The naso-orbitoethmoid complex (NOE) fracture represents the most wearisome and challenging of all facial fractures due to the complexity and intricacy of its surgical & anatomic components. A good working knowledge with regards its surgical anatomy, clinical features, sequence of treatment & surgical approaches, potential pitfalls in its treatment & postoperative consideration,. Appropriate diagnosis and timely treatment is crucial to avoid unfavorable & difficult to treat sequelae.

1. Management of NasoOrbitoEthmoidal Fractures Frederick Mars Untalan MD www.entmdclinic.webs.com

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6. Relevant anatomy Focused papers Clinical features Management www.entmdclinic.webs.com

7. NOE fractures Mga 15,000,000 (na) resulta (0.12 segundo) nasoorbitoethmoids fractures Mga 721 (na) resulta (0.22 segundo) nasoorbitoethmoidalfracture Mga 872 (na) resulta (0.09 segundo) nasoorbitoethmoid fracturesMga 890 (na) resulta (0.09 segundo) www.entmdclinic.webs.com

8. RELEVANT ANATOMY www.entmdclinic.webs.com

9. Nasoorbitoethmoid (NOE) complex The paired nasal bones The ethmoid sinus ethmoid air cells are present at birth and enlarge to adult size by age 12 years. ethmoid labyrinth separates the orbits from the nasal cavity fovea ethmoidalis forms the roof of the ethmoid sinuses laterally the cribriform plate descends approximately 1 cm below the level of the ethmoid roof www.entmdclinic.webs.com

10. Normal intercanthal distance is approximately 30-35 mm www.entmdclinic.webs.com = 1/ 2 of the interpupillary distance = width of the alar base

11. A Very important structure! www.entmdclinic.webs.com

12. medial canthal tendon arises from the anterior and posterior lacrimal crests and the frontal process of the maxilla. It surrounds the lacrimal sac and diverges to become the orbicularisoculi muscle, tarsal plate, and suspensory ligaments of the eyelids. www.entmdclinic.webs.com

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14. Horizontal buttresses of the NOE complex Vertical buttresses of the NOE complex www.entmdclinic.webs.com

15. Pathophysiology Voliation of the primary buttresses of the (NOE) comminution of the entire complex occurs Telecanthus enophthalmos diplopia midfaceretrusion www.entmdclinic.webs.com MVA / RTA Assault

16. Beta2-transferrin definitive test for CSF rhinorrhea. Collect 1 mL of the suspected fluid in a red top tube. www.entmdclinic.webs.com Workup: Laboratory Studies Watery rhinorrhea that is positive for beta2-transferrin is diagnostic for a CSF leak. (vitreous humor of the eye and the perilymph of the ear also have beta2-transferrin)

17. Thin-cut (1.5 mm) axial and coronal CT scans are the criterion standard for the diagnosis of NOE fractures. Axial images reveal injury to the frontal sinus, lamina papyracea, ethmoid complex, nasal septum, and nasal bones. Coronal images detail injuries to the cribriform plate, nasofrontal recess, orbital roof and floor, and lamina papyracea. Contrast enhancement of the CSF can assist with the diagnosis of CSF fistula. Plain radiographs - limited usefulness in NOE fractures. www.entmdclinic.webs.com Workup: Imaging Studies Axial CT scan demonstrates a comminuted NOE complex fracture.

18. FOCUSED PAPERS www.entmdclinic.webs.com

19. N :104 patients (severe nasoethmoid-orbital injuries) has facilitated the classification of these injuries into five types. The recognition and diagnosis of each specific injury pattern will define the correct treatment choice in each instance. Special attention should be focused on injuries with comminution and bone loss in the medial wall and floor of the orbit, loss of cartilaginous nasal support, and orbital displacement and dystopia. An open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments provides optimal repair. The use of craniofacial surgical techniques and immediate bone graft replacement of missing or severely damaged bone will allow reconstruction of even the most difficult injuries in one stage. Three hundred and nine primary bone grafts have been used in 66 patients. No significant complications of their use have occurred Gruss JS Ann Plast Surg. 1986 Nov;17(5):377-90 Complex nasoethmoid-orbital and midfacial fractures: role of craniofacial surgical techniques and immediate bone grafting. (1986) www.entmdclinic.webs.com injuries with comminution and bone loss in the medial wall and floor of the orbit, loss of cartilaginous nasal support, and orbital displacement and dystopia open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments

20. The proper management of nasoethmoid orbital fractures relies upon early accurate diagnosis and treatment. A surgical plan must be established after careful review of the physical examination and CT scans. Identification of the extent and type of fracture pattern determines the operative approach. Extended (wide) exposure, using craniofacial techniques, facilitates precise reduction and rigid fixation of all bone fragments. Transnasal reduction of the canthus-bearing central segment (medial orbital rim) is the critical operative maneuver required to achieve normal intercanthal distance. Immediate bone grafting replaces severely comminuted or missing bone fragments. The skin overlying the nasoethmoid area is carefully redraped by gentle pressure from padded external compression bolsters. These principles form the basis for superior aesthetic and functional results. Leipziger LS, Manson PN ClinPlast Surg. 1992 Jan;19(1):167-93. Nasoethmoid orbital fractures. Current concepts and management principles (1992). www.entmdclinic.webs.com (wide) exposure (craniofacial techniques) facilitates precise reduction & rigid fixation of all bone fragments reduction of the canthus-bearing central segment (medial orbital rim) is the critical operative maneuver required to achieve normal intercanthal distance

21. The aim of treatment of combined injuries of the cranium and face is the correct anatomic restoration of the maxilla in relation to the cranial base above and the mandible below and the reconstruction of any associated craniofacial, naso-orbitoethmoidal, and zygomatic fractures. The plethora of techniques described in this article for the management of these injuries attests to the controversy and confusion surrounding the management of these patients Gruss JS, Bubak PJ, Egbert MAClinPlast Surg. 1992 Jan;19(1):195-206 Craniofacial fractures. An algorithm to optimize results (1992) www.entmdclinic.webs.com correct anatomic restoration of the maxilla in relation to the cranial base above and the mandible

22. This article presents a strategy for treating NOE fractures. Eight steps for the management of such injuries are presented: surgical exposure identification of the medial canthal tendon/tendon-bearing bone fragment reduction/reconstruction of medial orbital rim reconstruction of the medial orbital wall transnasalcanthopexy reduction of septal fractures nasal dorsum reconstruction/augmentation soft tissue adaptation. Following these steps can make treatment outcomes more predictable. Ellis E 3rdJ Oral Maxillofac Surg. 1993 May;51(5):543-58. 5. transnasalcanthopexy 6. reduction of septal fractures 7. nasal dorsum 8. reconstruction/augmentation soft tissue adaptation www.entmdclinic.webs.com Sequencing treatment for naso-orbito-ethmoid fractures (1993) 1. surgical exposure 2. identification of the medial canthal tendon/tendon-bearing bone fragment 3. reduction/reconstruction of medial orbital rim 4. reconstruction of the medial orbital wall

23. Fractures of the nasoethmoid-orbital region present some of the more formidable challenges to the reconstructive surgeon in regard to aesthetic and functional restorations. As the severity of injury escalates, the surgical difficulties increase, making acceptable results of therapy difficult to achieve. Optimal management involves not only repair of the skeleton of the central midface, but also restoration of function and aesthetics of the orbits, frontal sinus, anterior cranial fossae, and the overlying soft tissue. Detailed physical examination and radiographic imaging are necessary to properly diagnose the extent of injuries. Various surgical techniques, such as interfragmentary wiring, microplate fixation and transnasal wiring, are utilized. This article reviews injuries of the nasoethmoid-orbital region, and describes the pertinent anatomy and classification of injuries. Currently accepted methods of evaluation and repair of specific injuries are outlined. Fedok FG J Craniomaxillofac Trauma. 1995 Winter;1(4):36-48. Comprehensive management of nasoethmoid-orbital injuries (1995) www.entmdclinic.webs.com repair of the skeleton of the central midface, restoration of function & aesthetics of the orbits, frontal sinus, anterior cranial fossae & the overlying soft tissue interfragmentary wiring, microplate fixation & transnasal wiring are utilized

