description of the fractures of the Naso-Orbito-Ethmoid complex, their clinical features, treatment

1. SAROJINI DEVI EYE HOSPITAL,
OSMANIA MEDICAL COLLEGE,
HYDERABAD.

2. ORBITAL ANATOMY

3. • THE NASO-ORBITO-ETHMOID (NOE) REGION OCCUPIESTHE MIDDLETHIRD
OFTHE FACE AND IS FORMED BY NUMEROUS NASAL AND ORBITAL BONES
INCLUDINGTHE ZYGOMATIC BONE AND MAXILLA. AS A CONSEQUENCE, NOE
FRACTURES ARETHE MOST DIFFI CULT FACIAL INJURIESTO DIAGNOSE AND
TREAT AND ARE OFTEN MISSED OR OVERLOOKED. MORETHANTHAT, EVEN IF
DIAGNOSED PROPERLY, OFTENTIMESTHE SURGICAL REPAIR IS NOT
ADEQUATE BECAUSETHE COMPLEXITY OFTHE ANATOMICAL
INTERRELATIONS INTHE REGION IS NOT PRECISELY UNDERSTOOD. AND
FINALLY, TO COMPOUNDTHE SITUATION,THESE FRACTURES OFTEN ARE
ASSOCIATED WITH INJURIES OFTHE SOFTTISSUESTHAT PLAY AVITAL ROLE
INTHE FORMATION OFTHE PROFI LE OFTHIS PART OFTHE FACE

4. NASO-ORBITO-ETHMOIDAL COMPLEX

5. • NOE fractures in essence are broken nasal bones and cartilages
telescoped backward into the interorbital space usually as a
result of an assault or a motor vehicle accident.
• The force vector resulting in a NOE fracture is usually
transmitted through and thus fracturing five sutures, the frontal
process of the maxilla in the place where it joins the internal
angular process of the frontal bone, then the medial orbital wall,
the infraorbital rim, the lateral nasal wall, and the nasomaxillary
suture of piriform aperture
• Formation of one or several movable fragments of the medial
orbital rim with the attached MCT is the key factor in
pathogenesis of NOE fracture.

6. NOE FRACTURE
TRAJECTORY OF A NOE FRACTURE

7. CLASSIFICATION
• Classification of NOE fractures is based on the integrity of the
central fragment. According to the Markowitz-Manson
classification, there are three types of fractures:

8. • Type I – isolated fracture resulting in one large fragment which
is also the central fragment.

9. • Type II – fracture of the central fragment resulting in
comminuted fragments with fracture lines going around the
MCT attachment site so that the latter remains intact.

10. • Type III – fracture of the central fragment involves comminuted
fragments with destruction of the MCT attachment site to the
extent of its avulsion.

11. CLINICAL PRESENTATION OFTYPE I NOE FRACTURES
• This group of fractures accounts for 18 % of all fractures in this region.
• Complete bilateral type I NOE fractures resulting in an isolated central fragment, detached
from the surrounding osseous structures by all five fracture lines, are more typically an
exclusion rather than a rule.
• It is usually a low-energy unilateral “greenstick” fracture located in the site of the junction of
the frontal process of maxilla and the internal angular process of the frontal bone above the
MCT attachment site.
• Sagging of the inner infraorbital rim alongside deformation of the piriform aperture is very
likely, but it is usually disguised by edema and hematoma of the soft tissues.
• Injury of the lateral nasal wall causes ipsilateral face asymmetry and obstruction of the lacrimal
pathways.

12. • In some cases, palpating the MCT
attachment site or testing central
fragment for flexibility under general
anesthesia makes diagnosis
considerably easier. In these cases, the
length of the nasal bridge and
intercanthal distance usually have not
changed, which gives an illusion of the
intact NOE complex.
• Crepitation or flexibility of the bone
fragment unmistakably indicates a
fracture that requires open
repositioning or rigid fixation.

