Naso orbito-ethmoidal fractures /certified fixed orthodontic courses by Indian dental academy


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Naso orbito-ethmoidal fractures /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education Abhijit Joshi
  3. 3. Contents : • Significance of NOE region & applied anatomy • Classification of NOE fractures. • Clinical features and pictures • Radiology. • Assessment of lacrimal drainage. • CSF leaks and management. • Steps in managing a NOE fracture • Managing a Post traumatic nasal deformity. Abhijit Joshi
  4. 4. NOE complex • Intricate anatomical structure. • At anatomical crossroads. • 4 cavities involved: – Cranium – Orbits – Nasal – maxilla • 4 bones involved: – Paired nasal – Frontal process of maxilla – Ethmoids – Lacrimal bones. Abhijit Joshi
  5. 5. NOE complex • Wedged in interorbital space. • Basically weak • Strength : – Vertical buttress : frontal pr of max – Horizontal : sup/inf orbital rims • Additional strength: – Lattice network of bones – Articulation at various angles. Abhijit Joshi
  6. 6. • Anatomy and applied aspects: – Osteology – Soft tissue anatomy Abhijit Joshi
  7. 7. Osteology • • • • Nasal bones Ethmoid Frontal process of maxilla Medial orbital rim and wall • Other bones involved: – Perpendicular and Cribriform plate of ethmoid. – Nasal process of frontal bone. – Sphenoid bone Abhijit Joshi
  8. 8. Nasal bones Abhijit Joshi
  9. 9. • Anteriorly: frontal process of max + max proc of frontal. • Lacrimal fossa : – depression on inferomedial orb rim. – Formed by max and lacrimal bones – Bound by Ant lacrimal and Post lacrimal crests. – 16mm high x 4-9mm wide x 2mm deep – Max-lacrimal suture: confluence of the 2 bones – Mean thickness of lacrimal bone here : 106microm  easy perforation Abhijit Joshi
  10. 10. Sutura notha/ sutura longitudinalis imperfecta of weber: • • • • Fine groove on frontal process of maxilla Anterior to ant lacrimal crest Contains small branches of infraorbital artery. Anticipate their presence during dissection Abhijit Joshi
  11. 11. Medial orbital wall • Paper thin  lamina papyracea • Strength from ethmoid air cells  dessipation. • Medial blow out # assoc with orb floor # in 50% cases. • Traversed by: – ant ethmoid art – 24mm – Post ethmoid art – 34mm • Care taken to identify these vessels can contribute to Retro Bulbar Hemorrhage • Entrapment of orbital fat media  horizontal diplopia – restriction of abduction-retraction of globe Abhijit Joshi
  12. 12. Ethmoid bone Abhijit Joshi
  13. 13. Abhijit Joshi
  14. 14. Ethmoid : Abhijit Joshi
  15. 15. Soft tissue anatomy: • medial canthal ligament • Lacrimal drainage apparatus • Associated vessels etc. Abhijit Joshi
  16. 16. Soft tissues. Right eye in primary position Abhijit Joshi
  17. 17. • The U/L are suspended in space, tethered medially and laterally by canthal ligaments • Orb. oculi attaches to the medial orbital wall via MCL • Fibrous diamond shaped, Tripartite arrangement. • Greater horizontally with Ant and post limbs Abhijit Joshi
  18. 18. Medial canthal ligament (MCL): Complex, strong interlocking 3-D arrangment of indivisual components and structures. • Strength derived from complex anatomy. • Intimately related to – lacrimal drainage apparatus. – lacrimal bone – Frontal process of maxilla – reinforces. Abhijit Joshi
  19. 19. Anterior limb: • 11.7mm length/4.9mm width – longer and more prominent. • medial attachment : •Frontal process of maxilla just lateral to suture with nasal bone. •Superior aspect of Ant lacrimal crest and beyond (zide). superior branch – periosteum of frontal bone(corrugator super cilli) Abhijit Joshi
  20. 20. Posterior limb of MCL • Small and poorly defined. • Attaches to posterior lacrimal crest. • Periosteum in this region is thicker and extends till anterior lacrimal crest in a triangular fashion • Applied : – makes post attachment strong. – Strengthens the whole structure. – Hence important to reconstruct the post segment. Both ant and post limbs envelope the lacrimal sac. Abhijit Joshi
