The document discusses naso-orbito-ethmoidal (NOE) fractures, their anatomy, classification, diagnosis, and treatment. NOE fractures are a spectrum of injuries involving the nose, orbits, and adjacent structures, and they can lead to various complications, including cerebrospinal fluid leaks and associated non-facial injuries. The document emphasizes the importance of a multidisciplinary approach for diagnosis and management, highlighting both open and closed treatment techniques to ensure effective care.

1. NOE FRACTURES
PRESENTED BY,
DR. BHAVIK MIYANI,
OMFS PG II,
NPDCH, VISNAGAR.
GUIDED BY,
DR. ANIL MANAGUTTI,
DR. SHAILESH MENAT,
DR. RUSHIT PATEL,
DR. JIGAR PATEL.

2. CONTENTS
 Introduction
 Anatomy
 Classification
 Diagnosis :
Clinical examination
Radiological examination
 Treatment
 Complications
 References

3. INTRODUCTION

4.  NOE region is an important area of face – not
only for cosmesis but also in determining facial
projection.
 NOE region relies on a complex inter-
relationship between uniquely specialized soft
tissues and bones formed into buttresses and
thin plates.
Peter Wardbooth

5.  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.
 NOE fractures represent a spectrum of injury , from
simple nasal fractures with minimal ethmoid
involvement to grossly comminuted fractures with
displacement.
Peter Wardbooth

6. NOMENCLATURE
‘fracture of the ethmoids’ Dawson and Fordyce,1953
‘naso-orbital fractures’ Converse and Smith ,1963
‘naso-ethmoid injuries’ Stranc ,1970
‘naso-ethmoido-maxillo-fronto-
orbitaire’complex injuries
Vaillant and Perry,1971
‘orbito-ethmoid’ Jackson,1989
‘upper central face injury’ Bowerman,1992

7. INCIDENCE
 Infrequent : 2-15% of all facial fractures
 According to Fonseca (Cruse et al) , in 182
major facial fractures approx. 18% were NOE
fractures.
 60% patients with NOE fractures have
associated nonfacial injuries
 CNS injury - 51% patients
CSF leak - 42 % cases
 In male – 66-91% cases
 In young – Average : 31 years

8. ANATOMY AND APPLIED ASPECTS

9.  The naso-orbito-ethmoidal region is situated in
the central upper mid face.
 It consists of a strong triangular frame.

10. BONY ANATOMY

11.  4 cavities involved:
 Cranium
 Orbits
 Nasal
 Maxilla
 4 bones involved:
 Paired nasal
 Frontal process of maxilla
 Ethmoids
 Lacrimal bones(Medial orbital rim and wall)

12. Other bones involved:
‒ Perpendicular and cribriform
plate of ethmoid
‒ Nasal process of frontal bone
‒ Sphenoid bone
 Strength :
• Vertical buttress : frontal
process of maxilla
• Horizontal buttress :
superior/inferior orbital rims
 Additional strength:
• Lattice network of bones
• Articulation at various angles.

13. Nasal bone

14. Ethmoid bone

15. Significance of ethmoidal foramina :
 Structure traversing
 Ant. ethmoid art – 24mm
 Post. ethmoid art – 34mm
o Can contribute to Retrobulbar
Hemorrhage
 The safe exploration in superomedial
wall can extend till 30-35 mm.
 A high medial wall exploration places
orbital apex and optic canal at risk.
 The foraminae are at the same level
as optic canal and hence the
exploration should not exceed post
foramina.

16. Medial orbital wall
 Paper thin  lamina papyracea of ethmoid bone
 Traversed by:
• Ant. ethmoid artery and Post. ethmoid artery
 Entrapment of orbital fat medially  horizontal
diplopia – restriction of abduction-retraction of globe

17. Lacrimal fossa :
• Formed by maxillary and lacrimal bones
• Bound by anterior and posterior lacrimal crests.
• 16mm high x 4-9mm wide x 2mm deep
• Mean thickness of lacrimal bone : 106micron  easy perforation
Sutura notha/ Sutura longitudinalis imperfecta of Weber:
• Fine groove on frontal process of maxilla
• Anterior to anterior lacrimal crest
• Contains small branches of infraorbital artery.
• Anticipate their presence during dissection

18. SOFT TISSUE ANATOMY

19. Medial canthal ligament
Lacrimal drainage apparatus
Associated vessels

20. Medial canthal ligament
 MCL Intimately related to :
• Lacrimal drainage apparatus
• Lacrimal bone
• Frontal process of maxilla – reinforces.

