The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Radiofrequency ablation can be chosen for lymphangiomas that are microcystic in nature and located on the supramylohyoid region.14–16 Radiotherapy, which nowadays is not used owing to malignant transformation of the lympangioma, was the treatment of choice in the past. In our case, we applied surgery as the treatment of choice so the lesion was excised totally without any complication. On follow-up, there was no recurrence and any complaint. Surgery is the best modality to reduce recurrence chance and complication rates.
CONCLUSIONS Lymphangiomas are congenital malformations of the lymphatic system, and most of the cases are seen on the head and neck region. After 2 years of age, lymphangiomas are rarely detected. The definite treatment modality is surgical excision of the tumor. We emphisize the importance of the posteriorly located cystic masses; these can be lymphangiomas that occur at any age.
Brief Clinical Studies
Purpose: The forced duction test (FDT) is important during the surgical treatment of ocular motility disturbance due to orbital wall fracture, but the lack of objective standards yields various test results based on individual examiners’ subjective assessments. Methods: Medial limbus abduction values of the affected eye were measured during preoperative and postoperative FDT, and the values were compared with those of the normal eye. Results: More accurate results were obtained using the modification of the FDT in the surgical repair of medial orbital wall fracture with entrapments. Conclusions: The modified FDT used here in medial orbital wall fracture with limited ocular motility can contribute to more effective and positive surgical outcomes by providing an objective reference point. Key Words: Medial orbital wall fracture, diplopia, ocular motility disorders, forced duction test
REFERENCES 1. Nanson EM. Lymphangioma (cystic hygroma) of the mediastinum. J Cardiovasc Surg 1968;9:447–452 2. Gupta N, Goyal A, Singh PP, et al. Isolated laryngeal lymphangioma: a rarity. Indian J Otolaryngol Head Neck Surg 2011;63:90–92 3. Rasaretnam R, Chanmugam D, Sabanathan K, et al. Cervicomediastinal lymphangioma. ANZ J Surg 1976;46:378–381 4. Wright CC, Cohen DM, Vegunta RK, et al. Intrathoracic cystic hygroma: a report of three cases. J Pediatr Surg 1996;31:1430–1432 5. Haksever M, Akduman D, Aslan S, et al. Nasopharyngeal lymphangioma in an adult: a rarity. Laryngoscope 2013;123:2972–2975 6. Ogita S, Tsuto T, Deguchi E, et al. OK-32 therapy for unresectable lymphangiomas in children. J Ped Surg 1991;26:263–270 7. Schmidt B, Schimpl G, Hollwarth ME. OK-32 therapy of lymphangiomas in children. Eur J Pediatr 1996;155:649–652 8. Parker GD, Harnsberger HR, Smoker WR. The anterior and posterior cervical spaces. Semin Ultrasound CT MR 1991;12:257–273 9. Childress ME, Baker CP, Samson PC. Lymphangioma of the mediastinum; report of a case with review of the literature. J Thorac Surg 1956;31:338–348 10. Dowd CN. XI. Hygroma cysticum colli: its structure and etiology. Ann Surg 1913;58:112–132 11. Bill AH, Summer DS. A unified concept of lymphangioma and cystic hygroma. Surg Gynecol Obstet 1965;120:79–86 12. Molitch HI, Unger EC, Witte CL, et al. Percutaneous sclerotherapy of lymphangiomas. Radiology 1995;194:343–347 13. Katsuno S, Ezawa S, Minemura T. Excision of cervical cystic lymphangioma using injection of hydrocolloid dental impression material. A technical case report. Int J Oral Maxillofac Surg 1999;28:295–296 14. cable BB, Mair EA. Radiofrequency ablation of lymphangiomatous macroglossia. Larygoscope 2001;111:1859–1861 15. Bloom DC, Perkins JA, Mannings SC. Managements od lymphatic malformations. Curr Opin Otolaryngol Head Neck Surg 2004;12:500–504 16. Goswamy J, Penney SE, Bruce IA, et al. Radiofrequency ablation in the treatment of pediatric microcystic lymphatic malformations. J Laryngol Otol 2013;127:279–284
Benefits of the Modified Forced Duction Test in Medial Orbital Wall Fracture With Ocular Motility Disturbance Seok Joo Kang, MD and Byung Mi Lee, MD #
2015 Mutaz B. Habal, MD
O
rbital wall fracture, which commonly occurs in maxillofacial trauma, causes functional impairment and facial deformity. The symptoms of medial orbital wall fracture are various and depend on the fracture site and degree.1 Muscle or surrounding soft tissue entrapment is relatively rare in medial orbital wall fracture. However, if diplopia, ocular motility dysfunction, restricted and painful abduction, or pseudo–sixth-nerve paresis occurs, correction is difficult. In such cases, most surgeons perform the forced duction test (FDT) to check whether surgical corrections were done properly, but the lack of objective standards yields various test results based on individual examiners’ subjective assessments. As such, in this study, we evaluated abduction of the medial limbus during preoperative and postoperative FDT and compared the results with those of normal eyes. This method allows for the comparison of preoperative and postoperative ocular motility as well as objective quantification of the degree of change. Therefore, it provides surgeons with a reference point and enables the determination of a more accurate postoperative prognosis of ocular movement. Even more accurate results were obtained by modification of the FDT used in the surgical repair of medial orbital wall fracture with entrapments reported here.
