Everything about NOE Fractures... :) by - Dr.Anchal Agarwal (Resident -Dept of Oral & Maxillofacial Surgery)

1. Nasoethmoidal Fractures
By – Dr. Anchal Agarwal
Guided by –
Dr. Rajanikanth Sir

2. Contents
• Anatomy of Ethmoid Bone
• Incidences
• Classification
• Clinical Features
• Investigations
• Management

3. NOE - Anatomy

4. Ethmoid Bone
• It is an unpaired bone in the skull
• Separates – Nasal cavity - from – Brain
• Located –
• - Roof of nose
• Between two orbits
• One of the bones that make up the orbit of the eye
• Ethmoid Bone has 3 parts –
1) Cribriform plate
2) Ethmoidal Labryinth
3) Perpendicular plate

6. • Articulations :
• 2 bones of Neurocranium – FRONTAL & SPHENOID
• 11 bones of Viscerocranium –
- 2 Nasal Bones
- 2 Maxilla
- 2 Lacrimals
- 2 Palatines
- 2 Inferior Nasal Conchae
- 2 Vomer

8. • Ethmoidal bone has various processes :
- Lamina papyracea - forms – medial wall of Orbit
- Behind it – Ethmoidal Air cells
- Cribriform Plate - forms – Floor of the Anterior Cranial Fossa.
- Perpendicular plate forms - the superior part of the nasal septum
and
- superiorly projects into the Anterior Cranial Fossa - Crista Galli - to
which the dura is attached
• Cribriform Plate transmits – Emissary Veins & Olfactory Nerves

11. Anatomy of Nasoethmoidal region

13. Ethmoid sinus

14. Frontal Bone and Frontal Sinus
showing relation of
Nasofrontal duct and nose

16. Anatomy of NOE Region

19. Soft Tissue Anatomy
• Medial Canthal Ligament
• Lacrimal Drainage Apparatus
• Associated vessels

20. Medical Canthal Tendon
Arises from –
• Anterior and Posterior lacrimal crest and
• Frontal process of Maxilla
Surrounds the Lacrimal Sac & diverges to become the –
• Orbicularis Occuli muscle,
• Tarsal Plate
• Suspensory Ligament of eyelids

21. Medical Canthal Tendon
• Tendon Splits around the
lacrimal sac & attaches to
- Anterior & Posterior lacrimal
crests, &
- Frontal process of Maxilla
• Canthal Tendon diverges to
become –
- Pre tarsal
- Pre septal
- Orbicularis Oculi muscle

22. MCT acts as a suspensory Sling for the Globe – Maintaining its support along the
lateral canthal tendon

24. Lacrimal System

25. Nasolacrimal System

26. Incidence
• Fracture of NOE – Infrequent – 2-15% of all facial fractures
• More Victims are Male – 66-91% cases
• & Young – 20-30 yrs of age
• Most fractures occur due to Motor Vehicle accidents (44-85%)
cases
• NOE fractures can occur in isolation
• Mostly occurs – in association with Midface fractures
• 60% patients with NOE fractures have ---- Associated Nonfacial
injuries

27. • Nasoethmoid Fractures – results from – Forceful Blow to the centre
of the face
• Fracture of nasal bone can occur in isolation or
• Maybe accompanied with fractures of Ethmoidal bone , Frontal
Process of Maxilla , and Lacrimal bone
• Complex Injuries involving these bones – termed – Nasoethmoidal
Complex Injuries

28. CLASSIFICATION OF NOE

29. Ayliff classification
• Type I: En bloc with minimum displacement.
• Type II: En bloc displaced # with large pneumatized sinus and
minimum fragmentation.
• Type III: Comminuted # with inatct MCT attached to large bone.
• Type IV:comminuted # with free MCT attached to boe not large
enough for plating.
• Type V:Gross comminution needing grafting.

30. Yaremchuk classification
• 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 cculo-orbital displacement
IV B: with orbital dystopia
• Type V: NOE with bone loss

31. Stranc and Robertson
classification(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
trangress the orbital rim.
• Plane III:Injuries are more serious involve orbital and
possibly intracranial structures.

