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Superior orbital fissure syndrome in a 7-year-old boy
Int. J. Oral Surg. 1980: 9: 216-220 (Key words: fracture, orbital; trauma; surge,.}" oral)
Superior orbital fissure syndrome in a 7-year-old boy N. P. J. B. SIEVER[NK AND K. G. H. VAN DER WAL Department of Oral and lv/axillo/adal Surgery, St. Radboud Hospital, Nijmegen, Holland
ABSTRACT - Traumatic injuries of the skull may lead to the superior orbital fissure syndrome. Etiology, clinical features. prognosis and treatment are discussed on the basis of the occurrence of the syndrome in a 7-year-old boy. The syndrome has never been described in a patient of this age. Until this case report, the youngest patient described in the literature was 32 years of age. (Received for publication 31 August, accepted 28 September 1979)
The superior orbital fissure is formed by the greater and lesser wing of the sfenoid. Its antera-lateral part is situated between the roof and the lateral wall and its posteromedial part lies in the apex of the orbit. It communicates with the middle cranial fossa. The posterior end of the fissure is confluent with the inferior orbital fissureS. The contents of the superior orbital fissure are: the oculomotor nerve, the trochlear nerve, the first division of the trigeminus nerve and the abducens nerve. The clinical features of the syndrome are caused by damage of the contents of the fissure. These clinical feature areS: a) ptosis of the upper eyelid b) complete immobility of the eye and slight exophthalmus c) paralysis of the pupillary and ciliary muscles resulting in dilated fixed pupil and accommodation paralysis d) anesthesia in the area of distribution of
all branches of the first division of the trigeminus nerve supplying the cornea, upper eyelid, bridge of the nose and forehead. Factors responsible for the syndrome may be classified into three groups: 1) Trauma1,3,4,5,11,15,lU 2) Inflammation2, 10, 12 3) Tumors2, 10, 12 Spontaneous recovery of motor and sensory functions generally occurs without surgical exploration1,3, 4, 16. Methods of decompression have been previously described4 ,13. When the syndrome of the superior orbital fissure is accompanied by involvement of the optic nerve, the condition is referred to as the syndrome of the apex of the 01'bitn. An exellent review of the history of the superior orbital fissure syndrome is given by LAKKE10. The first description of the syndrome dates back to 1858. HIRSCHFELD describes the syndrome in a 72-year-
0300-9785/80/030216-05$02.50/0 © 1980 Munksgaard, Copenhagen
SUPERIOR ORBITAL FISSURE SYNDROME
217
old woman10 . According to LAKKE'S review of history, trauma as the responsible factor for the appearance of the syndrome is hardly ever mentioned. In this paper only the traumatic origin of the superior orbital fissure syndrome will be discussed.
Case report A 7-year-old boy was pressed under the falling rim of a tractor wheel and admitted to hospital. On the right side of the face were a periorbital swelling, bruising and abrasions. There was a flattening of the right cheek and steps were palpated in the right lateral and infra-orbital rims and the right mandibular body (Fig. 1). The occlusion was disturbed and a large gap was palpated in the region of the right mandibular second molar. A commotio cerebri was diagnosed. X-rays revealed the fracture of the mandibular body as well as fractures of the right zygomatic bone, both with considerable
Fig. 2. Radiograph of the right and left orbita. The right superior orbital fissure is narrowed (arrow).
dislocation. In addition a narrowing of the right superior orbital fissure (Fig. 2) and a fracture of the right temporal bone were seen. After some days, when adequate ophthalmological examination was possible, the patient showed the classical signs of the superior orbital fissure syndrome. Complete ophthalmoplegia of the right eye, ptosis of th.e upper eyelid, a fixed dilated pupil and absence of the corneal reflex, exophthalmus and an area of
Fig. 3. Ptosis of the right upper eyelid. The Fig. 1. Flattening of the right cheek. Dilatation
of the pupil.
marked area represents the c1incal extent of anesthesia. This photo is made on the 5th day postoperative.