24. BACKGROUND AND OBJECTIVES: Trauma to the central midface may result in complex nasoethmoid orbital fractures. Due to the intricate anatomy of the region, these challenging fractures may often be misdiagnosed or inadequately treated. The purpose of this article is to aid in determining the appropriate exposure and method of fixation. METHODS AND MATERIALS: This article presents an organized approach to the management of nasoethmoid orbital fractures that emphasizes early diagnosis and identifies the extent and type of fracture pattern. It reviews the anatomy and diagnostic procedures and presents a classification system. The diagnosis of a nasoethmoid orbital fracture is confirmed by physical examination and CT scans. Fractures without any movement on examination or displacement of the NOE complex on the CT scan do not require surgical repair. Four clinical cases serve to illustrate the surgical management of nasoethmoid fractures. RESULTS AND/OR CONCLUSIONS: Early treatment using aggressive techniques of craniofacial surgery, including reduction of the soft tissue in the medial canthal area and restoration of normal nasal contour, will optimize results and minimize the late post-traumatic deformity. A high index of suspicion in all patients with midfacial trauma avoids delays in diagnosis. Sargent LA, Rogers GF J Craniomaxillofac Trauma. 1999 Spring;5(1):19-27. Nasoethmoid orbital fractures: diagnosis and management (1999) www.entmdclinic.webs.com Fractures without any movement on examination or displacement of the NOE complex on the CT scan do not require surgical repair reduction of the soft tissue in the medial canthal area and restoration of normal nasal contour

25. Surgical reduction of fractures involving the orbits, nasoethmoid complex, and adjacent cranium is challenging; adequate initial reduction and stabilization is essential because secondary reconstructive procedures usually provide less than satisfactory results. Our operative techniques for surgical exposure, as well as fracture reduction and fixation, have evolved from standard facial incisions and wire fixation to complete exposure of the orbits, nasoethmoid complex, and adjacent cranium using an extended bicoronal approach, application of ridged plating techniques, and cranial bone grafts when needed. This evolution of surgical technique has been accompanied by an overall improvement in immediate cosmetic and functional results Dennis M. Crockett M.D. and Robert B. Stanley, Jr. D.D.S M.D. Operative Techniques in Otolaryngology-Head and Neck SurgeryVolume 5, Issue 1, March 1994, Pages 32-36 The craniofacial approach to management of fractures involving the orbits and nasoethmoid complex in young children (2004) www.entmdclinic.webs.com adequate initial reduction and stabilization is essential because secondary reconstructive procedures usually provide less than satisfactory results complete exposure of the orbits, nasoethmoid complex & adjacent cranium using an extended bicoronal approach, application of ridged plating techniques & cranial bone grafts when needed

26. Blunt trauma to the midface frequently results in fractures of the nasoethmoid orbital skeleton. These complex injuries are often misdiagnosed or inadequately treated and are perhaps the most difficult of all facial fractures to treat. The purpose of this article is to describe the author's technique for the diagnosis and treatment of these complex fractures. Presented is an organized approach to the diagnosis and surgical management of nasoethmoid orbital fractures that has evolved in the author's treatment of over 450 nasoethmoid fractures. Early diagnosis is confirmed by computed tomographic scan using the simple classification system described. Fractures that demonstrate displacement or movement on examination require open reduction and stabilization. Identifying the extent and type of fracture pattern and associated injuries determines the exposure and method of fixation needed. Plate-and-screw fixation of the superior and inferior rim is performed with bone graft reconstruction of the nose as needed. Attention to redraping of soft tissue in the naso-orbital valley with the use of nasal compression bolsters is a crucial step in the repair. Multiple clinical cases are used to illustrate the different fracture patterns, soft-tissue injuries, and surgical technique recommended. This organized approach has proven effective in restoring preinjury appearance. Early diagnosis combined with the aggressive surgical techniques described will optimize results and minimize the late posttraumatic deformity Sargent LA PlastReconstr Surg. 2007 Dec Department of Plastic Surgery, University of Tennessee at Chattanooga, TN 37403, USA. Nasoethmoid orbital fractures: diagnosis and treatment (2007) www.entmdclinic.webs.com Fractures that demonstrate displacement or movement on examination require open reduction and stabilization. Wide exposure with meticulous reduction is necessary, w/ stabilization of the medial orbital rim fragment using a transnasal wire technique

