You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > TRAUMA Nasoorbitoethmoid FracturesArticle Last Updated: Apr 30, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: E Bradley Strong, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California at Davis E Bradley Strong is a member of the following medical societies: Alpha Omega Alpha and American Rhinologic Society Editors: Jack A Coleman, MD, Assistant Clinical Professor, Department of Otolaryngology, Middle Tennessee Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nasoorbitoethmoid fractures, nasoorbitoethmoid complex, NOE, nasoethmoid complex fractures, nasoethmoid fractures, NOE injury, facial injury, panfacial fracture, ethmoid complex, cerebrospinal fluid, CSF, medial canthal tendon, MCT, frontal sinus, ethmoid sinuses, anterior cranial fossa, orbits, frontal bone, nasal bones INTRODUCTIONSection 2 of 10
  The nasoorbitoethmoid (NOE) complex is the confluence of the frontal sinus, ethmoid sinuses, anterior cranial fossa, orbits, frontal bone, and nasal bones. The intricate anatomy of this area makes NOE injuries one of the most challenging areas of facial reconstruction. Inadequately repaired NOE fractures often result in secondary deformities that are extremely difficult (or impossible) to correct. Long-term sequelae of NOE fractures include blindness, telecanthus, enophthalmos, midface retrusion, cerebral spinal fluid (CSF) fistula, anosmia, epiphora, sinusitis, and nasal deformity. Accurate diagnosis and prompt surgical treatment of NOE fractures are critical to avoid complications and to obtain an aesthetic surgical result. PathophysiologyIf the primary buttresses of the NOE complex are violated, comminution of the entire complex may occur. This may result in telecanthus, enophthalmos, diplopia, and apparent midface retrusion. Isolated medial canthal tendon disruption releases the normal tension on the medial canthus, resulting in telecanthus. Disruption of the anterior cranial fossa may result in a CSF fistula, while disruption of the ethmoid complex and nasofrontal recess (NFR) may result in sinusitis. ClinicalPatients with NOE fractures often have associated facial injuries or panfacial fractures.
RELEVANT ANATOMYSection 3 of 10
The NOE complex represents the confluence of the nasal, lacrimal, ethmoid, maxillary, and frontal bones. The paired nasal bones attach to the frontal bone superiorly and to the frontal process of the maxilla laterally. The ethmoid bone is located posterior to the nasal bones (see Image 1). The ethmoid air cells are present at birth and enlarge to adult size by age 12 years. The overall growth and size of the ethmoid complex is highly variable among individuals. The ethmoid labyrinth separates the orbits from the nasal cavity, while the fovea ethmoidalis forms the roof of the ethmoid sinuses laterally. The cribriform plate is located approximately 1 cm inferior to the fovea ethmoidalis, and it forms the roof of the nasal cavity medially. The primary vertical buttresses of the NOE complex run from the frontal bone through the medial orbital region and into the frontal process of the maxillary bone. The primary horizontal buttresses of the NOE complex are the superior and inferior orbital rims (see Images 2-3). The medial canthal tendon arises from the anterior and posterior lacrimal crests and the frontal process of the maxilla. The medial canthal tendon surrounds the lacrimal sac and diverges to become the orbicularis oculi muscle, tarsal plate, and suspensory ligaments of the eyelids (see Image 4). Normal intercanthal distance is approximately 30-35 mm. Anatomically, this distance equates to one half of the interpupillary distance, or equal to the width of the alar base (see Image 5). Fracture classification The key component of NOE complex reconstruction is the bony central fragment onto which the medial canthal tendon inserts. Markowitz et al (1991) devised a classification system based on the degree of central fragmentinjury (see Image 6). Each fracture type is subclassified as either unilateral or bilateral.