218
SIEVER INK AND VAN DER WAL
Fig. 5. Orthopantomogram of the reduced fractUTes
dible.
of the right zygomatic bone and the man-
The patient was operateo on the 4th day posttraumatic. The fractured zygomatic bone was treated by open reduction. Transosseous wires were inserted in the lateral orbital rim and tbe infra-orbital rim. The fractured bone had the appearance of a broken willowbranch at the fracture lines; reduction was difficult.
Fig. 4. Total ophthalmoplegia of the right eye. Dilated pupil. 5th day postoperative. anesthesia of the skin of the forehead (Figs. 3, 4). The vision was disturbed.
Fig. 6. An occipita-mental radiograph showing the transosseous wiring of the lateral and infraorbital margins. Note the narrow right superior orbital fissure (arrow).
SUPERIOR ORBITAL FISSURE SYNDROME The fractured mandible was also reduced by open reduction after the insertion of arch bars and the removal of the right mandibular second molar from the fracture line. The body of the mandible was not only fractured in an oblique direction but also in a sagittal direction. Fixation of the parts was maintained by transosseous wires. The mandible was immobilized in occlusion. There were no postoperative complications. The postoperative radiographs showed an anatomical reduction of the zygomatic bone and the mandible (Figs. 5, 6). The superior orbital fissure was as narrow as preoperative (Fig. 6). On the 7th day postoperative some mobility of the eye could be noticed: there was less exophthalmus. The ophthalmological situation improved every week. At the check on the 12th postoperative week, all ophthalmological symptoms of the syndrome had disappeared, only a slight hypoesthesia of the skin of the forehead was still present. The vision was normal. Healing of the fractured zygomatic bone and the mandible was uneventful.
Discussion The superior orbital fissure syndrome of traumatic origin is rare. In large series of fractures of the zygomatic bone, the syndrome is not mentioned in any of the patients6, 7, 8,14. In our review of the literature, the superior orbital fissure syndrome after a trauma has never been described in someone as young as this boy. The age of the youngest patient with the superior orbital fissure syndrome described now was 32 years 1. The contents of the fissure may be damaged by displaced bone fragments. Another possibility is that hemorrhage and edema bring on the ophthalmological and neurological disturbances. A bleeding into the orbital muscle cone space, between the intermuscular membrane and Tenon's capsule, could press the ocular nerves against the bone margins of the fissure. Other findings 4,12 support this idea. These authors found blood cysts under tension at the apex of the muscle cone.
219
Several methods of surgical decompression were previously described4 ,ls. In this case it was difficult to decide whether exploration and decompression should be performed or not. According to some authors!, 3,16, an expectant policy is recommended because complete or partial spontaneous recovery of motor and sensory functions without surgical intervention is usual. We decided not to perform an exploration of the fissure but only to reduce the fractures of the zygomatic bone and the mandible. A complete spontaneous recovery of the ophthalmological disturbances was seen, despite the fissure still being narrowed after reduction of the maxillo-facial fractures. In general, exploration is indicated if after 4 months no improvement is seen in sensory and motor functions 12 Or in cases of acute and total ophthalmoplegia accompanied by progressive exophthalmus 4 , Acknowledgment - The ophthalmological consultations were performed by Mrs. K. U. Duinkerke-Eerola, M.D., Department of Ophthalmology, St. Radboud Hospital, Nijmegen, Holland.
References 1. BANKS, P.: The superior orbital fissure syn-
drome. Oral Surg. 1967: 24: 455-458.
2. BIBMOND, A.: Een bijzondere vorm van het
3.
4.
5.
6.
syndroom van de fissura orbitalis superior. Ned. T. Geneesk. 1959: 103: 545-548. BOWERMAN, J. E.: The superior orbital fissure syndrome complicating fractures of the facial skeleton. Br. 1. Oral Surg. 1969: 7: 1-6. !lA:RDT, N., VON & STEINHAUSER, E. W.: Orbitale Syndrome bei Mittelgesichts-OrbitaFrakturen. Dtsch. Z. Mund-Kiefer-Gesichts-Chir. 1979: 3: 71-76. HEDSTROM, J., PARSONS, J., MALONEY, Ph. L. & DOKU, H. Ch.: Superior orbital fissure syndrome: report of case. 1. Oral Surg. 1n4: 32: 198-201. HERK, W., VAN & HOVINGA, J.: Choice of treatment of orbital floor fractures as part
220
7.
