What is the appropriate management for a mildly displaced fracture of the maxillary sinus with orbital rim involvement?

Management of Mildly Displaced Maxillary Sinus Fracture with Orbital Rim Involvement

For a mildly displaced fracture involving the ventral and lateral wall of the left maxillary sinus with extension along the left inferior orbital rim, observation for 4-6 months is recommended as the initial management approach, unless specific criteria for early intervention are present. 1

Initial Assessment

• Vital signs monitoring: Check for bradycardia or heart block, along with symptoms of dizziness, nausea, vomiting, or loss of consciousness, which may indicate entrapped muscle causing oculocardiac reflex 2
• Ocular motility assessment: Perform forced duction and forced generation testing to distinguish restriction from paresis of extraocular muscles 1
• Imaging: CT scan is the preferred modality for evaluating orbital trauma, with 94.9% sensitivity for detecting fractures and foreign bodies 1

Management Algorithm

Immediate Surgical Repair Indications (Urgent Intervention)

• CT evidence of entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex
• "White-eyed blow-out fracture" with muscle entrapment (particularly in children)
• Globe subluxation into maxillary sinus (rare but requires immediate intervention) 2, 3

Early Repair Indications (Within 1-2 Weeks)

• Symptomatic diplopia with positive forced ductions or entrapment on CT with minimal improvement
• Significant fat or periorbital tissue entrapment
• Large floor fractures causing hypoglobus
• Progressive infraorbital hypoesthesia
• Early enophthalmos or hypoglobus causing facial asymmetry 2

Observation Approach (For Mildly Displaced Fractures)

• Appropriate for cases with:
  • Minimal diplopia (not in primary or downgaze)
  • Good ocular motility
  • No significant enophthalmos or hypoglobus 2
• Wait 4-6 months after orbital trauma as strabismus may resolve spontaneously 1
• Instruct patient to perform eye movement exercises to reduce need for surgical intervention 4

Medical Management During Observation

• Short course of oral steroids: Can hasten recovery and help identify persistent strabismus after resolution of orbital edema/hematoma 1
• Conservative measures for diplopia: Occlusion, filters, Fresnel prisms, or prism glasses may provide temporary or permanent relief 2

Follow-up Protocol

• Regular ophthalmologic evaluations to monitor for:
  • Persistent diplopia (occurs in 37% of patients even after surgical repair)
  • Associated ocular injuries (occur in 24% of blowout fracture cases)
  • Development of enophthalmos or hypoglobus 1
• Reassess at 2 weeks, 1 month, 3 months, and 6 months

Important Caveats

• Even with appropriate management, strabismus and diplopia can persist in many patients. In one series, 86% of patients had diplopia preoperatively and 37% continued to have diplopia postoperatively despite surgical repair 2
• Delayed repair may still be necessary for persistent restrictive strabismus and unresolved enophthalmos after observation period 2
• Globe subluxation into the maxillary sinus, though rare, has poor visual prognosis with only 11.5% achieving complete recovery of visual acuity 3
• "Blow-in" fractures (where the orbital floor is elevated into the orbit) require different management and should be considered when the anterior wall of the maxillary sinus is depressed 5

For this specific case of a mildly displaced fracture involving the ventral and lateral wall of the left maxillary sinus with extension along the left inferior orbital rim, observation with regular follow-up is the recommended initial approach, provided there are no signs of muscle entrapment, significant enophthalmos, or other criteria requiring immediate or early intervention.