21. ANTERIOR LIMB:
 11.7mm length/4.9mm width – longer and more
prominent.
Medial attachment :
 Frontal process of maxilla just lateral to suture with
nasal bone.
 Superior aspect of Ant lacrimal crest and beyond.
Superior branch – periosteum of frontal bone(corrugator
super cilli)

22. POSTERIOR LIMB :
 Small and poorly defined.
 Attaches to posterior lacrimal
crest.
 Periosteum in this region is thicker
and extends till anterior lacrimal
crest in a triangular fashion
 Applied :
• Makes post attachment strong.
• Strengthens the whole structure.
• Hence important to reconstruct.
Both anterior and posterior limbs envelope the lacrimal sac.

23. Other Relations:
 MCL TO ANT. CRANIAL FOSSA :
• Mean vertical dimension between MCL and level of
cribriform plate : 17mm +/- 4mm McCann’1998 Invest Opthal
• Distance between common internal punctum and most
ant. part of cribriform plate is 25mm botek ’93 Opthal Surgery
 MCL AND ANGULAR ART AND VEIN :
• Superficial to MCL
• 5-8mm anteromedial to ant lacrimal crest
• Anticipate bleeding.

24. Lacrimal System

25. BLOOD SUPPLY
 Branches of internal and the external carotid
arteries.
 The anterior and posterior ethmoid arteries descend
from the internal carotid artery.
 The maxillary artery from the external carotid artery

26. NERVE SUPPLY
 Ophthalmic and maxillary nerves, which are
derived from the Trigeminal nerve.

27. CAUSES
 RTA (44-85%)
 Sport injuries
 Fights
 Work related accidents

28. CLASSIFICATION

29. MARKOWITZ BL , MANSON PN , SARGENT L , et al
(1991) :
 These can be unilateral or bilateral injuries.
TYPE I :
There is a single large NOE fragment bearing the medial
canthal tendon.
 The nasal bone may also be involved and, in cases of
comminution,may not provide adequate dorsal support to
the nasal bridge.
Plast Reconstr Surg. 87(5):843-53

30. UNILATERAL TYPE II :
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.
UNILATERAL TYPE II +
INVOLVEMENT OF NASAL
BONE :
The nasal bone may also
be involved and, in cases of
comminution,may not
provide adequate dorsal
support to the nasal bridge.

31. BILATERAL TYPE II
FRACTURE WITH NASAL
BONE INVOLVEMENT :
Bone grafting of the nasal
dorsum may be necessary.
TYPE III :
There is often comminution
of the NOE area (as in type
II fractures) and a
detachment of the medial
canthal tendon from the
bone.

32.  TYPE III WITH
INVOLVEMENT OF NASAL
BONE
 BILATERAL TYPE III WITH
NASAL BONE
INVOLVEMENT

33. AYLIFF’S CLASSIFICATION :
 Type I – en bloc minimum displaced fractures
of the entire NOE complex
 Type II– en bloc displaced fractures, usually
associated with large pneumatized sinus and
minimal fragmentation
 Type III – comminuted fracture but canthal
ligament firmly attached with bone fragments
which are big enough to plate.
TYPE I
TYPE II
TYPE III

34.  Type IV– comminuted fracture with
free canthal ligament not large
enough to be plate.
 Type V – gross comminution needing
bone grafting
TYPE IV
TYPE V

35. STRANC AND ROBERTSON (1979) :
 Plane I:
Injuries do not extend beyond a line joining the lower
end of the nasal bones to the anterior nasal spine.
 Plane II:
Injuries are limited to the external nose and do not
transgress the orbital rim.
 Plane III:
Injuries are more serious involve orbital and possibly
intracranial structures.

