42
Chapter
Naso-Orbito-Ethmoid Fractures
H umans recognize each other by the shape of the eyes and the
middle third of the face.1 For this reason, successful repair of
the naso-orbito-ethmoid (NOE) region is difficult, and even minor
shortcomings in the final result are recognizable to others. In addi-
tion, the NOE area contains several types of specialized tissues
(bone, cartilage, sinus, tendon, and lacrimal and ocular tissues) and
distinctive architectures that, once lost, are difficult for the surgeon
to restore. The bone in this area is distinctly shaped, difficult to
access, and covered by the thinnest soft tissue in the face.
A post-traumatic NOE deformity can have three key components:
diminished nasal projection, increased intercanthal distance (tele-
canthus), and impaired nasofrontal or lacrimal drainage. The best
outcomes following significant NOE injury are the result of accurate
diagnosis and treatment of these three components.
ETIOPATHOGENESIS/CAUSATIVE
FACTORS
The etiology of NOE trauma differs from that of mandibular and
nasal trauma.2 NOE injuries are the result of focused high-energy
transfer to the intercanthal area. A motor vehicle accident is, for
example, a more likely cause than interpersonal violence. The
trauma surgeon should always remember that NOE injury is the
result of significant energy transfer and that patients who have sus-
tained considerable NOE trauma will often have associated cervical
spine, ocular, or intracranial injuries.3
PATHOLOGIC ANATOMY
AND EXAMINATION
The foundation of the NOE region is a paired set of midline facial
buttresses that flow vertically from the piriform rim up to the frontal
bar; these buttresses support nasal projection and attachment of the
medial canthal tendon (MCT).
MEDIAL CANTHAL TENDON
It is helpful to conceptualize the MCT as the medial extent of a tarsal
apparatus. The tarsal apparatus runs in the plane of the orbital
septum and extends from the lateral canthus at Whitnall’s tubercle,
through the upper and lower tarsi, and into the MCT, where it
attaches to the frontal process of the maxilla. The tarsal apparatus
provides support to the eyelids and defines the normal almond shape
of the palpebral fissure.
Before attaching to the frontal process of the maxilla, the MCT
splits into anterior and posterior components, with the lacrimal sac
 
Mark Engelstad
between them. The superficial component attaches broadly to the
anterior lacrimal crest, whereas the deep component of the MCT
attaches along the posterior lacrimal crest. Restoration of this deep
component after canthal detachment is critical for maintaining the
proper shape and appearance of the eyelids; it rounds the eyelids
against the medial aspect of the globe, thereby allowing normal lid
function. When the MCT is repaired, its deep direction of attachment
must be restored. The posterior component is also associated with a
slip of orbicularis oculi called Horner’s muscle; when Horner’s
muscle contracts, it assists movement of fluid through the lacrimal
system (Fig. 42-1).
Direct blunt force to the NOE region buckles the medial orbital
walls and fragments the thin nasal, lacrimal, ethmoid, and frontal
bones. The nasal root can also telescope posteriorly into the ethmoid
air cells as a single unit, lodge under the nasal process of the frontal
bone, and obstruct nasofrontal outflow of the frontal sinus (Fig.
42-2). Frequently, NOE injury will be accompanied by an increased
intercanthal distance (telecanthus) resulting from widening of the
canthal-bearing bones, MCT detachment, or both.
A thorough examination will distinguish NOE injuries from an
isolated nasal fracture. NOE injury has a distinctive appearance: a
horizontally widened intercanthal region along with a vertically
shortened nose that is flattened and widened with an upturned nasal
tip. The deformity has a remarkably consistent appearance in patients
(Fig. 42-3).
CLINICAL AND
RADIOGRAPHIC ASSESSMENT
Thorough digital NOE examination for mobility, crepitus, and
depressibility often yields the most information about the extent of
NOE injury. The entire nose—or portions of it—may be digitally
depressible. Formal preoperative ophthalmology consultation should
be considered for a patient who has sustained enough force to frac-
ture the orbital walls. Occult ocular injury may be present.
The status of the MCT attachment to bone can be assessed clini-
cally by the “bowstring” test (Fig. 42-4): the lateral canthus is
grasped and displaced laterally while observing and palpating the
medial canthal area. Lateral displacement of the medial canthal area
suggests a compromised bony attachment. This test can be difficult
to interpret accurately, especially in the presence of acute edema and
a conscious patient.
In the operating room, the status of the MCT can be assessed by
placing an instrument in the nose under the bony MCT attachment
while simultaneously palpating the area from the outside; manipula-
tion of the instrument will help one understand the status of the
MCT-bearing bone fragment.
339
340 Current Therapy in Oral and Maxillofacial Surgery

