Naso-Orbito-Ethmoidal Fractures

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Abhijit Joshi

NASO-ORBITO-ETHMOIDAL
FRACTURES
Abhijit Joshi

Contents :
• Significance of NOE region & applied anatomy
• Classification of NOE fractures.
• Clinical features and pictures
• Radiology.
• Assessment of lacrimal drainage.
• CSF leaks and management.
• Steps in managing a NOE fracture
• Managing a Post traumatic nasal deformity.

Abhijit Joshi

NOE complex
• Intricate anatomical structure.
• At anatomical crossroads.
• 4 cavities involved:
– Cranium
– Orbits
– Nasal
– maxilla
• 4 bones involved:
– Paired nasal
– Frontal process of maxilla
– Ethmoids
– Lacrimal bones.
Abhijit Joshi

NOE complex
• Wedged in interorbital space.
• Basically weak
• Strength :
– Vertical buttress : frontal pr of
max
– Horizontal : sup/inf orbital
rims
• Additional strength:
– Lattice network of bones
– Articulation at various angles.

Abhijit Joshi

• Anatomy and applied aspects:
– Osteology
– Soft tissue anatomy

Abhijit Joshi

Osteology
•
•
•
•

Nasal bones
Ethmoid
Frontal process of maxilla
Medial orbital rim and wall

• Other bones involved:
– Perpendicular and Cribriform plate of ethmoid.
– Nasal process of frontal bone.
– Sphenoid bone

Abhijit Joshi

Nasal bones

Abhijit Joshi

•

Anteriorly: frontal process of max + max proc of frontal.

• Lacrimal fossa :
– depression on inferomedial orb rim.
– Formed by max and lacrimal bones
– Bound by Ant lacrimal and Post lacrimal crests.
– 16mm high x 4-9mm wide x 2mm deep
– Max-lacrimal suture: confluence of the 2 bones
– Mean thickness of lacrimal bone here : 106microm  easy perforation

Abhijit Joshi

Sutura notha/ sutura longitudinalis imperfecta of weber:
•
•
•
•

Fine groove on frontal process of maxilla
Anterior to ant lacrimal crest
Contains small branches of infraorbital artery.
Anticipate their presence during dissection
Abhijit Joshi

Medial orbital wall
• Paper thin  lamina papyracea
• Strength from ethmoid air cells  dessipation.
• Medial blow out # assoc with orb floor # in
50% cases.
• Traversed by:
– ant ethmoid art – 24mm
– Post ethmoid art – 34mm
• Care taken to identify these vessels can
contribute to Retro Bulbar Hemorrhage
• Entrapment of orbital fat media  horizontal
diplopia – restriction of abduction-retraction of
globe
Abhijit Joshi

Ethmoid bone

Abhijit Joshi

Abhijit Joshi

Ethmoid :

Abhijit Joshi

Soft tissue anatomy:
• medial canthal ligament
• Lacrimal drainage apparatus
• Associated vessels etc.

Abhijit Joshi

Soft tissues.

Right eye in primary position

Abhijit Joshi

• The U/L are suspended in space, tethered medially and laterally by canthal ligaments
• Orb. oculi attaches to the medial orbital wall via MCL
• Fibrous diamond shaped, Tripartite arrangement.
• Greater horizontally with Ant and post limbs
Abhijit Joshi

Medial canthal ligament (MCL):
Complex, strong interlocking 3-D arrangment of indivisual
components and structures.

• Strength derived from complex
anatomy.

• Intimately related to
– lacrimal drainage apparatus.
– lacrimal bone
– Frontal process of maxilla –
reinforces.

Abhijit Joshi

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 (zide).
superior branch – periosteum of frontal bone(corrugator super cilli)

Abhijit Joshi

Posterior limb of MCL
• 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 the post segment.
Both ant and post limbs envelope the lacrimal sac.