27. Naso-orbital-ethmoidal fractures are arguably the most challenging fractures of the facial skeleton to restore properly. This article discusses their proper diagnosis, describes some of the controversies in their management, and makes recommendations regarding their proper treatment. Papadopoulos H, SalibNKOralMaxillofacSurgClin North Am. 2009 May;21(2):221-5, vi. Management of naso-orbital-ethmoidal fractures (2009) www.entmdclinic.webs.com most challenging fractures

28. CLINICAL FEATURES www.entmdclinic.webs.com

29. often have associated facial injuries or panfacial fractures www.entmdclinic.webs.com NOE injuries

30. Clinical features Flattened nasal bridge with splaying of nasal complex Saddle-shaped deformity of nose from side Epistaxis CSF rhinorrhea Tenderness, crepitus and mobility of nasal complex www.entmdclinic.webs.com

31. Clinical features Flattened nasal bridge with splaying of nasal complex Saddle-shaped deformity of nose from side Epistaxis CSF rhinorrhea Tenderness, crepitus and mobility of nasal complex www.entmdclinic.webs.com

32. Clinical features Traumatic telecanthus Circumorbitaloedema and ecchymosis Subconjunctivalhaemorrhage Diplopia Possible supra-orbital / supra-trochlear nerve paraesthesia Forehead paraesthesias www.entmdclinic.webs.com

33. Clinical features Traumatic telecanthus Circumorbitaloedema and ecchymosis Subconjunctivalhaemorrhage Diplopia Possible supra-orbital / supra-trochlear nerve paraesthesia Forehead paraesthesias www.entmdclinic.webs.com

34. Clinical features Nasal and forehead swelling or overlying lacerations www.entmdclinic.webs.com

35. Initial evaluation Establish ABCs. Diagnose any associated injuries. A thorough head and neck examination to reveal injuries to the brain, spine, orbits & facial skeleton is required A team approach involving the otolaryngologist, plastic surgeon, neurosurgeon, and ophthalmologist is recommended. Ophthalmologic consultation is mandatory. www.entmdclinic.webs.com Presentation

36. Examine the nasal cavity for the presence of CSF. presence of watery rhinorrhea or salty postnasal drainage. Test bloody fluid that is suspicious for CSF rhinorrhea www.entmdclinic.webs.com Direct examination of the NOE complex

37. Examine the nasal cavity for the 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 www.entmdclinic.webs.com Direct examination of the NOE complex With naso-ethmoidal fractures a CSF leak should be assumed to be present even if it is not clinically demonstrable & appropriate chemoprophylaxis should be commenced.

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40. Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation www.entmdclinic.webs.com Direct examination of the NOE complex

41. medial canthal tendon integrity A lax medial canthal tendon or medial orbital wall motion is consistent with a NOE complex fracture. www.entmdclinic.webs.com Direct examination of the NOE complex

42. Measure and document telecanthus and enophthalmos. www.entmdclinic.webs.com Direct examination of the NOE complex An intercanthal distance of >35mm is suggestive of traumatic telecanthus; measurement approaching 40mm are almost diagnostic

43. Palpate the nasal bones for crepitus and comminution. www.entmdclinic.webs.com Direct examination of the NOE complex

44. Evaluate the septum for septal hematoma. www.entmdclinic.webs.com Direct examination of the NOE complex

45. Evaluate the degree of nasal or midfaceretrusion. Preinjury photographs may be helpful. www.entmdclinic.webs.com Direct examination of the NOE complex

46. 1. Reduction 2. Immobilization 3. Rehabilitation The principles of treatment are the same as for any other fractures, namely www.entmdclinic.webs.com

