1) NOE fractures involve the nose, orbit, ethmoids, and frontal sinus floor, including the medial canthal tendon attachment area. 2) Classification systems include the Markowitz system of Types I-III based on medial canthal tendon involvement and displacement. 3) Treatment involves open reduction and internal fixation to restore anatomy, including medial canthal tendon reconstruction using transnasal wiring or plating.

1. Naso Orbito Ethmoid (NOE)
Complex Fracture
Presented by : Sailesh Kumar. R
PG Trainee

2. •Dawson and Fordyce coined the term " fracture of the
ethmoids" to denote an injury more severe than a
simple nasal fracture.
• Converse and Smith used the term “naso-orbital”.
•Stranc preferred the term “naso-ethmoid”.
• In 1973 Epker coined the term "naso-orbito-ethmoid“,
(NOE) the most popular term in use today."
Evolution of the term NOE

3. •Manson et al have used two terms for these injuries;
"naso-orbital-ethmoid" and "nasoethmoid orbital”.
•Gruss has also used the term "nasoethmoid- orbital”.
•Ian Jackson used the term "orbitoethmoid," believing
that the orbital component needed to be stressed in
these injuries because it accounted for the most
difficult complications."

4. ANATOMY of NOE

5. • The medial canthal
tendon arises from the
anterior and posterior
lacrimal crests and the
frontal process of the
maxilla.
• The medial canthal
tendon surrounds the
lacrimal sac and diverges
to become the orbicularis
oculi muscle, tarsal
plate, and suspensory
ligaments of the eyelids.
MEDIAL CANTHAL
TENDON

6. Relation to NOE region

7. DEFINITION of NOE Fracture
The naso orbito ethmoidal
(NOE) fracture refers to injuries
involving the area of
confluence of the
• nose, orbit, ethmoids,
• the base of the frontal
sinus and
• the floor of the anterior
cranial base.
• The area includes the
insertion of the medial
canthal tendon(s)

8. PATHOPHYSIOLOGY

9. Buttresses of Face

10. CLASSIFICATION
Type 1
Unilateral
Bilateral
Type 2
Unilateral
Bilateral
Type 3
Unilateral
Bilateral
Markowitz and Manson
classification (1991)
*Management of medial canthal tendon in nasoorbital ethmoid fractures: In importance of the central
fragment in classification and treatment.
Markowitz et al, plastic and reconstructive surgery,1991, vol 87

11. In unilateral Markowitz type I
fractures, there is a single large NOE
fragment bearing the medial canthal tendon.
Markowitz type I
Bilateral Markowitz type I
fractures,

12. In unilateral type II fractures, there is often
comminution of the NOE area, but the canthal
tendon remains attached to a fragment of
bone, allowing the canthus to be stabilized with
wires or a small plate on the fractured
segment.
Bilateral type II fracture with nasal bone
involvement
The illustration shows a bilateral NOE type II
fracture. In bilateral fractures the nasal bones are
commonly involved. In some instances, bone
grafting of the nasal dorsum may be necessary.
Markowitz type II

13. In unilateral type III fractures,
there is often comminution of the
NOE area (as in type II fractures) and
a detachment of the medial canthal
tendon from the bone.
Bilateral type III fracture with nasal
bone involvement
The illustration shows a bilateral NOE type
III fracture. The nasal bones are usually
involved. Bone graft of the nasal dorsum is
usually necessary.
Markowitz type III

14. Signs and Symptoms
• Decreased dorsal nasal projection
• Upturned nasal tip (pig snout)
• Periorbital ecchymosis and oedema
• Epistaxis
• CSF rhinorrhoea
• Epiphora
• Anosmia
• Nasal airway obstruction
• Traumatic telecanthus
• Traumatic hypertelorism
• Orbital dystopia
Type 1 &
Type 2
Type 3

15. Evaluation of intercanthal distance
Clinical
examination
Ideal nasofrontal angle – 115
to 130 degrees
Ideal nasal projection is 1:1 • Average intercanthal
distance – 28 to 35mm
(differ with Race)
• Found to be half the value
of interpupillary distance
• Evaluate pre injury photos

