Sino-orbital Fistula: A Complication of Exenteration

doi:10.1016/j.ophtha.2006.06.038

Ophthalmology

Volume 114, Issue 2, February 2007, Pages 355-361

https://doi.org/10.1016/j.ophtha.2006.06.038 Get rights and content

Purpose

To report the incidence, characteristics, and management of sino-orbital fistulas, a complication of orbital exenteration.

Design

Retrospective interventional case series.

Participants

One hundred ten patients who underwent orbital exenteration at 2 orbital units.

Methods

Retrospective chart review of all cases of orbital exenteration between 1993 and 2005 at one orbital unit and between 1999 and 2005 at a second orbital unit.

Main Outcome Measures

Incidence of sino-orbital fistulas.

Results

Seventy-three and 37 orbital exenterations were performed at the first and second orbital units, respectively. Five patients developed sino-orbital fistulas, 1 of whom developed 2 fistulas at separate sites. In the first unit, 4 fistulas developed in 3 of 73 (4.1%) patients who underwent orbital exenteration. In the second unit, 2 fistulas developed in 2 of 37 (5.4%) exenterated orbits. The majority (5/6) of fistulas occurred medially to the ethmoid sinus, whereas 1 occurred superiorly to the frontal sinus. Risk factors that may have contributed to fistula formation include radiotherapy (3/6), sinus disease (3/6), intraoperative penetration into a sinus (3/6), and immunocompromise (1/6). Management was tailored to the individual case and ranged from conservative socket hygiene to surgical repair with grafts or flaps. Four of the 6 fistulas recurred after repair. Three of these subsequently were closed successfully. Only 1 fistula persisted until the patient died from malignant disease.

Conclusions

Sino-orbital fistulas are uncommon but not rare complications of orbital exenteration that may be predicted by several risk factors. Bothersome symptoms may necessitate treatment, which can range from conservative management to surgical repair with various grafts or flaps. Despite repair, fistulas may be difficult to eradicate.

Section snippets

Materials and Methods

A retrospective chart review was performed on consecutive orbital exenterations performed at the orbital units at the University of Adelaide from 1993 to 2005 and at the Jules Stein Eye Institute at the UCLA School of Medicine from 1999 to 2005. Cases of exenteration complicated by sino-orbital fistulas were identified. Data included preoperative diagnosis, location, and treatment. In addition, presentation and location of the fistula, tests, management, and outcome were recorded. The study was

Results

One hundred ten patients underwent orbital exenteration at 2 orbital units, 73 at the first orbital unit (University of Adelaide) and 37 at the other unit (Jules Stein Eye Institute). Surgery ranged from a subtotal lid-sparing approach to exenteration with total orbitectomy. Reconstruction involved lid closure, myocutaneous flap, dermis fat graft, split-thickness skin graft, hydroxyapatite, free flap, granulation, or combinations thereof (Table 1). Five patients developed sino-orbital fistulas,

Incidence

The incidence of sino-orbital fistulas complicating exenteration is reported to range from 12% to 23%.1, 2, 3 Rathbun et al mention the occurrence of an occasional fistula between the orbit and ethmoid sinus in their series of 48 exenterations,⁴ whereas several other authors do not mention this complication in their series of exenterations.5, 6, 7, 8, 9, 10, 11 The incidence may be higher in exenterated sockets allowed to granulate, ranging from 28% (12/43) to 68% (17/25) of granulated sockets.3

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There are more references available in the full text version of this article.

