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Masticatory diplopia.


We report a case of diplopia that was exacerbated by chewing in a patient who had sustained facial fractures in a motorcycle crash. The diplopia was corrected surgically 1 year following the accident. To the best of our knowledge, masticatory diplopia as a result of adhesion of the temporalis muscle to the periorbita secondary to facial trauma has not been previously reported.


Each year in the United States, more than 1.5 million craniofacial and cervical spine injuries occur as a result of motor vehicle collisions alone. (1) Among affected patients, diplopia, trismus, and/or difficulties with mastication are not uncommon. In this article, we describe what we believe is the first reported case of diplopia that was exacerbated by chewing in a patient who sustained facial fractures in a motorcycle crash. The patient underwent surgery, and the diplopia resolved.

Case report

A 47-year-old woman who had sustained multisystem trauma in a near-fatal motorcycle crash was taken to the emergency department at another facility. Among her injuries were multiple orthopedic and facial fractures, including fractures of the right zygomaticomaxillary complex (ZMC) and the nasal bone, as well as extensive soft-tissue envelope trauma. In the emergency department, she underwent open reduction with internal fixation of the ZMC and nasal fractures. The orbital component of the ZMC fracture was not addressed at that time.

The patient recovered from her treated injuries, but she presented to our institution 1 year later with a chief complaint of diplopia in upward gaze and rhythmic diplopia in primary gaze while chewing. The diplopia in primary gaze disappeared when she stopped chewing.

Physical examination revealed well-healed facial scars, right-sided enophthalmos, and limitation of the superior gaze. Clenching of the jaw resulted in movement of the right eye. Maxillofacial computed tomography (CT) revealed a depressed right orbital floor and a defect in the right lateral orbital wall that resulted in protrusion of the periorbita into the masticatory space (figure).

The patient was taken to the operating room. The orbital floor and lateral orbit were exposed via a transconjuctival approach. Extensive scarring was encountered, and the inferior rectus muscle was trapped within the orbital floor defect. Laterally, the periorbita was densely scarred to the deep surface of the right temporalis muscle. The scarring was surgically released, and the floor defect was repaired with 1.3mm titanium mesh. The lateral orbital defect was repaired with a 2.5 x 2 x 2.3-mm porous, high-density polyethylene implant (Medpor; Porex Surgical; Newnan, Ga.).

The patient reported immediate resolution of her diplopia. She was discharged home after 23 hours of inpatient observation. At 1 and 3 months' follow-up, she remained symptom-free.


Zygomaticoorbital fractures are the third-most-common fractures of the facial skeleton, after nasal and mandibular fractures. (2) Common etiologies include motor vehicle accidents, assaults, and sports-related injuries. (2) As many as 45% of patients with ZMC and orbital fractures complain of binocular diplopia. (3)

ZMC fractures are complex. They typically include fractures of the zygomaticofrontal, zygomaticomaxillary, zygomaticotemporal, and zygomaticosphenoid buttresses. When the lateral orbital wall is fractured at the zygomaticosphenoid suture, problems--including increased orbital volume with enophthalmos or extraocular muscle entrapment--may ensue and lead to diplopia.

The temporalis muscle originates along the temporal line and occupies the temporal fossa before it attaches to the coronoid process of the mandible. Because of the intimate relationship of the temporalis muscle with the lateral orbital wall and zygoma, ZMC fractures may also result in trismus or problems with mastication.

What makes this case unusual is that although both diplopia and mastication difficulties are relatively common after ZMC fractures, the onset of rhythmic diplopia initiated by mastication is exceedingly rare. Patients with neuromuscular disorders, such as myasthenia gravis or multiple sclerosis, may present with chewing difficulties and diplopia, but these symptoms do not typically occur simultaneously. (4,5)


To the best of our knowledge, masticatory diplopia as a result of adhesion of the temporalis muscle to the periorbita secondary to facial trauma has not been previously reported. Despite the rarity of this complication, surgeons should be aware of the possibility. In such a case, division of the scar tissue between the periorbita and temporalis muscle and restoration of the lateral orbital wall integrity may result in complete resolution of the patient's symptoms.



(1.) Katzen JT, Jarrahy R, Eby JB, et al. Craniofacial and skull base trauma. J Trauma 2003;54(5): 1026-34.

(2.) Laski R, ZiccardiVB, Broder HL, Janal M. Facial trauma: A recurrent disease? The potential role of disease prevention. J Oral Maxillofac Surg 2004;62(6):685-8.

(3.)Tong L, Bauer RJ, Buchman SR. A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center. Plast Reconstr Surg 2001; 108 (3):612-21.

(4.) Sasakura Y, Kumasaka S, TakahashiT, Shindo J. Myasthenia gravis associated with reduced masticatory function. IntJ Or al Maxillofac Surg 2000;29(5):381-3.

(5.) Hauser SL, Goodin DS. Multiple sclerosis and other demyelinating diseases. In: Kasper DL, Braunwald E, Fauci AS, et al, eds. Harrison's Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2004.

Oleg Militsakh, MD; J. David Kriet, MD, FACS

From the Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City.

Corresponding author: J. David Kriet, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, University of Kansas School of Medicine, 3901 Rainbow Blvd., Mail Stop #3010, Kansas City, KS 66160. Phone: (913) 588-6731; fax: (913) 588-6708; e-mail:
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Article Details
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Author:Militsakh, Oleg; Kriet, J. David
Publication:Ear, Nose and Throat Journal
Article Type:Disease/Disorder overview
Geographic Code:1USA
Date:Jan 1, 2008
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