A B
Fig. 42-1  n  A, Tarsal apparatus extending from the lateral orbital wall to the frontal process of the
maxilla. B, Areas of bony attachment of the deep (blue) and superficial (red) components of the
medial canthal tendon.

A B
Fig. 42-2  n  Axial computed tomography showing the nasal radix displaced posteriorly into the
ethmoid air cells.

A B
Fig. 42-3  n  Five days following blunt naso-orbito-ethmoid (NOE) injury. This patient has a typical
appearance following NOE injury. Note the telecanthus, depression of the nasal radix and dorsum,
vertically shortened nose, and upturned nasal tip.
 Naso-Orbito-Ethmoid Fractures 341

Fig. 42-4  n  The “bowstring” test. A

Telecanthus

Fig. 42-5  n  Classification of naso-orbito-ethmoid fractures. (From

B
Fonseca RJ, et al: Oral and maxillofacial surgery, vol 2, ed 2. St Louis,
2009, WB Saunders.) Fig. 42-6  n  A, The normal intercanthal distance measured from one
medial palpebral angle to the other. B, Telecanthus, or increased inter-
canthal distance.
DIAGNOSIS
CLASSIFICATION OF NASO-ORBITO-
ETHMOID FRACTURES
Even though NOE trauma rarely resembles textbook diagrams, clas-
sifying the injury enhances both communication and treatment
planning. The most widely used and therefore useful NOE injury
classification scheme remains that developed by Markowitz and
colleagues.4 The status of the MCT, the canthal-bearing bone frag-
ment, and the fracture pattern define a clinically useful classification
system (Fig. 42-5). From type I to type III, the energy sustained from
the injury increases.
• Type I: single-segment central fragment
• Type II: comminuted central fragment with fractures remaining
external to the insertion of the MCT
• Type III: comminuted central fragment with fractures extending Fig. 42-7  n  Left-sided palpebral aperture changes following unilateral
into bone bearing the canthal insertion medial canthal tendon detachment.

