This document discusses nasoethmoidal fractures, which involve the nasal and ethmoid bones. It describes the anatomy of the nasoethmoid complex and classifies fractures. Clinical features include nasal deformity, frontal bone depression, cerebrospinal fluid leakage, hemorrhage, and diplopia. Diagnosis involves radiography and CT scans. Treatment involves reducing fractures, repairing dural tears causing CSF leakage, managing hemorrhage through cauterization or packing, and ensuring airway protection.

2. NASO ETHMOIDAL COMPLEX
• Dr V.RAMKUMAR
• CONSULTANT
DENTAL&FACIOM
AXILLARY
SURGEON
• REG NO: 4118-
TAMILNADU-INDIA(
ASIA)

3. Introduction
• Middle third fracture of the face often involves
Nasoethmoid complex. The skeletal foundation of the
Nasoethmoid complex consists of a strong triangular
shaped frame. Fractures in this region are almost invariably
comminuted and involve numerous bones.
• The skeletal structures situated in front of and behind
this frame are relatively fragile and force sufficient to
fracture the frame usually results in severe comminution
and displacement of these thin bones.

4. Nasoethmoid complex

5. Classification
( Nasoethmoid complex )
• Isolated nasoethmoidal injury
– Bilateral
– Unilateral
• Combined Nasoethmoid injury + midface fractures
– Bilateral
– Unilateral

6. Classification:
I: isolated naso- ethmoid and frontal region injury without
other fractures of midface
II: combined naso- ethmoid and frontal region injury with
other fractures of midface

7. Clinical features
• Nasal deformity
• Frontal bone depression
• Cerebrospinal fluid Rhinorrhoea
• Haemorrhage (anterior or posterior branch of ethmoid artery)
• Traumatic Telecanthus
• Diplopia

8. Clinical features

9. Radiograph
• Occipito -frontal view
• Occipito -mental
• Lateral view
• CT

10. SURGICAL APPROACH

11. Nasoethmoid Fracture Emergencies
• Cerebrospinal fluid leak
• Unconsciousness
• Skull fractures
• Increasing intra cranial pressure
• Meningitis
• Persistent CSF leakage

12. CSF leakage
Fracture of
• Floor of anterior cranial fossa/base of skull
Escape of CSF through
• Ethmoidal sinus
• Sphenoidal sinus
• Cribriform plate
• Frontal sinus
Communication between
• Meninges
• Nose
• Paranasal sinuses
Dural laceration
• Later becomes epithelialised - Fistula

13. • CSF leakage should be noted immediately after trauma
• Blood clot of brain tissue may obstruct fluid passage
• After lysis of clot or Increased intracranial pressure
leakage is seen
• Mobile midface fractures often creates pumping action-cause
increased CSF leak

14. In Maxillofacial Injuries
• Higher the level of fractures more chances for CSF
Rhinorrhoea, Otorrhoea
• Frequently missed
– Reclining position
– Blood stained
• Later clean watery discharge

15. How to detect?
• Pt position - Sitting and leans forward (drips from nose)
• Salty / Metallic taste
• “Tram line”
• “Double halo”- when dropped on gauze sponge
• Classical “bull’s eye ” ring will develop
• “Clinistix ” (but colour change can occur with Lacrimal secretions )

16. • “Glucose test” (>30mg/dl)
• Location of leak-CT scan
• Intrathecal injection and assaying in different locations
• Fluorescein & radioactive tracers (Indium)

17. Tram line

18. Precaution
• Pre-nasal route intubation – avoided (but in maxillofacial injury
it is safest & effective)
• Pt in – semi recumbent position
• Should not
– Strain
– Sneeze
– Blow the nose
• Avoid packing nose or ear- prevent retrograde infection
• Infection- Meningitis
• Antibiotics

19. Persistent/ recurrent leak
• Duration 4-5 days (with or without fracture reduction)
• Persistent leaks beyond 3 weeks- need formal dural repair
• Surgical repair failure – Lumbo peritoneal shunting
• Meningitis may occur

20. Treatment
• Fracture reduction
• Dural repair
• Lumbo peritoneal shunting
• Antibiotics

21. Hemorrhage management
• Nasoethmoid fracture with midface bleeding manifest itself as
Epistaxis
• To locate the site of bleeding good visualization is needed
• Mucous membrane should be shrunken & anesthetized with
Phenylephrine hydrochloride (Neo-synephrine) or 4% cocaine
solution or both
• Cotton pledget soaked with vasoconstrictor
• Cauterization with silver nitrate solution

22. • Merocel sponge
• Anterior nasal pack
• Posterior nasal pack
• Pressure balloon
If bleeding not stopped
• Arteriogram
• Embolization or Ligation

23. Airway obstruction
• Patient head is positioned forward to prevent drainage of
blood into pharynx which cause airway embarrassment
• Blood from nose or retropharyngeal hematoma is a
warning of potential airway obstruction

24. Anterior nasal pack
• Starting at junction of floor & septum as far back as
possible and built in layers
• Packs to be removed after 24hrs have elapsed and replaced
with fresh pack if needed to prevent infection

25. Posterior nasal pack
• Use of purpose made Surgitek (Reuter Epi-tek)
• Alternatively with insertion of two Foley catheter one on
either side and inflated

26. Posterior nasal pack

27. Pressure balloon
• Foley catheter
• Silicon dual cuffed catheter (Epistat)
• Double balloon tampon
• Epi-Tek nasal catheter

28. THANK YOU