32. Markhowitz classification:
• TYPE I: Involves single segment central fragment fractures.
• TYPE II: Comminuted central fragment with fracture lines
remaining peripheral to the MCT insertion.
• TYPE III: Comminuted central fragment with fracture lines
extending beneath the MCT insertion.

34. Classification of NOE Fractures

35. TYPE I FRACTURE
• In this simplest form,NOE fractures are isolated involving
only the portion of the medial orbital rim that contains
medial canthal tendon.
• Type I pattern consists of single central fragment bearing the
medial canthus.

36. • These fractures maybe bilateral ,complete or displaced.
• Uncommonly ,the medial canthal tendon is torn or avulsed
completely from an intact medial bony wall.

37. In unilateral Markowitz type I fractures, there is a single large NOE fragment
bearing the medial canthal tendon.

38. Involvement of the nasal bone: the nasal bone may also be involved and, in cases
of comminution, may not provide adequate dorsal support to the nasal bridge.

39. TYPE II FRACTURE
• Type II fractures are complete and maybe unilateral or
bilateral.
• They may be single segment or communited external to the
medial canthal insertion in the central segment.
• MCT maintains continuity with large fractured segment of
bone,which maybe used in the surgical reduction.

40. In unilateral type II fractures, 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.

41. The nasal bone may also be involved and, in cases of comminution, may not provide adequate
dorsal support to the nasal bridge.
Involvement of the nasal bone

42. The illustration shows a bilateral NOE type II fracture. In bilateral fractures the nasal bones
are commonly involved. In some instances, bone grafting of the nasal dorsum may be
necessary.
Bilateral type II fracture with nasal bone involvement

43. TYPE III FRACTURE
• Communition within the central fragment allows fracture to
extend beneath the canthal insertion characterising the type III
fracture pattern.
• The canthus is rarely avulsed but it is to bone fragments that are
too small to utilize in reconstruction.

44. In type III fractures, there is often comminution of the NOE area (as in type II fractures) and a
detachment of the medial canthal tendon from the bone.

45. The nasal bones are usually involved and might not provide adequate dorsal support to
the nasal bridge. In such cases bone graft reconstruction often is indicated.
Involvement of nasal bone

46. The illustration shows a bilateral NOE type III fracture. The nasal bones are
usually involved. Bone graft of the nasal dorsum is usually necessary.
Bilateral type III fracture with nasal bone involvement

47. Buttresses– Nasomaxillarybuttress

48. Rowe & William Classification
• I] Isolated Nosoethmoid and frontal region injury – without
other fractures of the mid-face
• A) Bilateral
• B) Unilateral
• II ] Combined nasoethmoid and frontal region injury – with
other fractures of the mid-face
• A) Bilateral
• B) Unilateral

49. Clinical features – Based on Classification

50. Isolated Bilateral NOE injury
• Central midface injury resulting from Direct blow over Bridge of
nose --- may occur without associated facial fractures
• Clinically :
• Nasal Deformity – Base of nose  driven backwards into 
Interorbital space & beneath Cribriform plate of Ethmoid
• Nasal Tip – upturned
• Stretching of Philtrum of Upper lip
• Deep Transverse Cleft at the Base of the nose
• Actual Increase in Intercanthal distance - may not be
demonstrable  Actual detachment may not have occurred

51. • Posterior displacement of Canthus –
- Tension of adjacent skin
- Accentuation of Nasojugal Skin Fold
- CSF Rhinorrhoea – should be assumed has occurred (even if it is
not clinically manifest )

52. IB) Isolated Unilateral NOE Injury
• Often misdiagnosed as – Nasal fractures and treated.  results in
Relapse – due to instability created by associated fracture of
underlying Ethmoid Bone
• Clinical Presentation -
• Unilateral Nasal Deformity
IIB) Combined Unilateral NOE Injury
- Frequently combined with Severe comminution of Orbit & ZMC
- Unilateral displacement of Medial Canthal Ligament – severe (maybe
associated with detachment of underlying bone)
- Antimongoloid Slant to the Palpebral Fissure – associated ZMC –
Downward & Lateral displacement of eye

