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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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33 Cases of Traumatic Superior Orbital Fissure Syndrome:
Cranial Nerve Recovery and Outcomes

Theresa Y. Wang, M.D.1, Chien-Tzung Chen, M.D.1, Pei-Kwei Tsay, Ph.D.1, Faye Huang, M.D.1, Yi-Chieh Chen, M.D.1, Yu-Te Lin, M.D.2, Han-Tsung Lian, M.D.1, Chih-Hung Lin, M.D.2, Yu-Ray Chen, M.D.1.
1Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taipei, Taiwan, 2Chang Gung Memorial Hospital, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.

Purpose: Superior orbital fissure syndrome (SOFS) is a rare complication of facial trauma characterized by ophthalmoplegia, ptosis, proptosis and hypoesthesia due to palsies of the 3rd, 4th, and 6th cranial nerves. SOFS can occur in mid-face fractures including LeFort, zygomatico-maxillary and orbital fractures. Because SOFS is uncommon, the clinical course, nerve recovery, and long-term outcomes are not well defined and based primarily on case reports. We present 33 cases of traumatic SOFS, the largest series reported. The goal of this study was to document fracture patterns associated with SOFS and assess recovery of cranial nerve function.
Methods: A retrospective review was performed of 11,284 patients with skull and facial fractures treated at a single institution between 1988 and 2002. Thirty-three patients (0.3%) with traumatic SOFS were identified, of which 23 were males and 10 females. Average patient age was 31 years (3 to 63). The major mechanisms of injury were motorcycle accidents (67%), pedestrian traffic accidents (21%), motorvehicle accidents (9%). Diagnosis of superior orbital fissure syndrome was made by clinical presentation, radiographic imaging and formal ophthalmology evaluation. Cranial nerve function was assessed by extraocular movements (EOM); grading was between 0-3, with 0 characterizing complete ophthalmoplegia, fixed and devoid of movement, and 3 indicating full, intact range of motion. Patients were evaluated every 2-3 weeks for the first 2 months and monthly for remaining time period. Twenty-two patients were treated conservatively by observation, while five were treated with high-dose steroids, and six patients, with evidence of compression of the SOF by fracture fragments, underwent prompt surgical decompression. All patients underwent early open reduction and internal fixation of facial fractures, if present.
Results: The major facial fracture pattern associated with SOFS were zygomico-maxillary (67%), orbital fractures (61%), LeFort fractures (18%), and sphenoid fractures (18%). Patients were followed for an average of 10.5 months post-injury. Of the 3 cranial nerves, the abducent nerve suffered the most damage, and the trochlear nerve sustained the least. In the first three months after injury, the abducent nerve improved the most with the greatest mean increase in EOM function. However, after nine months, its functional level remained the lowest of the three; the trochlear nerve had the highest average function. Functional recovery of all three cranial nerves plateaued at 6 months with no significant incremental improvement beyond that time. Eight patients (24%) had complete functional recovery of all three cranial nerves. The six patients who required surgical decompression all had sphenoid fractures and initially the worst functional levels of all three nerves compared to non-sphenoid fractures. However, in the recovery period, they achieved a comparable level of functional return.
Conclusion: Superior orbital fissure syndrome is an uncommon finding associated with craniofacial trauma. In this large retrospective review, fracture patterns and cranial nerve outcomes are characterized. The trochlear nerve had a better prognosis for recovery, whereas the abducent nerve suffered the most deficits. Surgical decompression with an intracranial or lateral orbital approach is recommended when there is evidence of compression of the orbital fissure.

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