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Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e565ee569
CASE REPORT
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study Toshihiro Fujiwara*, Ken Matsuda, Tateki Kubo, Koichi Tomita, Kenji Yano, Ko Hosokawa Department of Plastic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan Received 18 August 2008; accepted 8 November 2008
KEYWORDS Superior orbital fissure syndrome; facial bone fracture; the width of superior orbital fissure; CT scan; cadavers; compression of nerve
Summary Objective: The superior orbital fissure syndrome results from damage to the nerves passing through the superior orbital fissure. In the present case, the superior orbital fissure syndrome developed after repair of facial bone fractures, although the symptoms were not observed before surgery and no obvious cause was found. To investigate the aetiology of this syndrome, we examined the superior orbital fissure anatomically. Methods: We measured the width of superior orbital fissure on the horizontal plane including the optic canal using the computed tomography (CT) scans of other patients and cadavers. Results: The results indicated that the width was 3.73 1.64 mm in the CT scans of patients and 3.21 1.09 mm in the cadavers. There was no significant difference between the width in the CT scans and cadavers. The width in the present patient on the affected side was 1.6 mm, that is relatively narrow. Conclusion: After operation, narrow superior orbital fissure may reduce the tolerance to compression of the nerves by oedema. We consider the narrow superior orbital fissure as a risk factor for superior orbital fissure syndrome. When the superior orbital fissure is congenitally narrow, the surgeons should try to avoid excessive pulling of the bone fragment and compression of the orbital tissue during repair of the facial bone fractures. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. 2-2C11, Yamadaoka, Suita-city, Osaka 565-0871, Japan. Tel.: þ81 6 6879 6056; fax: þ81 6 6879 6059. E-mail address: [email protected] (T. Fujiwara).
The superior orbital fissure syndrome results from damage to structures passing through the superior orbital fissure. The syndrome was first reported by Hirschfeld in 1858.1 The structures passing via the superior orbital fissure include
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.052
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the lachrymal nerve, frontal nerve, nasociliary nerve, superior and inferior branches of the oculomotor nerve, abducent nerve and trochlear nerve and superior ophthalmic vein.2,3 The symptomatic combination depends on the damaged nerves, giving rise to ophthalmoplegia, ptosis, sensory anaesthesia along the distribution of the supraorbital nerve and a fixed dilated pupil. In case of a traumatic injury, direct compression of the bone fractures and orbital internal pressure increased by haematoma, haemorrhage, oedema and inflammation damage the nerves, resulting in a complete or incomplete form of the superior orbital fissure syndrome. The symptoms develop either immediately or several days after the accident. In this article, we report, a rare case of superior orbital fissure syndrome that developed after surgical treatment of facial bone fractures, although the superior orbital fissure was pre- and postoperatively intact and there was no symptom before surgical intervention. Then, to investigate the cause of the present superior orbital fissure syndrome, we anatomically examined the superior orbital fissure using computed tomography (CT) scans of the other patients and cadavers. From the results, we compared the relationship between the narrow width of the superior orbital fissure and the superior orbital fissure syndrome.