16. Clinical
examination
• Bimanual palpation using
Kelly clamp
• Determines whether the
canthal-bearing bone
fragment is displaced and
mobile
Furnas traction test/ Bow string test/
Eyelash traction test
Evaluating Crepitus
CSF Leakage

17. Examination of the Eye should also be done along with NOE examination
 A study reported by Holt et al, 67% of 727
patients with facial fractures sustained some
degree of ocular injury

18. Radiological examination

19. Management of NOE fractures
• NOE fractures are best treated by open reduction and internal fixation (
Dingman and Natvig 1964)
• Mustarde(1966) described an open technique for restoration of the
displaced medial canthal ligament by transnasal wiring
• This fracture is better overtreated than undertreated because the
secondary deformities (soft tissue retraction, scarring, malposition and
displaced bony fragments) that accompany inadequate therapy are
extremely difficult to correct
• Major reason for treating NOE fracture is esthetics

20. 1.Surgical exposure
2.Identification of the medial canthal tendon and
tendon-bearing bone fragment,
3. Reduction and reconstruction of the medial orbital
rim,
4.Reconstruction of the medial orbital wall,
5.Transnasal canthopexy,
6. Reduction of septal fractures,
7. Nasal dorsum reconstruction and augmentation,
8. Soft tissue adaptation
Eight key steps in the sequencing of NOE fractures by
Ellis
* Sequencing Treatment for Naso-orbito-ethmoid Fractures
EDWARD ELLIS III , JOMS 1993

21. Approaches
• Existing Lacerations
• Local incision
• Coronal incision
• Open Sky Approach (Converse &
Hogan,1970)
• Lynch incision/ Medial canthal
incision
• Midface Degloving incision
• Combination of coronal and lower
lid incisions
• Extended Glabellar approach
(Horizontal Y approach)

22. Surgical landmarks along the dissection of
the medial orbital wall are the:
•Anterior lacrimal crest
•Anterior ethmoidal artery (15 mm from the
crest)
•Posterior ethmoidal artery (25 mm from the
crest)
Pitfall:To avoid injury to the optic nerve
Dissection should stop at the posterior
ethmoidal artery in order not to endanger the
optic nerve at the optic foramen (located at
about 35-40 mm from the crest)

23. Extended Glabellar approach
(Horizontal Y approach)
• The incision should be planned in the glabellar furrows or, if appropriate, in the
region camouflaged by the bridge of eyeglasses.
• The incision is then extended from the lateral nasal bridge to about 3 mm
medial to the skin edge of the caruncle.
• From there it bifurcates into an upper and lower eyelid incision.
• These two extensions can be taken up to the midline of the globe.
Wide visualization of
• medial canthal area,
• lacrimal sac, and
• medial orbital wall

24. Midfacial degloving approach
The horseshoe type bilateral maxillary vestibular
incision is combined with a circumferential incision
(intercartilaginous, transfixion, and nasal floor)
inside both nostrils.
This enables lifting the soft-tissue envelope all the
way up to the nasal dorsum, radix and ethmoid
region.
Access area is extended cranially into the nasal
dorsum and ethmoid area as well as the entire
zygomatic body and the lower portion of lateral
orbital rim

25. The circular endonasal incision and soft-tissue
dissection is achieved using a combination of three
techniques:
•Intercartilaginous incision (A)
•Transfixion incision (B)
•Incision of the nasal floor along the piriform
aperture (C)
After intranasal freeing, the soft-tissue
envelope over the nose and the midface can be
lifted in a subperiosteal and subperichondrial
plane all the way up into the ethmoid region.

