Combined Open Reduction and Transantral Endoscopic Approach for Internal Fixation of Orbital Floor Fractures: A Tertiary Care Center Experience with Decision-Making Algorithm.

Introduction: Perfect reduction and fixation of orbital blowout fractures remain challenging due to difficulty in visualization of herniated orbital contents and intact bony ledge. This often leads to eyeballing during surgery, which results in inadequate soft tissue reduction or improper implant placement. The use of endoscopy greatly overcomes these challenges. Patients and Methods: In this paper, the authors have described 3 clinical scenarios where a combined approach of open reduction and transantral endoscopy (through an anterolateral wall defect of the maxillary sinus or Caldwell-Luc procedure) has been used for the reduction and fixation of orbital floor fractures with soft tissue entrapment. This approach has ensured perfect soft tissue reduction and precise implant position, which in turn have alleviated post-operative complications and improved patient symptoms. Discussion: Conventional techniques for orbital floor repair include lower lid transcutaneous or transconjunctival approaches. However, it is difficult to visualize the posterior intact bony shelf and difficult to confirm adequate herniated soft tissue reduction. Endoscopic techniques allow superior visualization of these structures. When transantral endoscopy is combined with a traditional open approach, it provides better illumination, visualization, and effective reduction and fixation of large defects with a provision for confirmation post-fixation. In the presence of a concomitant anterolateral wall of maxillary sinus fracture, an endoscope can be easily introduced into the sinus for better visualization and confirmation. The authors have also set down a few guidelines for approaching orbital floor fractures with the combined technique in the form of an algorithm. This algorithm can help surgeons decide which type of approach to adopt based on certain characteristics of the fracture. Conclusion: The combination of open reduction and transantral endoscopy is easy, effective, and shows promising results for orbital floor repair.