36. ROWE AND WILLIAM’S / BOWERMAN ET AL (1985) :
 Isolated naso-ethmoid and frontal region injury without
other fractures of the mid-face
a) Bilateral
b) Unilateral
 Combined naso-ethmoid and frontal region injury with other
fractures of the mid-face
a) Bilateral
b) Unilateral
 This is essentially the same as Manson’s classification in content.

37. YAREMCHUK CLASSIFICATION : /
J.S. GRUSS (1993) :
 Type I: Isolated bony NOE
 Type II: Bony NOE and central maxilla
II A: Central maxilla only
II B: Central and unilateral maxilla.
II C:Central and bilateral maxilla.
 Type III: extended NOE
III A :with craniofacial injuries
IIIB: with LF II and LF III
 Type IV: NOE with orbital displacement
IV A: with occulo-orbital displacement
IV B: with orbital dystopia
 Type V: NOE with bone loss

38. DIAGNOSIS

39. a) Clinical examination
b) Radiological examination
c) Examination of lacrimal system
d) CSF examination

40. INITIAL EVALUATION
 Establish ABCs.
 Diagnose any associated injuries.
 Direct examination of NOE complex.
 A thorough head and neck examination to reveal
injuries to the brain,spine, orbit and facial skeleton
is required.
 Team approach involving the otolaryngologist, plastic
surgeon, neurosurgeon and ophthalmologic
consultation is mandatory.

41. a) Clinical examination :
1) Clinical features
2) Clinical assessment
3) Distinguishing nasal # from NOE #

42. 1) Clinical features
 Associated with the location and severity of the NOE fracture.
GENERAL SIGNS AND SYMPTOMS :
 Gross facial edema may show firstly in the early stage of
fracture, which will result in distortion of soft tissue landmarks
 Laceration in the nose and forehead
 Intracranial involvement
 Eye, forehead, and nose pain
 Forehead paraesthesias
 Traumatic hypertelorism
 Mongoloid slant.

43. Nasal injuries :
 Reduced Dorsal nasal projection , Upturned nasal tip
 Accentuation of Naso-Frontal angle PIG SNOUT
 Inward Telescoping medial wall into ethmoid
 Flattened nasal bridge with splaying of nasal complex
 Saddle shaped deformity of nose from side
 Epistaxis
 Tenderness ,crepitus and mobility of nasal complex
 Reduced nasal projection and height
 Septal deviation or dislocation
 Anosmia caused by damage to the cribiform plate
 Nasal congestion secondary to septal hematoma or bony/cartilaginous deformity
 Nasolacrimal duct obstruction/severage  epiphora
 Nasal airway obstruction

44. Associated ocular injuries :
 Enopthalmos
 Diplopia
 Vertical dystopia
 Loss of globe integrity
 Almond shaped palpebral fissure
 Rounding of medial canthal angle
 Traumatic telecanthus
 Circumorbital oedema and ecchymosis
 Subconjuctival haemorrhage.
 Possible supraorbital/supra trochlear
nerve parasthesia.
 Mongoloid slant

45.  Cerebrospinal fluid leakage
• Subconjuctival
haemorrhage.
• Traumatic
telecanthus
• Circumorbital
oedema and
ecchymosis
• Epistaxis

46. 2) Clinical assessment
 According to Leipsiger and Manson
(1992), when properly performed,
bimanual palpation is the ‘gold
standard’ in evaluating NOE
fractures.
 Firm palpation of ant. Lacrimal
crest and frontal process of maxilla
 Firm compression of MC region to
displace the edema with thumb and
forefinger while displacing lateral
canthus laterally allows palpation of
 Fractured fragment,
 Mobility of MCL attachment
 Mobility of adjacent bone
Principles of management of complex craniofacial trauma; Marciani et al, JOMS ‘93

47. 3) Distinguishing Nasal from NOE fractures
 BIMANUAL EXAMINATION
 Place thumb and index finger over
Medial Canthus bilaterally
 Any Movement implies instability and
requires open reduction and stabilization
 Place instrument (Kelly’s Clamp) high
into the nose , with its tip directly
beneath the MCT
 Gentle lifting with the contralateral
finger palpates the canthal tendons &
allows – assessment of instability of
tendon attachment and necessity for
open reduction

48.  BOWSTRING TEST /
FURNAS TEST / EYELID
TRACTION TEST
 Pull the lids laterally while
palpating the tendon area
to detect movement of
fractured segments.

