Naso-orbital-ethmoid fractures involve the nasal bones, ethmoid bone, lacrimal bone, maxilla, and frontal bone. They are complex injuries that can damage the lacrimal apparatus and cause complications like epiphora. Diagnosis involves CT scans and clinical exams. Management principles include early repair, precise fixation to restore anatomy, and grafting of bone defects. Potential complications include telecanthus, enophthalmos, and cerebrospinal fluid leaks.

1. Dr Dibya Falgoon Sarkar
Department of Oral & Maxillofacial Surgery

2.  Introduction
 Surgical anatomy
Classification
Clinical features
Diagnosis
Management
Complications
Recent advances
Summary

3. • Naso-orbital-ethmoid (NOE) fractures are one of the most
complex facial fractures to diagnose and treat in maxillofacial
trauma.
• Incidence: Approx. 5% of adult and 15% of pediatric facial
fractures
• The region houses vital structures:
1. Lacrimal apparatus
2. Medial canthal ligament
3. Anterior ethmoidal artery

4. • NOE region represents the
confluence of:
1. Nasal bone
2. Ethmoid bone
3. Lacrimal bone
4. Maxillary bone
5. Frontal bone
• Medial canthal ligament is a fibrous
extension of tarsal plates. It has 3
limbs;
i. Anterior limb: Larger; attaches to
the frontal process of maxilla.
ii. Posterior limb: Thinner; inserts
into posterior lacrimal crest.
iii. Superior limb: Extension of fibers
of anterior and posterior limb.

5. • Lacrimal apparatus may get
damaged in NOE fractures.
• Lacrimal sac is present between
the anterior and posterior
lacrimal crests.
• Lacrimal sac drains into inferior
meatus via the nasolacrimal
duct.
• Injury may lead to epiphora.
Vertical buttresses Horizontal buttresses

6. • Normal intercanthal distance: 30-35
mm.
• Normal interorbital distance: 25 mm
• Normal interpupillary distance: 60-
62.5 mm
• Relevant blood vessels in NOE region:
i. Anterior ethmoidal artery
ii. Angular artery
Nerve supply of NOE region:
i. Ophthalmic nerve
ii. Maxillary nerve

7. • Markowitz classification (1991):
1. Type I
2. Type II
3. Type III
 According to involvement of
central fragment.
Each of these fractures can
present bilaterally/ unilaterally.
Type I
Type II
Type III

8. • Nasal lacerations
• Depression of nasal bridge
• Traumatic telecanthus
• Shortened palpebral fissure
• Ocular complications:
1. Epiphora
2. Diplopia
3. Enophthalmos
CSF rhinorrhea: Halo sign positive
Associated injuries:
i. Frontal sinus fracture
ii. Obstruction of nasofrontal
outflow tract
iii. Skull base injury: Spectacle
hematoma
 Airway compromise

9. • Imaging : Axial and coronal CT
scans of 1.5 -2mm cuts with 3D
reconstruction.
• Plain radiographs have limited
use.
• Bimanual palpation
• Bow string test : Positive
• Lacrimal apparatus assessment:
1. Jones test
2. Contrast dacrocystography
• Brown- Gruss vault compression
test: Positive; loss of nasal bridge
support.
Diagnosis of NOE fractures

10. • Principles of management:
i. Early one stage repair
ii. Exposure of all fracture
fragments
iii. Precise anatomic rigid fixation
iv. Immediate bone grafting as
indicated for bone loss
v. Definitive soft tissue
management

11. Ellis E. Sequencing treatment for naso-orbito-ethmoid fractures. Journal of oral and
maxillofacial surgery. 1993 May 1;51(5):543-58.
Surgical exposure
Identification of the medial canthal tendon and
tendon bearing fragment
Reduction and reconstruction of medial orbital
rim and wall
Transnasal canthopexy
Reduction of septal fractures
Nasal dorsum reconstruction and augmentation
Soft tissue adaptation

12. Open sky incision

13. • Non-resorbable 2-0 suture/ 28G stainless
steel wire is used
• Bite taken at 90° to tag the tendon
Identifying, capturing, and tagging
of Medial canthal ligament
Reduction of medial orbital rims
• Transnasal reduction is the most
important step in preserving intercanthal
distance
• If fragment bearing the MCL is large
enough we can reduce and fix it to
adjacent bones with 1.3mm titanium
miniplates

14. • Achieves correction of
enophthalmos in blow out fractures
• Regaining anatomic morphology
• Materials used:
1. Autogenous bone grafts: Calvarial
grafts
2. Alloplastic: Titanium mesh
implants, porous polyethylene
sheets
Reconstruction of the medial orbital wall

15. • Ideally the tendon is inserted at
the superior aspect of the
posterior lacrimal crest.
• Anatomic landmarks destroyed:
Placement is chosen arbitrarily
at a point 5mm posterior to
medial orbital rim midway
between the the orbital roof
and floor.
• Ipsilateral techniques:
 Nylon anchor suture
Bone anchoring device
Cantilevered miniplate
Transnasal cathopexy

16. • Goals:
i. Septal reduction
ii. Midline postioning of septum
iii. Lateral nasal cartilage reduction
with Walsham forceps
 Nasal dorsum reconstruction:
i. Adequate nasal tip support with
calvarial graft.
ii. Stabilisation of the graft with a
miniplate at glabella
iii. Maintainence of nasofrontal angle
 Soft tissue readaptation:
Thermoplastic stents/ Metal splints
reinforced with elastic tapes.
Nasal reconstruction

17. • Intra operative:
1. Hemorrhage
2. Frontal branch of facial nerve transection
3. Globe injury
• Postoperative :
i. Traumatic telecanthus
ii. Enophthalmos, orbital dystopia
iii. Contour deformity
iv. Midface retrusion
v. CSF leak
vi. Meningitis
vii. Anosmia
viii. Frontal sinus mucocele/ sinusitis
ix. Temporary/ permanent paresthesia
x. Inability to close upper eyelid
Halo sign

18.  Computer aided cranio-
maxillofacial surgery (CAS):
• Categories of computer assisted
surgery:
1. Virtual surgical planning and use
of 3D stereolithographic models
for fabrication of patient specific
implants (CAD-CAM).
2. Intraoperative navigation
3. Intraoperative CBCT/ MRI
imaging for confirmation

19.  Endoscopic management of NOE
fractures:
• Advantages:
1. Smaller incisions
2. Limited dissections
3. Faster recovery
4. Reduced complications
• Disadvantages:
1. Technique sensitive
2. Longer operating times
3. Reduced exposure
 Draf III endoscopic procedure can be used
for treatment of nasofrontal outflow tract
obstruction.
 Bone tissue engineering (Wei et al. 2014)

20. • Historically NOE fractures have been one of the most
difficult fracture to treat.
• Rowe and Williams considered NOE injuries difficult to repair
if left undetected for more than 2 weeks.
• Thus, accurate assessment of the injury, a comprehensive
treatment plan and an early intervention will lead to
satisfactory results.