14. CLINICAL PRESENTATION OFTYPE II AND III NOE FRACTURES
• These are moderate-energy fractures that
comprise 72 % of all the fractures in this region.
• The only difference between type II and type III
fractures is the condition of bones around the
MCT attachment site.Thus clinical features are
simiar.
• Symptoms determined by lateral displacement of
the central fragment caused, in turn, by the
orbicularis oculi strain (flattening and widening of
the nasal bridge, shortening of the palpebral
fissure and rounding of its medial angle, and the
increase in intercanthal distance – traumatic
telecanthus).

15. • Symptoms determined by
telescopic displacement of
fractured nasal bones (saddle nose
deformity, epicanthus caused by
displacement of nasal skin on the
medial palpebral commissure,
epiphora caused by obstruction of
the lacrimal pathways with bone
fragments, epistaxis, anosmia, and
obstruction of nasal passages)

16. • Only 10 % of NOE fractures are isolated; more commonly a NOE fracture is a part of the
extensive fracture that engages other facial bones or the skull base Fragments of the vomer,
ethmoid, and nasal bones may penetrate into the cranial cavity as they are telescoped backward.
• As a consequence, 50 % of the time this type of fracture involves brain injury; in 40 %, cerebral
spinal fluid (CSF) leak; and in 30 %, vision-threatening injuries of the eyeball and optic nerve.
• A CSF leak is usually caused by propagation of the fracture to the walls of the frontal sinus
associated with dura mater rupture.The leak can be detected through visual examination;
sometimes a patient himself/herself senses a metallic taste in the nasopharynx.CSF fluid may
also gather under the periosteum of the orbital wall either as palpable fluctuating formation or
intermittent swelling of orbital tissues worsening at straining and coughing or squeezing of the
jugular veins.

17. • In 4.5 % of cases, a high-energy fracture of NOE complex is accompanied by a
circular fracture of both orbits (3–4 walls), types I and III Le Fort fractures of the
zygomatic bones maxilla and mandible that lead to lateral transposition, increase
in orbital volume, and divergence of orbits.
• Widening of the face, lateral dislocation of both eyeballs, increase in interorbital,
inter-pupillary, and inter-canthal distances are the classic signs of traumatic
hypertelorism.
• In every second patient, injury of the optic nerve causes bilateral blindness. Half of
the patients surviving this trauma have bilateral blindness secondary to optic
nerve damage. Ruptured globes are often found in these traumas as well.

18. DIAGNOSIS OF NOE FRACTURES
• The difficulty lies in the fact is that in the early days following injury, the obvious signs
of fracture are disguised by swelling, ecchymosis, and emphysema of midfacial soft
tissues.
• The pathognomonic symptoms are a flattened nasal bridge and telecanthus.
• CSF leak, epistaxis, and epiphora are typical, yet not pathognomonic symptoms.
• This is where a clinician should be especially suspicious. As bones of the NOE complex
endure the load of up to 30 g/cm 2 , any nasal fracture may be a part of a more
extensive injury.
• That is why every midfacial trauma should be treated as a potential NOE fracture.

19. • Axial CT signs indicating a NOE fracture are as follows
1. spread of the nasomaxillary suture,
2. asymmetrical nasolacrimal ducts,
3. Shadowing and destruction of ethmoid air cells,
4. depression and displacement of nasal bones,
5. displaced fracture of the medial orbital wall accompanied by displacement of segments,
6. orbital emphysema.
• Coronal CT scans can reveal both inferomedial spread of the nasomaxillary suture and
fracture of the infraorbital rim with posterior displacement.

20. Telescopic displacement of broken nasal bones backward into the
interorbital space

21. Fracture line crosses both nasolacrimal
Ducts.
Unilateral (hemi-) NOE fracture.

22. Unilateral disruption of the naso-maxillary suture in an axial scan (long arrow).
Short arrow indicates zone of diastasis of the zygomatico-maxillary suture, verifying that the patient has a
combination of NOE and maxilla-orbital fractures.
The same combination of two fractures. The nasolacrimal duct is destroyed ( long arrow ), a fracture of the
zygomatic arch (short arrow).