49. b) Radiographic examination :
 Plain films(conventional – standard PNS view) are of almost
no use in diagnosing NOE fractures because most of # will go
undetected.
 CT :
Is of greatest value.
HRCT adds to the existing value.
Ask for :
1-2 mm axial and coronal slices with 3D recon.
 3D CT :
Help in assessing the severity of the injury but the final
diagnosis requires clinical findings and is usually made
intraoperatively.

50. Tests for Secretory
system
Tests for
Drainage/Excretory system
• Schirmer’s test(basal
tear secretion test)
• Primary dye test
c) Examination of lacrimal system :
• Syringing and probing
• Dye disappearance test
• Jones 1 and Jones 2
• DCG
• HRCT
• Tc 99 scan

51. Tests for Secretory system
 Schirmer’s test (Basal tear secretion test)
 Primary dye test (Jones 1)

52. Tests for Drainage/Excretory system
SYRINGING AND PROBING :

53. DYE DISAPPEARANCE TEST :
Simplest of tests
 2% Fluorescein dye placed on
conjunctival fornix
 Dye disappears.
 System patent

54. JONE’S TEST :
Jone’s 1 :
• 1 drop 2% fluorescein dye placed into conjunctival sac.
• Cotton bud soaked in LA placed in inferior meatus.
• Wait for 5 min and remove the bud.
• If bud stained with dye  test +ve

55. If Negative , then proceed to JONE’S 2 :
Clear saline irrigated through cannula inserted into inf. canaliculus
Patient bends forward
Nothing from nostril
Complete obstr.
distal to tip
Fluid regurgutates –
opp. punctum
Patency of both canaliculi till
int canaliculus
Clear fluid from nose
Dye not entered canaliculi
Blocked
punctum/canaliculi
Stained fluid
+ve test

56. DACROCYSTOGRAPHY :
 Radioactive oilbased dye injected into lacrimal drainage.
 Radiographed to know the course of duct
 CT used for imaging  CT dacrocystography.

57. DACROSCINTIGRAPHY :
• Dacroscintigraphy is done
using radionuclide (Tc-99)
• Mainly used to confirm a
diagnosis of functional
blockage when there is
delayed or no out- flow of
radioactive media in the
presence of a normal DCG.

58. d) CSF examination :
CLINICAL DIAGNOSIS
Reservoir sign
Salty taste
Handkerchief sign
Halo sign/double ring sign
Tramline effect
LABORATORY DIAGNOSIS
Glucose test
Protein analysis
Beta transferrin test
Beta-trace Protein
Electronic nose
High resolution CT
CT cisternography
Radionuclide cisternography
Intrathecal flourescein
MRI cisternography
RADIOGRAPHIC EVALUATION

59. RESERVOIR SIGN
• Simple bed side procedure 
nonspecific.
• Performed upon patient arising in
the morning.
• Place patients chin to chest for
1min.
• Copious leakage through nose like
an open faucet.
CLINICAL DIAGNOSIS :

60.  SALTY TASTE
 HANDKERCHIEF SIGN : mucous stiffens linen on drying but
CSF keeps it soft  distinguishes from allergic rhinitis.
 HALO SIGN / DOUBLE RING SIGN :
• Blood CSF mixture spreads on linen.
• Dark ring of blood encircles more lightly stained CSF

61.  TRAMLINE EFFECT :
• Occurs when CSF mixed with
blood.
• CSF appears later as yellowish
discharge  mixes with blood.
• CSF  higher protein content.
• More viscous CSF forms central
track with blood on either side
which diffuses to edge.

