypoesthe-sia has been reported as the most common symptom.2 – 6 Radi-ography, CT, and magnetic resonance imaging are used for the diagnosis of the fractures, but only coronal CT is known as the gold standard for diagnosis because it allows determining of the reliability of bone quality for autografts.5,25Previous studies have found significant correlations between postoperative extraocular movement and enopthalmus when operation is performed within 1 week of trauma; however, there is no difference in the incidence of diplopia depending on the timing of surgery.4,5Patients can be observed for 2 weeks without operation if delayed enopthalmus is unlikely.18We think that all patients should be observed during 1 week after injury to assess the improvement or regression of symptoms (especially enopthalmos) as edema resolves. In 1924, transconjunctival incision was described by Bourguet, and later in 1941 Converse described the subciliary incision. Lower eyelid or midlower incision, also known as subtarsal incision, was described by Converse.22Subciliary incision can be applied either as stepped (skin and orbicularis muscle trans-versed at same incision) or as nonstepped alternatives (orbicularis oculi muscle passed 2 – 3 mm below the skin incision).22 Retro-caruncular incision has been reported by Garcia in 1998 and is useful for medial wall fractures.32Transconjunctival incision has either retroseptal (easier and more direct) or preseptal choices (lower complication rates).19,22 Subciliary incision has been
widely used, and no significant difference has been found in the frequency of cicatrical eyelid complications between trans-conjunctival and subciliary approaches.16The transconjunctival approach is useful for medial orbital wall fractures and allows a wide view of the floor and inferior orbit.19Kothari et al22reviewed 31 studies recruiting 4406 patients with 4688 incisions collec-tively; they reported that transconjunctival, subciliary, and sub-tarsal incisions are widely used. Vertical and horizontal depths of the orbital floor increase with age and are not different between men and women.13 The orbital floor is deeper in the elderly, probably because of gravity, loss of ligamentous support, and decrease in not only bone remodeling but also potential pro-duction of collagen.13Nagasao et al13reported the orbital floor angle was greater in men than in women, because of a greater angle in childhood in men. The thickness of the orbital floor is around 0.26 0.1 mm, as found on micro CT analysis.10
Porous permanent titanium thickness is about 0.3 mm, porous perforated resorbable mesh thickness is about 0.6 mm, porous permanent polyethylene sheet thickness is about 0.85 mm, nonporous per-manent polyester fiber-reinforced silicone rubber sheet is about 1.0 mm thick, and calvarial bone thickness is about 1.5 to 3.0 mm, as reported by van Leeuwen et al.10The orbital volume measure-ments range between 20.45 and 29.16 preoperatively and between 19.89 and 26.85 postoperatively. Gordon et al32hypothesized that the postoperative volume would be similar to preoperative volume and would not be different from the contralateral uninjured orbit volume. Avashia et al reviewed 48 studies involving 3475 patients collectively and found that the most used materials were auto-genous calvarial bone graft and porous polyethylene and poly-dioxanone.15,23 Traditionally, autografts have been widely accepted and most used materials since years.9,25 – 38 Despite the studies, the management of orbital floor fractures remains controversial.5One of the most important aspects is selecting the correct reconstruction material. On the 1 hand, if the chosen material is thick, it would increase the orbital volume and may result in exopthalmos, and, on the other, if the material is thin, it
FIGURE 2. (A) Preoperative computed tomographic coronal image of the 20-year-old girl with blow out defect. (B) Postoperative 3th year coronal tomographic image of the patient. (C) Postoperative 3th year of the 3-dimensional image of the patient.