WORKUPSection 4 of 10
Lab Studies
Imaging Studies
TREATMENTSection 5 of 10
Surgical therapy
Preoperative detailsInform all patients undergoing NOE complex repair of the following risks:
Intraoperative detailsSurgical exposure can be obtained through coronal incision, subciliary incision, sublabial incision, or canthal stab incision. Coronal incision The coronal incision exposes the frontal bone, nasal bones, superior orbital rims, orbital roof, and frontomaxillary buttress. The patient is positioned 180° away from the anesthesia. Facial lacerations should be explored to augment surgical access. Unfortunately, lacerations alone are usually inadequate for exposure, diagnosis, and repair of NOE fractures. The hair is parted in a widows-peak pattern 4-6 cm behind the anterior hairline. The hair can be shaved along the incision site in a 1-2 cm strip, although this is not necessary. The scalp is incised and elevated in a subperiosteal plane. A subgaleal plane is used if a dural repair is anticipated (eg, posterior table frontal sinus fracture, known CSF leak). The pericranial flap then can be used for closure of the CSF leak. Lateral flap dissection is performed between the temporoparietal fascia (superficial temporal fascia) and the temporalis muscle fascia (deep temporal fascia) (see Image 8). The temporoparietal fascia and frontal branch of the facial nerve are elevated with the flap. The supraorbital and supratrochlear neurovascular pedicles are identified and protected. Exposure over the glabella, nasal bones, superior orbital rims, and orbital roof may require release of the supraorbital and supratrochlear neurovascular pedicles. The pedicles are released by outfracturing the inferior portion of the foramina with a fine osteotome. After completion of the bony repair, the galea aponeurosis and skin are closed in a layered fashion. The periosteum is resuspended carefully at the orbital rims and over the zygomatic arches to avoid postoperative ptosis. Two Penrose drains and a pressure dressing are applied, and care is taken to assure that the ears are not rolled forward under the pressure dressing. Subciliary incision The subciliary incision (see Image 9) exposes the inferior orbital rim, orbital floor, a portion of the medial orbital wall, the frontomaxillary buttress, and the lateral nasal bones. Corneal shields are placed over the eyes bilaterally. A small amount of local anesthesia is infiltrated into the lower lid just below the lash line. A 4-0 silk retention suture is placed through the gray line of the lower eyelid. Superior tension is applied to stabilize the lower eyelid. A subciliary incision is placed parallel to, and 2 mm below, the lash line. The incision extends from the medial lash margin to the lateral canthus. Westcott scissors are used to form a tunnel beneath the orbicularis oculi muscle but superficial to the orbital septum. One blade of the scissors then is placed in the tunnel, and the preseptal space is opened 2-3 cm below the skin incision. This incision preserves a strip of pretarsal orbicularis oculi muscle to support the lower eyelid and reduce the risk of postoperative ectropion. A Westcott scissor and a cotton swab are used for sharp and blunt dissection between the orbicularis oculi muscle and the orbital septum. The proper plane is relatively avascular. Minor bleeding can be controlled with bipolar cautery. If the dissection is performed too deeply, the orbital septum is violated and orbital fat is exposed. If the dissection is performed too superficially, the orbicularis oculi muscle is cut, which results in increased bleeding, possible skin perforation, and an increased risk of postoperative ectropion. Once the orbital rim is exposed, the periosteum is incised with a monopolar needle cautery. Careful subperiosteal dissection is performed to expose the orbital floor, medial orbital wall, and frontomaxillary buttress, as necessary. The medial dissection must remain on the orbital rim to avoid injuring the lacrimal apparatus. After reduction and plating of the NOE complex fractures, the periosteum is closed with 4-0 polyglycolic suture. The skin muscle flap is redraped, and the skin incisions are closed with 6-0 absorbable suture. Patients with lower lid laxity may require a lateral tacking stitch from the pretarsal/preseptal orbicularis oculi muscle to the lateral orbital rim. Transconjunctival incision Transconjunctival exposure of the orbit: The transconjunctival incision eliminates an external scar and reduces the risk of postoperative ectropion. Unfortunately, the lacrimal apparatus limits the exposure of the medial orbital wall and nasal nasomaxillary buttress. When using a transconjunctival approach (which the author prefers) the author often makes a 8-mm stab incision in the medial lower lid (in a natural skin crease) to obtain access to the nasomaxillary buttress. The palpebral conjunctiva is first infiltrated with a small amount of local anesthesia. Two 4-0 silk sutures are placed through the gray line to retract the lid inferiorly. A