53. IIB) Combined Bilateral NOE
• When NOE combined with
- Midface fractures at Le Fort II & III level
• ‘Long Face Syndrome’ – Gross separation of base of nose from
glabella & at FZ suture (Following lefort II & III)
• Traumatic Telecanthus – Maybe overlooked – due to
characteristic – ‘Elongation of both Mid Face & Nose’

54. Clinical Features
NOSE
• Open Book Deformity – flattening of nasal bridge
• Epistaxis – Hemorrhage due to rupture of Anterior and posterior
branches of Ethmoidal Artery
• Tenderness , Crepitus over nasal bone
• Deviated Nasal Septum
• Anosmia
• CSF Rhinorrhea
EYE
• Almond Shaped Palpebral Fissure
• Diplopia
• Meningitis
• Traumatic telecanthus
• Increased Canthal Angle
• Blindness

56. Intercanthal Distance

57. Intercanthal Distance

58. Clinical Features
Clinical Features
• Anosmia – Trauma to Olfactory Nerve – Direct extension of Gray
Matter --- Lacks Regenerative potential
• CSF Rhinorrhea
• Almond Shaped Palpabral fissure – Rounding of the Medial
Canthus – Fracture of Frontal Process of Maxilla – Detachment of
Medial Canthal Ligament.
• Meningitis. - Ethmoidal Air Cells -- normally not exposed to
External environment.
- In event of fracture -- they get exposed and infected
- Infection can pass in a retrograde manner in the cranial cavity
through the veins --- resulting in the intracranial infections ----

59. Ethmoid Air cells

60. EXAMINATION
• Mobility of the nasal bones
• Traumatic Telecanthus
• Wide and flattened nasal dorsum
• Upturned nasal tip
• From 1 hour to 5 days – there maybe enough edema to hide the
contour depression
• Palpation may reveal – Crepitation and tenderness over the
fracture site

61. Tests for CSF leakage
• Halo Test
• Tram line
• Tilt test
• B-transferrin
• Glucose and chloride

62. CSF Leakage
• Fractures involving the Frontal sinus or Cribriform plate may cause – CSF
Leakage
• Confirmation of presence of CSF – made by – collecting this fluid and
comparing its concentration of GLUCOSE & CHLORIDE with patient’s
serum concentration
• As little as 0.1ml of fluid is needed to determine the concentrations of
Glucose and chloride
• Chloride concentrations – greater (in collected specimen) than serum
• Glucose concentrations – Lesser (in collected specimen) than serum
• Collected fluid can also be tested for B2-transferrin – if positive confirms
presence of CSF

63. Halo test – CSF Leakage

64. • Bloody rhinorrhea suspicious for CSF can be
placed on filter paper and observed for a halo
sign.
• If CSF is present ,it diffuses faster than blood
and results in a clear halo around the central
stain.
• Routine chemistry analysis of the rhinorrhea
may reveal an elevated glucose content
consistent with CSF.

65. Distinguish 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
attachement and necessity for open reduction
• Bowstring Test –
• Pull the lids laterally while palpating the tendon area to detect
movement of fractured segments

66. Examination

67. Bow String Test

68. • FURNESS TEST –
• Grasping skin overlying the medial canthus with a small-tissue-
forceps
• A lack of creasing or resistance by underlying bone is indicative
– of an underlying fracture

69. Imaging
• In Past :
• Water’s Projection
• Reverse Towne’s Projection
• Lateral Skull Films
• Laminar Tomograms
• Todays :
• CT Scan – gold standard
• High degree of detail required for imaging NOE fractures –
necessitates – AXIAL & CORONAL view – slice thickness – 1.0
or 1.5mm