8.
9.
10. 11.
12.
SIEVERINK AND VAN DER WAL of facial fractures. J. Oral Surg. 1973: 31: 600-603. HOVlNGA, J. & HERlC, W., VAN: Frakturen van het middelste derde deel van het geziehl. Ned. T. Geneesk. 1970: 114: 13221330. HOTrn, H. H.: Orbital fractures. Royal VanGorcum Ltd., Assen 1970. KRUGER, K. E.: Die ophthalmologische Komplikationen bei Gesichts-Schiidel-Verletzungen nnd ihre Behandlungsmethoden. In: Traumatologie 1m Kiefer-gesichts-Bereich. Kapitel 23. Johann Ambrosius Barth, MUnchen 1969. L\Jorn, J. P. W. F.: Superior orbital fissure syndrome. Arch. Neurol. 1962: 7: 51-61. LEWIS, J. M., WHITE, N. S., SNYDER, S. R. & FLANNERY, R. C.: Consideration of the intrinsic nerve supply of the eye in orbital fractures. J. Oral Surg. 1970: 28: 707-710. MORTADA, A.: Superior orbital fissure syndrome of uncertain aetiology. Br. J. Ophthai. 1961: 45: 662-671.
13. MURAKAMI, 1.: Decompression of the superior orbital fissure. Am. J. Ophthal. 1965: 58: 803-807. 14. NJ!YT, L.: Zygomafrakturen. Academisch Proefschrift, Groningen 1972. 15. ROBINSON, B. C. & JARRETT, W. J.: Superior orbital fissure syndrome with Bell's palsy: report of case. J. Oral Surg. 1973: 31: 203-206. 16. ROWE, N. L..& Ku.LEY, H. C.: Fractures of the facial skeleton. Livingstone, Edinburgh and London 1970.
Address: K. G. H. vall der Wal Department of Oral and Ma;dllofacial Surgery Diakonessenziekenhuis Noordersingel 88 8917 Be Leeuwarden The Netherlands
Superior orbital fissure syndrome in a 7-year-old boy N. P. J. B. SIEVER[NK AND K. G. H. VAN DER WAL Department of Oral and lv/axillo/adal Surgery, St. Radboud Hospital, Nijmegen, Holland
ABSTRACT - Traumatic injuries of the skull may lead to the superior orbital fissure syndrome. Etiology, clinical features. prognosis and treatment are discussed on the basis of the occurrence of the syndrome in a 7-year-old boy. The syndrome has never been described in a patient of this age. Until this case report, the youngest patient described in the literature was 32 years of age. (Received for publication 31 August, accepted 28 September 1979)
The superior orbital fissure is formed by the greater and lesser wing of the sfenoid. Its antera-lateral part is situated between the roof and the lateral wall and its posteromedial part lies in the apex of the orbit. It communicates with the middle cranial fossa. The posterior end of the fissure is confluent with the inferior orbital fissureS. The contents of the superior orbital fissure are: the oculomotor nerve, the trochlear nerve, the first division of the trigeminus nerve and the abducens nerve. The clinical features of the syndrome are caused by damage of the contents of the fissure. These clinical feature areS: a) ptosis of the upper eyelid b) complete immobility of the eye and slight exophthalmus c) paralysis of the pupillary and ciliary muscles resulting in dilated fixed pupil and accommodation paralysis d) anesthesia in the area of distribution of
all branches of the first division of the trigeminus nerve supplying the cornea, upper eyelid, bridge of the nose and forehead. Factors responsible for the syndrome may be classified into three groups: 1) Trauma1,3,4,5,11,15,lU 2) Inflammation2, 10, 12 3) Tumors2, 10, 12 Spontaneous recovery of motor and sensory functions generally occurs without surgical exploration1,3, 4, 16. Methods of decompression have been previously described4 ,13. When the syndrome of the superior orbital fissure is accompanied by involvement of the optic nerve, the condition is referred to as the syndrome of the apex of the 01'bitn. An exellent review of the history of the superior orbital fissure syndrome is given by LAKKE10. The first description of the syndrome dates back to 1858. HIRSCHFELD describes the syndrome in a 72-year-
0300-9785/80/030216-05$02.50/0 © 1980 Munksgaard, Copenhagen
SUPERIOR ORBITAL FISSURE SYNDROME
217
old woman10 . According to LAKKE'S review of history, trauma as the responsible factor for the appearance of the syndrome is hardly ever mentioned. In this paper only the traumatic origin of the superior orbital fissure syndrome will be discussed.