CLINICAL REPORT Patients and Methods The study included 15 patients who were treated at our hospital for medial orbital wall fracture with entrapments between February 2011 and December 2013 (Table 1). This study was reviewed and approved by the ethics review board of the InJe University Health From the Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, Busan, Republic of Korea. Received August 20, 2014. Accepted for publication January 21, 2015. Address correspondence and reprint requests to Seok Joo Kang, MD, Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, 75 Bokji-ro, Busan Jin-gu 614-735, Busan, Republic of Korea; E-mail: [email protected] Supported by the 2013 Inje University research grant. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001604
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 26, Number 4, June 2015
TABLE 1. Patient Characteristics No.
Sex/Age
Cause of Injury
Lateral Gaze Limitation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
M/29 M/28 F/56 M/32 M/38 M/36 M/18 M/15 M/48 M/25 M/18 M/13 F/46 M/51 M/45
Fall/slip Violent assault Traffic accident Traffic accident Fall/slip Violent assault Sports Violent assault Violent assault Violent assault Fall/slip Sports Traffic accident Violent assault Fall/slip
1 1 1 1 1 1 1 2 2 2 2 2 3 3 3
Diplopia Mild horizontal Mild horizontal Mild horizontal Mild horizontal Mild horizontal Mild horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Severe horizontal Severe horizontal/mild vertical Severe horizontal/moderate vertical
F, female; M, male.
FIGURE 1. Preoperative CT scan showing fracture of the right medial wall with entrapment of the right rectus muscle.
Center. Patients with orbital rim fracture or bilateral orbital fracture were excluded, and all 15 patients included here complained of diplopia and ocular motility dysfunction. Computed tomography (CT) of the orbits was performed and demonstrated medial orbital wall fracture with entrapment of the medial rectus muscle and surrounding soft tissues (Fig. 1). The degree of extraocular motility disturbance was graded in 4 cardinal directions using the Hess screen test, consisting of values, 0 to 3 (0 indicates normal), that are assigned and added. Diplopia degree was quantified by measuring the field of single binocular vision: mild, diplopia appears 30 degrees or more from the primary position; moderate, diplopia appears 10 to 30 degrees from the primary position; and severe, diplopia appears within 10 degrees from the primary position.
Operation
(Katena Products, Inc, Denville, NJ) to abduct the globe. Forceps were used to gently grasp the limbus until restriction was encountered, at which point the distance from the center reference point to the medial limbus was measured (Fig. 3). Surgical repair was performed through a subciliary incision under general anesthesia. Dissecting was performed in the preseptal plane to the inferior orbital rim, and the periosteum was elevated off the medial wall, followed by visualization of the medial orbital wall fracture to confirm the CT diagnosis. The herniated orbital contents were gently moved back into the orbit. The FDT was repeated at this point to confirm complete release of the tissue entrapment, and a 1.0-mm barrier Medpor (Porex Surgical Products Group, Newnan, GA) polyethylene implant was used to reconstruct the original fracture.
RESULTS The 15 patients (13 males, 2 females) had a mean age of 28 years (range, 13–56 y). The most common cause of trauma was violent assault (40%), followed by falls or slips (26.7%), traffic accidents (20%), and sports injuries (13.3%). The patients were divided into 4 groups based on the differences in the FDT measurements: 1 mm or less, 2 mm, 3 mm, and 4 mm or greater, depending on the differences in ocular abduction between the 2 eyes (Table 1).
A total of 15 patients underwent unilateral medial orbital wall fracture repair performed by a single surgeon. At the start of the surgery, FDT in the direction of abduction was performed (Fig. 2). First, a point between the 2 medial canthi was marked and used as the center FDT reference point. Next, the limbus was grasped at the 3-o’clock position using 0.5-mm locking Stern-Castroviejo forceps
FIGURE 2. Illustration of the use of the modified FDT in this study.
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FIGURE 3. Photos during the FDT. M, The center point between the medial fissures of both sides. Abduction is performed until no resistance is felt, at which point the distance between the M point and the medial limbus is measured.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
TABLE 2. Preoperative and Postoperative FDT Result Differences Difference, mm
1 2 3 4
Before Operation, n
Intraoperative First FDT, n
Intraoperative Second FDT, n
0 4 8 3
12 2 (2)y 1 (1)y 0
14 (2)y 1 (1)y 0 0
Difference in ocular abduction between eyes.
y
Numbers in parentheses refer to numbers of patients with preoperative differences of 4 mm or greater in ocular abduction between eyes.