Cited by (24)

Sino-orbital cutaneous fistula with endoscopy guided technique: A case series
2022, International Journal of Surgery Case Reports
Citation Excerpt :
A fistula may also occur due to infection or the surgery itself. Incidence of fistula following orbital exenteration in cancer patients was ranged from 5.4 to 23% [1,2]. A study in Nigeria showed that 2 out of 228 chronic sinusitis patients (0.88%) developed frontal cutaneous fistula [3].
Sino-orbital cutaneous fistula (SOCF) directly connects the sinus, orbital space, and outer skin. SOCF has been reported mostly as a complication of orbital exenteration, although it may occur from other infrequent etiologies. The patient can be treated using an endoscopy-guided technique which requires a multidisciplinary approach.
We present three cases of SOCF due to less common etiologies (mucocele, chronic inflammation, and malignancy) in young adult patients with a history of orbital and surgical complications. The endoscopy-guided technique benefits from a minimally invasive procedure, having less tissue removal and a faster healing time.
Risk factors of developing SOCF are poor surgical technique, post-operative radiotherapy, concomitant immunocompromised state, diabetes mellitus, hypoproteinemia, or destruction caused by the tumor. The most commonly affected sinus is the frontal (60–89%). Fistula can occur with or without orbital/nasal wall destruction and bony erosion. Before starting the treatment, it is essential to make a precise diagnosis of the etiology and rule out the possibility of recurrence. SOCF can be treated with conservative or invasive management, depending on the severity of the fistula.
It is essential to perform a thorough diagnostic examination with radiographic imaging to determine the specific cause before deciding on definitive treatment. By using the endoscopy-guided technique, long-term favorable results can be achieved. Multidisciplinary collaborative teamwork is needed to have a successful result.
Total orbital exenteration with temporalis muscle transfer and secondary healing
2022, Canadian Journal of Ophthalmology
Citation Excerpt :
Here, the tumor types were similar to the present study, but the authors used eyelid skin, split skin grafts or spontaneous granulation, which provide less vascularization to the socket than a muscle flap, possibly contributing to higher fistula rates. Risk factors for the occurrence of sino-orbital fistulas include radiotherapy, sinus involvement, intraoperative penetration into a sinus, poor wound healing, and immunocompromise.20,23 Consultation with otolaryngology may be appropriate in such cases.
To evaluate the outcomes of orbital exenteration with temporalis muscle flap repair of the socket and secondary healing of the anterior surface of the flap in ocular, conjunctival, and eyelid malignancies.
Retrospective single-centre study.
Consecutive patients who underwent total exenteration for malignancy with temporal muscle flap repair of the socket between December 2009 and January 2016.
We report the outcomes of this surgical technique in terms of healing without fistula formation and time to epithelialization.
Twenty-nine patients underwent surgery using this technique. Diagnoses consisted of 18 conjunctival melanomas, 2 choroidal melanomas, 6 squamous cell carcinomas, 2 sebaceous cell carcinomas, and 1 basal cell carcinoma. Mean age at surgery was 70.7 years and mean follow-up was 27.4 months. On histological analysis, tumour excision was complete in 25 patients, of whom 3 had an orbital recurrence after exenteration (3 conjunctival melanomas). Four patients had incomplete tumour excision, of whom 3 underwent postoperative orbital radiotherapy with no subsequent orbital recurrences. Complete epithelialization of the socket occurred in mean 7.9 weeks (range 2–16 weeks). Flap necrosis occurred in 1 patient after postoperative radiotherapy (with sino-nasal fistula formation); 2 other patients developed sino-orbital fistulas.
After orbital exenteration, spontaneous epithelialization of the socket may take up to several months. Use of a temporalis muscle flap can reduce the duration of socket healing postoperatively, even if left to heal by secondary intention. This may facilitate early postoperative radiotherapy when indicated. Aesthetic results are acceptable and local surgical complications are rare.