Case report A 24-year-old man was hit across his face. When the patient was first examined in our hospital 3 days after the injury, the nose appeared slightly shifted to the right side (Figure 1A). He complained of mild nasal stiffness. He had slight palpebral and bulbar conjunctival petechia. In both eyes, the visual acuity was 20/20 and the ocular movement was normal. The light reflex was prompt and bilaterally complete. His cornea and retina were bilaterally normal. Preoperative laboratory investigations did not show any sign of infection. No physical finding such as ptosis, enophthalmos, diplopia, anisocoria, misalignment of the eyes, numbness or trismus was observed. A CT scan of the facial bone showed fractures of the bridge and septum of the nose, maxilla, ethmoid and orbital floor on the left side (Figure 2). Of particular interest was the fact that the superior orbital fissure on the left side was not involved in the fractures. There was no history of superior orbital fissure syndrome before surgical management. The surgical treatment with facial fracture reduction and fixation was performed, under general anaesthesia, 18 days after injury. The fractured bones were approached through the sub-cilial incision. There was little bleeding and no particular difficulty in repair during the operation. Neither the contents of the superior orbital fissure nor bone fragments were excessively stretched during surgery. The fractured bones were reduced and fixed with a plate. The wound was closed with 6/0 nylon sutures. A CT scan after surgery showed that the displaced fractured bones were reduced and restored to their original position (Figure 2E). On postoperative day 1, however, complete ptosis, complete external ophthalmoplegia of the superior rectus muscle alone and diplopia occurred on the left side. Moreover, the patient had anaesthesia in the upper eyelid
Figure 1 (A) The nose was slightly shifted to the right side 3 days after the injury. He had slight palpebral and bulbar conjunctival petechia. (B) Mild ptosis was observed on the left side on postoperative day 23.(C) The patient completely recovered from ptosis and sensory anaesthesia of eyelid and forehead on the left side and diplopia 51 days after surgery.
and forehead on the left side. There was neither visual loss nor anisocoria. Laboratory investigations did not show any sign of infection. The patient had no fever. The postoperative CT scan did not show the obvious cause such as compression to the nerves by the reduced fractured bones or haematoma. The manifestations did not improve several days after operation. After consultation with an ophthalmologist, superior orbital fissure syndrome was diagnosed. The patient was treated with intravenous prednisolone postoperative days 6e8 (625 mg on the first day; 500 mg on the second and third days). After steroid pulse therapy, ptosis gradually improved. Nonetheless, ophthalmoplegia of the superior rectus muscle and anaesthesia of the upper eyelid and forehead on the left side incomplete persistence till postoperative day 23 (Figure 1B). However, ptosis, phthalmoplegia and anaesthesia completely recovered by postoperative day 51 (Figure 1C). The superior orbital fissure syndrome never recurred. The present case is unique because superior orbital fissure syndrome occurred after repair of the facial bone fractures. Regarding the aetiology of this syndrome, we noticed that the width of the superior orbital fissure on the left side was relatively narrow compared to the one on the right side (Figure 2A). We considered the narrow superior orbital fissure as a risk factor for superior orbital fissure syndrome. Therefore, to investigate the cause of the
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study
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superior orbital fissure syndrome in the present case, we anatomically examined the superior orbital fissure using the CT scans of the other patients and cadavers in comparison to the findings in our patient.
Anatomical study Materials and methods Computed tomography The CT scans of 32 patients (64 sides), who presented to our department, were randomly selected. Of the 32 patients, 19 were men and 13 women, and their mean age was 39.6 18.3 years (range: 21e87 years). In all patients, the superior orbital fissure was intact. We tried to investigate the size of the superior orbital fissure through which the nerves pass. The superior orbital fissure typically varies in width at different locations. Most of the nerves passing through the superior orbital fissure are located on the same level with the optic canal. Therefore, to examine the size of the superior orbital fissure, its width on the horizontal plane including the optic canal was measured using CT scans with calipers (Figure 3A and B). Cadavers As a next step, five adult, formalin-fixed cadavers (nine sides) were prepared. A part of the superior orbit was removed. Then the width of superior orbital fissure was directly measured with calipers at the horizontal plane including the optic canal (Figure 3C).
Results Computed tomography The width of superior orbital fissure was 3.61 1.70 and 3.87 1.60 mm on the right and left side, respectively (Figure 4). There was no significant difference between the right and left sides. The mean width on both sides was 3.73 1.64 mm (range: 0.9e8.0 mm). On the other hand, the width in the present patient was 5.0 mm on the right side and 1.6 mm on left side. The values did not change preand postoperatively. The data from CT scans suggested that the width of the fissure on the affected side in the present patient was relatively narrow, congenitally.
