The impact of suction drainage on orbital compartment syndrome after craniofacial surgery.

PURPOSE: Postoperative orbital compartment syndrome is a potentially blinding complication of surgery in the orbital region. We describe the technique of orbital drain placement as a method of preventing vision loss resulting from orbital compartment syndrome. METHODS: We present a retrospective case series of 29 patients who underwent orbital fracture, facial fracture, and orbital implant removal from 7/4/2008 to 5/3/2013 by the same craniofacial surgeon. An orbital drain was placed in each patient. The drainage was recorded daily until drain removal. Criteria for removal included less than or equal to 5 mL of drainage in 24 hours. RESULTS: Of the 29 patients included in this study, 21 were men and 8 were women. Ages ranged from 17 to 67 years. The postoperative drainage ranged from less than 1 mL to 71 mL of serosanguinous fluid. All drains were removed between the first and sixth postoperative days. No postoperative visual loss, infections, or additional antibiotics were recorded with follow-up reaching as far as 40 months. CONCLUSIONS: Postoperative orbital compartment syndrome is a dangerous complication of surgery in the orbital region. Its rapid onset necessitates immediate intervention to prevent permanent vision loss. Morphologic changes to the optic nerve as well as reductions in electroretinogram a- and b-wave amplitudes have been demonstrated with as little as 7 mL of fluid accumulation. Intraoperative orbital drain placement should be considered in all patients undergoing surgery in the orbital region as a preventative measure.

Outcomes of periocular reconstruction for facial nerve paralysis in cancer patients.

BACKGROUND: Facial nerve paralysis is a common event in patients with head and neck cancer or metastasis of cancer to the parotid region. The aim of this study was to evaluate the outcomes of periocular reconstruction for facial nerve paralysis in cancer patients. METHODS: The medical records of all patients who had undergone periocular surgery for facial nerve paralysis between January of 1999 and December of 2003 were retrospectively reviewed. The outcome measures included the ocular symptoms and signs, improvement in symptoms of exposure keratopathy postoperatively, timing of periocular surgery in relation to radiotherapy, and surgical complications. RESULTS: Preoperative symptoms included burning sensation (25 of 78 patients), difficulty with vision (30 of 78), frequent use of lubricating drops and ointments (52 of 78), and excessive tearing (37 of 78). The degree of lagophthalmos ranged from 1.5 to 12 mm (mean, 6.5 mm) preoperatively and from 0 to 4.5 mm (mean, 1.5 mm) postoperatively. Seventy-eight patients had gold weight placement; 72 of them also had lateral tarsorrhaphy, 56 had lower eyelid tightening via a lateral tarsal strip procedure in addition to the gold weight and lateral tarsorrhaphy, and 22 had brow elevation in addition to all the above-mentioned procedures. Four also required a medial tarsorrhaphy. All patients reported less dependence on lubricating drops and ointments after periocular surgery. Eighteen of 25 patients who had foreign body sensation as their main preoperative symptom experienced improvement after surgery. Forty-four patients had radiotherapy to the head and neck region. Twenty-seven patients completed radiotherapy before and 17 after periocular reconstruction. Complication rates were low and comparable in both preoperative and postoperative radiation groups. CONCLUSIONS: Periocular reconstruction for facial paralysis results in improvement of exposure keratopathy and less dependence on lubricating drops and ointments. Complications are minimal and infrequent. The timing of external beam radiotherapy does not affect the outcomes of periocular surgery.

Surgical management of locally advanced adenoid cystic carcinoma of the lacrimal gland.

PURPOSE: To review our experience with multidisciplinary surgical management of locally advanced adenoid cystic carcinoma of the lacrimal gland. METHODS: We present a case series of 7 patients with lacrimal gland adenoid cystic carcinoma treated at our institution between June 2001 and October 2003. Clinical records, histologic sections, and radiographic images were reviewed. RESULTS: The study included 3 men and 4 women (mean age at diagnosis, 44 years). All 7 patients underwent an orbital exenteration with bone removal. Five patients had an orbitectomy through a craniotomy approach and 2 patients had an exenteration through a fronto-orbito-zygomatic approach, all with removal of the bone of the superior and lateral wall. Six patients underwent reconstruction of the socket through the use of a vascularized flap. The surgical approach involved a neurosurgeon, an oculoplastic or head and neck surgeon, and a plastic surgeon. Six patients received postoperative radiation therapy. One patient with a recurrent tumor had already received radiation therapy, which precluded additional radiation therapy after surgical resection. The radiation field included the orbit and the skull base because all patients had evidence of perineural invasion. As of this writing, there have been no local recurrences. Five patients had development of distant metastases and died of disease, at follow-up times from 12 to 32 months after surgery. Two patients are alive without evidence of disease, both at 24 months' follow-up. CONCLUSIONS: Orbitectomy with bone removal may be indicated for achieving local and regional control in advanced cases of adenoid cystic carcinoma of the lacrimal gland. This surgery does not decrease the risk of distant metastasis. The cases in our series highlight the locally invasive and metastatic behavior of this cancer.

Surgical resection of locally advanced granular cell tumor of the orbit.

We report a case of locally advanced granular cell tumor of the orbit treated by a multidisciplinary surgical approach. A 49-year-old woman with a recently biopsied granular cell tumor of the orbit was referred to our tertiary care cancer center for evaluation of a right-sided globe ptosis and a palpable mass in the right orbit that had been present for approximately two years. Magnetic resonance imaging showed a large orbital mass that extended posteriorly to the orbital apex and anteriorly to the levator and superior rectus muscle complex. A workup including computed tomography of the chest, abdomen, and pelvis did not show any metastatic foci. Surgical resection of the mass was undertaken via a frontozygomatic craniotomy supplemented by an anterior orbitotomy to repair the levator aponeurosis and the superior oblique tendon, which were partially resected with the mass. Histologic evaluation of the mass revealed solid nests of polygonal cells that had centrally located, round nuclei with abundant eosinophilic granular cytoplasm. The cytoplasmic granules were positive on the periodic acid-Schiff reaction and were diastase-resistant. Immunohistochemical staining was positive for S-100 protein. During the most recent follow-up visit six months after surgery, the patient had no clinical evidence of tumor recurrence, had minimal residual ptosis and exposure keratopathy, and had stable visual function.

Canalicular and nasolacrimal duct blockage: an ocular side effect associated with the antineoplastic drug S-1.

PURPOSE: To report canalicular stenosis as a side effect of the new antineoplastic agent S-1. DESIGN: Interventional case series. METHODS: Three patients who received S-1 for treatment of gastrointestinal cancer at a tertiary cancer center were evaluated and treated for epiphora. RESULTS: Two patients were found to have severe canalicular stenosis and nasolacrimal duct blockage after approximately 6 months of S-1 therapy. One patient underwent dacryocystorhinostomy with silicone tube placement on one side and dacryocystorhinostomy and Pyrex glass tube placement on the other side. The other patient declined a surgical intervention. One additional patient with epiphora had punctal stenosis early in the course of S-1 therapy. His epiphora resolved after probing and irrigation and 4 weeks of topical corticosteroid therapy. CONCLUSIONS: Canalicular and nasolacrimal duct blockage is a previously unreported side effect of S-1 and should be recognized and treated at its earliest possible stage so that complete closure of the canaliculi can be avoided.