62. LABORATORY DIAGNOSIS :
 Glucose test - >30mg/dl
 Protein analysis
 Beta transferrin test
 Beta-trace Protein
 Electronic nose

63. RADIOGRAPHIC EVALUATION:
 High resolution CT : bone defect is filled with CSF
density fluid extracranially.
 CT cisternography
 Radionuclide cisternography
 Intrathecal flourescein
 MRI cisternography

64. TREATMENT

65.  Better overtreated than undertreated .
 Why overtreat?
Inadequate treatment
Secondary deformities
Missing or displaced bony fragments, soft
tissue retraction, scarring, malposition
Difficult to correct
Ellis E. Sequencing treatment for naso-orbito-ethmoid fractures. Journal of Oral

66. Early Versus Late Management??
• Treatment should begin as soon as the edema
from the initial traumatic event has resolved,
but waiting no later than 10 to 14 days, as long
as the patient is stable enough to undergo the
procedure.
Papadopoulos H . Management of Naso-Orbital-EthmoidalFractures
Oral Maxillofacial SurgClinN Am 21 (2009) 221–225

67. Closed Versus Open Reduction??
 Open techniques are recognized as the
best way to manage NOE fractures.
(given by Mustarde & Dingman in 1964)
Papadopoulos H . Management of Naso-Orbital-EthmoidalFractures
Oral Maxillofacial SurgClinN Am 21 (2009) 221–225

68. GOALS
a) Management of CSF leaks.
b) Management of damage to nasolacrimal
drainage system – dacrocystorhinostomy.
c) Sequencing treatment for naso-orbito
ethmoidal fractures.

69. a) Management of CSF leaks
 Tailored to individual : fracture reduction often stops the leak
 Conservative approach
 Antibiotic prophylaxis
 Surgical repair of dura
o Extracranial - Endoscopic
o Intracranial
• Extradural
• Intradural
• Combination
o Grafts: pericranium, fascia lata, muscle etc.
 Obliteration / Cranialization of frontal sinus

70. b) Management of lacrimal drainage
DACROCYSTORHINOSTOMY (8-18%) :
 Is the repair of the lacrimal drainage system through the
creation of a new “ostomy” or tract from the lacrimal
canaliculi to the nasal cavity.
 Principle: Large nasal osteotomy can allow greater lacrimal
drainage in upright position than will a lacrimal sac with an
interrupted lacrimal pump.
 Techniques:-
 Open (external)
 Endonasal
 Soft tissue conjuctivorhinostomy.

71. 1. Exposure
2. Identify the MCL or the MCL bearing bone.
3. Reduce / reconstruct medial orbital rims
4. Reconstruct medial orbital walls
5. Transnasal canthopexy
6. Reduce septal fracture/displacement
7. Nasal dorsum reconstruction/augmentation
8. Soft tissue re-adaptation/nasal splint
c)

72. 1. Exposure (surgical approaches)
 Existing lacerations
 Bicoronal / coronal incision
 Eyelid incisions
 Vertical/horizontal radix incisions (Stranc ‘70)
 Open sky approach - H shape incision (Converse & Smith ‘80)
 W shape incision (Bowermann ‘75)
 Bilateral Z approach (Dingman ‘60)
 Lynch incision.
 Transcaruncular incision No external scars
 Pre caruncular incision
 Transoral - degloving incision
 Midfacial degloving incision - great access - No scar.

73. Bicoronal /coronal approach
 This approach provides excellent exposure of the
nasal bones with the frontal bone down to the
upper lateral cartilages, with sufficient exposure
for plate and screw application.
 Rarely indicated for isolated fractures limited to
the nasal skeleton.
 Commonly used for fractures extending into the
nasoorbitoethmoidal (NOE), nasofrontal, or frontal
sinus regions.