Abhijit Joshi

Lacrimal drainage:

Abhijit Joshi

Relationship betw excretory system and MCL

• Sac is wrapped by lacrimal fascia ( split periorbita)
• Wrapped by MCL ant and post limbs
• Deep portion of Pretarsal orb oculi – horner-duverney
muscle passes posterior to post limb of MCL and attaches
to upper portion of PLC.
Abhijit Joshi

Other Relations:
MCL to ant cranial fossa:
• Mean vertical dimension betw 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.

Abhijit Joshi

Markowitz and Manson
• Type I – central fragment
• Type II – comminuted fracture
with lateral extension not
involving MCL
• Type III – comminuted fracture
with extension into MCL

Abhijit Joshi

Classification - Ayliffe
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

Abhijit Joshi

Type III – comminuted fracture
but canthal ligament firmly
attached with bone fragments
which are big enough to plate

Type IV– comminuted fracture
with free canthal ligament not
large enough to be plated

Abhijit Joshi

Type V – gross comminution needing bone grafting

Abhijit Joshi

Ideal proportions

The ideal nasofrontal angle 115° to 130°

The ideal nasal project  1:1.


ideal intercanthal distance should be approximately 1/3.

Abhijit Joshi

In a NOE fracture
Direct blow to nasal bony dorsum

Medial canthal ligament detaches /
disarticulation of bone containing
attachement

Crushing of Fragile perpendicular
plate, ethmoidal air cells

• Rounding of medial canthal angle
•Widening of intercanthal distance.

post displacement

Removes dorsal support for nose.
Adherent dura , Crista Galli/ cribriform plate
move as a unit  olfactory damage.
 CSF leak
Abhijit Joshi

Clinical features:
•
•
•
•

Reduced Dorsal nasal projection , Upturned nasal tip
Accentuation of Naso-Frontal angle.
Accentuated naso-jugal fold.
Inward Telescoping medial wall into ethmoid.

•
•
•
•

Traumatic telecanthus (loss of stabilization of MCL).
Traumatic hypertelorism
Orbital dystopia
Mongoloid slant

•
•
•
•

Cerebrospinal fluid leakage.
Nasolacrimal duct obstruction/severage  epiphora .
Anosmia
Nasal airway obstruction

Pig snout.

Abhijit Joshi

• accentuated N-F angle
• Decreased dorsal nasal projection.
• Upturned nasal tip.
• traumatic telecanthus

Abhijit Joshi

• Edema, emphysema, echymosis
• Traumatic telecanthus
• Orbital dystopia
• rounding of medial canthal angle
• Mongoloid slant
Abhijit Joshi

Subconjunctival emphysema

In a patient with medial wall fracture assc with NOE #
(after blowing his nose)

Abhijit Joshi

Injury to lacrimal drainage:

Abhijit Joshi

Clinical assessment.
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 Joshi
Abhijit ‘93

Physical examination
• Eyelid traction test / Furnas traction test

Furnas DW, Bircoll MJ Plast Reconstr

Surg. 1973 Sep;52(3):315-7

• Bimanual palpation by placing an instrument into the
nose to determine canthal bearing bone fragment 
displaced and mobile

Abhijit Joshi

Diagnostic Imaging.
Conventional : standard PNS view

Plain films are of ALMOST NO USE in diagnosing NOE fractures
because most will be undetected; Edward ellis ;Sequencing treatment for NOE fractures
JOMS ‘93
Abhijit Joshi

CT
• Is of greatest value
• HRCT adds to the existing value
• What to ask for?
– 1-2 mm Axial and coronal slices with 3D recon.
– Top of skull-frontal sinus-orbits-maxilla
– Bone window  NOE bony complex
– Soft tissue window  brain/ocular adnexa.

Abhijit Joshi

Axial cuts.
• Position and status of frontal
process of maxilla  central
fragment.
• Medial walls of orbit if they are
“blown in” nasally,
•Anterior and posterior tables of
frontal bone
•Nasolacrimal system

Abhijit Joshi

Coronal cuts

• Cuts taken from nasal
bridge to orbital apex
• junction of floor to medial
wall assessed.
• Disruption of ant. Cranial
fossa around cribriform
plate.
• CSF leak  CT value
• localization of CSF leaks.

