Dr. Mohamed El Sayed

2. Management ofManagement of
NasoOrbitoEthmoidNasoOrbitoEthmoid
complex fracturescomplex fractures
((NOENOE((

3. IntroductionIntroduction

4. -The NOE complex is the confluence of frontal sinus,
ethmoid sinuses, anterior cranial fossa, orbits, frontal
bone and nasal bones.
-The intricate anatomy of this area makes NOE one of the
most challenging areas of facial reconstruction.
-Inadequately repaired NOE fracture often result in
secondary deformities that are extremly difficult or
impossible to correct
….Blindness …Telecanthus
….Enophthalmos …Midface retrusion
….CSF fistula …Anosmia
….Epiphora …Sinusitis
….Nasal deformity

5. AnatomyAnatomy

6. BonesBones -The NOE complex represents the confluence of nasal,
lacrimal, ethmoid, maxillary and frontal bones.
-The paired nasal bones attach to the frontal bone
superiorly and to the frontal process of maxilla
laterally.
-The ethmoid bone is located posterior to the nasal
bones.
-The ethmoid labyrinth separates the orbites from the
nasal cavity, while the fovea ethmoidalis forms the
roof of ethmoid sinus laterally.
-The cribriform plate is located approximately 1cm
inferior to the fovea ethmoidalis, and it forms the
roof of nasal cavity medially..

8. ButtressesButtresses
-The primary vertical buttress of NOE complex run
from the frontal bone through the medial orbital
region and into the frontal process of maxillary
bone.
-The primary horizontal buttresses are the superior
and inferior orbital rims

9. Medial canthal tendonMedial canthal tendon-Arises from the anterior and
posterior lacrimal crists and
the frontal process of
maxilla.
-It surrounds the lacrimal sac
and diverges to become the
orbicularis oculi muscle,
tarsal plate and suspensory
ligaments of eyelids.

10. -Normal intercanthal
distance is
approximately 30-
35mm. Anatomically,
this distance equates to
one half of
interpupillary distance
or equal to the width of
alar base.

11. Lacrimal apparatusLacrimal apparatus
-Lacrimal drainage system is intimately related to NOE
region.
-The system removes any excess tears that accumulate after
lubrication of the surface of the globe.
-The superior and inferior lacrimal canaliculi drain the
lacrimal lake.
-The puncta of canaliculi open just lateral to lacrimal lake and
are surrounded by Horner’s muscle.
-The two canaliculi pierce the lacrimal fascia and enter the
lacrimal sac which lies in a fossa on the anteromedial wall
of bony orbit.
-The sac continues inferiorly into the nasolacrimal duct ,
which is housed in a bony canal.
-The duct empties into the inferior meatus in the nasal cavity.

12. PatientPatient
EvaluationEvaluation

13. Clinical findingsClinical findings
-Nasal and forehead swelling or
lacerations
-Edema and ecchymosis of eyelids
-Subconjunctival hemorrhage
-Eye, forehead, and nose pain
-Forehead paraesthesias
-Diplopia
-Traumatic Telecanthus
-CSF rhinorrhea
-Wide and flattened nasal dorsum
-Upturned nasal tip
-Enophthalmos

14. ExaminationExamination
-Examine the nasal cavity for presence of CSF.
-Query all conscious patients about the presence of watery
rhinorrhea or salty postnasal drainage.
-Test bloody fluid that is suspicious for CSF rhinorrhea.
-Examine facial lacerations under sterile conditions to assess
depth of penetration or intracranial violation.
-Measure and document telecanthus and enophthalmos
-Assess and document pupil responses and extraocular
muscle mobility
-Palpate the nasal bones for crepitus and comminution
-Evaluate the septum for septal hematoma
-Evaluate the degree of nasal or midface retrusion

15. --Evaluate the integrity of MCTEvaluate the integrity of MCT::
-))11((Bowstring test:Bowstring test: involves pulling the lid laterally
while palpating the tendon area to detect movement of
fractured segments, a lack of resistance by the
underlying bone is indicative of an underlying fracture.
))22((Bimanual examination:Bimanual examination: requires placing Kelly clamp
high into the nose with its tip directly beneath MCT
gentle lifting with the contralateral finger palpates the
canthal tendon allows an assessment of the instability of
tendon attachment.

17. Radiographical ExaminationRadiographical Examination
-Computed tomography CT scans
are the gold standard for imaging
NOE fractures.
-Axial and coronal views with slice
thickness of 1 or 1.5 mm.
-For severe fractures of NOE two-
and three –dimensional CT
scans provide the most
information about the medial
orbital wall, medial maxillary
buttress and the piriform
aperture.