  21. 21. Lacrimal drainage: Abhijit Joshi
  22. 22. Abhijit Joshi
  23. 23. Relationship betw excretory system and MCL • Sac is wrapped by lacrimal fascia ( split periorbita) • Wrapped by MCL ant and post limbs • Deep portion of Pretarsal orb oculi – horner-duverney muscle passes posterior to post limb of MCL and attaches to upper portion of PLC. Abhijit Joshi
  24. 24. Other Relations: MCL to ant cranial fossa: • Mean vertical dimension betw MCL and level of cribriform plate : 17mm +/- 4mm McCann’1998 Invest Opthal • Distance between common internal punctum and most ant part of cribriform plate is 25mm botek ’93 Opthal Surgery MCL and Angular art and vein: • Superficial to MCL • 5-8mm anteromedial to ant lacrimal crest • Anticipate bleeding. Abhijit Joshi
  25. 25. Markowitz and Manson • Type I – central fragment • Type II – comminuted fracture with lateral extension not involving MCL • Type III – comminuted fracture with extension into MCL Abhijit Joshi
  26. 26. Classification - Ayliffe Type I – en bloc minimum displaced fractures of the entire NOE complex Type II– en bloc displaced fractures, usually associated with large pneumatized sinus and minimal fragmentation Abhijit Joshi
  27. 27. Type III – comminuted fracture but canthal ligament firmly attached with bone fragments which are big enough to plate Type IV– comminuted fracture with free canthal ligament not large enough to be plated Abhijit Joshi
  28. 28. Type V – gross comminution needing bone grafting Abhijit Joshi
  29. 29. Ideal proportions The ideal nasofrontal angle 115° to 130° The ideal nasal project  1:1. ideal intercanthal distance should be approximately 1/3. Abhijit Joshi
  30. 30. In a NOE fracture Direct blow to nasal bony dorsum Medial canthal ligament detaches / disarticulation of bone containing attachement Crushing of Fragile perpendicular plate, ethmoidal air cells • Rounding of medial canthal angle •Widening of intercanthal distance. post displacement Removes dorsal support for nose. Adherent dura , Crista Galli/ cribriform plate move as a unit  olfactory damage.  CSF leak Abhijit Joshi
  31. 31. Clinical features: • • • • Reduced Dorsal nasal projection , Upturned nasal tip Accentuation of Naso-Frontal angle. Accentuated naso-jugal fold. Inward Telescoping medial wall into ethmoid. • • • • Traumatic telecanthus (loss of stabilization of MCL). Traumatic hypertelorism Orbital dystopia Mongoloid slant • • • • Cerebrospinal fluid leakage. Nasolacrimal duct obstruction/severage  epiphora . Anosmia Nasal airway obstruction Pig snout. Abhijit Joshi
  32. 32. • accentuated N-F angle • Decreased dorsal nasal projection. • Upturned nasal tip. • traumatic telecanthus Abhijit Joshi
  33. 33. • Edema, emphysema, echymosis • Traumatic telecanthus • Orbital dystopia • rounding of medial canthal angle • Mongoloid slant Abhijit Joshi
  34. 34. Subconjunctival emphysema In a patient with medial wall fracture assc with NOE # (after blowing his nose) Abhijit Joshi
  35. 35. Injury to lacrimal drainage: Abhijit Joshi
  36. 36. Clinical assessment. Firm palpation of ant. Lacrimal crest and frontal process of maxilla Firm compression of MC region to displace the edema with thumb and forefinger while displacing lateral canthus laterally allows palpation of • fractured fragment, •mobility of MCL attachment •Mobility of adjacent bone Principles of management of complex craniofacial trauma; Marciani et al, JOMS Joshi Abhijit ‘93
  37. 37. Physical examination • Eyelid traction test / Furnas traction test Furnas DW, Bircoll MJ Plast Reconstr Surg. 1973 Sep;52(3):315-7 • Bimanual palpation by placing an instrument into the nose to determine canthal bearing bone fragment  displaced and mobile Abhijit Joshi
  38. 38. Diagnostic Imaging. Conventional : standard PNS view Plain films are of ALMOST NO USE in diagnosing NOE fractures because most will be undetected; Edward ellis ;Sequencing treatment for NOE fractures JOMS ‘93 Abhijit Joshi