Cadavers Measuring the superior orbital fissure in cadavers revealed that the width was 3.16 1.24 and 3.27 1.05 mm on the right and left side, respectively (Figure 4). There was no significant difference between the right and left sides. The
Figure 2 Fractures of the maxillary and nasal bones were observed on the CT scans. Some of the orbital contents fell underneath the orbital floor. The fractured maxillary bone
shifted posteriorly. The superior orbital fissure was intact. (A) Anterior orbital view on 3D-CT. (B) Posterior orbital view on 3D-CT. (C) Coronal plane. (D) Horizontal plane. (E) 3D-CT scans after the surgical treatment. The fractured bones were reduced and fixed. The superior orbital fissure did not change before and after operation.
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Figure 4 The width of the superior orbital fissure in the CT scans was 3.61 1.70 mm on the right side and 3.87 1.60 mm on the left side. The width of the superior orbital fissure in cadavers was 3.16 1.24 mm on the right side and 3.27 1.05 mm on the left side. In both CT scans and cadavers, there was no significant difference between the right and left sides. The data are mean S.D.
approximately similar to that in the CT scans, although the former was slightly narrower, indicating that the technique of measuring the width using CT scans is simple, yet effective.
Discussion
Figure 3 The technique of measuring the width of the superior orbital fissure on horizontal plane including the optic canal in the CT scans. The arrow indicates the length to measure. (A) 3D-CT. (B) CT scan on the horizontal plane. (C) The technique of measuring the width of the superior orbital fissure on the horizontal plane including the optic canal in the cadavers. The arrow indicates the length to measure.
mean width on both sides was 3.21 1.09 mm (range: 2.11e5.29 mm). There was no significant difference between the width in the CT scans and cadavers. The real width of the superior orbital fissure in cadavers was
The causes of the superior orbital fissure syndrome are classified into traumatic and non-traumatic. In case of traumatic injury, the fractured bones and haematoma directly compress the nerves, and the subsequent infection and oedema impair the blood circulation around the superior orbital fissure, resulting in superior orbital fissure syndrome. In this case, the specific manifestations appear either immediately or several days after injury. In the present traumatic case, the superior orbital fissure was intact, and no specific manifestations were observed before surgical treatment. No haematoma was observed in the CT scan before and after operation. Blood tests revealed no sign of infection. The contents in the orbit and the superior orbital fissure were not stretched and compressed excessively during surgery. The present superior orbital fissure syndrome had no obvious cause. Under careful observation, we felt that the width of the superior orbital fissure on the affected side seemed narrow, as compared to that in the other patients. Therefore, we hypothesised that the narrow superior orbital fissure was a risk factor for the superior orbital fissure syndrome. To confirm this hypothesis, we performed an anatomical
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study investigation of the width of the superior orbital fissure using the CT scans of the other patients and cadavers. The width of superior orbital fissure in the CT scans (3.73 1.64 mm) was similar to that in the cadavers (3.21 1.09 mm). This result proved that the width of superior orbital fissure measured with CT scanning was approximately accurate, as compared to the real width. Some anatomical studies regarding the size, contents and positional relationship of the superior orbital fissure have been previously reported.2e7 The size of the superior orbital fissure is reportedly 3 22 mm.7 This report supports our examination of the width of the superior orbital fissure. Many plastic surgeons may not be familiar with this technique of measuring the width of the superior orbital fissure, but this technique is easy to perform and no new examination is required except for the routine CT scan to investigate the facial bone fractures. Therefore, this method is thought to be useful to predict the superior orbital fissure syndrome after surgery. In case that the width does not exceed 1.6 mm, then surgical intervention of the facial bone fractures may trigger the superior orbital fissure syndrome. In