Case report A 7-year-old boy was pressed under the falling rim of a tractor wheel and admitted to hospital. On the right side of the face were a periorbital swelling, bruising and abrasions. There was a flattening of the right cheek and steps were palpated in the right lateral and infra-orbital rims and the right mandibular body (Fig. 1). The occlusion was disturbed and a large gap was palpated in the region of the right mandibular second molar. A commotio cerebri was diagnosed. X-rays revealed the fracture of the mandibular body as well as fractures of the right zygomatic bone, both with considerable
Fig. 2. Radiograph of the right and left orbita. The right superior orbital fissure is narrowed (arrow).
dislocation. In addition a narrowing of the right superior orbital fissure (Fig. 2) and a fracture of the right temporal bone were seen. After some days, when adequate ophthalmological examination was possible, the patient showed the classical signs of the superior orbital fissure syndrome. Complete ophthalmoplegia of the right eye, ptosis of th.e upper eyelid, a fixed dilated pupil and absence of the corneal reflex, exophthalmus and an area of
Fig. 3. Ptosis of the right upper eyelid. The Fig. 1. Flattening of the right cheek. Dilatation
of the pupil.
marked area represents the c1incal extent of anesthesia. This photo is made on the 5th day postoperative.
218
SIEVER INK AND VAN DER WAL
Fig. 5. Orthopantomogram of the reduced fractUTes
dible.
of the right zygomatic bone and the man-
The patient was operateo on the 4th day posttraumatic. The fractured zygomatic bone was treated by open reduction. Transosseous wires were inserted in the lateral orbital rim and tbe infra-orbital rim. The fractured bone had the appearance of a broken willowbranch at the fracture lines; reduction was difficult.
Fig. 4. Total ophthalmoplegia of the right eye. Dilated pupil. 5th day postoperative. anesthesia of the skin of the forehead (Figs. 3, 4). The vision was disturbed.
Fig. 6. An occipita-mental radiograph showing the transosseous wiring of the lateral and infraorbital margins. Note the narrow right superior orbital fissure (arrow).
SUPERIOR ORBITAL FISSURE SYNDROME The fractured mandible was also reduced by open reduction after the insertion of arch bars and the removal of the right mandibular second molar from the fracture line. The body of the mandible was not only fractured in an oblique direction but also in a sagittal direction. Fixation of the parts was maintained by transosseous wires. The mandible was immobilized in occlusion. There were no postoperative complications. The postoperative radiographs showed an anatomical reduction of the zygomatic bone and the mandible (Figs. 5, 6). The superior orbital fissure was as narrow as preoperative (Fig. 6). On the 7th day postoperative some mobility of the eye could be noticed: there was less exophthalmus. The ophthalmological situation improved every week. At the check on the 12th postoperative week, all ophthalmological symptoms of the syndrome had disappeared, only a slight hypoesthesia of the skin of the forehead was still present. The vision was normal. Healing of the fractured zygomatic bone and the mandible was uneventful.
Discussion The superior orbital fissure syndrome of traumatic origin is rare. In large series of fractures of the zygomatic bone, the syndrome is not mentioned in any of the patients6, 7, 8,14. In our review of the literature, the superior orbital fissure syndrome after a trauma has never been described in someone as young as this boy. The age of the youngest patient with the superior orbital fissure syndrome described now was 32 years 1. The contents of the fissure may be damaged by displaced bone fragments. Another possibility is that hemorrhage and edema bring on the ophthalmological and neurological disturbances. A bleeding into the orbital muscle cone space, between the intermuscular membrane and Tenon's capsule, could press the ocular nerves against the bone margins of the fissure. Other findings 4,12 support this idea. These authors found blood cysts under tension at the apex of the muscle cone.
