classification,features,management

2.  NOE - naso-orbital ethmoid
 NEC - naso-ethmoid complex
 Naso ethmoid orbital
 Naso-orbital ethmoidal

3.  The
nasoorbitoethmoidal
(NOE) fracture refers to
injuries involving the
area of confluence of
the nose, orbit,
ethmoids, the base of
the frontal sinus, and
the floor of the anterior
cranial base.

4.  NOE fractures, by
definition, are a
different entity than
isolated nasal bone
fractures. However,
they are often
associated with
fractures of the nasal
bones.

6.  The NOE complex, as
seen in the image
represents the
confluence of the
nasal, lacrimal,
ethmoid, maxillary,
and frontal bones

7.  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.

8.  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.

11.  the foundation of NOE
complex is two mIdline
facial buttresses runs
vertically from pyriform
rim up to frontal bar.
 These buttresses
support the nasal
projection and
attachment of MCL.

12.  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.

15.  Sac is wrapped by lacrimal fascia
 Wrapped by MCL fascia.
 deep portion of orb oculi muscle attaches
posterior to post limb of MCL

22.  NOE fractures are most commonly classified according to Markowitz BL,
Manson PN, Sargent L, et al (1991)
 Type I
 Type II
 Type III
 These can be unilateral or bilateral injuries.
 Plast Reconstr Surg. 87(5):843-53:

23.  In unilateral Markowitz type I fractures, there is a single large NOE
fragment bearing the medial canthal tendon.
 The nasal bone may also be involved and, in cases of comminution,
may not provide adequate dorsal support to the nasal bridge.

24.  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

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

26.  bone grafting of the nasal dorsum may be
necessary

27.  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.

48.  Reestablishing the bony & soft tissue architecture
of NOE region
 Orbital volume, integrity
 Integrity of medial canthus
 Status of nasal support
 Function of frontal sinus
 Lacrimal drainage system

50.  perfect reduction of
the frontal process of
the maxilla
 internal fixation to
maintain its proper
position. This could
include 1-, 2-, or 3-
point fixation.

51.  require an extended
glabellar approach or
a transconjunctival
approach with medial
extension for fixation
at this fracture site

53.  The canthal-bearing bone
fragment requires exact
repositioning.
 The intercanthal distance
should be restored.
 nasal projection should be
restored by addressing nasal
bone fractures and by adding
bone graft if necessary.
 Rule out CSF leak particularly
in bilaterally displaced
fractures in order to minimize
the risk of early or delayed
meningitis.

55.  Transnasal wire
The transnasal wire
technique may be
necessary to properly
reposition and fix the
bone fragments.

56.  When confronted with
a NOE fracture
requiring a transnasal
wire, it is important to
place the wire fixation
in its proper posterior
position.

57.  medial canthus has become
detached from the bone. A
transnasal canthopexy must
be performed.
 The most important aspect
is the medial and posterior
positioning of the medial
canthal ligament.
 In order to accomplish this,
a cantilever technique
(plate 4 in the illustration)
may be utilized

58.  NOE injuries have been the most complex and difficult
facial fractures to treat.
 The complex anatomy of the region and difficulty with
access makes the repair of NOE fracture a challenging
task .
 The complete knowledge including etiology, surgical
anatomy, and classification with proper examination of
patient and treatment planning will lead to better
management of patients with NOE fractures .