  39. 39. CT • Is of greatest value • HRCT adds to the existing value • What to ask for? – 1-2 mm Axial and coronal slices with 3D recon. – Top of skull-frontal sinus-orbits-maxilla – Bone window  NOE bony complex – Soft tissue window  brain/ocular adnexa. Abhijit Joshi
  40. 40. Axial cuts. • Position and status of frontal process of maxilla  central fragment. • Medial walls of orbit if they are “blown in” nasally, •Anterior and posterior tables of frontal bone •Nasolacrimal system Abhijit Joshi
  41. 41. Coronal cuts • Cuts taken from nasal bridge to orbital apex • junction of floor to medial wall assessed. • Disruption of ant. Cranial fossa around cribriform plate. • CSF leak  CT value • localization of CSF leaks. Abhijit Joshi
  42. 42. 3D CT Abhijit Joshi
  43. 43. Investigations of the lacrimal system Tests for Secretory system Tests for drainage/excretory system • Schirmer’s test • Dye disappearance test • basal tear secretion test • primary dye test • Jones 1 and Jones 2 • DCG • HRCT • Tc 99 scan Abhijit Joshi
  44. 44. Dye disappearance test: Simplest of tests. • Flouriscine dye placed on conjunctival fornix • Dye disappears. • Patency of system Abhijit Joshi
  45. 45. Jone’s test Jone’s 1. • 1 drop fluorescein dye placed into conjunctuval sac. • Cotton bud soaked in LA placed in inf meatus. • Wait for 5 min and remove the bud. • If bud stained with dye  test +ve Abhijit Joshi
  46. 46. If –ve then proceed to jone’s 2: Clear saline irrigated thru cannula inserted into inf canaliculus Patient bends forward 1. Nothing frm nostril 2. Fluid regurgutates – opp. punctum Complete obstr. distal to tip 3. Clear fluid from nose Stained fluid Patency of both canaliculi till int canaliculus Dye not entered canaliculi +ve test Blocked punctum/canaliculi Abhijit Joshi
  47. 47. Dacrocystography: • Radioactive oilbased dye injected into lacrimal drainage. • Radiographed to know the course of duct • CT used for imaging  CT dacrocystography. Abhijit Joshi
  48. 48. CSF leak and management. Abhijit Joshi
  49. 49. Cerebrospinal fluid. • CSF is essentially an ultrafiltrate of plasma • Clear colourless fluid  bathes brain and spinal cord. • Fills ventricles within the subarachnoid space. • Main funtion: – Cushions brain against trauma (sp. Gravity of brains within 4% of that of CSF brain floats !!) nourishment. – Removal of waste products. – Abhijit Joshi
  50. 50. Production and composition. Production : • Choroid plexus and ventricular ependyma • @ 500cc/day. • Volume : 150cc  turnover is TID • Pressure mantained at 60-150mm H2O  valsalva, coughing, straining. Composition: • Insoluble salts. • Ph  7.33 • Total proteins content: 20.0mg/dl • Glucose : 64.0mg/dl • Beta transferrin. Abhijit Joshi
  51. 51. CSF leaks • Barriers to contain CSF and prevent its communication with external: – Dura, – Skull – Periosteum – Galea and skin. • Barriers violated  CSF leak. • Risk of meningitis  4-50% Abhijit Joshi
  52. 52. CSF leaks. Traumatic Surgical 16% Atraumatic - 3-4% High-pressure Non-surgical 80% Normal-pressure spontaneous 3% closed head injuries 9% penetrating head injuries 10-30% basilar skull fractures Abhijit Joshi
  53. 53. Common sites for CSF leak • Cribriform plate, frontal sinus, Ant. Eth. roof. • posterior ethmoid roof, • sphenoid sinus. • temporal bone (pseudorhinoliquorrhea). Abhijit Joshi
  54. 54. Reservoir sign • Simple bed side procedure  nonspecific. • Performed upon patient arising in the morning. • Place patients chin to chest for 1min. • Copious leakage thru nose like an open faucet. • Intermittent drainage: •Use Ipratropium bromide •Nasal secretions will stop •CSF leaks continue. Abhijit Joshi
  55. 55. • Salty taste: • Handkerchief sign: – mucous stiffens linen on drying but csf keeps it soft  distinguishes from allergic rhinitis. • Halo sign/double ring sign: – blood CSF mixture spreads on linen. – Dark ring of blood encircles more lightly stained CSF Abhijit Joshi