74. Incision placement with patients with
male patterns of hair recession .the
incision is stripped posteriorly just
above the attachment of helix of ear
.the incision is moved more posteriorly
as required
Incision placement in most females and
male with no family history baldness .
Incision is kept 4cm behind the hair
line

76. VIDEO (Bicoronal flap)

77. Eyelid incisions
D - Transcaruncular approach
E - Lynch approach

78. Vertical incision over the nasal radix
Horizontal radix incision

79. Open sky
approach –
H shape
Two gull
wings
Butterfly - a
combination of
the open sky and
gull wing
Sewall -
Single side
medial orbital
incision

80. Transbuccal/transoral

82. Miniplate or wire osteosynthesis :
 Type I fracture – 3 point stabilization.
 Frontal process of maxilla to Frontal bone
 Nasofrontal junction to nasal complex.
 Nasal complex to maxillary buttress.
 Type II fracture –
 small bony fragments – interosseous wiring
 stabilize them to frontal process of maxilla – this to frontal bone.
 Type III fracture – Interosseous wiring of small fragments – anatomic
reduction, rigid fixation – canthopexy, bone grafting if required.

83. 2. Identify MCL
Capturing/tagging MCL:
 Canthal ligament grasped
with forceps and pierced
with braided 2.0 / 3.0
Mersilene/ethibond.
 MCL pierced again but at 90
degree to previous first pass
 This completely encircles
and secures the tendon.
A.Wire support of avulsed medial canthal tendon
B.Transnasal reduction of medial canthal tendon
with transnasal wire fixation to raise tendon
superiorly and posteriorly

84. 3. Reconstruction Of Medial Orbital Rim
 Most important step in preserving intercanthal
distance.
 Done by : Transnasal wiring of this bone fragment
with 25- or 26-gauge wire.
 Fragment bearing the MCL identified. Loose nasal bones
may be removed temporarily for better access.
 If fragment is large enough, reduce and fix it to
adjacent bone with miniplates

85.  Transnasal wiring for type II & III:
 Drill one hole posterior to lacrimal fossa
to prevent lateral splaying posteriorly
and telecanthus
 Other wire passed superior and posterior
to lacrimal fossa on other side.
 Wires tightened as much as possible to
“overreduce” and narrow the base to
gain the projection.
 Once the canthal-bearing bone has been
reduced with a transnasal wire, other
large fragments are positioned and either
wired or plated in place

86. 4. Reconstruction of medial orbital wall
Importance :
 To regain anatomic morphology
 To regain lost orbital volume
 To achieve normal eye position after injury
 Bone graft of choice for reconstruction : calvarial
graft/rib graft
 Long pieces of bone used and should extend just behind
the medial orbital rim
 Fixed with lag screws or miniplates or wires.

87. 5. Medial Canthal Reconstruction / Medial
canthopexy
A. Transnasal wiring
B. Ipsilateral/homolateral techniques :
 Nylon anchor suture,
 Stainless steel screw,
 Cantilevered miniplate (Y-shaped, five holes),
 Bone anchor systems.

88.  Holes:
 Medial orbital rim , posterior and superior to
posterior lacrimal crest.
 2-4mm diameter.
 Direction of transnasal wire is from high to low
 The essential biomechanical principle is that
although the tightening produces a vertical force,
the MCT moves medially in its prepared area of
attachment.

89.  A contouring burr is used to create a depression in
the frontal process of the maxilla just superior and
posterior to the anterior lacrimal crest to insert the
MCT.
 On the contralateral fronto-glabellar area, a 1.5-mm
hole is drilled and taken through to the depression
created to receive the MCT. A second drill hole is
made 5 mm below the first.
 18-gauge syringe needle is passed through the first
hole to the medial canthal area and the superior
wire is fed through .

90.  This is repeated through the
second hole, and the wire is
tightened until the canthus is
firmly secured.
 This is again inspected from
the skin side to be absolutely
sure of the correct location.
 The twisted wire is clipped
short and tucked close and
tightly to the fronto-glabellar
area .

91. 6.Reduce septal displacement
 Following medial canthal
ligament repair, the nasal
septum is addressed.
 The septum is reduced and
brought into its anatomical
position with ASCHE forceps.
 Using upward and anterior
force with the forceps, and
with digital manipulation on
the external portion of the
nose, the fractured septum
can be guided accurately into
midline position.