71. Management

72. Sequencing naso-orbito-ethmoidal fractures Edward Ellis 1993
• Eight steps in treatment:
• Step I—exposure through existing laceration, open sky and/or W incision,
coronal + lower eyelid.
• Step II—identify the medial canthal tendon/ tendon bearing bone
• Step III- reduce/reconstruct the medial orbital rim. Atleast one hole is
drilled posterior to lacrimal fossa to prevent lateral splaying of posterior
portion of bone fragment, which can result in telecanthus. Other wire
superior to lacrimal fossa. 2–4 mm diameter hole so that ligament is
pulled in the hole canthal bearing bone fixed first.
• Step IV—reconstruction of medial orbital wall with bone graft (rib,
cranial bone)
• Step V—transnasal canthopexy
• Step VI—reduce septal fracture/displacement (upwards, anteriorly)
• Step VII—nasal dorsum reconstruction/augmentation
• Step VIII—soft tissue readaptation, nasal split

73. PapadopoulosH.ManagementofNaso-Orbital-EthmoidalFractures. Oral
MaxillofacialSurgClinNAm21(2009)221–225
• Before 1960, the treatment of NOE fractures generally involved –
- Closed reduction with external plates and splint fixation techniques.
• The most important advancement in the treatment of such fractures
came in 1964, when both Mustarde and Dingman demonstrated -
superior results with open reduction and internal fixation using
interfragmental wiring.
• In 1970, Stranc highlighted –
- incidence of the medial canthal tendon avulsion and advocated
- exploration through existing lacerations or local incisions and
- treatment with anterior transnasal wires.
• Current treatment modalities both combine and extend these previous
contributions.

74. • Early Versus Late Management
• Although there is no absolute consensus in literature as to - how long
one should wait before treating these fractures,
• Some investigators suggested  waiting no more than 2 weeks.
• Waiting longer  increases the likelihood of requiring osteotomies to
properly reduce and fix the fractures.
• Delayed repair is particularly difficult for type III injuries, which
involve the canthal ligaments.
• Once healing and scarring have begun, finding the avulsed medial
canthal ligament becomes more difficult.
• Also, scarring may prevent adequate correction of the Intercanthal
distance, even with proper reduction of the bones.
• Therefore, one should treat these fractures as soon as possible.
• 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.
PapadopoulosH.ManagementofNaso-Orbital-EthmoidalFractures. Oral
MaxillofacialSurgClinNAm21(2009)221–225

75. • Closed Versus Open Reduction
• Proper management of the medial canthal tendon and the
adjacent bones is the lynchpin to obtaining optimal results with
NOE fractures.
• Closed reduction methods performed in the past, including those
involving the use of external splints, have yielded poor esthetic
results.
• Such techniques do not allow for the proper reduction of the
medial canthal bearing segment, leading to posttreatment
telecanthus.
• Closed techniques also do not afford the opportunity to
reestablish nasal projection, leading to posttreatment nasal
deformities.
• Therefore, open techniques are now recognized as the best way
to manage NOE fractures.
PapadopoulosH.ManagementofNaso-Orbital-EthmoidalFractures. Oral
MaxillofacialSurgClinNAm21(2009)221–225

76. Surgical Access
• Existing Laceration
• Coronal Approach – Best appproach (past decade)
• “Open Sky” approach – H shaped scar over the brows
• Midline Verticle incision
• Bilateral Z
• W- shaped
• Gullwing or Spectacle incision

78. Coronal flap
• Advantages :
• Correction of associated frontal sinus fracture.
• Harvesting of calvarial bone graft or primary reconstruction
• Harvesting of pericranial flap of sufficient length for sealing of defects in
the ant.cranial fossa.
• Disadvantage:
• Cannot be used when the skull has been opened up previously for
craniotomies by the neurosurgeons.