  56. 56. • Tramline effect: – occurs when CSF mixed with blood. – CSf appears later as yellowish discharge  mixes with blood. – CSF  higher protein content. – More viscous CSF forms central track with blood on either side which diffuses to edge. Abhijit Joshi
  57. 57. Laboratory diagnosis • Glucose test • Protein analysis • Beta transferrin test • beta-Trace Protein • Electronic nose Abhijit Joshi
  58. 58. • Glucose test : CSF collected in vial and if glucose levels are > 45mg/dl  CFS existence. Abhijit Joshi
  59. 59. glucose oxidase stick technique • Normally nasal secretions are devoid of glucose whereas CSF has a glucose level related to the plasma glucose. The literature generally supports a glucose value of 30 mg/dL in rhinorrhea fluid as indicative of CSF. However, there are opportunities for falsepositives and false-negatives. For example, a postsurgical patient may have a serous exudate which physiologically contains glucose. • To measure the glucose concentration of nasal secretions in the absence or presence of rhinorrhoea Abhijit Joshi
  60. 60. Beta transferrin test • This protein is found in only three bodily fluids – CSF, perilymph, and vitreous humor . • Unless a patient has an open globe, ongoing production of clear nasal discharge that is positive for beta-2-transferrin is highly diagnostic for CSF • Is a protein produced by neuraminidase activity Abhijit Joshi
  61. 61. b-2 transferrin • Immunofixation electrophoresis of nasal secretions in the laboratory  used to detect b-2 • This test is not sufficiently rapid to provide support for clinical decision making in emergency departments and may not be available in all hospitals, particularly in developing countries Abhijit Joshi
  62. 62. Beta Trace protein. • B-TP is a naturally occurring secretory enzyme  present in human CSF  concentration of 15 to 20 mg/L. • The CSF to serum ratio of b-TP (33:1)  highest of all CSF specific proteins • Ideal marker for the detection of CSF traces. • Most abundant protein in human CSF, (also in prealbumin, albumin, Ig G). • Also in urine, aqueous humor, and inner ear fluids,glomerular filtr. • In healthy subjects, the serum concentration of B-TP is 0.3 mg/L. Abhijit Joshi
  63. 63. • Immunoelectrophoresis / Nephelometric assay used. • In comparison to the 2-transferrin test, the b-TP assay superior higher predictive values. • Test can be performed within 20 minutes • Smallest traces of CSF (5%) can be detected by B-TP. • Limitation : Pts with acute glomerulonephritis or terminal renal insufficiency; in these patients, the BTP concentration increases in the serum. Bachmann et al Predictive Values of -Trace Protein by Use of Laser-Nephelometry Assay for the Identification of Cerebrospinal Fluid Neurosurgery, Vol. 50, No. 3, March 2002 Abhijit Joshi
  64. 64. Nephelometer An apparatus used to measure the size and concentration of particles in a liquid by analysis of light scattered by the liquid.` • It does so by employing a light beam (source beam) and a light detector set to one side of the source beam. • Particle density is then a function of the light reflected into the detector from the particles. • How much light reflects  dependent upon properties of the particles  shape, color, and reflectivity. An assay is a procedure where the concentration of a component part of a mixture is determined Abhijit Joshi
  65. 65. Electronic nose • Vapor-sensing devises used primarily in the food and beverage industries. • Numerous publications have addressed the medical utility of such devices. • Electronic nose technology has been used for breath analysis to identify: – Campylobacter pylori in the stomach, – Study lactose malabsorption, – Vapor pressure in sweat analysis  in screening for cystic fibrosis. Abhijit Joshi
  66. 66. A. Headspace over a liquid sample is aspirated into an analyzer (electronic nose). B. Headspace gas (containing the sample aroma) is allowed to interact with array of 32 conducting polymers with differing sensitivities to specific chemical types (eg, alcohols, ketones). C. Electrical resistance of each of the conducting polymers changes reproducibly after exposure to an aroma, allowing the aroma to be represented as a point in a 32dimensional space Abhijit Joshi