During the test performed just before the surgery, a 2-mm difference was found in 4 patients, a 3-mm difference was found in 8 patients, and a 4 mm or greater difference was found in 3 patients. During the test performed immediately after the surgery, a 1 mm or less difference was found in 12 patients, a 2-mm difference was found in 2 patients, and a 3-mm difference was found in 1 patient (Table 2). All 3 patients who exhibited differences of 2 mm or greater on the first intraoperative FDT had demonstrated 4-mm differences on the preoperative FDT. For these patients, the surgical site was immediately reopened for a repeated muscle and soft tissue release. When the FDT was performed after the second surgical procedure, a difference of 2 mm was seen in 1 patient and a difference of 1 mm or less was seen in 2 patients. All patients displayed significantly improved ocular movements compared with those before surgery (Fig. 4).
DISCUSSION Medial orbital wall fracture can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although medial rectus entrapment caused by medial orbital wall fracture is rare, when complications such as diplopia, restricted and painful abduction, and pseudo–sixth-nerve paresis do occur, they are not easily corrected.2 The frequency of medial orbital wall fracture is relatively high among Asians3; according to Shin et al,4 among 952 cases of pure blowout fracture, medial orbital wall fracture was the most common (45.8%). These authors reported that 67% of patients with fracture exhibited diplopia, 24.2% exhibited extraocular movement limitation, and 8.8% exhibited enophthalmos.4 A higher incidence of isolated medial orbital wall fracture has been reported in Asians and is thought to result from a thinner orbital rim, reduced nasal prominence, and delicate medial wall and nasofrontal buttress in Asians.5 Although the indications and time required for medial orbital blowout fracture surgery remain controversial, prompt and appropriate surgical treatment is necessary if diplopia or eye movement limitations are present. Complications related to ocular motility
Brief Clinical Studies
disturbances can have a critically adverse effect on patient quality of life. It is essential to determine whether the procedure was successful before finishing surgery. To date, determinations during FDT were made by the surgeon according to the presence or absence of tightness. This method lacks objectivity because it depends on the individual examiner’s subjective assessment. Furthermore, there are no existing studies on the correlation between FDT, which is commonly performed during orbital wall fracture repair surgery, and postoperative ocular muscle function. As such, in this study, we modified the FDT to include a measurement of the abduction distance of the medial limbus and compared the results with the normal side. This method has 3 major advantages, providing objective quantification of changes in the degrees of ocular motility before and after surgery. First, it provides the surgeon with a point of reference. In the traditional FDT method, surgeons determine only whether tightness was present. However, the method used in this study uses direct comparison with the normal side, thus allowing the surgery to be performed more accurately. In this study, patients who showed differences of 3 mm or greater preoperatively compared with the normal eye appeared to have experienced significant improvement, but when measured with a ruler, a 2-mm difference was observed. That is, the surgeon may be satisfied with sufficient release of reduction in tightness but the actual measurement may prove otherwise. Accordingly, referencing the preoperatively measured distance can enable a more effective surgery. Second, with the use of the preoperative values obtained during FDT, postoperative ocular movement recovery can be predicted to a certain degree. In this study, all 3 patients who exhibited differences of 2 mm or greater in postoperative FDT showed 4-mm differences between the 2 sides during preoperative FDT. Moreover, a patient with a preoperative measurement of 3 mm or greater displayed a 2mm measurement even after 2 corrective surgeries, while ocular motility limitation and diplopia in this patient persisted throughout the postoperative observation period of greater than 1 year. In cases in which differences in the ocular movements of both eyes are 3 mm or greater because of severe trauma, the surgeon must consider that the ocular motility disturbance may persist even after surgery and clearly communicate such risks to the patient. In other words, although objective FDT performed during surgery may be the most meaningful for surgical outcome, the degree of preoperative ocular motility disturbance may still affect postoperative ocular motility dysfunction or diplopia. Third, the modified method reduces unnecessary damage to the surrounding tissues. Setting of the reference point at the normal eye’s ocular movement eliminates the need for meaningless repetition of FDT during surgery. Kassem6 reported on globe perforation that occurred during FDT performed before strabismus surgery and stated that the incidence of sclera perforation during various stages of strabismus surgery has been reported to range from 0.3% to 2.8%. The FDT method described in this study has the limitation that the pulling force applied by the surgeon is difficult to maintain at a constant level, meaning that the center of force may shift. Nevertheless, the modified FDT used in this study for medial orbital wall fracture with ocular motility disturbance can contribute to greater accuracy and more positive surgical outcomes by providing an objective reference point.
REFERENCES FIGURE 4. A, Extraocular movements on presentation of medial blowout fracture with medial rectus muscle entrapment. B, Postoperative assessment of lateral gaze at 8 weeks with full motion and no diplopia.