84. Intraoperative Evaluation of the
Nasofrontal Duct
• Condition of the frontal sinus floor and the nasofrontal ducts
can be assessed by direct visualization.
• The relative patency of the duct can then be evaluated by
placing an angiocatheter into the nasofrontal duct and
introducing an appropriate fluid medium so that flow can be
assessed.
• A 3.8 cm (1.5 inch) 18-gauge angiocatheter is the best
instrument for this purpose. Patency of the nasofrontal duct
can be confirmed by introducing normal saline and observing
its emergence from beneath the medial turbinate or its
collection in the posterior pharynx

86. Nasofrontal Duct Obstruction
• Condition of the nasofrontal duct - most important factor in maintaining
the health of the frontal sinus.
• This duct permits the exit of mucin, seroma, or hematoma after injury.
• If the duct is injured and obstructed,  sinusitis, meningitis, or
osteomyelitis may develop.
• If the duct is not patent,  thorough removal of every possible remnant
of sinus mucosa is performed by curettage.
• This procedure is followed by removal of additional mucosa from every
cul-de-sac and crevice with a small (no. 8 or larger) diamond bur under
copious amounts of irrigation and with the aid of magnification.
• Any remaining remnants of the nasofrontal duct mucosa are then
inverted into the nose.

87. Sinus Obliteration
• Nasofrontal duct obstruction is necessary to seal off the frontal
sinus from nasal contaminants.
• Sinus obliteration adds one more layer to the seal but also
eliminates the “dead space” or air within the sinus that may permit
fluids to accumulate, thus causing a seroma or a hematoma.
• Furthermore, after cranialization, sinus obliteration cushions and
protects the brain.
• Historically, sinus obliteration has been accomplished in a number
of ways, :
- including inserting no substance or object (theoretically permitting
bone fill after curettage) or hydroxylapatite, glass wool, bone,
cartilage, muscle, absorbable gelatin sponge, absorbable knitted
fabric, acrylic, or fat.
• The use of fat has been reported most frequently, and this method
historically has provided the most desirable results.

88. NOE Reconstruction
• Type I fractures - less difficult to treat
- and can at times be reduced transnasally and
- treated without fixation.
• More often, single-segment NOE fractures are reduced through –
- coronal incision and
- secured at the nasofrontal junction, the maxillary buttress, and the
infraorbital rims.
- Markowitz type II or higher.
• Transnasal wiring is recommended for fractures graded as
• Although we are truly in an era of rigid fixation (bone plates and screws),
complete reduction of the NOE area and reattachment of the MCT, or
replacement of a small bone segment, seem never to be adequate with
microplates alone.
• For NOE fractures including avulsion of the MCT or in which the MCT is
attached to a small bone segment, transnasal wiring should be
considered.

89. • The point of fixation of the wires should be directed :
- posterior and superior to the lacrimal fossa so that
- the medial canthal distance is decreased and
- widening of the nasal bones and blunting of the medial canthal area
can be avoided.
• Wires must be passed through the medial orbital bone and the
superior nasal septum or the perpendicular plate of the ethmoid.
• Their passage can be facilitated with the use of a spinal needle or a
wire-passing awl.
• Drill holes can also be used to aid in wire passing.

90. • The MCT and its bony segment can be incorporated into the
transnasal wire fixation, or
• an avulsed MCT can be attached to the transnasal wire with sutures.
• Slight overcorrection of the medial canthal distance is desired.
• In cases in which fracture comminution prevents adequate fixation
of the MCT to a bone segment, stabilization with fixation to a
calvarial bone graft has been advocated.
• In cases in which sufficient medial orbital wall remains, placing a
microplate and screw for attaching the MCT behind the lacrimal
crest has been suggested.
• Bone grafting may often be necessary in cases of severe
comminution of the nasal bones or the medial orbital walls.
• Onlay of cranial bone grafts to maintain dorsal height and nasal tip
projection can be performed through a coronal incision, and these
grafts can be fixated rigidly or with wire.

