2017-18 HSC Section 3 Green Book

Reprinted by permission of Laryngoscope. 2016; 126 Suppl 4:S5-S11.

The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc.

TRIOLOGICAL SOCIETY CANDIDATE THESIS

Orbit Fractures: Identifying Patient Factors Indicating High Risk for Ocular and Periocular Injury

Brian T. Andrews, MD, MA; Anee Sophia Jackson, MD; Niaman Nazir, MD; Alan Hromas, MD; Jason A. Sokol, MD; Todd E. Thurston, MD

Objectives/Hypothesis: Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomi- tant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient’s history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. Study Design: A retrospective clinical chart review was performed at a tertiary academic medical center. Methods: Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomi- tant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. Results: In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury ( P 5 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury ( P 5 0.0029 and 0.0001, respectively). Depth of orbit fracture on radio- graphic imaging was statistically associated with ocular injury ( P 5 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. Conclusion: Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Sub- jects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment. Key Words: Orbit fracture, orbit trauma, ocular injury, globe injury, vision loss. Level of Evidence: IV. Laryngoscope , 126:S5–S11, 2016

INTRODUCTION Maxillofacial trauma often involves fractures of the orbit. Ocular injury and vision loss are rare but devas- tating complications related to maxillofacial trauma and

orbit fractures. Vision loss may be caused by direct injury to the globe, optic nerve and/or canal injury, reti- nal edema or detachment, vascular compromise to the eye, and/or intracranial injury to the optic chiasm or brain. The incidence of vision loss associated with maxil- lofacial trauma varies widely in the literature, with pub- lished ranges of 0.32% to 10.8%. 1–5 A meta-analysis by Magarakis reported an actual vision loss rate of 1.7%. 6 Of interest, this same study demonstrated that the inci- dence of orbit fracture and concomitant ocular injury is much higher (range 5 9.8%–29.8%). Recognition of ocular injury is important for vision preservation. Early identification of ocular injury may change the management of maxillofacial fractures in some circumstances and possibly preserve vision. 7 As a result, a comprehensive ophthalmologic evaluation on all patients with maxillofacial trauma, and specifically those with orbital fractures, would be ideal. However, a comprehensive ophthalmologic evaluation by a trained ophthalmologist is not available at every medical institution. Additionally, com- prehensive ophthalmologic evaluation may be hindered by

From the Department of Otolaryngology and Department of Plas- tic Surgery ( B . T . A ., A . S . J ., T . E . T .); the Department of Preventative Medicine and Public Health ( N . N .); and the Department of Ophthalmology ( A . H ., J . A . S .), University of Kansas Medical Center, Kansas City, Kansas, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 4, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Computed tomography maxillofacial three-dimensional reconstruc- tion demonstrating severe right orbit blow-in fracture involving the entire orbit (roof, lateral wall, rim, medial wall, and floor) Send correspondence to Brian T. Andrews, MD, MA, Director of Cleft and Craniofacial Surgery, Assistant Professor, University of Kansas Medical Center, Department of Otolaryngology–Head and Neck Surgery, Department of Plastic Surgery, Sutherland Institute, MS 3015, 3901 Rainbow Blvd., Kansas City, KS 66160. E-mail: bandrews@kumc.edu

DOI: 10.1002/lary.25805

Andrews et al.: Ocular Injury and Orbit Fractures

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