PMC8202373_01
(a) Preoperative computed tomography coronal sections bone window showing the complex anterior cranial fossa fracture with floating lateral lamella of cribriform plate. (b) Preoperative computed tomography coronal section soft-tissue window with fracture fragment impinging on the superior rectus muscle. (c) Preoperative picture of the patient showing left eyeball displaced downward and laterally with conjunctival chemosis. Also note the edema of upper eyelid with linear sutured laceration through which the transorbital neuroendoscopic surgery approach was undertaken
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F1
There was left upper eyelid ecchymosis with inferior and mild lateral displacement of the globe [Figure 1c]. ACF and the orbit [Figure 1a and b]. Although the patient's general condition improved the proptosis and chemosis of the left eye was increasing, and patient's vision was deteriorating from counting fingers to light perception, in spite of conservative measures. A transorbital endoscopic approach was initially undertaken through the upper eyelid lacerated wound [Figures 1c and 2].
Transorbital neuroendoscopic surgery approach. (a) (>) Dissection of fracture fragment from inferior orbital periosteum and superior dural attachments. (*) The dural defect (tear) through which the basifrontal cortex with contusion can be visualized. (b) (>) Removal of the fracture fragment. (c and d) Visualizing the bony defect and the (*) dural defect. Note that all the margins of the bony defect are visualized except the medial margin
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F2
A transorbital endoscopic approach was initially undertaken through the upper eyelid lacerated wound [Figures 1c and 2]. The orbital roof fracture fragments were dissected and removed [Figure 2a and b]. Dural tear was identified, and the defect margins were delineated all around except medially [Figure 2c and d].
Endoscopic transnasal approach. (a) (>) Anterior ethmoidal artery (cauterized). (b) (>) Cauterized anterior ethmoidal artery. (*) The floating fragment of the lateral lamella of the cribriform plate. (c) (.) Torn medial dural margin. (*) Basifrontal cerebral cortex. (<) The lateral margin of the bony defect of the roof of orbit. (d) The margins of the bony defect on the nasal side. (*) Dura. (e) Fascia lata has been spread from the orbital side and pulled through to the nasal side and is tucked along the margins of the bony defect. (*) Fascia lata on the nasal side
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F3
Fracture fragments in the cribriform area were removed [Figure 3a and b]. The margins of the bony defect were delineated from the anterior fovea to junction with planum sphenoidale posteriorly (approximately 6 cm), medial lamella of cribriform to orbital roof laterally [Figure 3d]. There was a linear tear in the dura through which the basifrontal cortex region with contusion was visualized [Figure 3c]. We used a novel maneuver wherein the fascia lata graft was spread from the orbit side [Figure 4 Upper], pulled through to the nasal side, draped over the entire defect and tucked [Figure 3e].
Upper - Fascia lata spread on the orbital roof. (*) Fascia lata on the orbital side. Lower - Multi-layered reconstruction on the nasal side with nasal septal cartilage and Hadad flap over the fascia lata. (*) Hadad flap
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F4
We used a novel maneuver wherein the fascia lata graft was spread from the orbit side [Figure 4 Upper], pulled through to the nasal side, draped over the entire defect and tucked [Figure 3e]. Septal cartilage harvested was used to support the fascia lata on the nasal side, and this was covered with Hadad flap [Figure 4 Lower].
(a) Postoperative computed tomography coronal cut. (^) Shows the fascia lata spread across the defect. (b) One week postoperative picture of the patient which showed improvement of orbital signs. (c) Four months postoperative picture of the patient which showed complete resolution of orbital signs with very minimal enophthalmos
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F5
Postoperatively, the patient's left eye proptosis and chemosis resolved, and his vision improved within a week with no further CSF leak [Figure 5a and b]. His 4 months postoperative follow-up showed a complete resolution of orbital signs and complete visual improvement with no CSF leak [Figure 5c].