#
2015 Mutaz B. Habal, MD
1. Park CH, Choi Ch, Lee JH, et al. Endoscopic reduction of medial orbital wall fractures using the rolled Silastic sheet technique. J Trauma 2009;66:1421–1424
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The Journal of Craniofacial Surgery
2. Lee TH, Lee HM, Lee JM, et al. Endoscopic reduction of orbital medial wall fracture using rotational repositioning of the fractured: lamina papyracea fragment. J Craniofac Surg 2014;25:460–462 3. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures an associated ocular symptoms. J Craniofac Surg 2013;24:703–707 5. Manson PN. Pure orbital blowout fracture: new concepts and importance of the medial orbital blowout fracture. Plast Reconstr Surg 1994;104:878 6. Kassem RR. Presumed sclera perforation during forced duction test of the superior oblique muscle. J AAPOS 2011;15:291–292
Does Prolonged Reconstruction of Disarticulation Defect With Bone Plate Affect the Electromyography Records of Masticatory Muscles? Emad Tawfik Daif, BDS, MSc Objectives: For medical or socioeconomic reasons, the primary reconstruction of disarticulation defects with bone plates stays for many years. This study was performed to assess the effect of this delay on electromyography (EMG) records of masticatory muscles. Materials and Methods: Twenty-five patients treated by insertion of reconstruction plates in disarticulation defects were prospectively included in this study. Electromyography records for masticatory muscles were obtained before surgery and 3 months, 6 months, 1 year, 2 years, and 3 years afterward. Paired t-test was used to determine whether there was significant difference between the EMG values. Results: At 3 years after surgery, the amplitude values of the masseter and temporalis muscles, on the resected side, have decreased by 39% and 60%, respectively, whereas on the nonoperated side, they have increased by 35% and 29%. The peak decrease, on the resected sides, has occurred at 3 months for the temporalis and 2 years for the masseter. On the nonoperated side, the peak increase has occurred at 6 months for both the temporalis and the masseter. From the Department of Oral and Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University; and Oral & Maxillofacial Surgery Department, Alharm Hospital, Ministry of Health, Cairo, Egypt. Received September 9, 2014. Accepted for publication January 22, 2015. Address correspondence and reprint requests to Emad Tawfik Daif, BDS, MSc, PhD, Oral & Maxillofacial Surgery Department, Alharm Hospital, Ministry of Health, 2 Street No. 100, Maadi, Cairo, Egypt; E-mail: [email protected] The author reports no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001616
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Volume 26, Number 4, June 2015
Conclusions: A prolonged use of bone plates to reconstruct disarticulation defects leads to alterations in EMG values of masticatory muscles. These alterations present clinically as muscle atrophy on the operated side and hypertrophy on the nonoperated side. Key Words: Hemimandibulectomy, masticatory muscles, electromyography
S
egmental resection is required for a variety of pathologic processes of the mandible. Sometimes, in certain aggressive types of odontogenic cysts and benign tumors, a hemimandibular resection with disarticulation is highly indicated.1 Loss of a mandibular segment alters jaw motion, occlusal forces, and mastication, whether or not the jaw is reconstructed. It usually results in serous disabilities including impairment of chewing, swallowing, and speaking; poor control of salivary secretions; and moderate-to-severe cosmetic disfigurement. The degree of disability varies with the size and location of the defect. The biomechanical changes, of masticatory muscles, associated with this ablative surgery are difficult to assess clinically, and therefore, they are not well documented or researched.2,3 Reconstruction of the disarticulation defect as soon as possible is recommended to avoid deviation of the mandibular stump.4 Sometimes, the patients could not undergo immediate autogenous bone grafting procedures because of medical or socioeconomic factors.5,6 In such cases, immediate placement of a reconstruction bone plate is necessary. Use of a reconstruction plate in a disarticulation defect favorably supports facial form, symmetry, and occlusion such that many patients delay their definitive bony reconstruction or even consider it a permanent reconstruction.7,8 This method also preserves the possibility of secondary reconstruction.9 Surface electromyography (EMG) is a suitable tool for neuromuscular function analysis in the field of oral and maxillofacial surgery. The EMG measurements can provide objective, documentable, valid, and reproducible data on the functional condition of the masticatory muscles.10 In the literature, several authors have used EMG to evaluate the effect of orthognathic surgeries and fractures of the mandible on activities of the masticatory muscles.11– 15 The purpose of this study was to evaluate the EMG values of masticatory muscles after using bone plates for unilateral reconstruction of the disarticulation defects. The specific aim of the study was to measure the EMG values of masticatory muscles, on operated and nonoperated sides, before surgery and 3 years after surgery. The investigator hypothesized that changes in the EMG values of masticatory muscles on operated and nonoperated sides throughout the 3 years after surgery would not be significant.
MATERIALS AND METHODS Study Design and Sample The study population was composed of patients who attended the Department of Oral and Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University, between 2006 and 2013 for evaluation and management of mandibular ameloblastoma. This study was approved by the research ethics committee at the Faculty of Oral & Dental Medicine, Cairo University, and informed consent was obtained from all patients involved in this study. To be included in the study, the patients had to have mandibular ameloblastoma indicating hemimandibulectomy and deferred or refused the secondary reconstruction, by bone grafting procedures. The patients who underwent hemimandibulectomy and bone grafting at the same surgical intervention were excluded from this study. All patients involved in this study had #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Volume 26, Number 4, June 2015
Radiofrequency ablation can be chosen for lymphangiomas that are microcystic in nature and located on the supramylohyoid region.14–16 Radiotherapy, which nowadays is not used owing to malignant transformation of the lympangioma, was the treatment of choice in the past. In our case, we applied surgery as the treatment of choice so the lesion was excised totally without any complication. On follow-up, there was no recurrence and any complaint. Surgery is the best modality to reduce recurrence chance and complication rates.