Évaluer les résultats de l'exentération orbitaire s'accompagnant d'un comblement de la cavité au moyen d'un lambeau de muscle temporal de même que la cicatrisation secondaire de la surface antérieure du lambeau dans le traitement d'un cancer intéressant l’œil, la conjonctive ou la paupière.
Étude rétrospective réalisée dans un seul centre.
Patients consécutifs présentant un cancer, qui ont subi une exentération totale et dont la cavité a été comblée par un lambeau de muscle temporal entre décembre 2009 et janvier 2016.
Nous présentons ici les résultats de cette technique chirurgicale quant à la cicatrisation sans fistule et au délai avant l’épithélialisation.
Les 29 cas soumis à l’évaluation comprenaient 18 mélanomes de la conjonctive, 2 mélanomes choroïdiens, 6 carcinomes épidermoïdes, 2 carcinomes sébacés et 1 carcinome basocellulaire. L’âge moyen au moment de la chirurgie était de 70,7 ans, et la durée moyenne du suivi était de 27,4 mois. Selon l'analyse histologique, l'excision tumorale était complète chez 25 patients, dont 3 ont subi une récurrence orbitaire après l'exentération (3 cas de mélanome de la conjonctive). Quatre patients ont subi une excision tumorale incomplète, et 3 d'entre eux ont dû faire l'objet d'une radiothérapie postopératoire de l'orbite sans qu'il se produise de récurrence orbitaire ultérieure. L’épithélialisation complète de la cavité a pris 7,9 semaines en moyenne (fourchette : 2–16 semaines). On a noté une nécrose du lambeau chez 1 patient après la radiothérapie postopératoire (qui s'est accompagnée de la formation d'une fistule sino-nasale); 2 autres patients ont présenté des fistules sino-orbitaires.
L’épithélialisation spontanée de la cavité peut prendre plusieurs mois après l'exentération orbitaire. Le recours à un lambeau de muscle temporal peut raccourcir le délai de cicatrisation postopératoire de la cavité, même dans les cas où on laisse guérir la plaie par intention secondaire. Voilà qui peut faciliter le recours à la radiothérapie postopératoire précoce, le cas échéant. Les résultats esthétiques sont acceptables, et les complications chirurgicales locales sont rares.
Orbital exenteration: an updated review with perspectives
2021, Survey of Ophthalmology
Citation Excerpt :
A sino-orbital fistula may lead to chronic socket discharge and infection;2,42 however, fistula closure is rarely required.82 If needed, regional flaps can be used, but relapse is frequent.74 The intraoperative use of biodegradable polydioxanone foils may reduce the risk of postoperative fistulas.2
Orbital exenteration is a radical and disfiguring surgery mainly performed in specialized tertiary care centers. Orbital exenteration has long been considered the treatment of choice for managing periocular tumors invading the orbit or primary orbital malignancies. Over the past decades, attention has been directed toward reducing the perioperative morbidity by developing new surgical devices and new strategies and promoting cosmetic rehabilitation by providing adequate facial prostheses. Despite these advances, several studies have questioned the role of orbital exenteration in improving overall survival. The last decade has been marked by the emergence of a new paradigm: the “eye-sparing” strategies based on conservative surgery with or without adjuvant radiotherapy and/or targeted therapies and immunotherapies. We summarize the data on orbital exenteration, including epidemiology, etiologies, use of surgical ablative and reconstructive techniques, complications, outcomes, and the related controversies.
Does orbital exenteration still has a place in 2019?
2020, Journal Francais d'Ophtalmologie
La chirurgie d’exentération orbitaire est une chirurgie traumatisante tant sur le plan anatomique que psychologique. Elle est principalement réservée à la prise en charge de cancers orbitaires ou à extension orbitaire. L’absence de bénéfice en termes de survie globale et le développement de nouveaux traitements médicaux ces dernières années tendent à remettre en cause cette intervention. L’objectif de notre revue est de répondre à la question suivante : la chirurgie d’exentération orbitaire a-t-elle encore sa place en 2019 ?
Une revue de la littérature a été réalisée à partir des bases de données PUBMED et MEDLINE. Les termes suivants ont été saisis puis croisés ensemble : « orbital exenteration », « exenterated socket », « overall survival », « life expectancy », « orbital reconstruction », « socket reconstruction ». Ont été inclus dans cette revue les articles de cancérologie datant des 15 dernières années en dichotomisant les articles publiés par les équipes oculoplastiques versus ORL.