INTERCANTHAL DISTANCE
Increased intercanthal distance, called telecanthus, is one of the key
deformities of NOE injuries. The normal intercanthal distance is
approximately equal to the width of the palpebral aperture or half
the interpupillary width. The distance, measured from one medial
palpebral angle to the other, is approximately 29 to 34 mm in adult
women and 29 to 36 mm in adult men, but it can vary considerably5
(Fig. 42-6). An increase in intercanthal distance greater than 40 mm
is strongly correlated with NOE injury requiring surgical treatment.
However, accurate measurement is difficult in the presence of acute
edema, and a surgical NOE treatment plan should not be based on
a single measurement alone. Overall, intercanthal distance is less
meaningful than the distance of each canthus from the facial midline;
measuring each side independently helps diagnose unilateral injury.
REPAIR OF TELECANTHUS
Repair of telecanthus is one of the key components of NOE treat-
ment. Telecanthus is caused by disruption of the MCT attachment,
which slackens the entire tarsal apparatus. After disruption of the
MCT, contraction of the orbicularis oculi muscle increases the inter-
canthal distance and causes lateral displacement and rounding of the
medial palpebral fissure. Measuring the distance of each palpebral
fissure to the facial midline will distinguish unilateral injury from
bilateral injury (Fig. 42-7).
342 Current Therapy in Oral and Maxillofacial Surgery
IMPAIRMENT OF NASOFRONTAL DRAINAGE
Assessment plus restoration of adequate frontal sinus drainage is
another key component of NOE treatment. Rodriguez and co-workers
demonstrated that nasofrontal obstruction is common with com-
bined frontal sinus–NOE injury and that 99% of frontal sinus com-
plications are a result of inadequate nasofrontal drainage.6 Restoration
of drainage is more likely when NOE projection is reestablished.
Historically, nasofrontal patency was assessed by injecting a
fluid (saline, methylene blue, or fluorescein) into the nasofrontal
duct and watching for its appearance in the nose. Definitive results
of this test can be difficult to interpret in an acutely traumatized
field. Assessment of the NOE injury for nasofrontal patency is
more helpful preoperatively, during the treatment-planning phase.
Modern-day fine-cut computed tomography (CT) in all three planes
will demonstrate gross bony compromise of sinus outflow. Imaging
alone is not entirely predictive of postoperative patency of the
outflow tract, but it may be as predictive as invasive techniques.
When nasofrontal obstruction is a concern, postoperative CT
a few months after treatment will reveal inadequate frontal sinus
drainage. At that point, endoscopic frontal sinus surgery may
reestablish sinus drainage.7
TREATMENT/RECONSTRUCTIVE GOALS
Success in repairing NOE injuries can vary, but the principles of
treatment are constant: establish nasal projection and narrow the
intercanthal distance.
TIMING OF NASO-ORBITO-ETHMOID REPAIR
There is general consensus that early repair of NOE injuries gives
superior results.8 Unless extreme, prolonged waiting for resolution
of facial swelling is probably of little value. Trauma starts a cascade
of inflammation, fibrosis, and healing. Surgery is a “second hit” of
tissue injury. When repair is performed early rather than late, surgi-
cal inflammation may blend with the initial wound healing. What
early repair means, however, is debatable. To the modern surgeon,
the right time to perform a lengthy NOE repair is more dependent
on operating room availability than on ideal physiology.
Achieving a satisfactory result from the primary repair is crucial.
Secondary NOE repairs, as well as the scarring and fibrosis that
follow them, are notoriously unsatisfactory and should be avoided
if possible.
SURGICAL ACCESS AND FIXATION
A single-fragment, type I NOE injury without superior displacement
can be accessed, reduced, and fixated entirely through a transoral
approach. In these cases, the piriform and infraorbital rim alignment
can be verified through the transoral approach, and a separate orbital
incision is not required. A single plate along the piriform rim is
usually adequate fixation for these injuries. If significant superior
displacement of the type I fragment exists, accurate reduction may
not be possible without additional access and fixation.
In type II and III NOE injuries, the goal of surgery is restoration
of nasal projection and intercanthal distance. To achieve this objec-
tive, a coronal approach is generally necessary. Accessory approaches
are also required, including a transconjunctival or subciliary incision
for access to the infraorbital rim and orbital floor, as well as a tran-
soral incision. There is little likelihood of achieving an acceptable
outcome after a serious NOE injury without full surgical access. The
coronal approach provides this and also allows cranial bone grafting
for nasal dorsal struts or orbital wall defects. During dissection,
close attention should be paid to the MCT and care taken to not
detach it from its bony insertion.
Mid-facial degloving, which requires an extended transoral
approach, has also been described for NOE repair,9 but if orbital
access for canthopexy or medial wall repair is needed, a coronal
approach will still be necessary. A coronal approach, at its full
extent, will provide access to the entire medial half of the orbit and
most of the nasal dorsum.
Existing lacerations rarely provide adequate access for NOE
reconstruction; enlargement of a facial laceration for NOE repair
should be avoided when possible. Transcutaneous approaches, such
as the gull wing, or “open sky,” approach, also leave unacceptable
facial scars that cannot be camouflaged.10
The size and position of bone plates for NOE repair are impor-
tant. The skin overlying the medial orbital rim and lateral nasal bone
area is quite thin. The presence of plates and screws can cause
low-grade chronic inflammation of the overlying soft tissues, which
is readily noticeable and difficult to resolve. Generally speaking,
placement of plates, screws, and wires directly under the soft tissues
in the MCT region should be minimized.
SEQUENCING OF NASO-ORBITO-ETHMOID
REPAIR AND ASSOCIATED BONE INJURIES
NOE injury is often associated with significant orbital and frontal
sinus trauma. Accurate reconstruction of the orbital walls is abso-
lutely necessary for a successful outcome. Unless the normal orbital
volume is restored, the result of NOE repair will be inadequate.
Access to the deep orbit and orbital rims from the coronal approach
is enhanced by canthal disruption. The nasal dorsum and radix can
be reduced at any time, but once canthopexy is performed, visualiza-
tion within the orbit is lost. For this reason, all associated facial
buttress and orbital repairs should be accomplished before cantho-
pexy. The proper sequence of steps for repair of NOE and associated
injuries was described by Ellis.11
NASAL PROJECTION
Restoration of nasal length and dorsal projection is a key objective
of NOE treatment. With a severe NOE injury, nasal dorsal strut
grafting is often required to reestablish support for the entire nose.
Definitive rhinoplasty can be done on a delayed basis if the nasal
projection is excessive, but once the nose begins to heal in a col-
lapsed and shortened state, regaining its premorbid length and pro-
jection is very difficult.
Nasal projection and telecanthus are inversely related: adequate
projection of the nasal dorsum can mask telecanthus, whereas inad-
equate dorsal projection actually enhances the appearance of tele-
canthus. This phenomenon is called pseudo-telecanthus.
The dorsal nasal strut graft is cantilevered from stable frontal bone
and placed in the subcutaneous plane, all the way down to the region
of the nasal tip (Fig. 42-8). An endonasal approach to visualize the
tip area and align the strut graft with the nasal cartilage can be helpful.
To prevent shortening and provide support for the nasal cartilage and
septum, the graft should span the length of the nasal dorsum.
A dorsal strut graft can be harvested from a variety of sites, but
cranial bone is readily available and can be precisely contoured and
stably fixated. Potter and colleagues have thoroughly described
nasal management in patients after NOE injury.12 Alloplastic materi-
als are too often the source of chronic inflammation and should be
avoided for nasal dorsum grafting.13
MEDIAL CANTHOPEXY
Except in the case of a gunshot wound or penetrating NOE
trauma, the MCT is often left attached to some kind of central
canthal-bearing bone fragment.4,10 The size of the remaining
 Naso-Orbito-Ethmoid Fractures 343

