Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Abstract

FEATURED GRAND ROUNDSOrbital wall fractures result from external impact injuries which cause an abrupt increase in intraorbital pressure. 1 Patients usually present to the emergency room with periorbital swelling and limited eye movements, with or without changes in vision. Relatively common in the Philippines, these fractures are frequently caused by violent assault followed by vehicular accidents involving motorcycles. 2 Among 119 maxillofacial trauma cases seen and treated by the Department of Otorhinolaryngology of the East Avenue Medical Center from 2008-2009, 42 were diagnosed as cases of orbital fractures with 36% having concomitant involvement of the orbital floor. Various techniques in diagnosis and treatment developed in the past 20 years, each having its own strengths and weaknesses. The challenge of choosing which among these methods will best achieve the goals of function and aesthetics always confronts surgeons particularly in a developing country setting.We present a case of bilateral orbital floor fractures with diplopia repaired with conchal auricular cartilage graft in a 22-year-old female. CASE REPORTA 22-year-old female was immediately brought to our emergency room following a headon collision with an Asian utility vehicle while driving a motorcycle without a helmet. She was conscious and coherent with stable vital signs.On examination, contusion hematomas were noted over both periorbital areas. Visual acuity was 20/30 OD and 20/40 OS with bilateral limitations of extraocular muscle movement. Bilateral ocular pressures were measured at 14.6 mmHg. Craniofacial CT Scans revealed linear frontal bone fractures with subdural hemorrhages and pneumocephalus in the frontal area, fractures of the calvarial bones, lateral orbital walls, inferior orbital rims and orbital floors (Figure 1). A mannitol drip was started for the hemorrhage.She developed a persistent headache and binocular vertical diplopia with monocular diplopia, OS on left gaze accompanied by pain on lateral left duction. Visual acuity was 20/25 OU. On the 17 th hospital day, she underwent open reduction and internal fixation of multiple facial fractures using titanium plates and screws with reconstruction of both orbital floors using conchal cartilage autografts. The right eye diplopia resolved on the third postoperative day while the diplopia on left lateral downward gaze in the left eye resolved from the ninth postoperative day until the day of discharge.There was complete resolution of diplopia and improvement in visual acuity to 20/20 OD and 20/25 OS on follow up at one year. DICUSSIONOrbital floor fractures are relatively common midfacial injuries encountered in urban areas 2 and were first described by Smith and Regan in 1957. 1 Since then, many articles have been written about their diagnosis and treatment, including indications and optimal time for surgery as well as optimal surgical methods. 1 Epidemiological studies reveal that despite different settings, the majority of cases involve the young male population with violent assau...