Dix-neuf articles ont été inclus dans cette revue. Les tumeurs palpébrales représentent la première cause d’exentération orbitaire. Le carcinome basocellulaire est la tumeur la plus fréquemment incriminée, même si le carcinome sébacé et le carcinome épidermoïde conjonctival sont les tumeurs les plus fréquemment rencontrées dans les séries asiatiques. L’exentération non conservatrice des paupières est l’intervention la plus souvent pratiquée. La reconstruction orbitaire dépend des chirurgiens qui la pratiquent : la cicatrisation dirigée et la greffe de peau mince sont privilégiés par les oculoplasticiens alors que les lambeaux régionaux, voire libres sont l’apanage des ORL. La principale complication peropératoire est la fistule de LCR qui survient entre 0 et 13 % suivant les séries. Les complications postopératoires sont dominées par la fistule ethmoïdale et l’infection du site opératoire qui surviennent entre 0 et 50 % et 0 et 43 % des cas respectivement. La chirurgie d’exentération permet la réalisation de résections tumorales R0 dans 42,5 à 97 % des cas. La survie globale post-exentération orbitaire est en moyenne de 83 % (50,5–97) et 65 % (37–92) à 1 et 5 ans respectivement. Les principaux facteurs de risque péjoratifs identifiés sont : l’âge, l’histologie tumorale (mélanome choroïdien de mauvais pronostic, carcinome basocellulaire de meilleur pronostic), une chirurgie d’exérèse non R0 et une tumeur localement avancée (taille > 20 mm, une acuité visuelle < 20/400 et la présence de métastases au moment du diagnostic). Ces dernières années, plusieurs études ont rapporté des résultats encourageants dans la gestion des carcinomes basocellulaires, des cancers épithéliaux de la glande lacrymale ainsi que dans les mélanomes conjonctivaux localement avancés traités par thérapie ciblée ou immunothérapie. Dans certains cas, ces traitements ont permis d’éviter la réalisation d’une exentération orbitaire.
La chirurgie d’exentération conserve une place centrale dans notre arsenal thérapeutique. Bien qu’elle n’ait jamais clairement démontré son bénéfice en termes de survie globale, elle permet un contrôle local de qualité au prix d’une intervention de moins en moins invasive. L’avènement des thérapies ciblées et immunothérapies pourrait conduire à modifier nos attitudes thérapeutiques à l’avenir.
Orbital exenteration is a radical anatomically and psychologically disfiguring procedure. It is mostly performed for management of orbital cancers or cancers with orbital involvement. The lack of benefit in terms of overall survival and the development of new molecular therapies (targeted therapies, immunotherapy) in recent years leads us to question its use. The goal of our review is to answer to the following question: is orbital exenteration a viable procedure in 2019?
A literature review was performed using the PUBMED and MEDLINE databases. The following terms were used then crossed with each other: “orbital exenteration”, “exenterated socket”, “overall survival”, “life expectancy”, “orbital reconstruction”, “socket reconstruction”. Oncology articles from the past 15 years were included and separated into those in the oculoplastic literature and those in the ENT literature.
Nineteen articles were included in this review. Eyelid tumours represent the main etiology of orbital exenteration. Basal cell carcinoma is the most frequently incriminated tumor, while sebaceous carcinoma and conjunctival squamous cell carcinoma are the most frequently encountered in Asian series. Non-conservative orbital exenteration is the most prevalent surgery performed. Orbital reconstruction depends on the surgeon's speciality: healing by secondary intention and split thickness skin grafts are mostly performed by oculoplastic surgeons, whereas regional or free flaps are mostly performed by ENT surgeons. Cerebrospinal fluid leakage is the most common intraoperative complication, encountered in 0 to 13 % of cases. The most common postoperative complications are ethmoid fistula and infection of the operative site, encountered in 0 to 50 % and 0 to 43 % of cases respectively. Orbital exenteration allows surgical resection of R0 tumors in 42.5 % to 97 % of cases. Overall survival following orbital exenteration is 83 % (50.5–97) and 65 % (37–92) at 1 and 5 years respectively. Identified risk factors for poor overall survival are: age, tumor histology (worse prognosis with choroidal melanoma, better prognosis with basal cell carcinoma), non-R0 surgical resection, locally advanced tumors (size > 20 mm, BCVA < 20/400 and the presence of metastases at diagnosis). Recent studies have demonstrated favorable outcomes when managing locally advanced basal cell carcinoma, lacrimal gland cancer and conjunctival melanoma with targeted therapies or immunotherapies without performing orbital exenteration.