CONCLUSIONS Lymphangiomas are congenital malformations of the lymphatic system, and most of the cases are seen on the head and neck region. After 2 years of age, lymphangiomas are rarely detected. The definite treatment modality is surgical excision of the tumor. We emphisize the importance of the posteriorly located cystic masses; these can be lymphangiomas that occur at any age.
Brief Clinical Studies
Purpose: The forced duction test (FDT) is important during the surgical treatment of ocular motility disturbance due to orbital wall fracture, but the lack of objective standards yields various test results based on individual examiners’ subjective assessments. Methods: Medial limbus abduction values of the affected eye were measured during preoperative and postoperative FDT, and the values were compared with those of the normal eye. Results: More accurate results were obtained using the modification of the FDT in the surgical repair of medial orbital wall fracture with entrapments. Conclusions: The modified FDT used here in medial orbital wall fracture with limited ocular motility can contribute to more effective and positive surgical outcomes by providing an objective reference point. Key Words: Medial orbital wall fracture, diplopia, ocular motility disorders, forced duction test
REFERENCES 1. Nanson EM. Lymphangioma (cystic hygroma) of the mediastinum. J Cardiovasc Surg 1968;9:447–452 2. Gupta N, Goyal A, Singh PP, et al. Isolated laryngeal lymphangioma: a rarity. Indian J Otolaryngol Head Neck Surg 2011;63:90–92 3. Rasaretnam R, Chanmugam D, Sabanathan K, et al. Cervicomediastinal lymphangioma. ANZ J Surg 1976;46:378–381 4. Wright CC, Cohen DM, Vegunta RK, et al. Intrathoracic cystic hygroma: a report of three cases. J Pediatr Surg 1996;31:1430–1432 5. Haksever M, Akduman D, Aslan S, et al. Nasopharyngeal lymphangioma in an adult: a rarity. Laryngoscope 2013;123:2972–2975 6. Ogita S, Tsuto T, Deguchi E, et al. OK-32 therapy for unresectable lymphangiomas in children. J Ped Surg 1991;26:263–270 7. Schmidt B, Schimpl G, Hollwarth ME. OK-32 therapy of lymphangiomas in children. Eur J Pediatr 1996;155:649–652 8. Parker GD, Harnsberger HR, Smoker WR. The anterior and posterior cervical spaces. Semin Ultrasound CT MR 1991;12:257–273 9. Childress ME, Baker CP, Samson PC. Lymphangioma of the mediastinum; report of a case with review of the literature. J Thorac Surg 1956;31:338–348 10. Dowd CN. XI. Hygroma cysticum colli: its structure and etiology. Ann Surg 1913;58:112–132 11. Bill AH, Summer DS. A unified concept of lymphangioma and cystic hygroma. Surg Gynecol Obstet 1965;120:79–86 12. Molitch HI, Unger EC, Witte CL, et al. Percutaneous sclerotherapy of lymphangiomas. Radiology 1995;194:343–347 13. Katsuno S, Ezawa S, Minemura T. Excision of cervical cystic lymphangioma using injection of hydrocolloid dental impression material. A technical case report. Int J Oral Maxillofac Surg 1999;28:295–296 14. cable BB, Mair EA. Radiofrequency ablation of lymphangiomatous macroglossia. Larygoscope 2001;111:1859–1861 15. Bloom DC, Perkins JA, Mannings SC. Managements od lymphatic malformations. Curr Opin Otolaryngol Head Neck Surg 2004;12:500–504 16. Goswamy J, Penney SE, Bruce IA, et al. Radiofrequency ablation in the treatment of pediatric microcystic lymphatic malformations. J Laryngol Otol 2013;127:279–284
Benefits of the Modified Forced Duction Test in Medial Orbital Wall Fracture With Ocular Motility Disturbance Seok Joo Kang, MD and Byung Mi Lee, MD #
2015 Mutaz B. Habal, MD
O
rbital wall fracture, which commonly occurs in maxillofacial trauma, causes functional impairment and facial deformity. The symptoms of medial orbital wall fracture are various and depend on the fracture site and degree.1 Muscle or surrounding soft tissue entrapment is relatively rare in medial orbital wall fracture. However, if diplopia, ocular motility dysfunction, restricted and painful abduction, or pseudo–sixth-nerve paresis occurs, correction is difficult. In such cases, most surgeons perform the forced duction test (FDT) to check whether surgical corrections were done properly, but the lack of objective standards yields various test results based on individual examiners’ subjective assessments. As such, in this study, we evaluated abduction of the medial limbus during preoperative and postoperative FDT and compared the results with those of normal eyes. This method allows for the comparison of preoperative and postoperative ocular motility as well as objective quantification of the degree of change. Therefore, it provides surgeons with a reference point and enables the determination of a more accurate postoperative prognosis of ocular movement. Even more accurate results were obtained by modification of the FDT used in the surgical repair of medial orbital wall fracture with entrapments reported here.