the CT scans, the width (1.6 mm) on the affected side in our present patient was relatively narrow. The narrow superior orbital fissure may reduce tolerance to compression of the nerves by direct force and oedema. The slight postoperative oedema might compress the nerves and impair blood circulation, resulting in superior orbital fissure syndrome. In the present case, the lachrymal, frontal and nasociliary nerves and a part of the oculomotor nerve were damaged. However, the trochlear and abducent nerves and a part of the oculomotor nerve were intact. Therefore, the tolerance of the nerves passing via the superior orbital fissure to compression may be different in degree and probably depends on the diameter and location and the running direction of the nerves. The superior orbital fissure has many different shapes,8 pointing to the fact that the width of the superior orbital fissure on the horizontal plane including the optic canal does not always reflect the total size. Therefore, the entire superior orbital fissure should be carefully observed on three-dimensional CT (3D-CT) before operation. Careful examination of the superior orbital fissure permits the surgeons to predict the development of the superior orbital fissure syndrome, thus allowing early treatment. To decompress the tissue around the superior orbital fissure, steroid administration was previously described as non-surgical treatment for the superior orbital fissure syndrome.9 In the case in which steroid administration is initiated early, the manifestations improve well. The present patient was given a dose of prednisolone 6 days after the start of manifestations. Consequently, complete recovery from the superior orbital fissure syndrome took a long time. Unless the present patient is treated with steroid administration, the patient might spontaneously recover from the superior orbital fissure syndrome several weeks after surgery.10 However, if the obvious cause of the superior orbital fissure syndrome such as the compression
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to the nerves by the fractured bone or haematoma is not found, the decompression of the intraorbital contents is strongly recommended.9 There was no report stating that the postoperative oedema causes superior orbital fissure syndrome, even though this syndrome is not observed preoperatively. If the width of the superior orbital fissure is narrow, the surgeons should try to avoid excessive pulling of the bone fragment and compression of the orbital tissue during repair of the facial bone fractures and consider a possibility of the superior orbital fissure syndrome after surgery.
Acknowledgment We thank Professor Masaya Tohyama from the Department of Anatomy and Neuroscience, Graduate School of Medicine, Osaka University, for his support during this study. This work was supported by a research Grant-in-Aid from the Japanese Ministry of Education, Science, Sports, and Culture (18791321).
Conflict of interest The authors do not report any potential or perceived conflict of interest concerning in the materials or methods used in this study or findings specified in this paper.
Ethics The research protocol of the present article was approved by our Ethical Committee.
References 1. Banks P. The superior orbital fissure syndrome. Oral Surg Oral Med Oral Pathol 1967;24:455e8. 2. Govsa F, Kayalioglu G, Erturk M, et al. The superior orbital fissure and its contents. Surg Radiol Anat 1999;21:181e5. 3. Natori Y, Rhoton Jr AL. Microsurgical anatomy of the superior orbital fissure. Neurosurgery 1995;36:762e75. 4. Shi X, Han H, Zhao J, et al. Microsurgical anatomy of the superior orbital fissure. Clin Anat 2007;20:362e6. 5. Ammirati M, Bernardo A. Anatomical study of the superior orbital fissure as seen during a pterional approach. J Neurosurg 2007;106:151e6. 6. Karakas P, Bozkir MG, Oguz O. Morphometric measurements from various reference points in the orbit of male Caucasians. Surg Radiol Anat 2003;24:358e62. 7. Morard M, Tcherekayev V, de Tribolet N. The superior orbital fissure: a microanatomical study. Neurosurgery 1994;35: 1087e93. 8. Sharma PK, Malhotra VK, Tewari SP. Variations in the shape of the superior orbital fissure. Anat Anz 1988;165:55e6. 9. Acarturk S, Sekucoglu T, Kesiktas E. Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes. Ann Plast Surg 2004;53:60e4. 10. Seiff SR. High dose corticosteroids for treatment of vision loss due to indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389e95.
