Acquired Brown Syndrome in Head Trauma: Does Fixation of Associated Nasal and Frontal Bone Fractures Provide a Cure?

A 43-year-old gentleman presented with vertical double vision following nasal and frontal bone fractures resulting from blunt trauma to the glabella. Orthoptic assessment revealed a diagnosis of traumatic Brown syndrome affecting the right eye. The fractures were fixed with open reduction internal fixation via a coronal flap nine days after the injury was sustained. Evidence of resolution of the syndrome became apparent clinically within 15 days following surgery, which was confirmed with a later orthoptic evaluation. This case demonstrates that prompt surgical intervention of fractures associated with traumatic Brown syndrome may lead to resolution without the need to resort to extraocular muscle surgery.


Case report
A 43-year-old male waiter was hit in the glabella region with a bottle by a customer.
He sustained a depressed skull fracture of the frontal and nasal bones, classified as a 'bi-lateral Markowitz type 1' nasoorbitoethmoidal fracture (Markowitz et al. 1991). The fracture extended through to the anterior cranial fossa and cribiform plate. He presented with double vision on upward gaze and on gaze up and left. On examination there was restriction of elevation of the right eye in adduction (Figure 1).
A pre-operative orthoptic assessment (Hess chart [Appendix B.1]), field of binocular single vision (BSV) (Appendix A.1) and motility testing in the nine cardinal views of gaze (Appendix C), confirmed a right traumatic Brown syndrome.
A neuro-ophthalmology examination was otherwise unremarkable, with normal optic nerve function (normal visual acuity, pupillary reactions, fundus examination, colour vision and visual fields).
Surgical access was obtained via a coronal flap, retracted down to the supra-orbital margins.
A step in the frontal bone superior to the nasofrontal suture was identified, reduced and fixed with a 1.3 mm 'Y' plate and 6 mm screws. The nasal bone fractures were exposed para-nasally through intra-oral incisions and fixed with two titanium plates with 4 mm screws. The nose was then stabilised with a splint and intra-nasal packs. There was no intra-orbital intervention. Fifteen days post-operatively, the patient was symptomatically better with a reduction in the severity of diplopia and restriction of elevation of the right eye in adduction.
Orthoptic assessment carried out seven weeks postoperatively found that the extra-ocular motor function had returned to normal, as seen on the post-operative Hess chart (Appendix B.2) and post-operative clinical photographs (Figure 2). Additionally, the area of double vision had resolved (Appendix A.2). A study of 85 patients with Brown syndrome (38 congenital onsets and 47 acquired) reported spontaneous resolution in 5 of 85 patients (6%). All five were nontraumatic acquired Brown syndrome cases and recovery occurred over a 6-to 48-month period (Wright 1999). The above study supports the fact that repositioning fractured frontal and nasal bone segments to their correct anatomical position, stabilised using titanium plates, in our case of traumatic Brown syndrome, may be responsible for its resolution.

Discussion
It is possible that the fractures may have restricted the motility of the superior oblique tendon through the trochlea, causing the Brown syndrome pattern of limitation of elevation in adduction and that surgical reduction of the fractures effected a cure. Though it is possible that the Brown syndrome may have resolved spontaneously, it is equally possible that failure to promptly intervene may have heralded a permanent limitation of elevation in adduction as scarring set in. In addition, there are no case reports of spontaneous resolution of traumatic Brown syndrome associated with frontal and nasal bone fractures.

Conclusion
To our knowledge, this is the first case report of traumatic Brown syndrome where prompt clinical assessment and surgical management of fractures of the frontal and nasal bones was associated with resolution of the syndrome, without the need to resort to extraocular muscle surgery.

Additional Files
The additional files for this article can be found as follows: • Appendix A.

Ethics and Consent
Informed consent has been obtained from the patient for publication of the text, clinical photographs and clinical charts. Ethical approval not required.