CLINICAL REPORT Patients and Methods The study included 15 patients who were treated at our hospital for medial orbital wall fracture with entrapments between February 2011 and December 2013 (Table 1). This study was reviewed and approved by the ethics review board of the InJe University Health From the Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, Busan, Republic of Korea. Received August 20, 2014. Accepted for publication January 21, 2015. Address correspondence and reprint requests to Seok Joo Kang, MD, Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, 75 Bokji-ro, Busan Jin-gu 614-735, Busan, Republic of Korea; E-mail: [email protected] Supported by the 2013 Inje University research grant. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001604
e325
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 26, Number 4, June 2015
TABLE 1. Patient Characteristics No.
Sex/Age
Cause of Injury
Lateral Gaze Limitation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
M/29 M/28 F/56 M/32 M/38 M/36 M/18 M/15 M/48 M/25 M/18 M/13 F/46 M/51 M/45
Fall/slip Violent assault Traffic accident Traffic accident Fall/slip Violent assault Sports Violent assault Violent assault Violent assault Fall/slip Sports Traffic accident Violent assault Fall/slip
1 1 1 1 1 1 1 2 2 2 2 2 3 3 3
Diplopia Mild horizontal Mild horizontal Mild horizontal Mild horizontal Mild horizontal Mild horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Moderate horizontal Severe horizontal Severe horizontal/mild vertical Severe horizontal/moderate vertical
F, female; M, male.
FIGURE 1. Preoperative CT scan showing fracture of the right medial wall with entrapment of the right rectus muscle.
Center. Patients with orbital rim fracture or bilateral orbital fracture were excluded, and all 15 patients included here complained of diplopia and ocular motility dysfunction. Computed tomography (CT) of the orbits was performed and demonstrated medial orbital wall fracture with entrapment of the medial rectus muscle and surrounding soft tissues (Fig. 1). The degree of extraocular motility disturbance was graded in 4 cardinal directions using the Hess screen test, consisting of values, 0 to 3 (0 indicates normal), that are assigned and added. Diplopia degree was quantified by measuring the field of single binocular vision: mild, diplopia appears 30 degrees or more from the primary position; moderate, diplopia appears 10 to 30 degrees from the primary position; and severe, diplopia appears within 10 degrees from the primary position.
Operation
(Katena Products, Inc, Denville, NJ) to abduct the globe. Forceps were used to gently grasp the limbus until restriction was encountered, at which point the distance from the center reference point to the medial limbus was measured (Fig. 3). Surgical repair was performed through a subciliary incision under general anesthesia. Dissecting was performed in the preseptal plane to the inferior orbital rim, and the periosteum was elevated off the medial wall, followed by visualization of the medial orbital wall fracture to confirm the CT diagnosis. The herniated orbital contents were gently moved back into the orbit. The FDT was repeated at this point to confirm complete release of the tissue entrapment, and a 1.0-mm barrier Medpor (Porex Surgical Products Group, Newnan, GA) polyethylene implant was used to reconstruct the original fracture.
RESULTS The 15 patients (13 males, 2 females) had a mean age of 28 years (range, 13–56 y). The most common cause of trauma was violent assault (40%), followed by falls or slips (26.7%), traffic accidents (20%), and sports injuries (13.3%). The patients were divided into 4 groups based on the differences in the FDT measurements: 1 mm or less, 2 mm, 3 mm, and 4 mm or greater, depending on the differences in ocular abduction between the 2 eyes (Table 1).
A total of 15 patients underwent unilateral medial orbital wall fracture repair performed by a single surgeon. At the start of the surgery, FDT in the direction of abduction was performed (Fig. 2). First, a point between the 2 medial canthi was marked and used as the center FDT reference point. Next, the limbus was grasped at the 3-o’clock position using 0.5-mm locking Stern-Castroviejo forceps
FIGURE 2. Illustration of the use of the modified FDT in this study.
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FIGURE 3. Photos during the FDT. M, The center point between the medial fissures of both sides. Abduction is performed until no resistance is felt, at which point the distance between the M point and the medial limbus is measured.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
TABLE 2. Preoperative and Postoperative FDT Result Differences Difference, mm
1 2 3 4
Before Operation, n
Intraoperative First FDT, n
Intraoperative Second FDT, n
0 4 8 3
12 2 (2)y 1 (1)y 0
14 (2)y 1 (1)y 0 0
Difference in ocular abduction between eyes.
y
Numbers in parentheses refer to numbers of patients with preoperative differences of 4 mm or greater in ocular abduction between eyes.