92. 7. Nasal dorsum reconstruction
 Telescoping collapse of the nasal
dorsum with direct digital pressure
indicates complete loss of support
and the need for cantilever bone
graft reconstruction
 A split skull bone graft is best used
for this purpose.
 The bone is fixed as a cantilever
graft.
 The bone graft must be of adequate
length to support the nasal dorsum.

93.  If nasal tip support is adequate, the bone
graft extends only as far as the alar
domes.
 If, however, nasal tip support is
inadequate, the graft must span the
distance from the root to the tip of the
nose.
 Stabilization must be adequate and is
achieved by a single miniplate from the
glabella to the dorsal nasal graft.
 Finally, it is imperative that the
nasofrontal angle be maintained and not
obliterated by the bone graft

95. 8. Soft tissue re-adaptation
 Control of soft-tissue redraping is the single most
problematic issue in NOE fracture reconstruction
 Postoperative edema and formation of subperiosteal
seroma or hematoma result in a
• permanent thickening of the soft tissue
• loss of definition in the nasofrontal angle and
nasoorbital valley
• development of epicanthal fullness.

96. External Splint :
• Problem with NOE
fracture – even after
perfect bony reduction –
lack of definition in the
medial canthal area
(Epicanthal fold)
• Placing external nasal
splints at the end of
procedure

97.  PERCUTANEOUS
BOLSTERS – to
ensure adaptation of
the skin to the
underlying bone
Should be applied
with great caution
to avoid underlying
skin necrosis

98. COMPLICATIONS

99.  PRINCIPAL TYPES – those that occur :
- Directly at the time of injury
- Infectious nature
- Chronic problems
 Most devastating – Neuro problems :
- displacement/penetration of frontal bones – into brain
Can Result in : Concussion , Severe Brain injury , Death
 Displacement of frontal bone – Orbital damage
 Most common ocular complication – Diplopia
 Trauma to the floor of the frontal sinus or displacement of the medial
supraorbital rim may cause a CSF leak.
Generally, reduction of the fractures corrects this problem. If it is
persistent,however, neurosurgical repair is indicated.

100.  Retrobulbar haemorrhage
 Superior orbital fissure syndrome
 Orbital apex syndrome-blindness
 Carotid-cavernous fistula

101. RETROBULBAR HAEMORRHAGE :
 Signs-
-Proptosis
- Globe very hard on palpation
- Increased intraocular pressure
-Dilating pupil
-Loss of direct light reflex
-Preservation of consensual light reflex
-Constriction of the retinal arterioles
-Ophthalmoplegia
 Symptoms -
-Pain, diplopia and decreased visual acuity or blindness,
chemosis

102. Clinical features :
1. Loss of sensation over forehead
2. Edema of the periorbital regions
3. Proptosis
4. Dilation of pupils
5. Ptosis
6. Opthalmoplegia
7. Loss of corneal reflex
8. Loss of direct light reflex
9. Presence of consensual reflex
SUPERIOR ORBITAL FISSURE SYNDROME

103. ORBITAL APEX SYNDROME
 Combination of superior orbital fissure syndrome
and optic nerve injury
 Etiology: bony compression of optic nerve and
superior orbital fissure
 Symptoms: loss of direct light reflex
• fundoscopic changes -- pallor of disk
• maintenance of consensual reflex

104. CAROTID-CAVERNOUS FISTULA
 Injury extends to cause cranial base fracture
 Tears carotid artery -- arterio-venous fistula
 Clinical features :
• pulsating exopthalmos
• sub-conjunctival ecchymosis
• dilated pupil
• visual acuity decreased
• diplopia
• machinery murmur frontal region

105. References
 Fonseca – Trauma vol 2
 OMFS Fonseca – vol 3
 Trauma and Esthetic reconstruction – Peter Ward Booth
 Surgical approaches to facial skeleton – Edward Ellis
 Rowe and William’s Maxillofacial Injuries – Vol 2 -3rd edition
 Oral & Maxillofacial Surgery Clinics of North America – Orbital
Trauma
 Text book of oral and maxillofacial surgery R M BORLE