18. FractureFracture
ClassificationClassification

19. --Unilateral or bilateral
--Open or closed
--Markowitz classificationMarkowitz classification::
Type I :Type I : a single noncomminuted
central fragment without MCT
disruption.
Type II :Type II : involve comminution of
central fragment but MCT
remains firmly attached to a
definable segment of bone..
Type III :Type III : uncommon and result in
severe central fragment
comminution with disruption of
MCT insertion.

20. TreatmentTreatment

21. -General goals of surgical treatment of NOE fracture include
protection of orbital and intracranial contents, prevention
of early and late complications and restoration of aesthetic
facial contour ( normal intercanthal distance , orbital
volume(.
Surgical ExposureSurgical Exposure::
Coronal incisionCoronal incision::
-It exposes frontal bone , nasal bones , superior orbital rims ,
orbital roof and frontomaxillary buttress.
-Scalp is incised and elevated in a subperiosteal plane.
-Lateral flap dissection is performed between superfacial
temporal fascia and deep temporal fascia
-Superfacial temporal fascia and frontal branch of facial
nerve are elevated with the flap
-The supratrochlear and supraorbital neurovascular pedicles
are identified and protected and released by outfracturing
in the inferior portion of foramina with a fine osteotome

22. Subciliary incisionSubciliary incision::
-Exposes inferior orbital rim , orbital floor , a portion of
medial orbital wall , frontomaxillary buttress and lateral
nasal bones
-Is placed parallel to and 2mm below the lash line and
extends from medial lash margin to lateral canthus
Transconjunctival incisionTransconjunctival incision::
--Eliminates external scar and reduces the risk of
postoperative ectropion
Sublabial incision:
-Provides exposure of piriform aperature , face of maxilla
and frontomaxillary buttress
Canthal stab incisionCanthal stab incision::
-Allows identification of severed medial canthal tendon

23. FractureFracture
RepairRepair

24. Type I fractureType I fracture::
-Nondisplaced single fragment injuries do not require
surgical repair.
-Two separate microplates (1-1.2mm) are applied from the
frontal bone to the central fragment and from maxilla to
the central fragment..
Type II fractureType II fracture::
-Comminuted fractures need more extensive surgical
exposure, microplate reduction and transnasal wiring.
-Holes are drilled in central fragment above and below
MCT, 28-guage stainless steel wire is passed lateral to
medial through the central fragment and twisted tightly on
the medial aspect of central fragment

25. -Separate holes are drilled through the
medial orbital wall posterior and
superior to lacrimal fossa.
-Exit holes are drilled on the
contralateral side.
-A large spinal needle is passed through
the holes toward NOE injury. The
transnasal wires are passed through
the lumen of needle and the needle is
extracted , the wires are secured to a
microscrew or plate on the
contralateral superior orbital rim.
-Micro plates are applied to rigidly
fixate the central fragment to stable
medial orbital bone.

26. Type III fractureType III fracture::
-May require primary bone grafting
-If frank nasolacrimal injury is present, the
nasolacrimal apparatus should be
cannulated and stented.
-If the central fragment can not be
identified or reconstituted with a suitable
bone fragment in the surgical field
(ethmoid or maxillary bone) an outer
table clavarial bone graft can be used.
-Microplates are applied to rigidly fixate
the central fragment to stable medial
orbital bone.
-In case of significant loss of nasal
projection, a clavarial bone graft is
harvested to reconstruct the nasal
dorsum, the graft is cantilevered off the
frontal bone with a miniplate or with
two position screws

27. A) Diagram illustrates a
bilateral comminuated NOE
fracture.
B) Close-up showing reduction
of central bone fragments and
stabilization with wires.
Comminuated midline nasal
bone fragments have been
temporarily removed
providing exposure to nasal
side of medial orbital wall
fractures. Two circular
transnasal wires are used: 1)
one posterior and superior to
the tendon insertion, and 2)
one anterior and inferior to the
tendon insertion.
C) Superior and inferior
orbital rim fragments are
reduced and stabilized with
miniplates as illustrated.
D) Nasal bones are frequently
reconstructed with a cantilever
bone graft secured with llag
screws or a miniplate.

28. Fellow -Fellow - UpUp

29. Routine fellow- up care is performedRoutine fellow- up care is performed
postoperatively at 2 weeks, 1 month , 3postoperatively at 2 weeks, 1 month , 3
months and 6 months and then as needed ifmonths and 6 months and then as needed if
revision procedures are necessaryrevision procedures are necessary

30. Thank youThank you

31. Dr. Mohamad El SayedDr. Mohamad El Sayed
Maxillofacial ConsultantMaxillofacial Consultant
20172017