Surgical approach to medial wall fracture of the orbit by osteotomy

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Background: As endoscopic endonasal sinus surgery is now commonly applied, low-invasive surgery via an intranasal approach has become actively employed for the treatment of medial wall fracture of the orbit, but various issues remain unresolved, such as surgical indications and methods. To reliably reduce and reconstruct fractured regions, we developed an osteotomic procedure in which the maxillary and lacrimal bones are cut en bloc. Methods: In establishing the osteotomy line, the upper end was set to a site lower than the frontomaxillary suture, the lower end to the fossa of the lacrimal sac, the anterior end to a site more posterior than the nasomaxillary suture, and the posterior end to a site posterior to the ridge of the lacrimal sac. Results: Eleven patients with orbital medial wall fracture underwent osteotomy of the maxillary and lacrimal bones en bloc. The maxillary and lacrimal bones were excised en bloc, through which the entire fractured region was exposed. Since the fractured region could be observed well, bone transplantation to the defective region was straigtforward, and effective reduction of the orbital content and reconstruction of the defective bone region could be performed. Conclusion: A sufficient visual field was secured by osteotomy, enabling us to atraumatically perform surgery. This may be a useful treatment method for cases with marked deviation of the bulbar content and incarceration of the medial rectus muscle.