Nasal-orbital-ethmoid fractures usually result from traumatic force to the midface and nose. They frequently involve multiple bone fractures and can damage surrounding structures like the lacrimal system and dura. Diagnosis involves ophthalmologic and neurological exams along with CT imaging of the face. Treatment may require surgical reduction of fractures and repair of associated injuries.

1. Nasal-Orbital-
Ethmoid (NOE)
Fractures
Dr.Simon Rock
12/28/20
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Dr.Simon Rock

2. Nasal-Orbital-Ethmoid (NOE)
Fractures
 Usually not isolated event
 Frequently associated with
multiple midface fractures
 Secondary to traumatic insult
to radix area of nose
 Low resistance to directional
force
 only 35-80 gm necessary to
produce fracture
12/28/2020 Dr.Simon Rock

3. Naso-Ethmoidal-Orbital
Fracture
 Fractures that extend into the
nose through the ethmoid bones.
 Associated with lacrimal
disruption and dural tears.
 Suspect if there is trauma to the
nose or medial orbit.
 Patients complain of pain on eye
movement.
12/28/2020 Dr.Simon Rock

4. Nasal-Orbital-Ethmoid
Fractures
 Diagnosis
 Ophthalmalogic evaluation
 Document visual acuity
 Pupillary response to light
 Neurologic evaluation
 Frontal lobe contusion
 Glasgow coma scale
 Increase in ICP and need for monitoring
12/28/20
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Dr.Simon Rock

5. Naso-Ethmoidal-Orbital
Fracture
 Clinical findings:
 Flattened nasal bridge or a saddle-shaped deformity of the
nose.
 Widening of the nasal bridge (telecanthus)
 CSF rhinorrhea or epistaxis.
 Tenderness, crepitus, and mobility of the nasal complex.
 Intranasal palpation reveals movement of the medial
canthus.
12/28/20
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Dr.Simon Rock

6. Nasal-Orbital-Ethmoid Fractures
Traumatic telecanthus
 Difficult to measure due to
edema
 Average 33-34 mm
 Can measure interpupillary
distance and divide in half for
approximate intercanthal
distance
 Average 60-65 mm
 Damage to lacrimal
apparatus-epiphora
 CSF leak
12/28/2020 Dr.Simon Rock

7. Nasal Hemorrhage
 Nasal packing
 Merocel sponge
 Nasopharyngeal
balloon
 Epistat
 Foley catheter
12/28/2020 Dr.Simon Rock

8. Nasal-Orbital-Ethmoid
Fractures Lacrimal system injury
 When the medial canthal ligament has been injured or displaced, damage
to the lacrimal system should be assumed
 Nasolacrimal duct is often damaged within its bony course
 Epiphora: Need to evaluate patency of the nasolacrimal system
12/28/20
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Dr.Simon Rock

9. Naso-Ethmoidal-Orbital
Fracture
 Imaging studies:
 Plain radiographs are insensitive.
 CT of the face with coronal cuts through the medial orbits
12/28/20
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Dr.Simon Rock

10. Nasal-Orbital-Ethmoid Fractures
 Radiographic examination
 CT - definitive imaging
modality
 Axial images supplemented
with coronal
 Plain films to fail demonstrate
the degree and location of
fractures secondary to over-
lapping of bony archi- tecture
12/28/2020 Dr.Simon Rock

11. Nasal-Orbital-Ethmoid
Fractures
CT Scans
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Dr.Simon Rock

12. Nasal-Orbital-Ethmoid Fractures
 Surgical considerations
 Definitive surgery as soon
as possible after:
 Appropriate consultations
 Definitive radiographic
imaging
 Significant edema allowed to
resolve
12/28/2020 Dr.Simon Rock

13. Nasal-Orbital-Ethmoid
Fractures
 Surgical considerations
 In panfacial trauma The final phase involves
reduction of the NOE and nasal bone fractures
 Access to NOE through
 existing lacerations,
 bicoronal flap, or
 local incisions
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Dr.Simon Rock

14. Nasal-Orbital-Ethmoid Fractures
Surgical Reduction
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Dr.Simon Rock

15. Nasal-Orbital-Ethmoid Fractures
Surgical Reduction
12/28/20
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Dr.Simon Rock

16. Nasal Fractures
 Most common of all facial fractures.
 Injuries may occur to other surrounding bony structures.
 3 types:
 Depressed
 Laterally displaced
 Nondisplaced
12/28/20
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Dr.Simon Rock

17. Nasal Fractures
 Depression or
angulation
 Periorbital ecchymosis
 Epistaxis
 Tenderness
 Crepitus
 Septal deviation
 Septal hematoma
12/28/2020 Dr.Simon Rock

18. Nasal Fractures
12/28/2020 Dr.Simon Rock

19. Nasal Fractures
 Diagnosis:
 History and physical
exam.
 Lateral nasal view to
confirm your
diagnosis.
12/28/2020 Dr.Simon Rock

20. Nasal Fractures
 Treatment:
 Control epistaxis.
 Drain septal
hematomas.
12/28/2020 Dr.Simon Rock

21. Nasal Fractures
 Treatment
 Restoration of form and
function
 Proper reduction of
nasal fracture
 Plaster splint
 Correction of lacrimal
system injuries
12/28/2020 Dr.Simon Rock

22. Frontal Sinus/ Bone Fractures
Pathophysiology
 Results from a direct blow to the frontal bone with blunt object.
 Associated with:
 Intracranial injuries
 Injuries to the orbital roof
 Dural tears
12/28/20
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Dr.Simon Rock

23. Frontal Sinus/ Bone Fractures
Clinical Findings
 Disruption or
crepitance orbital
rim
 Subcutaneous
emphysema
 Associated with a
laceration
12/28/2020 Dr.Simon Rock

24. Frontal Sinus/ Bone Fractures
Diagnosis
 Radiographs:
 Facial views should
include Waters,
Caldwell and lateral
projections.
 Caldwell view best
evaluates the anterior
wall fractures.
12/28/2020 Dr.Simon Rock

25. Frontal Sinus/ Bone Fractures
Diagnosis
 CT Head with bone
windows:
 Frontal sinus
fractures.
 Orbital rim and
nasoethmoidal
fractures.
12/28/2020 Dr.Simon Rock

26. Frontal Sinus/ Bone Fractures
Treatment Patients with depressed skull fractures
or with posterior wall involvement.
 nuerosurgery consultation.
 Admission.
 IV antibiotics.
 Tetanus.
 Patients with isolated anterior wall
fractures, nondisplaced fractures can
be treated outpatient after
consultation with neurosurgery.
12/28/20
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Dr.Simon Rock

27. Frontal Sinus/ Bone Fractures
Complications Associated with intracranial injuries:
 Orbital roof fractures.
 Dural tears.
 Epidural empyema.
 CSF leaks.
 Meningitis.
12/28/20
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Dr.Simon Rock