91. GRAFTINGTHE NASAL DORSUM

92. Transnasal Canthopexy wire

93. • Transanasal Canthopexy wire is requires  to secure  Medial
Canthal Tendon
• Technique to assure the position of the Medical Canthal Tendon
is necessary
• 4th plate is utilized to hold the Medial Canthus in proper posterior
and horizontal position (3dimensionally)
• Achieved using Anchor Technique – With or Without barb

95. Identifying the medial canthus
• First step in Canthopexy is
identifying the Medial Canthus
• BY Forceps , through Coronal
or Extended glabellar
approach
• Find and pull on the medial
canthus area to confirm that
the proper structure has been
identified

96. Wire placement into MCT
• Once medial canthus has been found – Transnasal wire is placed
through the medial canthus
• Metal wire with a swedged-on needle that can be detached from
the wire should be used

97. Adapt fourth bone plate and pass wire though
it
• If transnasal wire not in proper 3-D position, plate is needed to
support the transnasal wire.
• Pass the wire through the most posterior hole of the fourth plate
and check for position

98. Create hole for the wire
• Depending on stability of bone in NOE, surgeon may drill hole
from – contralateral side , or
• Use an awl to create passage way
• Extreme caution – not to advance too far , injuring the globe
• Malleable or spoon retractor to protect the globe.

99. Pull the wire throught the hole
• Smaller needle should be used to pass needle through the
ligament to avoid shredding the ligament
• Two ends of the wire are placed through the lumen of the
needle and both the spinal needle and wire are pulled out of
the contralateral side of NOE

100. Alternative – using an Awl
• Awl was first placed through the contralateral side, then
advanced to the side of the NOE Type III fracture
• Wire has been placed through the medial canthus using a
swedged-on needle

101. Fixation of the Fourth plate
• Fourth plate is placed to secure the transnasal wire to its
proper location
• Plate is secured superiorly to the frontal bone

102. Securing Transnasal wire
• Transnasal wire is secured to a screw placed in the frontal
bone. ( on the contralateral side)
• And tightened with appropriate tension needed to secure
the medial canthus into its proper position

103. Alternative technique using wire with
barb

104. Proper position of Transnasal wire
• Upper illustration – wire that has been placed anteriorly,
 resulting in lateral splaying of bone supporting medial
canthus & worsening of the telecanthus

105. Alternative support for Transnasal
canthopexy wire
• Using mesh on one of the two sides to support the
transnasal wire in its proper 3-D location.
• Particularly useful when NOE combined with Medial Orbital
Wall Fracture

106. Post - Op

107. 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

108. • Some surgeons use – Percutaneous bolsters – to
ensure adaptation of the skin to the underlying
bone
• Should be applied with great caution to avoid
underlying skin necrosis

109. Complications
• 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

110. • 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.
• INFECTIOUS COMPLICATIONS - most frequently arise from
- occlusion of the nasofrontal duct or
- contamination of the sinus by penetrating foreign bodies.
• Most frequently encountered infection is – meningitis.
( If nasofrontal duct is occluded  blood may accumulate in sinus,
creating an environment that is conducive to the growth of
anaerobic bacteria.)
• Frontal sinus abscess is spread by  direct extension through
small fractures of frontal bone or
through transosseous anastomotic vessels.
The result is brain abscess, meningitis, cavernous sinus
thrombosis, or (if the abscess is long term) osteomyelitis.

111. • Respiratory mucosa trapped between fracture segments or left behind
during obliteration procedures may continue to grow. This continued
growth may lead to  formation of  mucoceles or pyoceles.
• Pain and headache may be chronic and - may persist without an
identifiable cause.
• Cosmetic deformities such as contour deficits and irregularities stem from
several causes.
• Anosmia—the loss of the sense of smell—and
• Hyposmia are known complications of NOE fractures and
- can occur in as many as 38% of patients with high central midface
fractures.
- In addition, 23% of patients with high midface fractures report a
decreased sense of taste (hypogeusia).
• Complications can occur as late as upto 20 years postoperatively, and
patients should be encouraged to have routine yearly follow-ups.