219
Several methods of surgical decompression were previously described4 ,ls. In this case it was difficult to decide whether exploration and decompression should be performed or not. According to some authors!, 3,16, an expectant policy is recommended because complete or partial spontaneous recovery of motor and sensory functions without surgical intervention is usual. We decided not to perform an exploration of the fissure but only to reduce the fractures of the zygomatic bone and the mandible. A complete spontaneous recovery of the ophthalmological disturbances was seen, despite the fissure still being narrowed after reduction of the maxillo-facial fractures. In general, exploration is indicated if after 4 months no improvement is seen in sensory and motor functions 12 Or in cases of acute and total ophthalmoplegia accompanied by progressive exophthalmus 4 , Acknowledgment - The ophthalmological consultations were performed by Mrs. K. U. Duinkerke-Eerola, M.D., Department of Ophthalmology, St. Radboud Hospital, Nijmegen, Holland.
References 1. BANKS, P.: The superior orbital fissure syn-
drome. Oral Surg. 1967: 24: 455-458.
2. BIBMOND, A.: Een bijzondere vorm van het
3.
4.
5.
6.
syndroom van de fissura orbitalis superior. Ned. T. Geneesk. 1959: 103: 545-548. BOWERMAN, J. E.: The superior orbital fissure syndrome complicating fractures of the facial skeleton. Br. 1. Oral Surg. 1969: 7: 1-6. !lA:RDT, N., VON & STEINHAUSER, E. W.: Orbitale Syndrome bei Mittelgesichts-OrbitaFrakturen. Dtsch. Z. Mund-Kiefer-Gesichts-Chir. 1979: 3: 71-76. HEDSTROM, J., PARSONS, J., MALONEY, Ph. L. & DOKU, H. Ch.: Superior orbital fissure syndrome: report of case. 1. Oral Surg. 1n4: 32: 198-201. HERK, W., VAN & HOVINGA, J.: Choice of treatment of orbital floor fractures as part
220
7.
8.
9.
10. 11.
12.
SIEVERINK AND VAN DER WAL of facial fractures. J. Oral Surg. 1973: 31: 600-603. HOVlNGA, J. & HERlC, W., VAN: Frakturen van het middelste derde deel van het geziehl. Ned. T. Geneesk. 1970: 114: 13221330. HOTrn, H. H.: Orbital fractures. Royal VanGorcum Ltd., Assen 1970. KRUGER, K. E.: Die ophthalmologische Komplikationen bei Gesichts-Schiidel-Verletzungen nnd ihre Behandlungsmethoden. In: Traumatologie 1m Kiefer-gesichts-Bereich. Kapitel 23. Johann Ambrosius Barth, MUnchen 1969. L\Jorn, J. P. W. F.: Superior orbital fissure syndrome. Arch. Neurol. 1962: 7: 51-61. LEWIS, J. M., WHITE, N. S., SNYDER, S. R. & FLANNERY, R. C.: Consideration of the intrinsic nerve supply of the eye in orbital fractures. J. Oral Surg. 1970: 28: 707-710. MORTADA, A.: Superior orbital fissure syndrome of uncertain aetiology. Br. J. Ophthai. 1961: 45: 662-671.
13. MURAKAMI, 1.: Decompression of the superior orbital fissure. Am. J. Ophthal. 1965: 58: 803-807. 14. NJ!YT, L.: Zygomafrakturen. Academisch Proefschrift, Groningen 1972. 15. ROBINSON, B. C. & JARRETT, W. J.: Superior orbital fissure syndrome with Bell's palsy: report of case. J. Oral Surg. 1973: 31: 203-206. 16. ROWE, N. L..& Ku.LEY, H. C.: Fractures of the facial skeleton. Livingstone, Edinburgh and London 1970.
Address: K. G. H. vall der Wal Department of Oral and Ma;dllofacial Surgery Diakonessenziekenhuis Noordersingel 88 8917 Be Leeuwarden The Netherlands