Fig. 42-8  n  The outer table calvaria is contoured and then cantilevered from stable frontal bone
to restore dorsal nasal stability, projection, and length. The plate may be placed superior or inferior
to the bone graft. (Clinical images courtesy Gorman Louie, M.D.)

canthal-bearing bone fragment is critical. The surgeon will need to

know whether it can be accurately positioned among the other frag-
ments and whether it can be stabilized or fixated with the proper
vector of reduction.
Reduction plus fixation of the canthal tendon–bearing bone frag-
ment is the most direct way to restore intercanthal distance. If it is
large enough to hold screws superiorly and inferiorly, internal fixa-
tion alone can stabilize the canthal-bearing fragment. If the central
fragment is not large enough to be reliably reduced and fixated, the
MCT itself should be identified, captured, and reduced to restore
intercanthal distance. This is referred to as medial canthopexy.
During medial canthopexy, the canthus should be directed to a point
on the medial orbital wall that is slightly posterior and superior to
the posterior lacrimal crest. This point is essential.
Medial canthopexy is one of the final steps in repair and is neces- Fig. 42-9  n  The use of transnasal wiring and bolsters to treat telecan-
sary only for severe NOE injuries. In these cases, the bone in the thus actually causes widening of the bony medial canthal tendon
area of canthal attachment is often pulverized, with no stable bone insertion points, thereby making the telecanthus worse.
left for canthal attachment or passage of a transnasal wire. Decreasing
the intercanthal distance by simply wiring or suturing the canthi
to one another will not achieve the correct posteriorly oriented The postoperative axial CT scan in Figure 42-9 shows the possible
medial canthal reduction necessary to restore normal appearance result of using transnasal wire and external bolsters alone for MCT
and function. canthopexy. When the wires are applied anterior to the MCT, widen-
Traditionally, medial canthopexy is accomplished from the ing of the MCT insertion points and telecanthus can result. This is
coronal approach by first identifying the MCT and then capturing it a well-known phenomenon.12 It should also be noted that external
with wire or suture. Depending on the degree of trauma and presence bolsters do little to effect change at the depth of the MCT, where
of stable bone, the combination of transnasal wiring techniques and narrowing is most required.
bone grafting of comminuted areas is used to reduce and stabilize
the MCT. There is a body of literature that describes these tech- CEREBROSPINAL FLUID RHINORRHEA
niques.12,14 Successfully capturing the MCT or a small canthal- The absence of cerebrospinal fluid (CSF) rhinorrhea is also a goal
bearing bone fragment and then directing and stabilizing it in the of NOE reconstruction. When associated cribriform plate or anterior
proper vector are easier to diagram than to actually perform. In skull base fractures are present, CSF rhinorrhea is possible. The
addition, finding and capturing the MCT can cause significant reduction of NOE fragments may stimulate CSF rhinorrhea from a
trauma to the delicate soft tissues of the NOE region. previously undetectable dural injury. CSF rhinorrhea is usually self-
External nasal bolsters and splints, even when transnasally wired, limited but, when persistent, could require antibiotic therapy along
are poor substitutes for accurate internal reduction and stabilization. with direct or endoscopic dural repair.
 B