47. 1. Access to give good exposure of the fracture 2. Reconstruction of the cranial base & mngmt of the frontal sinus if necessary 3. Frontonasal buttress & orbital rim, usually these fragments are easy to locate & reduce 4. nasal dorsum should be reconstructed & nasal projection restored 5. Medial orbit 6. Medial canthal ligament 7. Lacrimal system 8. Closure & drain 9. Nasal plaster 10. Dressings & antibiotic eye drops www.entmdclinic.webs.com Sequencing surgical treatment

48. The naso-ethmoidal region can be accessed through the existing laceration, or through modification to a H-shaped or W-shaped incision. A bicoronal flap may be required for access to the frontal bone or orbital walls. www.entmdclinic.webs.com Surgical Access

49. The naso-ethmoidal fracture often shows extensive comminution, although the nasal bridge may be intact, but depressed. This can be elevated back into position and stabilized by direct wiring, or using mini-plates to the frontal bone. www.entmdclinic.webs.com Surgical Access

50. The medial canthal ligament must be identified and repositioned into its position in the frontal process of the maxilla, and stabilized by wiring to the opposite anterior lacrimal crest (transnasalcanthopexy). If both canthal ligaments are detached then the telecanthus can be repaired by means of wiring the two medial canthal ligaments to each other (transnasally). www.entmdclinic.webs.com Surgical Access

51. Surgical approaches • existing laceration • H-shaped • Bilateral 'Z' approach • Midline vertical approach • W-shaped approach • Coronal approach Surgical Access www.entmdclinic.webs.com

53. (B) Type II fractures involve comminution of the central fragment without medial canthal tendon disruption (left-unilateral, right-bilateral).

55. Postoperative 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. www.entmdclinic.webs.com Postoperative Details

56. Patients should be asked to perform standard nasal hygiene (nasal saline irrigations and no nose blowing). www.entmdclinic.webs.com Postoperative Details

57. Routine 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. www.entmdclinic.webs.com Follow-up

58. Disruption of the delicate ethmoid complex and comminution of the nasal bones can make the repair of nasoorbitoethmoid (NOE) complex fractures extremely difficult. These injuries often test the capabilities of even the most experienced surgeons. www.entmdclinic.webs.com Outcome and Prognosis

59. 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. www.entmdclinic.webs.com Outcome and Prognosis

60. Herford AS, Ying T, Brown B. PURPOSE: Nasoorbitoethmoid (NOE) fractures are complex and often challenging to repair. Inadequate treatment may result in secondary deformities which are difficult to treat. Severely comminuted fractures require repositioning of the medial canthal tendon. The purpose of this study was to evaluate all results in treating these challenging injuries. The work is to be used as a basis for continuing quality improvement of our surgical technique. PATENTS AND METHODS: Ten consecutive patients who sustained a comminuted NOE (type III) fracture were included in this study. All patients had comminution of the central fragment involving the detachment of the medial canthus. RESULTS: Transnasal reduction, primary grafting, and plate and screw fixation were used for all patients. Two patients demonstrated slight asymmetry between the medial canthi. Two patients were observed to have overprojection in the nasofrontal region. CONCLUSION: Severely comminuted type III NOE fractures are best treated primarily to avoid secondary deformities. J Oral Maxillofac Surg. 2005 Sep;63(9):1266-77. www.entmdclinic.webs.com Outcomes of severely comminuted (type III) NOE fractures Transnasal reduction, primary grafting, and plate and screw fixation were used for all patients Severely comminuted type III NOE fractures are best treated primarily to avoid secondary deformities

61. Aesthetic reconstruction of the nasal root and medial canthal region continues to be a significant surgical challenge. www.entmdclinic.webs.com Future and Controversies

62. use of surgical navigation systems intraoperative imaging Return of the bony architecture to its premorbid state more accurately. www.entmdclinic.webs.com Future and Controversies

63. www.entmdclinic.webs.com Appropriate & timely treatment is crucial

64. www.entmdclinic.webs.com NOE injuries remains a challenging surgical problem

65. Relevant anatomy Focused papers Clinical features Management www.entmdclinic.webs.com We discussed these.

66. Management of NasoOrbitoEthmoidal Fractures Frederick Mars Untalan MD www.entmdclinic.webs.com