Abhijit Joshi

3D CT

Abhijit Joshi

Investigations of the lacrimal system

Tests for Secretory
system

Tests for drainage/excretory
system

• Schirmer’s test

• Dye disappearance test

• basal tear secretion test
• primary dye test

• Jones 1 and Jones 2
• DCG
• HRCT
• Tc 99 scan

Abhijit Joshi

Dye disappearance test:
Simplest of tests.
• Flouriscine dye placed on
conjunctival fornix

• Dye disappears.

• Patency of system

Abhijit Joshi

Jone’s test
Jone’s 1.

• 1 drop fluorescein dye placed into conjunctuval sac.
• Cotton bud soaked in LA placed in inf meatus.
• Wait for 5 min and remove the bud.
• If bud stained with dye  test +ve
Abhijit Joshi

If –ve then proceed to jone’s 2:
Clear saline irrigated thru cannula
inserted into inf canaliculus
Patient bends forward

1. Nothing frm nostril
2. Fluid regurgutates
– opp. punctum
Complete obstr.
distal to tip

3. Clear fluid from nose
Stained fluid

Patency of both canaliculi till
int canaliculus

Dye not entered canaliculi

+ve test

Blocked punctum/canaliculi
Abhijit Joshi

Dacrocystography:

• Radioactive oilbased dye injected into lacrimal
drainage.
• Radiographed to know the course of duct
• CT used for imaging  CT dacrocystography.
Abhijit Joshi

CSF leak and management.

Abhijit Joshi

Cerebrospinal fluid.
• CSF is essentially an ultrafiltrate of plasma
• Clear colourless fluid  bathes brain and spinal cord.
• Fills ventricles within the subarachnoid space.
• Main funtion:
– Cushions brain against trauma (sp. Gravity of brains
within 4% of that of CSF brain floats !!)

nourishment.
– Removal of waste products.
–

Abhijit Joshi

Production and composition.
Production :
• Choroid plexus and ventricular ependyma
• @ 500cc/day.
• Volume : 150cc  turnover is TID
• Pressure mantained at 60-150mm H2O  valsalva,
coughing, straining.
Composition:
• Insoluble salts.
• Ph  7.33
• Total proteins content: 20.0mg/dl
• Glucose : 64.0mg/dl
• Beta transferrin.
Abhijit Joshi

CSF leaks
• Barriers to contain CSF and
prevent its communication
with external:
– Dura,
– Skull
– Periosteum
– Galea and skin.
• Barriers violated  CSF leak.
• Risk of meningitis  4-50%

Abhijit Joshi

CSF leaks.

Traumatic
Surgical
16%

Atraumatic - 3-4%
High-pressure

Non-surgical
80%

Normal-pressure
spontaneous

3% closed head injuries
9% penetrating head injuries
10-30% basilar skull fractures
Abhijit Joshi

Common sites for CSF leak

• Cribriform plate, frontal sinus, Ant. Eth. roof.
• posterior ethmoid roof,
• sphenoid sinus.
• temporal bone (pseudorhinoliquorrhea).
Abhijit Joshi

Reservoir sign
• Simple bed side procedure  nonspecific.
• Performed upon patient arising in the
morning.
• Place patients chin to chest for 1min.
• Copious leakage thru nose like an open
faucet.
• Intermittent drainage:
•Use Ipratropium bromide
•Nasal secretions will stop
•CSF leaks continue.

Abhijit Joshi

• 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

Abhijit Joshi

•

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.

Abhijit Joshi

Laboratory diagnosis
• Glucose test
• Protein analysis
• Beta transferrin test
• beta-Trace Protein
• Electronic nose

Abhijit Joshi

• Glucose test : CSF collected in vial and if glucose
levels are > 45mg/dl  CFS existence.

