Improvement of diagnosis and treatment of the middle face zone sensory disorders in patients with izolated orbital bottom fractures

Abstract

Summary. Among the bone fractures of the midface, blow-out fractures amount to 11–28 % and occupy the third place after zygomatic and zygomatic arch fractures and fractures of nasal bones. According to our observations for the period from 2014 till 2017, among patients who were treated in the Department of Maxillofacial Surgery of the Communal City Clinical Emergency Hospital of Lviv with bone fractures of the middle field of facial skull, blow-out fractures occurred in 8.9 % of cases. With the blow-out fracture, the presence of clinical signs of neuritis of the infraorbital nerve is an important pathognomonic symptom indicating the localization of bone fracture at the orbital floor. The main factors that determine the rate and quality of unprompted recovery of affected functions and, accordingly, the scope and target of the therapeutic interventions in cases of peripheral traumatic neuropathies include: the degree of nerve guide lesion, the level of destruction, tissue ischemia, the kind of the disturbing factor. When the nerve is constricted, the degree of conductivity failure depends primarily on the duration and intensity of constriction injury.

The aim of the study – to improve diagnostics and local treatment of traumatic lesions of infraorbital and zygomatic nerves in patients with blow-out fractures.

Materials and Methods. Clinical, radiological, neurofunctional and biochemical methods of research were applied in 19 patients, aged 20 to 65 years, with blow-out fractures. Intensity of edema and hemorrhage in the area of ​​the orbital cavity was evaluated using the methodology of Mohsen Rajati et al. (2013). After hospitalization, all patients underwent computer tomography of the facial skull bones with 3D reconstruction. There were found roentgenologic fractures of orbital floor according to the classification of G.F. Fueger and A.T. Milauskas (1966). The degree of destruction of infraorbital and zygomatic nerves (with regard to dynamic clinical observations) was assessed by classification of H. Seddon (1943), which allows determining the degree of lesion of the nerve trunk according to the changes in conductivity in each of its segments; 3 types of complications are distinguished: neurapraxia, axonotmesis, neurotmesis. The degree of lesion of the branches of the maxillary nerve was determined according to the data of electrophysiological tests according to Nechaieva N.K. et al. (2014). The reference values ​​are between 25-35 μA.

Electroodontometry of teeth on the corresponding side of the upper jaw was carried out using a portable electroodontometer «Pulptester» (Taiwan). Electrodiagnostics of sensitivity of skin branches of maxillary nerve was carried out in their exit sites on the surface of face using low-frequency electrotherapy device «Radius-01 FT» (Belarus) in the mode of electrical stimulation. In the peripheral venous blood of patients, there was determined the concentration of neuron-specific enolase (NSE), which is a neuron-specific isoform of enolase found in neurons. It was analyzed by an immunochemical method with the use of electrochemiluminescent detection, using a Cobas 6000 analyzer and test system by Roche Diagnostics (Switzerland). Reference value of NSE – up to 16.3 ng/ml.

In the acute flow period of traumatic process in the presence of pronounced hemorrhage in the orbital cavity and perifocal edema during comprehensive treatment, for the prevention of the occurrence of spike processes in the damaged branches of maxillary nerve, the patients were injected parabulbarly, along the orbital floor, to infraorbital sulcus, where the homonymic nerve lies, fibrinolytic medication Gemaza (recombinant prourokinase) – 1 time per day, over 5000 ME in 0.5 ml of 0.9 % solution of sodium chloride on a daily basis for 4–5 days. In the subacute period – the solution of Traumeel S was injected to the infraorbital and zygomaticofaciale foramen by 2.2 ml in a day, on a course of treatment – 6 injections. The drug has anti-inflammatory, analgesic, anti-exudative, immuno-corrective and reparative effect. The effect of the drug is based on the activation of the body defences and normalization of disturbed functions due to substances of vegetable and mineral origin, which are part of the drug.

Statistical processing of the results of research was carried out with the help of a computer program for statistical computation «Statistica 8».

Results and Discussion. The first, mild degree – neurapraxia – has been detected in 12 patients. Injury to the nerve might have occured as a result of constriction of the nerve trunk due to pronounced swelling and bruises. Imaging study recorded actual passing of fracture through the infraorbital canal and the infraorbital sulcus in 7 cases, and in 5 patients there was revealed a fracture line that crossed the infraorbital fissura. These patients had the second, fourth and sixth types of fractures according to the radiological classification  of
G.F. Fueger and A.T. Milauskas. Content of concentrations of neuron-specific enolase in blood did not exceed the upper limit of the norm – (15.9±1.4) ng/ml (р > 0.05). Violation of the sensitivity of teeth and soft tissues in the area of ​​innervation of infraorbital and zygomatic nerves in all patients in this group were temporary. After a course of local therapy with Gemaza and Traumeel S, edema of soft tissues of the orbital cavity decreased and hematoma waned faster. The sensitivity of the damaged nerves was completely restored after 3–4 weeks.

The presence of axonotmesis of the infraorbital and zygomatic nerves in 7 patients was the cause of expressed sensory abnormalities in soft tissues of infraorbital and zygomatic areas, loss of sensitivity in the teeth of the upper jaw on the side of the lesion. Among the revealed causes of these pathological changes, the determinant factor was their constriction by bone fractures of the orbital floor which were displaced in the maxillary sinus. Data obtained in computer tomography fully correlated with the results of clinical and electrophysiological diagnostics. In the blood of such patients, the concentration of neuron-specific enolase increased, which was beyond the upper limit of the norm – (20.6±1.7) ng/ml (р < 0.01). In this category of the examined patients sensitivity, as a rule, was restored in full after 1.5 – 2 months after surgery treatment for the reconstruction of the orbital floor.

Conclusions. Application of electrophysiological testing and blood research of the marker of nervous tissue lesion – neuron-specific enolase – allow determining the degree of lesion of infraorbital and zygomatic nerves in patients with blow-out fractures. The local combined application of fibrinolytic agent Gemaza and homeopathic medication Traumeel S in the comprehensive treatment accelerates the elimination of clinical symptoms of inflammation, orbital hematoma waning, and prevents the development of neuritis of infraorbital and zygomatic nerves.