CASE REPORT
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study Toshihiro Fujiwara*, Ken Matsuda, Tateki Kubo, Koichi Tomita, Kenji Yano, Ko Hosokawa Department of Plastic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan Received 18 August 2008; accepted 8 November 2008
KEYWORDS Superior orbital fissure syndrome; facial bone fracture; the width of superior orbital fissure; CT scan; cadavers; compression of nerve
Summary Objective: The superior orbital fissure syndrome results from damage to the nerves passing through the superior orbital fissure. In the present case, the superior orbital fissure syndrome developed after repair of facial bone fractures, although the symptoms were not observed before surgery and no obvious cause was found. To investigate the aetiology of this syndrome, we examined the superior orbital fissure anatomically. Methods: We measured the width of superior orbital fissure on the horizontal plane including the optic canal using the computed tomography (CT) scans of other patients and cadavers. Results: The results indicated that the width was 3.73 1.64 mm in the CT scans of patients and 3.21 1.09 mm in the cadavers. There was no significant difference between the width in the CT scans and cadavers. The width in the present patient on the affected side was 1.6 mm, that is relatively narrow. Conclusion: After operation, narrow superior orbital fissure may reduce the tolerance to compression of the nerves by oedema. We consider the narrow superior orbital fissure as a risk factor for superior orbital fissure syndrome. When the superior orbital fissure is congenitally narrow, the surgeons should try to avoid excessive pulling of the bone fragment and compression of the orbital tissue during repair of the facial bone fractures. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. 2-2C11, Yamadaoka, Suita-city, Osaka 565-0871, Japan. Tel.: þ81 6 6879 6056; fax: þ81 6 6879 6059. E-mail address: [email protected] (T. Fujiwara).
The superior orbital fissure syndrome results from damage to structures passing through the superior orbital fissure. The syndrome was first reported by Hirschfeld in 1858.1 The structures passing via the superior orbital fissure include
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.052
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T. Fujiwara et al.
the lachrymal nerve, frontal nerve, nasociliary nerve, superior and inferior branches of the oculomotor nerve, abducent nerve and trochlear nerve and superior ophthalmic vein.2,3 The symptomatic combination depends on the damaged nerves, giving rise to ophthalmoplegia, ptosis, sensory anaesthesia along the distribution of the supraorbital nerve and a fixed dilated pupil. In case of a traumatic injury, direct compression of the bone fractures and orbital internal pressure increased by haematoma, haemorrhage, oedema and inflammation damage the nerves, resulting in a complete or incomplete form of the superior orbital fissure syndrome. The symptoms develop either immediately or several days after the accident. In this article, we report, a rare case of superior orbital fissure syndrome that developed after surgical treatment of facial bone fractures, although the superior orbital fissure was pre- and postoperatively intact and there was no symptom before surgical intervention. Then, to investigate the cause of the present superior orbital fissure syndrome, we anatomically examined the superior orbital fissure using computed tomography (CT) scans of the other patients and cadavers. From the results, we compared the relationship between the narrow width of the superior orbital fissure and the superior orbital fissure syndrome.