During the test performed just before the surgery, a 2-mm difference was found in 4 patients, a 3-mm difference was found in 8 patients, and a 4 mm or greater difference was found in 3 patients. During the test performed immediately after the surgery, a 1 mm or less difference was found in 12 patients, a 2-mm difference was found in 2 patients, and a 3-mm difference was found in 1 patient (Table 2). All 3 patients who exhibited differences of 2 mm or greater on the first intraoperative FDT had demonstrated 4-mm differences on the preoperative FDT. For these patients, the surgical site was immediately reopened for a repeated muscle and soft tissue release. When the FDT was performed after the second surgical procedure, a difference of 2 mm was seen in 1 patient and a difference of 1 mm or less was seen in 2 patients. All patients displayed significantly improved ocular movements compared with those before surgery (Fig. 4).
DISCUSSION Medial orbital wall fracture can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although medial rectus entrapment caused by medial orbital wall fracture is rare, when complications such as diplopia, restricted and painful abduction, and pseudo–sixth-nerve paresis do occur, they are not easily corrected.2 The frequency of medial orbital wall fracture is relatively high among Asians3; according to Shin et al,4 among 952 cases of pure blowout fracture, medial orbital wall fracture was the most common (45.8%). These authors reported that 67% of patients with fracture exhibited diplopia, 24.2% exhibited extraocular movement limitation, and 8.8% exhibited enophthalmos.4 A higher incidence of isolated medial orbital wall fracture has been reported in Asians and is thought to result from a thinner orbital rim, reduced nasal prominence, and delicate medial wall and nasofrontal buttress in Asians.5 Although the indications and time required for medial orbital blowout fracture surgery remain controversial, prompt and appropriate surgical treatment is necessary if diplopia or eye movement limitations are present. Complications related to ocular motility
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disturbances can have a critically adverse effect on patient quality of life. It is essential to determine whether the procedure was successful before finishing surgery. To date, determinations during FDT were made by the surgeon according to the presence or absence of tightness. This method lacks objectivity because it depends on the individual examiner’s subjective assessment. Furthermore, there are no existing studies on the correlation between FDT, which is commonly performed during orbital wall fracture repair surgery, and postoperative ocular muscle function. As such, in this study, we modified the FDT to include a measurement of the abduction distance of the medial limbus and compared the results with the normal side. This method has 3 major advantages, providing objective quantification of changes in the degrees of ocular motility before and after surgery. First, it provides the surgeon with a point of reference. In the traditional FDT method, surgeons determine only whether tightness was present. However, the method used in this study uses direct comparison with the normal side, thus allowing the surgery to be performed more accurately. In this study, patients who showed differences of 3 mm or greater preoperatively compared with the normal eye appeared to have experienced significant improvement, but when measured with a ruler, a 2-mm difference was observed. That is, the surgeon may be satisfied with sufficient release of reduction in tightness but the actual measurement may prove otherwise. Accordingly, referencing the preoperatively measured distance can enable a more effective surgery. Second, with the use of the preoperative values obtained during FDT, postoperative ocular movement recovery can be predicted to a certain degree. In this study, all 3 patients who exhibited differences of 2 mm or greater in postoperative FDT showed 4-mm differences between the 2 sides during preoperative FDT. Moreover, a patient with a preoperative measurement of 3 mm or greater displayed a 2mm measurement even after 2 corrective surgeries, while ocular motility limitation and diplopia in this patient persisted throughout the postoperative observation period of greater than 1 year. In cases in which differences in the ocular movements of both eyes are 3 mm or greater because of severe trauma, the surgeon must consider that the ocular motility disturbance may persist even after surgery and clearly communicate such risks to the patient. In other words, although objective FDT performed during surgery may be the most meaningful for surgical outcome, the degree of preoperative ocular motility disturbance may still affect postoperative ocular motility dysfunction or diplopia. Third, the modified method reduces unnecessary damage to the surrounding tissues. Setting of the reference point at the normal eye’s ocular movement eliminates the need for meaningless repetition of FDT during surgery. Kassem6 reported on globe perforation that occurred during FDT performed before strabismus surgery and stated that the incidence of sclera perforation during various stages of strabismus surgery has been reported to range from 0.3% to 2.8%. The FDT method described in this study has the limitation that the pulling force applied by the surgeon is difficult to maintain at a constant level, meaning that the center of force may shift. Nevertheless, the modified FDT used in this study for medial orbital wall fracture with ocular motility disturbance can contribute to greater accuracy and more positive surgical outcomes by providing an objective reference point.
REFERENCES FIGURE 4. A, Extraocular movements on presentation of medial blowout fracture with medial rectus muscle entrapment. B, Postoperative assessment of lateral gaze at 8 weeks with full motion and no diplopia.
