Management of nasoethmoidal fractures


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The naso-orbitoethmoid complex (NOE) fracture represents the most wearisome and challenging of all facial fractures due to the complexity and intricacy of its surgical & anatomic components. A good working knowledge with regards its surgical anatomy, clinical features, sequence of treatment & surgical approaches, potential pitfalls in its treatment & postoperative consideration,. Appropriate diagnosis and timely treatment is crucial to avoid unfavorable & difficult to treat sequelae.

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  • PCOMS 27th National Conference Jan 24-25, 2004. Hotel intercontinental. Pres Joven Javier; Dr. Mario Esquillo was the Pres Elect.
  • The nasoorbitoethmoid (NOE) complex is the confluence of the frontal sinus, ethmoid sinuses, anterior cranial fossa, orbits, frontal bone, and nasal bones. The intricate anatomy of this area makes NOE injuries one of the most challenging areas of facial reconstruction. Inadequately repaired NOE fractures often result in secondary deformities that are extremely difficult (or impossible) to correct. Long-term sequelae of NOE fractures include blindness, telecanthus, enophthalmos, midfaceretrusion, cerebral spinal fluid (CSF) fistula, anosmia, epiphora, sinusitis, and nasal deformity. Accurate diagnosis and prompt surgical treatment of NOE fractures are critical to avoid complications and to obtain an aesthetic surgical result. The image below depicts the nasoorbitoethmoid complex.
  • The nasoorbitoethmoid (NOE) complex, represents the confluence of the nasal, lacrimal, ethmoid, maxillary, and frontal bones.The paired nasal bones attach to the frontal bone superiorly and to the frontal process of the maxilla laterally. The ethmoid bone is located posterior to the nasal bones. The ethmoid air cells are present at birth and enlarge to adult size by age 12 years. The overall growth and size of the ethmoid complex is highly variable among individuals. The ethmoid labyrinth separates the orbits from the nasal cavity, while the fovea ethmoidalis forms the roof of the ethmoid sinuses laterally.
  • The tendon splits around the lacrimal sac and attaches to the anterior & posterior lacrimal crests, as well as to the frontal process of the maxilla. The canthal tendon diverges to become the pretarsal, preseptal, & orbital orbicularisoculi muscle.
  • Laboratory StudiesBeta2-transferrin is the definitive test for CSF rhinorrhea. Collect 1 mL of the suspected fluid in a red top tube. Beta2-transferrin is a "send out" laboratory at most institutions. Watery rhinorrhea that is positive for beta2-transferrin is diagnostic for a CSF leak. Besides CSF, only the vitreous humor of the eye and the perilymph of the ear have been found to contain beta2-transferrin.Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign. If CSF is present, it diffuses faster than blood and results in a clear halo around the central stain.Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF.
  • A detailed review of 104 patients with severe nasoethmoid-orbital injuries has facilitated the classification of these injuries into five types. The recognition and diagnosis of each specific injury pattern will define the correct treatment choice in each instance. Special attention should be focused on injuries with comminution and bone loss in the medial wall and floor of the orbit, loss of cartilaginous nasal support, and orbital displacement and dystopia. An open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments provides optimal repair. The use of craniofacial surgical techniques and immediate bone graft replacement of missing or severely damaged bone will allow reconstruction of even the most difficult injuries in one stage. Three hundred and nine primary bone grafts have been used in 66 patients. No significant complications of their use have occurredGruss JS Ann Plast Surg. 1986 Nov;17(5):377-90
  • With naso-ethmoidal fractures a CSF leak should be assumed to be present even if it is not clinically demonstrable, and appropriate chemoprophylaxis should be commenced
  • A good question that might now arise is how you tell if fluid coming out the nose or ears is CSF - it could be pure blood, or it (in the case of nasal discharge) it could be the normal nasal secretions. There are a number of tests you can do.Firstly, CSF should have glucose in it, whereas this is unlikely in normal nasal secretions, and so measuring the glucose (initially on dipstix, and then formally) is helpful.Secondly, if you are dealing with a bloody fluid, you could try to look for the halo sign (or ring sign). Dab some of the blood on a tissue. If there is CSF mixed with the blood, it will move by capillary action further away from the centre than the blood will. You'll get something like this
  • To evaluate the integrity of the medial canthal tendon, place the thumb and index finger over the nasal root and carefully apply lateral tension to each lower lid. Normally, a defined endpoint to the maneuver is evident without palpable motion at the medial canthus. A lax medial canthal tendon or medial orbital wall motion is consistent with a NOE complex fracture. A periosteal elevator also can be inserted through the nose to palpate the stability of the medial canthal tendon complex. The clinical medial canthal integrity should be compared with the CT evidence to classify the fracture and associated injuries and used to develop an early comprehensive management plan
  • Transnasal wires placed anterior to the lacrimalfossa result in rotation of the central fragment laterally, which results in postoperative telecanthus. (Below) Transnasal wires placed posterior and superior to the lacrimalfossa provide adequate support for the medial canthal tendon, and postoperative telecanthus is avoided.
  • Fracture classificationThe key component of NOE complex reconstruction is the bony central fragment onto which the medial canthal tendon inserts. Markowitz et al (1991) devised a classification system based on the degree of central fragment injury.2 Each fracture type is subclassified as either unilateral or bilateral.Type I fractures represent a single noncomminuted central fragment without medial canthal tendon disruption.Type II fractures involve comminution of the central fragment, but the medial canthal tendon remains firmly attached to a definable segment of bone.Type III fractures are uncommon and result in severe central fragment comminution with disruption of the medial canthal tendon insertion.
  • Future advances may address this issue with the use of surgical navigation systems and/or intraoperative imaging, which returns the bony architecture to its premorbid state more accurately.
  • PCOMS 27th National Conference Jan 24-25, 2004. Hotel intercontinental. Pres Joven Javier; Dr. Mario Esquillo was the Pres Elect.
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