Endoscopic-assisted elevation of orbital blowout fracture in children: a case report

Introduction

There are limited detailed case reports of orbital floor blowout fractures in children under the age of seven. At this developmental stage, the upper portion of the face is more prominent and, therefore, more prone to injury than the cheekbone. As a result, fractures of the orbital roof occur more frequently than those of the orbital floor (1,2). The etiology of blowout fractures is generally explained by three theories: direct impact causing globe-to-wall contact, increased intraorbital pressure (hydraulic theory), and the buckling mechanism (3). Young children, in particular, are more vulnerable to the buckling mechanism due to the direct trauma sustained at the orbital rim (4). In pediatric patients, bone reconstruction is not always necessary because the defects caused by entrapped orbital tissues are often small. However, if the bony defects are found to be large after entrapped tissue was released, orbital floor reconstruction may be needed. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-62/rc).

Case presentation

We present a case of a 7-year-old boy who sustained trauma to the right eye and presented to our unit with persistent diplopia, minimal periorbital hematoma, and subconjunctival ecchymosis (Figure 1). The patient complained of binocular diplopia and restricted upward gaze (Figure 2). Computed tomography (CT) scan showed fractured of right floor of orbit and herniation of orbital contents into the right maxillary sinus (Figure 3). After adhering to the preoperative fasting protocol, the patient was brought to the operating theatre for surgical intervention to release the entrapped right infraorbital soft tissue. The procedure was carried out through a right preseptal transconjunctival approach, with the aid of endoscopic illumination to help identify the fractured segment. An intraoperative forced duction test was conducted before making the incision. Upon exploration, a displaced orbital floor fracture with herniation of orbital contents into the right maxillary sinus was identified. The herniated tissues were carefully elevated, revealing a fractured orbital floor with an intact periosteum (Figure 4). Direct endoscopic lighting was used to access the posterior extent of the defect, allowing for the controlled and gentle repositioning of the fractured bone while preserving the remaining periosteum (Video 1). A repeat forced duction test conducted immediately after repositioning showed no signs of ocular movement restriction. The gaze assessment on postoperative day 1 indicated significant improvement, with no limitations in ocular motility and resolution of diplopia. An annual follow-up revealed no signs of diplopia or enophthalmos. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and in line with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for the publication of the case report accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Right periorbital hematoma. This image is published with consent from the patient’s legal guardians.

Figure 2 Minimal restriction of upward gaze on the right eye. This image is published with consent from the patient’s legal guardians.

Figure 3 Displaced right floor of orbit and herniation of orbital contents, bending of orbital floor can be appreciated at the sagittal cut.

Figure 4 Intraoperative image of the right orbital floor defect.

Discussion

The appropriate surgical technique, along with a thorough release of any entrapment, is essential in treating orbital blowout fractures. Any incomplete release of residual entrapment behind the procedure site could lead to the need for a second surgery, which would likely result in significantly higher morbidity (5,6). Utilizing the endoscope’s direct light source to examine the posterior extension of the entrapped periorbital tissue and guide the gentle release while preserving the periosteum at the posterior segment has proven to be an effective technique (5). This method is especially useful in cases whereby the fractures are involving the posterior part of the orbital floor or in cases with limited posterior shelves (7). The Caldwell-Luc procedure can be used to reduce orbital blowout fractures, releasing entrapped tissue and elevating the fractured segment. However, this procedure requires creating an additional osteotomy in the area of the maxillary sinus (8,9).

Children’s bones are more flexible and tend to bend rather than break when subjected to significant forces. If the eye has recessed more than 2 mm into the orbit, resulting in restricted ocular movements and persistent diplopia, surgery is indicated (9). Taking advantage of the elastic nature of pediatric bones, the so-called fractured segment can be repositioned to its original position, provided the periosteum remains intact. In this case, endoscopic illumination was utilized to accurately identify the site of the fracture, followed by careful dissection around the periorbital area to confirm that the bone fragment remained partially attached. This represents the second instance at our center where an endoscope-assisted transconjunctival approach was employed to elevate an orbital blowout fracture. The first case at our center that utilized this technique was to release an entrapped white-eyed blowout fracture in a 14-year-old boy (5). Complications from a blowout fracture can include herniation of orbital fat into the maxillary sinus, orbital emphysema, maxillary sinus bleeding, ocular muscle entrapment or rupture, ischemic muscle contractures, cellulitis, and diplopia (10,11). The main advantage of the preseptal transconjunctival approach is its scarless nature; however, it carries the risk of complications such as entropion if not performed correctly. The benefits of an endoscopic approach include precise fracture visualization, small incisions, no facial incisions, minimal soft tissue dissection, shorter hospital stays, and cosmetically acceptable results (12,13). The use of direct vision assisted by endoscopic light is expected to reduce overall surgical time. Prolonged surgery is a generally recognized factor that increases the risk of complications (14).

In our case, we demonstrated that the transconjunctival approach assisted by endoscopy can help the surgeon identify the fractured segment and reposition it after elevating the herniated orbital content. However, this technique is suitable for cases with linear fractures, not comminuted fractures. Direct endoscopic-assisted exploration also allows for the identification of the posterior ledge of the orbit, which is beneficial for the surgeon in planning the reconstruction of orbital wall defects and avoiding excessive dissection (5).

Conclusions

Endoscopic-assisted repair of orbital floor blowout fractures through a transconjunctival approach appears to be a safe and effective technique for treating orbital blowout fractures in children. The pediatric orbital floor fracture can be repositioned with gentle dissection and preservation of the periosteum, as long as the bone is not comminuted.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-62/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-62/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-62/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and in line with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for the publication of the case report and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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