may offer inadequate structural support and may result in sagging of the globe.10 The main purpose of surgery is to establish a successful cosmetic and functional result, not only recovering the orbital cavity volume and position of eyeball with an implant but also ensuring free movement of the herniated orbital tissue as close as possible to the preoperative status.8,24If the surgical aim is to prevent fibrosis, operations have to be performed within the 2 weeks after trauma.6Orbital floor defect size, thickness of the reconstruction material, pressure resistance of the orbital volume on the material, and special properties of the material are the most important factors that must be considered when selecting the reconstruction material.20 – 30 Conchal cartilage graft has low
resorption risks because of their anaerobic metabolism; further-more, it not only is of high quality but also has natural concavity of the cartilage. In our cases, we do not prefer alloplastic or allogenic materials because of high infection risk, high cost, foreign body reactions, and extrusion and migration risks associated with these materials (Table 1). Brockhoff et al30reported conchal cartilage thickness from 0.77 to 1.79 mm for men and from 0.95 to 1.45 mm for women. The thickest part is the helical root, which is more rigid in men. The depth was 10.75 2.5 mm in men and 10.5 3.0 mm in women.30
Cavum found that the deepest part of the conchal graft was 8 to 10 mm. Nonsurgical management can be applied in patients without functional and cosmetic problems.5 No significant difference, including the anatomical details, has been reported between titanium meshes and autogenous bone grafts.7 There are several different implant materials reported with variable results. In this regard, each author argues that their choice is more technical. Despite all research, studies have not arrived at a consensus on blow-out fracture repair management— the material to be used, time of surgery, and incision type. All chosen materials have some advantages and disadvantages. We believe that surgical experience and literature outcomes should be the main source to decide the right treatment method. Thus far, many of the tested autogenous materials are most useful with their clinical outcomes. We have used the auricular conchal graft in all our patients with successful long-term results, without resorption and with minimal donor area morbidities (Fig. 3). As a pliable and thin autologous tissue, the conchal cartilage is a good choice for orbital floor reconstruction without any compli-cation risk such as exposure, infection, and extra volume of the orbital cavity. We did have some patients of extra incision, extra operation time, and some donor area morbidities and probable risks, but when these parameters are compared with correspond-ing data for other implant material complications, ours seemed negligible.
CONCLUSION
Unlike other orbital walls, orbital floor is a simple osseous layer that separates the orbit from the maxillary sinus and is easily affected from pressure load during trauma. Orbital floor fractures can be easily reconstructed by using a conchal cartilage graft as an auto-genous graft. The conchal graft is easy, acceptable, biocompatible, easy to harvest, and rigid material that has minimal donor area morbidity, has anatomically appropriate concavity, is adequate for structural support, and accompanied with low infection risks; it is not only relatively avascular but also offers improved graft viability properties.
REFERENCES
1. Gart MS, Gosain AK. Evidence-based medicine: orbital floor fractures. Plast Reconstr Surg 2014;134:1345–1355
2. Pereira Rdos S, Jorge-Boos FB, Hochuli-Vieira E. Management of pure medial orbital wall fracture with autogenous bone graft. J Craniofac Surg 2013;24:e475–e477
3. Kirby EJ, Turner JB, Davenport DL, et al. Orbital floor fractures: outcomes of reconstruction. Ann Plast Surg 2011;66:508–512 4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout
fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–707
5. Piombino P, Iaconetta G, Ciccarelli R, et al. Repair of orbital floor fractures: our experience and new technical findings. Craniomaxillofac Trauma Reconstr 2010;3:217–222
6. Bartoli D, Fadda MT, Battisti A, et al. Retrospective analysis of 301 patients with orbital floor fracture. J Craniomaxillofac Surg 2015;43:244–247
7. Jaquie´ry C, Aeppli C, Cornelius P, et al. Reconstruction of orbital wall defects: critical review of 72 patients. Int J Oral Maxillofac Surg 2007;36:193–199
8. Guo L, Tian W, Feng F, et al. Reconstruction of orbital floor fractures: comparison of individual prefabricated titanium implants and calvarial bone grafts. Ann Plast Surg 2009;63:624–631
9. O’Connell JE, Hartnett C, Hickey-Dwyer M, et al. Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives. J Craniomaxillofac Surg 2015;43:192–198
FIGURE 3. Postoperative 3th year of the 20-year-old girl’s conchal cartilage graft donor ear. (A) Lateral view. (B) Posterior view. (C) Posterior close view. (D) Anterior-oblique view.