26. Coronal approach
Access areas
Entire calvarial vault
•Anterior and lateral skull base
•Frontal sinus/Ethmoid
•Zygoma
•Zygomatic arch
•Orbit (lateral/cranial/medial)
•Nasal dorsum
•Temporomandibular joint (TMJ)
•Condyle and subcondylar region

27. Lower lid incision - Transcutaneous
There are three basic approaches through the
external skin of the lower eyelid to give access to
the inferior, lower medial, and lateral aspects of
the orbital cavity:
•Subciliary (A, synonym: lower blepharoplasty)
•Subtarsal (B, synonym: lower or mideyelid)
•Infraorbital (C, synonym: inferior orbital rim)
The subciliary approach can be extended laterally
to gain access to the lateral orbital rim (D).
Hypertrophic scarring and keloid formation is very
uncommon following lower lid skin incisions. In
general, the scars become inconspicuous with
time.

28. Open Reduction and Internal Fixation
(Dingman and Natvig 1964)

30. Open Reduction and Internal Fixation
• Disimpaction done by –
Asch’s forceps
• Requires 3-point
exposure and
fixation.

31. Medial canthus fixation- Trans nasal canthopexy
4th plate is needed to support the transnasal
wire

33. The upper illustration represents a wire that has
been placed anteriorly, resulting in a further lateral
splaying of the bone supporting the medial
canthus, and a worsening of the telecanthus.
The lower illustration represents the proper
posterior placement of the transnasal wire with a
proper reduction of the bone attached to the
medial canthus.
Proper position of Transnasal wiring

34. Barb ended wire for Trans nasal canthopexy

35. Reconstruction of medial wall of orbit and
Trans nasal canthopexy

36. Bilateral NOE fracture with nasal bone involvement
With bilateral displacement of the two
canthal ligaments are wired
transnasally to each other.

37. • Bone grafting done to
augment the dorsum of
nose and also bone grafting
can be done in medial
orbital wall fracture ( using
calvarial / rib graft)
• Bolsters are placed to
prevent edema and
maintain graft in position

38. Post operative management
• Nose-blowing should be avoided for at least 10 days following NOE fracture
repair.
• Medications - Ophthalmic ointment, Steroids, Antibiotics and analgesics
• Ophthalmological Examination
• Vision
• Extraocular motion (motility)
• Diplopia
• Globe position
• Visual field test
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be
checked
• If the patient complains of eye pain, evaluate for corneal abrasion
• Periodic monitoring of globe position, vision and nasal airway obstruction

39. Evaluating the patency of lacrimal apparatus
post operatively
• Dye test – flouriscin dye used
• Jones test I & II
• Direct
• Indirect
• Dacrocystography – lacrimal system is injected with contrast and the
midface is scanned by CT (Ashenhurst et al)
Differential diagnosis of Epiphora:
• Aging, with resultant pulling away from the puncta,
• Paralysis of CN VII,
• Disruption of the medial canthal ligament, and
• Obstruction of hasner’s valve

40. Dacrocystorhinotomy (DCR)
• DCR is done to bypass the nasolacrimal duct by
anastomosing the lacrimal sac with the nasal
mucosa.

41. The sac is dissected free from its bony
attachments and the bony ostium is
made medial to the lower part of the
sac with a 10-mm trephine bur.
The lacrimal bone and part of the
anterior lacrimal crest are removed.
The posterior nasal and sac flaps are
sutured, as are the corresponding
anterior flaps.
Hollwich has modified – that the
anterior mucosal flap of the sac is
sutured to the overlying subcuticular
skin.

43. • The nasal bone opening must be large enough, its borders must be
smooth so that granulomas do not form, and daily lavage with
Ringer’s solution should be started on the postoperative day 2 and
continued for approximately 4 weeks.
• DCR usually can be performed safely 3 to 4 months after the initial
reconstruction if the lacrimal obstruction was initially left unnoticed

44. References
• AO Foundation. “Nasal/NOE”. https://www2.aofoundation.org
• Rowe and Williams’ Maxillofacial Injuries
• Fonseca walker, 4th ed
• Management of medial canthal tendon in nasoorbital ethmoid fractures: In importance
of the central fragment in classification and treatment. Markowitz et al, plastic and
reconstructive surgery,1991, vol 87
• Sequencing Treatment for Naso-orbito-ethmoid Fractures , EDWARD ELLIS III , JOMS
1993
• Grays Anatomy, 40th ed
*

45. THANK YOU