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Transantral endoscopic repair of orbital floor fractures with the use of a flexible endoscope holder: a cadaver study.


We conducted a cadaver study to determine the ease of use and functionality of a flexible endoscope holder in the visualization and repair of orbital floor fractures via a transantral approach. Four fresh cadaver heads were dissected through a sublabial antrotomy incision with a 30[degrees] endoscope attached to a flexible holder. An implant was placed to restore the normal anatomy. With the use of this exclusive endoscopic approach, all orbital floor fractures were identified in their entirety and completely reduced with alloplastic material. We conclude that the flexible endoscope holder provides clearer visualization, greater instrument mobility, and an overall superior dissection and placement of implants in the endoscopic repair of orbital floor fractures.


Over the past decade, endoscopic surgical approaches have become more widely accepted as an alternative to external approaches in all facets of head and neck surgery. Endoscopic techniques for the repair of orbital, frontal sinus, mandibular, and midface fractures have all been described. (1) Orbital floor fractures have historically been repaired through subciliary or transconjunctival incisions, but these approaches are associated with a number of complications. (1,2) As a result, interest in endoscopic approaches has increased. (l-6)

We believe that using a flexible endoscope holder for orbital repair via a sublabial transantral approach improves visualization, instrument mobility, and the overall ease of dissection. Use of the holder provides the surgeon much greater bimanual dexterity and stable visualization of the orbital floor. And, of course, use of the holder obviates the need for an assistant to hold the endoscope.

Materials and methods

A standard 30[degrees] endoscope was used in this cadaveric dissection. (Any degree endoscope can be attached to the holder.) We used a Mitaka Point Setter (Mitaka USA; Park City, Utah) as our flexible endoscope holder. The Point Setter device has been approved by the federal Food and Drug Administration. It acts as a surgeon's "third arm and hand" in that it holds an endoscope firmly. (7) The arm portion, which operates under nitrogen pressure, can be moved and locked by pressing one switch. Arnholt and Mair previously demonstrated the greater accuracy and precision of nitrogen-powered arms compared with flexible tension arms. (8) The alloplastic material used for the repair of the orbital floor was a 50 x 76 x 1.5-mm Medpor surgical implant (Porex Surgical; Newnan, Ga.)

Four fresh cadaveric heads (8 orbital floors) were dissected. Two orbital floors were dissected without the use of the endoscope holder; instead, one surgeon held the endoscope while the other performed the procedure. The remaining 6 orbital floors were dissected with the aid of the endoscope holder.


Blowout fractures were created prior to the dissection by applying force with a mallet to the cylindrical handle of an osteotome that was placed directly on the cadaveric eye. A sublabial incision was made bilaterally, and the periosteal elevator was used to dissect down to the anterior maxillary wall. An approximate 2.0 x 1.5-cm antrotomy was made with a 3-mm osteotome and mallet.

A 30[degrees] endoscope was placed by the nonoperating surgeon for the 2 orbital floors where the holder was not used. For the 6 orbital floors where the endoscope holder was used, the operating surgeon placed the endoscope in the desired location himself and locked the scope into place (figure 1). The extent of the fracture was evaluated, the infraorbital vessels were identified, and the periosteum was carefully dissected and reduced until an adequate shelf of bone could be visualized (figure 2, A).

Once a complete dissection was carried out, a piece of Medpor was fashioned to an approximate size that would adequately reduce the orbital floor contents; the Medpor was successfully placed in all cases (figure 2, B). Medpor was used because it is the authors' implant preference for orbital floor reduction, but other materials--autologous bone, Silastic, and a myriad of other implants--may be used.


All 8 orbital floor fractures were reduced and implanted with alloplastic material under direct visualization. The infraorbital nerve and vessels were visualized in all cases.

The most significant finding of this study was the increased maneuverability afforded to the operating surgeon with the use of the endoscope holder. When the endoscope holder was used, the operating surgeon did not have to adjust his hands to accommodate the placement of the endoscope. For those cases when the endoscope holder was not used, the operating surgeon was forced to make more cumbersome hand adjustments in order to accommodate the hand position of the nonoperating surgeon who was holding the endoscope.


We also observed that the endoscope holder provided a more stable image of the orbital floor throughout the dissection. It is difficult for a human assistant operating an endoscope to maintain a stationary image throughout the procedure. In most dissections, the holder did not have to be moved; even in those instances when a better vantage point was needed, the operating surgeon would only have to use one hand to make the small adjustment. Overall, both the operating and nonoperating surgeons concluded that the endoscope holder provided better visibility and an easier dissection and placement of alloplastic material compared with a handheld endoscope.