TABLE 1. Comparison Advantages and Disadvantages of Implant Materials1 –38
Implant Materials Autogenous Allogenic Alloplastic Rapid revascularization — —
Infection —
Availability —
Low resorption rate — —
Osteoinductive, osteoconductive — —
Second operative site — —
Extrusion —
Foreign body reaction — Suitable for pediatric
population (lack of any potential for growth)
10. van Leeuwen AC, Ong SH, Vissink A, et al. Reconstruction of orbital wall defects: recommendations based on a mathematical model. Exp Eye Res 2012;97:10–18
11. Wajih WA, Shaharuddin B, Razak NH. Hospital Universiti Sains Malaysia experience in orbital floor reconstruction: autogenous graft versus Medpor. J Oral Maxillofac Surg 2011;69:1740–1744 12. Cavusoglu T, Vargel I, Yazici I, et al. Reconstruction of orbital floor
fractures using autologous nasal septal bone graft. Ann Plast Surg 2010;64:41–46
13. Nagasao T, Hikosaka M, Morotomi T, et al. Analysis of the orbital floor morphology. J Craniomaxillofac Surg 2007;35:112–119
14. Yavuzer R, Tuncer S, Bas¸terzi Y, et al. Reconstruction of orbital floor fracture using solvent-preserved bone graft. Plast Reconstr Surg 2004;113:34–44
15. Avashia YJ, Sastry A, Fan KL, et al. Materials used for reconstruction after orbital floor fracture. J Craniofac Surg 2012;23 (7 suppl 1):1991–1997 16. Nowinski D, Messo E, Hedlund A. Treatment of orbital fractures: evaluation of surgical techniques and materials for reconstruction. J Craniofac Surg 2010;21:1033–1037
17. Gander T, Essig H, Metzler P, et al. Patient specific implants (PSI) in reconstruction of orbital floor and wall fractures. J Craniomaxillofac Surg 2015;43:126–130
18. Harris GJ. Orbital blow-out fractures: surgical timing and technique. Eye (Lond) 2006;20:1207–1212
19. Novelli G, Ferrari L, Sozzi D, et al. Transconjunctival approach in orbital traumatology: a review of 56 cases. J Craniomaxillofac Surg 2011;39:266–270
20. Schmelzeisen R, Gellrich NC, Schoen R, et al. Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction. Injury 2004;35:955–962
21. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology
2002;109:1207–1210
22. Kothari NA, Avashia YJ, Lemelman BT, et al. Incisions for orbital floor exploration. J Craniofac Surg 2012;23 (7 suppl 1):1985–1989 23. Kozakiewicz M, Szymor P. Comparison of pre-bent titanium mesh
versus polyethylene implants in patient specific orbital reconstructions. Head Face Med 2013;9:32
24. Banica B, Ene P, Vranceanu D, et al. Titanium preformed implants in orbital floor reconstruction—case presentation, review of literature. Maedica (Buchar) 2013;8:34–39
25. Insull EA, Hart RH, Sloan BH, et al. Use of x-ray film implant for the repair of orbital fractures. Ophthal Plast Reconstr Surg
2013;29:393–395
26. Kyung H, Song SH, Kang N, et al. Medpor implant fixation using fibrin glue in blowout fracture surgery. J Craniofac Surg 2013;24: 1781–1784
27. Yan Z, Zhou Z, Song X. Nasal endoscopy-assisted reconstruction of orbital floor blowout fractures using temporal fascia grafting. J Oral Maxillofac Surg 2012;70:1119–1122
28. Ellis E 3rd. Reconstruction of orbital floor defects. J Oral Maxillofac Surg 2012;70:2255
29. Ciprandi MT, Primo BT, Gassen HT, et al. Calcium phosphate cement in orbital reconstructions. J Craniofac Surg 2012;23:145–148
30. Brockhoff HC 2nd, Morris CD, Throckmorton GS, et al. Anatomic analysis of the conchal bowl cartilage. J Oral Maxillofac Surg 2014;72:2248–2255
31. Potter JK, Malmquist M, Ellis E 3rd. Biomaterials for reconstruction of the internal orbit. Oral Maxillofac Surg Clin North Am 2012;24: 609–627