Case report A 24-year-old man was hit across his face. When the patient was first examined in our hospital 3 days after the injury, the nose appeared slightly shifted to the right side (Figure 1A). He complained of mild nasal stiffness. He had slight palpebral and bulbar conjunctival petechia. In both eyes, the visual acuity was 20/20 and the ocular movement was normal. The light reflex was prompt and bilaterally complete. His cornea and retina were bilaterally normal. Preoperative laboratory investigations did not show any sign of infection. No physical finding such as ptosis, enophthalmos, diplopia, anisocoria, misalignment of the eyes, numbness or trismus was observed. A CT scan of the facial bone showed fractures of the bridge and septum of the nose, maxilla, ethmoid and orbital floor on the left side (Figure 2). Of particular interest was the fact that the superior orbital fissure on the left side was not involved in the fractures. There was no history of superior orbital fissure syndrome before surgical management. The surgical treatment with facial fracture reduction and fixation was performed, under general anaesthesia, 18 days after injury. The fractured bones were approached through the sub-cilial incision. There was little bleeding and no particular difficulty in repair during the operation. Neither the contents of the superior orbital fissure nor bone fragments were excessively stretched during surgery. The fractured bones were reduced and fixed with a plate. The wound was closed with 6/0 nylon sutures. A CT scan after surgery showed that the displaced fractured bones were reduced and restored to their original position (Figure 2E). On postoperative day 1, however, complete ptosis, complete external ophthalmoplegia of the superior rectus muscle alone and diplopia occurred on the left side. Moreover, the patient had anaesthesia in the upper eyelid
Figure 1 (A) The nose was slightly shifted to the right side 3 days after the injury. He had slight palpebral and bulbar conjunctival petechia. (B) Mild ptosis was observed on the left side on postoperative day 23.(C) The patient completely recovered from ptosis and sensory anaesthesia of eyelid and forehead on the left side and diplopia 51 days after surgery.
and forehead on the left side. There was neither visual loss nor anisocoria. Laboratory investigations did not show any sign of infection. The patient had no fever. The postoperative CT scan did not show the obvious cause such as compression to the nerves by the reduced fractured bones or haematoma. The manifestations did not improve several days after operation. After consultation with an ophthalmologist, superior orbital fissure syndrome was diagnosed. The patient was treated with intravenous prednisolone postoperative days 6e8 (625 mg on the first day; 500 mg on the second and third days). After steroid pulse therapy, ptosis gradually improved. Nonetheless, ophthalmoplegia of the superior rectus muscle and anaesthesia of the upper eyelid and forehead on the left side incomplete persistence till postoperative day 23 (Figure 1B). However, ptosis, phthalmoplegia and anaesthesia completely recovered by postoperative day 51 (Figure 1C). The superior orbital fissure syndrome never recurred. The present case is unique because superior orbital fissure syndrome occurred after repair of the facial bone fractures. Regarding the aetiology of this syndrome, we noticed that the width of the superior orbital fissure on the left side was relatively narrow compared to the one on the right side (Figure 2A). We considered the narrow superior orbital fissure as a risk factor for superior orbital fissure syndrome. Therefore, to investigate the cause of the
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study
e567
superior orbital fissure syndrome in the present case, we anatomically examined the superior orbital fissure using the CT scans of the other patients and cadavers in comparison to the findings in our patient.
Anatomical study Materials and methods Computed tomography The CT scans of 32 patients (64 sides), who presented to our department, were randomly selected. Of the 32 patients, 19 were men and 13 women, and their mean age was 39.6 18.3 years (range: 21e87 years). In all patients, the superior orbital fissure was intact. We tried to investigate the size of the superior orbital fissure through which the nerves pass. The superior orbital fissure typically varies in width at different locations. Most of the nerves passing through the superior orbital fissure are located on the same level with the optic canal. Therefore, to examine the size of the superior orbital fissure, its width on the horizontal plane including the optic canal was measured using CT scans with calipers (Figure 3A and B). Cadavers As a next step, five adult, formalin-fixed cadavers (nine sides) were prepared. A part of the superior orbit was removed. Then the width of superior orbital fissure was directly measured with calipers at the horizontal plane including the optic canal (Figure 3C).
Results Computed tomography The width of superior orbital fissure was 3.61 1.70 and 3.87 1.60 mm on the right and left side, respectively (Figure 4). There was no significant difference between the right and left sides. The mean width on both sides was 3.73 1.64 mm (range: 0.9e8.0 mm). On the other hand, the width in the present patient was 5.0 mm on the right side and 1.6 mm on left side. The values did not change preand postoperatively. The data from CT scans suggested that the width of the fissure on the affected side in the present patient was relatively narrow, congenitally.