Abhijit Joshi

glucose oxidase stick technique
• Normally nasal secretions are devoid of glucose
whereas CSF has a glucose level related to the plasma
glucose. The literature generally supports a glucose
value of 30 mg/dL in rhinorrhea fluid as indicative of
CSF. However, there are opportunities for falsepositives and false-negatives. For example, a postsurgical patient may have a serous exudate which
physiologically contains glucose.
• To measure the glucose concentration of nasal
secretions in the absence or presence of rhinorrhoea
Abhijit Joshi

Beta transferrin test
• This protein is found in only three bodily fluids – CSF,
perilymph, and vitreous humor .

• Unless a patient has an open globe, ongoing production of
clear nasal discharge that is positive for beta-2-transferrin
is highly diagnostic for CSF

• Is a protein produced by neuraminidase activity
Abhijit Joshi

b-2 transferrin

• Immunofixation electrophoresis of nasal secretions in
the laboratory  used to detect b-2
• This test is not sufficiently rapid to provide support for
clinical decision making in emergency departments
and may not be available in all hospitals, particularly
in developing countries

Abhijit Joshi

Beta Trace protein.
• B-TP is a naturally occurring secretory enzyme  present in
human CSF  concentration of 15 to 20 mg/L.
• The CSF to serum ratio of b-TP (33:1)  highest of all CSF
specific proteins
• Ideal marker for the detection of CSF traces.
• Most abundant protein in human CSF, (also in prealbumin,
albumin, Ig G).
• Also in urine, aqueous humor, and inner ear fluids,glomerular filtr.
• In healthy subjects, the serum concentration of B-TP is 0.3 mg/L.
Abhijit Joshi

• Immunoelectrophoresis / Nephelometric assay used.
• In comparison to the 2-transferrin test, the b-TP
assay superior higher predictive values.
• Test can be performed within 20 minutes
• Smallest traces of CSF (5%) can be detected by B-TP.
• Limitation : Pts with acute glomerulonephritis or
terminal renal insufficiency; in these patients, the BTP concentration increases in the serum.
Bachmann et al Predictive Values of -Trace Protein by Use of Laser-Nephelometry Assay for the Identification of Cerebrospinal Fluid Neurosurgery, Vol. 50, No. 3, March
2002

Abhijit Joshi

Nephelometer
An apparatus used to measure the size and concentration of
particles in a liquid by analysis of light scattered by the
liquid.`

• It does so by employing a light beam (source beam)
and a light detector set to one side of the source
beam.
• Particle density is then a function of the light reflected
into the detector from the particles.
• How much light reflects  dependent upon properties
of the particles  shape, color, and reflectivity.
An assay is a procedure where the concentration of a component
part of a mixture is determined

Abhijit Joshi

Electronic nose
• Vapor-sensing devises used primarily in the food and
beverage industries.
• Numerous publications have addressed the medical utility
of such devices.
• Electronic nose technology has been used for breath
analysis to identify:
– Campylobacter pylori in the stomach,
– Study lactose malabsorption,
– Vapor pressure in sweat analysis  in screening for
cystic fibrosis.
Abhijit Joshi

A. Headspace over a liquid sample is
aspirated into an analyzer (electronic
nose).
B. Headspace gas (containing the sample
aroma) is allowed to interact with
array of 32 conducting polymers with
differing sensitivities to specific
chemical types (eg, alcohols,
ketones).
C. Electrical resistance of each of the
conducting polymers changes
reproducibly after exposure to an
aroma, allowing the aroma to be
represented as a point in a 32dimensional space
Abhijit Joshi

Efficacy of electronic nose

• The amount required,0.3 mL, may be obtained with
only a few drops of nasal discharge
• The electronic nose was also able to reliably place
unknown specimens in the appropriate category of
CSF or serum Anna Aronzon et al Otolaryngology–Head and Neck Surgery (2005) 133, 16-19

Abhijit Joshi

Radiographic evaluation:
• High resolution CT : bone defect is filled with CSF
density fluid extracranially.
• CT cisternography
• Radionuclide cisternography
• Intrathecal flourscien
• MRI cisternography

Abhijit Joshi

CT Cisternography
• Contrast dye oil based, nonionic (metrizimide)used.
• Lumbar puncture into subarachnoid space.
• Trendelenburg position.
• Subject to CT scan.
• High resolution CT Coronal 2mm slices obtained :
– confirm CSF leak
– Locate site of leak.