32. Gordon CR, Susarla SM, Yaremchuk MJ. Quantitative assessment of medial orbit fracture repair using computer-designed anatomical plates. Plast Reconstr Surg 2012;130:698e–705e
33. Piombino P, Spinzia A, Abbate V, et al. Reconstruction of small orbital floor fractures with resorbable collagen membranes. J Craniofac Surg 2013;24:571–574
34. Ozyazgan I, Eskitas¸c¸ioglu T, Baykan H, et al. Repair of traumatic orbital wall defects using conchal cartilage. Plast Reconstr Surg
2006;117:1269–1276
35. Kosaka M, Matsuzawa Y, Mori H, et al. Orbital wall reconstruction with bone grafts from the outer cortex of the mandible. J Craniomaxillofac Surg 2004;32:374–380
36. Yes¸ilog˘lu N, Sirinog˘lu H, Sarici M, et al. A new option for the reconstruction of orbital floor defects: the olecranon bone graft. Ann Plast Surg 2014;75:401–406
37. Krishnan V, Johnson JV. Orbital floor reconstruction with autogenous mandibular symphyseal bone grafts. J Oral Maxillofac Surg 1997;55:327–330
38. Liliav B, Kalimuthu R. Mantle design: a composite construct for orbital floor reconstruction. J Craniofac Surg 2012;23:1125–1126
39. Telliog˘lu AT, Yilmaz S, Baydar S, et al. Computed tomographic evaluation before cranial bone harvesting to avoid unexpected hazards during aesthetic procedures. Aesthetic Plast Surg 2001;25:198– 201
40. Yadalla D, Rajagopalan J. Re: ‘‘Use of x-ray film for the repair of orbital blow out fractures’’. Ophthal Plast Reconstr Surg 2014;30:355 41. Hart RH, Insull EA, Ben-Simon GJ, et al. Reply re: ‘‘Use of sterilized
x-ray film implant for the repair of orbital blow-out fractures’’. Ophthal Plast Reconstr Surg 2014;30:355
Transnasal Endoscopic Resection
of a Pleomorphic Adenoma
Originate From Nasal Floor
Yesun Cho, MD, Yul Gyun Kim, MD, Eunhye Shin, MD, and Boo-Young Kim, MD, PhD
Abstract:A 81-year-old female presented to our hospital frequent epistaxis. Nasal endoscopy showed a mass obstructing nasal cavity completely and occupying middle meatus. Magnetic resonance imaging was performed, an about 4.8 4 4.2 cm sized hetero-geneous T2 high signal intensity and T1 enhancing mass mainly involving right nasal cavity with invasion of right hard palate with bony destruction. Therefore, the authors planned to do endoscopic mass excision, under general anesthesia for diagnosis and treatment. The authors removed the mass from lateral nasal wall, nasal roof, nasal septum, medial maxillary wall by piece-meal. Margins of mass were clear except the nasal floor. So, the authors did frozen biopsy to confirm the clear margin in nasal floor. Endoscopy enables better visualization of tumor margins, facilitating complete removal and avoiding excessive resection and following up using good visualization.
Key Words:Pleomorphic adenoma, nasal cavity, transnasal endoscopic resection
From the Department of Otolaryngology—Head and Neck Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Gyeonggi-do, Korea.
Received January 17, 2017.
Accepted for publication March 1, 2017.
Address correspondence and reprint requests to Boo-Young Kim, MD, PhD, Department of Otolaryngology—Head and Neck Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 65-1 Geum-odong, Uijeongbu city, Gyeonggi-do, Korea 11765; E-mail: ungii81@catholic.ac.kr
The experiment was performed with the approval of the Institutional Review Board at the Catholic University of Korea.
The authors report no conflicts of interest. Copyright#2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