Orbital floor fracture is one of the more common injuries seen in facial trauma. Eighteen percent of all facial fractures involve the orbit, and 90% of those involve the orbital floor. (6)

There is considerable controversy concerning the indications and timing for repairing an orbital floor fracture. (9) The purpose of this study was not to compare the advantages of surgical versus nonsurgical treatment, but rather to determine if the operative technique could be improved when endoscopic surgery is the chosen treatment. As mentioned, orbital floor fractures have historically been repaired through subciliary or transconjunctival incisions. These approaches provide relatively quick and simple access to the orbital rim and floor. However, the disadvantages of these approaches include inadequate posterior floor visualization in cases of large floor fractures and complications such as ectropion, entropion, lacrimal injury, corneal abrasion, granuloma formation, seroma formation and, in the case of the subciliary approach, a visible scar. (1,2)

The popularity of endoscopic approaches to sinus surgery has led to interest in using endoscopy for the treatment of facial trauma. (3-6) Saunders et al described the first endoscopically assisted approach in 1997 when they carried out a cadaver and clinical study. (3) They used an endoscope for visualization via a sublabial antrotomy approach to aid in the external placement of titanium mesh. Their findings indicated that endoscopic orbital floor exploration allows for precise determination of the fracture size and aids in implant placement, particularly in posterior shelf fractures.

Ikeda et al described an endoscopic endonasal technique for reduction with a balloon catheter. (4) The drawbacks to this approach included the development of enophthalmos and diplopia in several patients after the balloon was deflated and a failure to recognize the posterior extent of the fracture in 2 patients, which resulted in persistent diplopia.

Chen and Chen were the first to carry out transantral floor repairs without an external excision. (5) They modified the technique described by Saunders et al (3) by making a larger antrotomy (2.0 x 1.5 cm) for the transantral placement of orbital implants (Medpor or titanium mesh). Their study demonstrated that the transantral endoscopic approach provided an alternate option for floor fractures. External excisions were avoided, and the risk of enophthalmos, ectropion, and entropion was theoretically lessened.

Most recently, Strong et al published a cadaver and clinical study in which orbital floor fractures were repaired endoscopically through a sublabial antrotomy incision. (6) Repairs were successfully achieved in 16 of 16 cadaveric orbits and in 9 of 10 patients. The stated advantages of using the endoscopic approach in this study included more accurate visualization, minimal external incisions, and less soft-tissue dissection. The disadvantages included a moderately difficult learning curve, poor depth perception, and the need for an assistant surgeon to hold the endoscope.

We believe that the endoscope holder provides for easier dissection, smoother manipulation, and improved visibility compared with the techniques described by Chen and Chen (5) and Strong et al. (6) Precise positioning without drift and the lack of need for an assistant are additional advantages. We have used the Point Setter endoscopic holder at our institution for endoscopic approaches to the pituitary gland, skull base, maxillary sinus, and orbital floor. One drawback to the use of the endoscope holder is its relatively high cost. This may preclude widespread use for the time being, but as minimally invasive procedures, such as those at the skull base, become more common, the use of endoscope holders will likely become more popular. We believe that our cadaver study demonstrates that the endoscope holder is a useful aid for facilitating an endoscopic approach to orbital floor fractures.


(1.) Kellman RM. Endoscopy in craniomaxillofacial skeletal surgery. Curr Opin Otolaryngol Head Neck Surg 2001;9:253-5.

(2.) Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach: A review of 400 cases. Arch Otolaryngol Head Neck Surg 1997;123(4):385-8.

(3.) Saunders CJ, Whetzel TP, Stokes RB, et al. Transantral endoscopic orbital floor exploration: A cadaver and clinical study. Plast Reconst Surg 1997;100(3):575-81.

(4.) Ikeda K, Suzuki H, Oshima, T, Takasaka T. Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg 1999;125(1):59-63.

(5.) Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 2001;108(7):2011-18; discussion 2019.

(6.) Strong EB, Kim KK, Diaz RC, et al. Endoscopic approach to orbital blowout fracture repair. Otolaryngol Head Neck Surg 2004; 131(5):683-95.

(7.) Operating/User's Manual for Point Setter, Model PSMS2. Mitaka Kohki Co., Ltd., Mitaka USA, Inc., Park City, Utah.

(8.) Arnholt JL, Mair EA. A "third hand" for endoscopic skull base surgery. Laryngoscope 2002;112(12):2244-9.

(9.) Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003; 14(5):236-40.

Maj. Stephen C. Maturo, MD; Col. Joe Wiseman, MD; Col. Eric Mair, MD

From the San Antonio Uniformed Services Health Education Consortium, Wilford Hall Medical Center, Lackland AFB, San Antonio, Tex.

Corresponding author: Maj. Steve Maturo, MD, Wilford Hall Medical Center, 2200 Bergquist Dr., Suite 1, Lackland AFB, San Antonio, TX 78236. Phone: (210) 292-7075; fax: (210) 916-0274; e-mail: stephen.

Financial disclosure: None reported.

Disclaimer: The opinions presented in this article are those of the authors only and are not to be construed as representing the official view of the United States Air Force, the Department of Defense, or the United States Government.

Previous presentation: The information in this article was originally presented as a poster at the annual meeting of the American Academy of Otolaryngology--Head and Neck Surgery; Sept. 25-28, 2005; Los Angeles.
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Author:Maturo, Stephen C.; Wiseman, Joe; Mair, Eric
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:1USA
Date:Dec 1, 2008
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