23. TREATMENT
• Treating NOE Fractures often requires the multidisciplinary approach involving a
neurosurgeon, a maxillofacial surgeon, and an ophthalmologist.
• The treatment begins with stabilization of vital signs and evaluation of the neurological
status.
• The surgical treatment of a NOE fracture can be started only after the risk of penetrating
brain injury or open globe injury has been eliminated. In the situation where there is either
open brain injury or an open globe, neurosurgical and ophthalmic surgical interventions are
performed first, followed by reduction of the NOE fracture.
• On condition that the patient’s neurological status is stable, a CSF leak should not prevent
early fracture repositioning, because the intervention may stop the leak.

24. • The goal of the treatment is to reconstruct the initial appearance of the palpebral
fissure and nose, which involves restoration of the inter-canthal distance, height,
and contour of the nasal bridge and symmetry of medial palpebral commissures.
• The goal of the treatment is to reconstruct the initial appearance of the palpebral
fissure and nose, which involves restoration of the inter-canthal distance, height,
and contour of the nasal bridge and symmetry of medial palpebral commissures.

25. • Five incisions are used to give proper exposure of the NOE region: subciliary, upper
gingivobuccal, coronal, limited median vertical, and the gull-wing approach.

26. • Subciliary and gingivobuccal incisions will suffi ce to deglove a unilateral type I NOE fracture
with inferior displacement.
• All other cases (superior dislocation of the central fragment, type I bilateral fractures,
comminuted fractures) require a combination of the superior and inferior (subciliary and
gingivobuccal) approaches.
• A coronal incision is used for extended fractures, and median vertical and the gullwing
incisions for isolated fractures.
• Identifi cation of the MCT and central fragment sometimes poses a serious challenge, as
there is a risk of complete avulsion of the former from the central fragment if one is not
careful.
• In order to avoid this iatrogenic complication, one should start the surgical dissection at the
nasal bones to identify the anatomy.
• Restoration of the medial orbital rim via open repositioning and rigid fixation of the central
fragment is the key stage of surgery whose technique is defined by the fracture type.

27. • In patients with complete bilateral types I
NOE fractures , the central fragment
which is displaced postero-inferiorly is
fixed with 1.5- and 2-mm titanium
microplates to the supraorbital rim and
piriform aperture.
• Lateral displacement of the fragment can
be effectively treated by a trans-nasal
reduction.

28. • The surgical approach to a
type II fracture implies
separating the fragment with
the attached MCT from the
periosteum followed by wire
fixation through holes made
postero-superiorly to the
lacrimal sac fossa.
• After that, all fragments
surrounding the tendon are
gathered together, and the
reconstructed central
fragment is attached to the
adjacent bones with titanium
microplates

29. • There are two possible ways of treating the
rare type III fractures involving avulsion of
the MCT.
• If fragments are so small that it is
impossible to make two holes 4 mm away
from each other in a single fragment, and
glue fixation failed, bone autografting is
needed. Fortunately, such cases are very
rare.
• More often, it is possible to fi x the detached
canthal tendon to a large fragment of the
medial orbital rim and then perform
transnasal canthopexy for each tendon
alone.

30. • Trans-nasal canthopexy is an
important stage of the surgery
without which it is impossible
to restore the nasal bridge and
medial orbital rim.
• Canthopexy comes within the
purview of surgeons
experienced in repairing
midfacial traumas.The specific
canthopexy technique depends
on the type of fracture.
• Immobilization using
transnasal wiring is
recommended in patients with
bilateral avulsion of the MCTs,
whereas ipsilateral canthopexy
will suffice for unilateral
injuries.

31. • The normal anatomical features of the MCT
have a thick anterior pedicle attached to
the frontal process of maxilla at the level of
the fronto-maxillary suture and a thin
posterior pedicle attached to the posterior
lacrimal crest. In order to prevent
ectropion, while repositioning the MCT, it
should be pulled not only medially, but also
posteriorly, to the anterior lacrimal crest.
This surgical maneuver will approximate
the normal anatomical anchors of the MCT
and thus reduce the likelihood of
postoperative ectropion.
• A simplified technique for fixation of the
MCT has recently been proposed. It
consists in attaching the MCT to the long
leg of aY-shaped titanium mini plate that is
oriented toward the depth of the orbit and
attached to nasal bones with its short legs
or to a special fixing system.