lateral canthotomy is performed using a scalpel. An inferior cantholysis is performed using Westcott scissors and microforceps. Bleeding is controlled with bipolar cautery. The Westcott scissors are used to elevate a transconjunctival plane deep to the lower lid retractors but superficial to the orbital septum (see Image 9). The scissors are then inserted and the conjunctiva is tented upward. A needlepoint electrocautery is used (on very low power) to cauterize the conjunctiva at the proposed incision site. The scissors are used to incise the area. The exposure is carried medially to a point just lateral to the lower lid punctum. Dissection to the orbital rim is completed with the Westcott scissors and a cotton swab. The correct dissection plane is relatively avascular. Once the orbital rim is reached, the needlepoint cautery is used to expose the rim, and the dissection is carried along the floor and medial orbital wall. Once the repair is complete, the conjunctiva is closed with a running 6-0 fast absorbing gut, the lateral canthotomy is closed with a 5-0 absorbing monofilament suture, and theskin isclosedwith 6-0 nylon. Sublabial incision The sublabial incision provides exposure of the piriform aperture, the face of the maxilla, and the frontomaxillary buttress. The gingivobuccal sulcus is infiltrated with local anesthetic, and electrocautery is used to incise the mucosa. The incision is placed 1-2 cm above the gingival margin and extends from the midline to the canine fossa, leaving an adequate gingival cuff for closure of the incision. The incision can be extended laterally for greater exposure; however, take care not to enter the buccal fat pad, which obstructs the field of view. The dissection is carried to the face of the maxilla. A periosteal elevator is used to expose the face of the maxilla, piriform aperture, maxillary branch of the trigeminal nerve, inferior orbital rim, and the frontomaxillary buttress. After completion of the bony repair, the incision is closed with running, locking, 3-0 chromic suture. Canthal stab incision The canthal stab incision allows identification of a severed medial canthal tendon. Local anesthetic is infiltrated over the medial canthal tendon. A 3- to 4-mm horizontal stab incision is placed approximately 5 mm medial to the medial palpebral fissure, and the fibrous tissue making up the medial canthal tendon is dissected free. After medial canthal tendon repair, the wound is closed with deep 4-0 interrupted polyglycolic sutures, and the skin is closed with 6-0 interrupted nylon sutures. Other exposures Transcaruncular exposure of the orbit: The transcaruncular approach allows excellent exposure of the medial orbital wall, but it does not allow exposure of the nasal bones or medial canthal tendon. Glabellar and open-sky incision: This incision is generally avoided because of unfavorable external scars and postoperative paresthesias. Fracture repair Surgical repair of facial fractures should be performed from the periphery (ie, the skull base, which is stable) toward the central facial skeleton. Any maxillary or frontal bone fractures should be reduced and plated to provide an accurate template for NOE fracture repair.
Postoperative detailsPostoperative ophthalmologic examination is recommended, as well as gross visual acuity checks every 6 hours for a 24-hour period. The Penrose drains are removed from the scalp at 24 hours, and the pressure dressing is discontinued after 3 days. The lead bolsters and scalp sutures are removed at 10 days postoperatively. The patient should be examined and queried again, looking for any evidence of a CSF leak. Follow-upRoutine follow-up care is performed postoperatively at 2 weeks, 1 month, 3 months, 6 months, and then as needed if revision procedures are necessary. Long-term follow-up care can be difficult in this patient population. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Facial Fracture and Broken Nose. COMPLICATIONSSection 6 of 10
OUTCOME AND PROGNOSISSection 7 of 10
Disruption of the delicate ethmoid complex and comminution of the nasal bones can make the repair of NOE complex fractures extremely difficult. These injuries often test the capabilities of even the most experienced surgeons. To obtain an aesthetic surgical result, the surgeon must meticulously identify, accurately reduce, and rigidly fixate the medial canthal tendon and central fragment. Special attention also must be focused on the overlying soft tissue to avoid hematoma, chronic induration, and pseudotelecanthus. FUTURE AND CONTROVERSIESSection 8 of 10
Aesthetic reconstruction of the nasal root and medial canthal region continues to be a significant surgical challenge. Future advances may address this issue with the use of surgical navigation systems and/or intraoperative imaging, which returns the bony architecture to its premorbid state more accurately. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Nasoorbitoethmoid Fractures excerpt Article Last Updated: Apr 30, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