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1. Park CH, Choi Ch, Lee JH, et al. Endoscopic reduction of medial orbital wall fractures using the rolled Silastic sheet technique. J Trauma 2009;66:1421–1424
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The Journal of Craniofacial Surgery
2. Lee TH, Lee HM, Lee JM, et al. Endoscopic reduction of orbital medial wall fracture using rotational repositioning of the fractured: lamina papyracea fragment. J Craniofac Surg 2014;25:460–462 3. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures an associated ocular symptoms. J Craniofac Surg 2013;24:703–707 5. Manson PN. Pure orbital blowout fracture: new concepts and importance of the medial orbital blowout fracture. Plast Reconstr Surg 1994;104:878 6. Kassem RR. Presumed sclera perforation during forced duction test of the superior oblique muscle. J AAPOS 2011;15:291–292
Does Prolonged Reconstruction of Disarticulation Defect With Bone Plate Affect the Electromyography Records of Masticatory Muscles? Emad Tawfik Daif, BDS, MSc Objectives: For medical or socioeconomic reasons, the primary reconstruction of disarticulation defects with bone plates stays for many years. This study was performed to assess the effect of this delay on electromyography (EMG) records of masticatory muscles. Materials and Methods: Twenty-five patients treated by insertion of reconstruction plates in disarticulation defects were prospectively included in this study. Electromyography records for masticatory muscles were obtained before surgery and 3 months, 6 months, 1 year, 2 years, and 3 years afterward. Paired t-test was used to determine whether there was significant difference between the EMG values. Results: At 3 years after surgery, the amplitude values of the masseter and temporalis muscles, on the resected side, have decreased by 39% and 60%, respectively, whereas on the nonoperated side, they have increased by 35% and 29%. The peak decrease, on the resected sides, has occurred at 3 months for the temporalis and 2 years for the masseter. On the nonoperated side, the peak increase has occurred at 6 months for both the temporalis and the masseter. From the Department of Oral and Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University; and Oral & Maxillofacial Surgery Department, Alharm Hospital, Ministry of Health, Cairo, Egypt. Received September 9, 2014. Accepted for publication January 22, 2015. Address correspondence and reprint requests to Emad Tawfik Daif, BDS, MSc, PhD, Oral & Maxillofacial Surgery Department, Alharm Hospital, Ministry of Health, 2 Street No. 100, Maadi, Cairo, Egypt; E-mail: [email protected] The author reports no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001616
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Conclusions: A prolonged use of bone plates to reconstruct disarticulation defects leads to alterations in EMG values of masticatory muscles. These alterations present clinically as muscle atrophy on the operated side and hypertrophy on the nonoperated side. Key Words: Hemimandibulectomy, masticatory muscles, electromyography
S
egmental resection is required for a variety of pathologic processes of the mandible. Sometimes, in certain aggressive types of odontogenic cysts and benign tumors, a hemimandibular resection with disarticulation is highly indicated.1 Loss of a mandibular segment alters jaw motion, occlusal forces, and mastication, whether or not the jaw is reconstructed. It usually results in serous disabilities including impairment of chewing, swallowing, and speaking; poor control of salivary secretions; and moderate-to-severe cosmetic disfigurement. The degree of disability varies with the size and location of the defect. The biomechanical changes, of masticatory muscles, associated with this ablative surgery are difficult to assess clinically, and therefore, they are not well documented or researched.2,3 Reconstruction of the disarticulation defect as soon as possible is recommended to avoid deviation of the mandibular stump.4 Sometimes, the patients could not undergo immediate autogenous bone grafting procedures because of medical or socioeconomic factors.5,6 In such cases, immediate placement of a reconstruction bone plate is necessary. Use of a reconstruction plate in a disarticulation defect favorably supports facial form, symmetry, and occlusion such that many patients delay their definitive bony reconstruction or even consider it a permanent reconstruction.7,8 This method also preserves the possibility of secondary reconstruction.9 Surface electromyography (EMG) is a suitable tool for neuromuscular function analysis in the field of oral and maxillofacial surgery. The EMG measurements can provide objective, documentable, valid, and reproducible data on the functional condition of the masticatory muscles.10 In the literature, several authors have used EMG to evaluate the effect of orthognathic surgeries and fractures of the mandible on activities of the masticatory muscles.11– 15 The purpose of this study was to evaluate the EMG values of masticatory muscles after using bone plates for unilateral reconstruction of the disarticulation defects. The specific aim of the study was to measure the EMG values of masticatory muscles, on operated and nonoperated sides, before surgery and 3 years after surgery. The investigator hypothesized that changes in the EMG values of masticatory muscles on operated and nonoperated sides throughout the 3 years after surgery would not be significant.
MATERIALS AND METHODS Study Design and Sample The study population was composed of patients who attended the Department of Oral and Maxillofacial Surgery, Faculty of Oral & Dental Medicine, Cairo University, between 2006 and 2013 for evaluation and management of mandibular ameloblastoma. This study was approved by the research ethics committee at the Faculty of Oral & Dental Medicine, Cairo University, and informed consent was obtained from all patients involved in this study. To be included in the study, the patients had to have mandibular ameloblastoma indicating hemimandibulectomy and deferred or refused the secondary reconstruction, by bone grafting procedures. The patients who underwent hemimandibulectomy and bone grafting at the same surgical intervention were excluded from this study. All patients involved in this study had #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