Abhijit Joshi

CSF fistulas

CSF leak

Metrizamide CT scan showing CSF leak in left frontal sinus
s/p SW to left orbit.
Abhijit Joshi

Use of low concentration flourescein dye
• Cotton pledgets placed in the nose.
• Sterile dilution of 0.3ml flourescein + 10cc CSF made.
• Infused intrathecally.
• Pledgets removed after 30min to 1hr
• Analyzed under ultraviolet light.

can be given simultaneously with contrast material, and thus
one can use CT cisternography and endoscopic examination
in a complementary fashion .
Abhijit Joshi

Nuclear cisternography
• Sensitive method to evaluate CSF leaks
• Indium 111 (bonds to CSF protiens) used  ½ life of
48hrs  delayed imaging.
• Injected intrathecaly.
• Tracer takes 2-4hrs to reach basal cisterns
• Intranasal pledgets Endoscopically placed in the
middle meatus and sphenoethmoidal

Abhijit Joshi

Treatment :
• Tailored to individual
• Intracranial versus extracranial
• Endoscopic versus microscopic

Abhijit Joshi

Intracranial approach.
Advantages :
– direct visualization,
– ability to repair adjacent cortex,
– Better chance of repairing a leak caused by
increased intracranial pressure.
Disadvantages:
– increased morbidity,
– longer hospitalization,
– higher incidence of post-operative anosmia.
Abhijit Joshi

extracranial repair
– has decreased morbidity and anosmia,
– superior exposure of the posterior ethmoid,
parasellar, and sphenoid regions.
– Disadv: less suited for defects in the frontal sinuses
with prominent lateral extension and is less
successful in high-pressure leaks

Abhijit Joshi

Grafts :
• Free nasal mucosa,Pedicled nasal mucosa,
• bone grafts harvested from the nasal septum or middle
turbinate
• Temporalis fascia,muscle ,Adipose tissue.
• Vascularized free flap.
Graft stabilization:
• with cyanoacrylate glue/fibrin glue
Packing
• Microfibrillar collagen(over the graft),
• Absorbable gelatin sponges
• Oxidized cellulose.
• All repairs intraoperatively tested  Valsalva maneuver.
Abhijit Joshi

What can be used??
Grafts/flaps
fat, fascia, muscle, cartilage,
mucosa
simple or composite
Biological glue
collagen, fibrin,
cyanoacrylate
Gelfoam, Merocel

Abhijit Joshi

Skull Base (extracranial) approaches:
Cribiform plate fistula: Transethmoidal repair
• Nasal septal mucosal flap to cover ethmoid sinus.
Sphenoid sinus fistula: Transseptal transsphenoidal
approach
• Recent endoscopic advances allow for a fully
endoscopic transsphenoidal approach
Primary repair of dural opening is attempted
• Grafts of pericardium, fascia lata, or endogenous fat
Abhijit Joshi

Endoscopic approach to a CSF leak.
CSF leak

Abhijit Joshi

Final word on CSF….
• CSF fistulae arise from a variety of etologies.
• Diagnosis based on physical, laboratory and radiologic
techniques
• Treatment divided into surigical and non-surgical.
• Future holds refinement of existing techniques,
development of new ones

Abhijit Joshi

Thank you
Abhijit Joshi

Naso-Orbito-Ethmoidal Fractures

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (20)

Ähnlich wie Naso-Orbito-Ethmoidal Fractures

Ähnlich wie Naso-Orbito-Ethmoidal Fractures (20)

Mehr von Indian dental academy

Mehr von Indian dental academy (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Naso-Orbito-Ethmoidal Fractures