Orbital exenteration remains a major part of our therapeutic arsenal. Although orbital exenteration has failed to demonstrate any overall survival benefit, it allows satisfactory local control of the disease with an increasingly less invasive procedure. The development of targeted therapies and immunotherapies may change our therapeutic decisions in the future.
Indication and technique of orbital exenteration
2018, Operative Techniques in Otolaryngology - Head and Neck Surgery
Citation Excerpt :
Postoperative hemorrhage and infection are always risks with this procedure.10 Other complications include sino-orbital fistulas,11 skin breakdown from grafting, thrombosis, flap necrosis, CSF leak,12 and pneumocephalus.13 Potential need for further surgery is always possible.
Orbital exenteration is a rare, severely disfiguring operation for the treatment of malignant orbital tumors. The tumors can arise from the orbit, metastasize to the orbit from distant sites, or invade the orbit from surrounding structures. The technique of exenteration mandates complete removal of the intraorbital contents, sometimes including the encompassing bony structures. This article will describe the indications and technique of orbital exenteration, as well as complications and several reconstructive strategies.
A novel approach for successful closure of sinonasal fistulae
2014, Journal of Plastic, Reconstructive and Aesthetic Surgery
Medial canthus sinonasal fistula is associated with troublesome aesthetic and functional issues. Corneal irritation and drying results from escape of both air and secretions from the nasal cavity across the ocular surface as well as misting of spectacles if worn. Reconstruction of such fistulae is associated with a high rate of recurrence and thus presents a difficult surgical challenge.
This paper describes the senior author's surgical approach to manage medial canthus sinonasal fistulae utilizing an interpolated forehead flap combined with extended galeafrontalis and pericranial flap for stepped closure. The technique of flap elevation and inset is discussed, with emphasis on key manoeuvres to prevent sinus recurrence. A retrospective review of consecutive cases is presented.
Four patients were treated using this technique over 12 months. In all cases, fistulae developed following adjuvant radiotherapy for tumour resection. Flap elevation was performed in combination with a bicoronal approach in 2 patients and via direct forehead approach in 2 patients. No post-operative complications or recurrence of fistula have occurred over 12 months follow-up.
The success of this technique is attributed to inclusion of a galeafrontalis and pericranial extension to the forehead flap. In addition, the fistula site must be prepared to accommodate the flap by dissection of a wide subcutaneous pocket. This stepped method of closure provides an effective barrier to air and nasal secretions and also achieves an excellent aesthetic outcome.

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: Manuscript no. 2006-223.

: The authors have not received any financial support for this publication.

: The authors have no conflicting relationships involving any products, materials, or ideas discussed in the article.

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Original ArticleSino-orbital Fistula: A Complication of Exenteration

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Materials and Methods

Results

Incidence

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Otolaryngol Clin North Am

Orbital exenteration: results of an individualized approach

Ophthal Plast Reconstr Surg

Orbital exenteration at the Mayo Clinic: 1967-1986

Ophthalmology

Orbital exenteration: a 13 year Manchester experience

Br J Ophthalmol

Survival after malignant tumors of the orbit and periorbit treated by exenteration

Acta Ophthalmol Scand

Original Article
Sino-orbital Fistula: A Complication of Exenteration