  67. 67. Efficacy of electronic nose • The amount required,0.3 mL, may be obtained with only a few drops of nasal discharge • The electronic nose was also able to reliably place unknown specimens in the appropriate category of CSF or serum Anna Aronzon et al Otolaryngology–Head and Neck Surgery (2005) 133, 16-19 Abhijit Joshi
  68. 68. Radiographic evaluation: • High resolution CT : bone defect is filled with CSF density fluid extracranially. • CT cisternography • Radionuclide cisternography • Intrathecal flourscien • MRI cisternography Abhijit Joshi
  69. 69. CT Cisternography • Contrast dye oil based, nonionic (metrizimide)used. • Lumbar puncture into subarachnoid space. • Trendelenburg position. • Subject to CT scan. • High resolution CT Coronal 2mm slices obtained : – confirm CSF leak – Locate site of leak. Abhijit Joshi
  70. 70. CSF fistulas CSF leak Metrizamide CT scan showing CSF leak in left frontal sinus s/p SW to left orbit. Abhijit Joshi
  71. 71. Use of low concentration flourescein dye • Cotton pledgets placed in the nose. • Sterile dilution of 0.3ml flourescein + 10cc CSF made. • Infused intrathecally. • Pledgets removed after 30min to 1hr • Analyzed under ultraviolet light. can be given simultaneously with contrast material, and thus one can use CT cisternography and endoscopic examination in a complementary fashion . Abhijit Joshi
  72. 72. Nuclear cisternography • Sensitive method to evaluate CSF leaks • Indium 111 (bonds to CSF protiens) used  ½ life of 48hrs  delayed imaging. • Injected intrathecaly. • Tracer takes 2-4hrs to reach basal cisterns • Intranasal pledgets Endoscopically placed in the middle meatus and sphenoethmoidal Abhijit Joshi
  73. 73. Abhijit Joshi
  74. 74. Treatment : • Tailored to individual • Intracranial versus extracranial • Endoscopic versus microscopic Abhijit Joshi
  75. 75. Intracranial approach. Advantages : – direct visualization, – ability to repair adjacent cortex, – Better chance of repairing a leak caused by increased intracranial pressure. Disadvantages: – increased morbidity, – longer hospitalization, – higher incidence of post-operative anosmia. Abhijit Joshi
  76. 76. extracranial repair – has decreased morbidity and anosmia, – superior exposure of the posterior ethmoid, parasellar, and sphenoid regions. – Disadv: less suited for defects in the frontal sinuses with prominent lateral extension and is less successful in high-pressure leaks Abhijit Joshi
  77. 77. Grafts : • Free nasal mucosa,Pedicled nasal mucosa, • bone grafts harvested from the nasal septum or middle turbinate • Temporalis fascia,muscle ,Adipose tissue. • Vascularized free flap. Graft stabilization: • with cyanoacrylate glue/fibrin glue Packing • Microfibrillar collagen(over the graft), • Absorbable gelatin sponges • Oxidized cellulose. • All repairs intraoperatively tested  Valsalva maneuver. Abhijit Joshi
  78. 78. What can be used?? Grafts/flaps fat, fascia, muscle, cartilage, mucosa simple or composite Biological glue collagen, fibrin, cyanoacrylate Gelfoam, Merocel Abhijit Joshi
  79. 79. Skull Base (extracranial) approaches: Cribiform plate fistula: Transethmoidal repair • Nasal septal mucosal flap to cover ethmoid sinus. Sphenoid sinus fistula: Transseptal transsphenoidal approach • Recent endoscopic advances allow for a fully endoscopic transsphenoidal approach Primary repair of dural opening is attempted • Grafts of pericardium, fascia lata, or endogenous fat Abhijit Joshi
  80. 80. Endoscopic approach to a CSF leak. CSF leak Abhijit Joshi
  81. 81. Final word on CSF…. • CSF fistulae arise from a variety of etologies. • Diagnosis based on physical, laboratory and radiologic techniques • Treatment divided into surigical and non-surgical. • Future holds refinement of existing techniques, development of new ones Abhijit Joshi
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  91. 91. Thank you Abhijit Joshi