Cadavers Measuring the superior orbital fissure in cadavers revealed that the width was 3.16 1.24 and 3.27 1.05 mm on the right and left side, respectively (Figure 4). There was no significant difference between the right and left sides. The
Figure 2 Fractures of the maxillary and nasal bones were observed on the CT scans. Some of the orbital contents fell underneath the orbital floor. The fractured maxillary bone
shifted posteriorly. The superior orbital fissure was intact. (A) Anterior orbital view on 3D-CT. (B) Posterior orbital view on 3D-CT. (C) Coronal plane. (D) Horizontal plane. (E) 3D-CT scans after the surgical treatment. The fractured bones were reduced and fixed. The superior orbital fissure did not change before and after operation.
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Figure 4 The width of the superior orbital fissure in the CT scans was 3.61 1.70 mm on the right side and 3.87 1.60 mm on the left side. The width of the superior orbital fissure in cadavers was 3.16 1.24 mm on the right side and 3.27 1.05 mm on the left side. In both CT scans and cadavers, there was no significant difference between the right and left sides. The data are mean S.D.
approximately similar to that in the CT scans, although the former was slightly narrower, indicating that the technique of measuring the width using CT scans is simple, yet effective.
Discussion
Figure 3 The technique of measuring the width of the superior orbital fissure on horizontal plane including the optic canal in the CT scans. The arrow indicates the length to measure. (A) 3D-CT. (B) CT scan on the horizontal plane. (C) The technique of measuring the width of the superior orbital fissure on the horizontal plane including the optic canal in the cadavers. The arrow indicates the length to measure.
mean width on both sides was 3.21 1.09 mm (range: 2.11e5.29 mm). There was no significant difference between the width in the CT scans and cadavers. The real width of the superior orbital fissure in cadavers was
The causes of the superior orbital fissure syndrome are classified into traumatic and non-traumatic. In case of traumatic injury, the fractured bones and haematoma directly compress the nerves, and the subsequent infection and oedema impair the blood circulation around the superior orbital fissure, resulting in superior orbital fissure syndrome. In this case, the specific manifestations appear either immediately or several days after injury. In the present traumatic case, the superior orbital fissure was intact, and no specific manifestations were observed before surgical treatment. No haematoma was observed in the CT scan before and after operation. Blood tests revealed no sign of infection. The contents in the orbit and the superior orbital fissure were not stretched and compressed excessively during surgery. The present superior orbital fissure syndrome had no obvious cause. Under careful observation, we felt that the width of the superior orbital fissure on the affected side seemed narrow, as compared to that in the other patients. Therefore, we hypothesised that the narrow superior orbital fissure was a risk factor for the superior orbital fissure syndrome. To confirm this hypothesis, we performed an anatomical
Superior Orbital Fissure Syndrome After Repair of Maxillary and Naso-orbito-ethmoid Fractures: A Case Study investigation of the width of the superior orbital fissure using the CT scans of the other patients and cadavers. The width of superior orbital fissure in the CT scans (3.73 1.64 mm) was similar to that in the cadavers (3.21 1.09 mm). This result proved that the width of superior orbital fissure measured with CT scanning was approximately accurate, as compared to the real width. Some anatomical studies regarding the size, contents and positional relationship of the superior orbital fissure have been previously reported.2e7 The size of the superior orbital fissure is reportedly 3 22 mm.7 This report supports our examination of the width of the superior orbital fissure. Many plastic surgeons may not be familiar with this technique of measuring the width of the superior orbital fissure, but this technique is easy to perform and no new examination is required except for the routine CT scan to investigate the facial bone fractures. Therefore, this method is thought to be useful to predict the superior orbital fissure syndrome after surgery. In case that the width does not exceed 1.6 mm, then surgical intervention of the facial bone fractures may