112. Dacryocystorhinostomy

113. Involvementof Lacrimal Systemin NOE
fractures
• Any injury that involves multiple structures, appropriate
sequencing of the repair is important
• If NOE + Lacrimal disruption
- Reduction of fracture and
- stabilization of Craniofacial Skeleton should precede any
attempt to reconstruct Lacrimal System
• If fracture along the path of the Nasolacrimal Duct –
- Treatment of the fracture
- Stenting of the duct
- Performing Nasolacrimal duct reconstruction (
Dacryocystorhinostomy)

114. • OUTLINE OF METHOD OF TREATING LACRIMAL SYSTEM INJURY IN
PATIENTS WITH NOE FRACTURE
• First Step – Reposition the Medial – Canthal – bearing fragment
• (this will require stabilization with some form of transnasal wiring)
• Reconstruction of lacrimal system can be performed
• It is  Repair of the lacrimal drainage system through  creation
of new “ostomy” or track from  lacrimal canaliculi  to the
nasal cavity.
• TECHNIQUES :
• Open (External)
• Endonasal
• Soft tissue Conjuctivorhinostomy

115. • Proximal portion of the lacrimal system- Inferior and Superior Canaliculi are
identified – by placing lacrimal probes – within the lumen
• Distal segment of the affected canaliculi are identified within the laceration
• 6-0 – slow – absorbing – Monofilament sutures are placed but not tied
superior and inferior to the affected canaliculi
• Probes are then removed

116. • Ritleng Introducer with the Stylette in place – passed into the distal segment – of
laceration
• Advanced parallel to eyelid – through common canaliculus – - until hard stop
encountered
• At this point it is in the Lacrimal Sac –
• Next rotate Ritleng Introducer 90 degree – (Perpendicular to the eyelid) –
Advanced down the nasolacrimal duct

117. • Stylene is removed & Ritleng stent is then advanced
through the Ritleng Introducer into the nose
• Using Ritleng hook, stent is retrieved from the nose

118. • Sutures then tightened and once appropriate
tension has been achieved, knots are tied and the
sutures trimmed

119. • PIC 1. – Knot is then pulled through the upper canaliculus by applying gentle
traction to Silicone tube
• Pic 2. – a Second Knot (B) is tied proximal to First (A) corresponding to level of
Lacrimal sac
• This is typically approx 1.5cm above the position at which the tubes emerge from
the lower and upper punctum
• Second Knot (B) is then positioned in the lacrimal sac by pulling the two ends of
the stent back through the nose
• So that the first knot is again positioned at the level of the nostril

120. • The second knot (B) is positioned
in the lacrimal sac by pulling the
two ends of the stent back
through the nose so that the first
knot is again positioned at the
level of the nostril.
• The stent are then cut just above
the lower knot (A).

122. • Performing A Dacryocystorhinostomy At The Time Of Fracture
Treatment
• Lacrimal dysfunction has not been noted to be a significant problem with
NOE fractures unless treatment is delayed or performed secondarily.
• Interestingly, an increased incidence of lacrimal dysfunction has been
shown with closed techniques compared with open approaches.
• Unless an obvious injury is noted, such as a laceration in the region of
the nasolacrimal apparatus, routine exploration of the apparatus or a
dacryocystorhinostomy is not indicated.
• A dacryocystorhinostomy should not be performed prophylactically as
the incidence of nasolacrimal dysfunction after NOE injury is only 5% to
17.4%.
PapadopoulosH.ManagementofNaso-Orbital-EthmoidalFractures. Oral
MaxillofacialSurgClinNAm21(2009)221–225

123. References :
• Peterson’s Principles of Oral and Maxillofacial Surgery – 2nd
Edition
• Rowe & Williams Maxillofacial Injuries
• Fonseca’s Trauma
• Textbook of Oral & Maxillofacial Surgery by Dr.Rajiv M Borle
• Papadopoulos H . ‘Management of Naso-Orbital-
Ethmoidal Fractures’ . Oral Maxillofacial Surg Clin N Am
21 (2009) 221–225

125. ORIF