32. • Fixation of the medial tendon
to the central fragment

33. • Ipsilateral canthopexy at
unilateral telecanthus.

34. • Repositioning/restoration of the nasal septum and
dorsum .
• A NOE fracture is defined by telescoped
fragments and, consequently, the loss of bone
support for the middle and distal thirds of the
nose.This results in the typical sign of an upturned
nose.
• The typical shortened and upturned nose is the
sign of a NOE fracture.This is caused by
telescoped fragments and, consequently, the loss
of bone support for the middle and distal thirds of
the nose.
• A nasal tip droop sometimes seen in the injured
patients also indicates the loss of septal support.
Because of the trauma to the support system,
without bone grafting in these cases, it is
impossible to restore the normal nasal contour.
• Early intervention is extremely important as
reconstruction in the later post-operative period is
a very difficult task

35. • Reapposition of soft tissues is the final and the most difficult stage of NOE fracture
treatment.
• There is no other facial zone where both alignment of bones and covering tissues
plays such an important role.
• It is where cicatricial contraction may nullify a surgeon’s best efforts to restore the
original contour of the NOE region
• Even if the bone fragments have been perfectly aligned, cicatrization in the
canthal tendon area may pull the skin off the bone and create an impression of
telecanthus

36. LATE RECONSTRUCTION OFTHE NOE REGION
• Late reconstruction of the NOE region is possible only on condition that blood
supply and lymph drainage are restored.
1. Mobilization of soft tissues by separating them from the periosteum. Aside from
the already mentioned incisions, other ones can also be used (e.g.,Y-U- and Z-
shaped); the choice is defined by the type of cicatricial deformity of the NOE
region.
2. Restoration of osseous structures . Osteotomy is typically accompanied by
elements of autografting and contour osteoplasty.
3. Restoration of the shape of the palpebral fi ssure and location of the palpebral
commissure require overcorrection in the course of repositioning of the central
fragments combined with transnasal canthopexy.
4. Reapposition of soft tissues requires the surgical removal of subcutaneous scar
tissue in order to make the skin thinner, fixing it, and using soft compression
pads.

37. LACRIMAL OUTFLOW PATHOLOGY
• Epiphora occurring in the acute trauma period can be a result of rupture of lacrimal
pathways caused by the trauma or more often by obstruction of the bone segment of
the nasolacrimal duct by dislocated fragments.
• In the late post trauma period, one of the possible reasons for epiphora is cicatricial
eversion of the lacrimal punctum and or cicatricial ectropion.
• The treatment technique depends on the reason for the epiphora.
• In the acute trauma period , lacrimal pathways pathology is handled only when it is
evident that those structures are injured. Primary surgical management of injuries of
the lacrimal ducts or lacrimal sac is performed according to the conventional methods.

38. • Because one third of patients who have post-trauma epiphora recover
spontaneously, if there is no clear indication of injury to the lacrimal pathway,
surgery can be delayed for 3–5 months. Such wait-and-see policy is especially
reasonable after early repositioning and rigid fixation of a NOE fracture, because
the risk of lacrimal pathway obstruction is only 5 %.
• Untreated fractures are associated with epiphora in 90 % of cases, and closed
repositioning and external compression of bone fragments that have not aligned
properly have a rate as high as 60 %.
• Delayed surgical treatment of a NOE fracture or late reconstruction of this region
leaves the lacrimal pathways little chance to recover patency

39. • Tear overfl ow persisting for 3–5 months is a signal to perform X-ray examination of the lacrimal
pathways, which usually reveals an obstruction of the nasolacrimal duct.The operation of choice is
classic external dacryocystorhinostomy, which is successful in 94 % of cases.
• SURGICALTREATMENT FORTHETELECANTHUSASSOCIATEDWITH CHRONIC DACRYOCYSTITIS:
• Single-stage intervention is technically difficult.
• Dacryocystorhinostomy performed as the first stage poses a risk of obstruction of the anastomosis in
the course of subsequent correction of telecanthus.
• Canthoplasty with subsequent external dacryocystorhinostomy appears to be the optimal variant,
although the transcutaneous approach to the lacrimal sac may worsen the aesthetic outcome
achieved at the previous treatment stage