trigger the superior orbital fissure syndrome. In the CT scans, the width (1.6 mm) on the affected side in our present patient was relatively narrow. The narrow superior orbital fissure may reduce tolerance to compression of the nerves by direct force and oedema. The slight postoperative oedema might compress the nerves and impair blood circulation, resulting in superior orbital fissure syndrome. In the present case, the lachrymal, frontal and nasociliary nerves and a part of the oculomotor nerve were damaged. However, the trochlear and abducent nerves and a part of the oculomotor nerve were intact. Therefore, the tolerance of the nerves passing via the superior orbital fissure to compression may be different in degree and probably depends on the diameter and location and the running direction of the nerves. The superior orbital fissure has many different shapes,8 pointing to the fact that the width of the superior orbital fissure on the horizontal plane including the optic canal does not always reflect the total size. Therefore, the entire superior orbital fissure should be carefully observed on three-dimensional CT (3D-CT) before operation. Careful examination of the superior orbital fissure permits the surgeons to predict the development of the superior orbital fissure syndrome, thus allowing early treatment. To decompress the tissue around the superior orbital fissure, steroid administration was previously described as non-surgical treatment for the superior orbital fissure syndrome.9 In the case in which steroid administration is initiated early, the manifestations improve well. The present patient was given a dose of prednisolone 6 days after the start of manifestations. Consequently, complete recovery from the superior orbital fissure syndrome took a long time. Unless the present patient is treated with steroid administration, the patient might spontaneously recover from the superior orbital fissure syndrome several weeks after surgery.10 However, if the obvious cause of the superior orbital fissure syndrome such as the compression
e569
to the nerves by the fractured bone or haematoma is not found, the decompression of the intraorbital contents is strongly recommended.9 There was no report stating that the postoperative oedema causes superior orbital fissure syndrome, even though this syndrome is not observed preoperatively. If the width of the superior orbital fissure is narrow, the surgeons should try to avoid excessive pulling of the bone fragment and compression of the orbital tissue during repair of the facial bone fractures and consider a possibility of the superior orbital fissure syndrome after surgery.
Acknowledgment We thank Professor Masaya Tohyama from the Department of Anatomy and Neuroscience, Graduate School of Medicine, Osaka University, for his support during this study. This work was supported by a research Grant-in-Aid from the Japanese Ministry of Education, Science, Sports, and Culture (18791321).
Conflict of interest The authors do not report any potential or perceived conflict of interest concerning in the materials or methods used in this study or findings specified in this paper.
Ethics The research protocol of the present article was approved by our Ethical Committee.
References 1. Banks P. The superior orbital fissure syndrome. Oral Surg Oral Med Oral Pathol 1967;24:455e8. 2. Govsa F, Kayalioglu G, Erturk M, et al. The superior orbital fissure and its contents. Surg Radiol Anat 1999;21:181e5. 3. Natori Y, Rhoton Jr AL. Microsurgical anatomy of the superior orbital fissure. Neurosurgery 1995;36:762e75. 4. Shi X, Han H, Zhao J, et al. Microsurgical anatomy of the superior orbital fissure. Clin Anat 2007;20:362e6. 5. Ammirati M, Bernardo A. Anatomical study of the superior orbital fissure as seen during a pterional approach. J Neurosurg 2007;106:151e6. 6. Karakas P, Bozkir MG, Oguz O. Morphometric measurements from various reference points in the orbit of male Caucasians. Surg Radiol Anat 2003;24:358e62. 7. Morard M, Tcherekayev V, de Tribolet N. The superior orbital fissure: a microanatomical study. Neurosurgery 1994;35: 1087e93. 8. Sharma PK, Malhotra VK, Tewari SP. Variations in the shape of the superior orbital fissure. Anat Anz 1988;165:55e6. 9. Acarturk S, Sekucoglu T, Kesiktas E. Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes. Ann Plast Surg 2004;53:60e4. 10. Seiff SR. High dose corticosteroids for treatment of vision loss due to indirect injury to the optic nerve. Ophthalmic Surg 1990;21:389e95.