G
Fig. 42-10  n  A, After a coronal approach, a small horizontal incision is made in the caruncle.
B, The needle end of the canthal barb is passed through the caruncular incision and the medial
canthal tendon (MCT). Special identification of the MCT is not required. The needle is then identi-
fied and pulled through from the deep side of the coronal flap. C, As it is pulled toward the caruncle,
the canthal barb is guided into the incision in a horizontal orientation. D, The canthal barb is
pulled into the incision and becomes engaged in the dense substance of the MCT. The barb is no
longer visible. No closure of the caruncular incision is required. E, A thick miniplate is adapted to
stable frontal bone and along the medial orbital wall. The most posterior hole of the plate is posi-
tioned slightly posterior and superior to the posterior lacrimal crest. The wire is then passed through
the posterior plate hole. F, The miniplate is positioned and fixed to stable frontal bone. When the
needle end of the wire is pulled, the barb will reduce the MCT toward the posterior plate hole and
into an anatomically correct position, posterior and superior to the posterior lacrimal crest. The
images demonstrate a unilateral technique. Alternatively, an awl could be used to create transnasal
passage for the wire from the plate hole to the other orbit. G, The pulley configuration created by
the canthal barb, wire, and plate can be visualized. After reduction of the MCT, the wire has been
secured to a single frontal screw.
 Naso-Orbito-Ethmoid Fractures 345

SPECIFIC TREATMENT AND TECHNIQUES

MEDIAL CANTHOPEXY WITH A CANTHAL
BARB AND MINIPLATE
In this chapter the use of a canthal barb and miniplate to achieve
anatomically correct medial canthopexy will be described. This
technique is a minor modification of one previously described by B.
Hammer (Orbital fractures: Diagnosis, operative treatment, second-
ary corrections, Hogrefe and Huber Publishers, 1995). Refer to the
images in Figure 42-10 for illustration of the technique.
The technique requires a coronal approach and two simple A
implants. The first is a canthal barb, which is a micro-anchor–like
device that becomes securely embedded within the MCT and can
withstand the firm reduction tension required for canthopexy without
pulling out. Commercially available barbs are attached to a length
of wire or suture and needle. The second requirement is a titanium
miniplate adapted to the contour of the frontal bone and medial
orbital wall. The miniplate should be thick enough to resist deforma-
tion from the static tension required for medial canthopexy (see
Fig. 42-10).
This canthal barb and plate technique has advantages over
traditional transnasal wire canthopexy. First, surgical identification
of the MCT is not necessary. In cadaver studies,15 passage of the B
needle through the caruncle consistently engaged the canthal barb Fig. 42-11  n  A, A gunshot has caused a unilateral type III naso-
in dense medial canthal connective tissue without pulling through. orbito-ethmoid injury with canthal disruption and left-sided telecan-
Second, the presence of stable bone in the medial orbit for passage thus. B, One year after medial canthopexy with a canthal barb and
of the wire is not necessary. Instead, the plate, which can be posi- miniplate technique.
tioned by the surgeon, provides the fulcrum and proper vector for
canthal reduction. Third, a unilateral approach is possible. Transnasal
wiring is not necessary and contralateral orbital dissection can be
avoided.
As with any canthopexy technique, the MCT should be slightly PEARLS AND PITFALLS
over-reduced; it will predictably remodel and relax over the subse-
• Good outcomes after NOE injuries depend on restoring nasal
quent months (Fig. 42-11). Although bone at the medial wall is not projection and narrowing the intercanthal distance and then
required, grafting of the medial wall should be considered for exten- allowing the delicate soft tissues to heal over the restored bony
sive injuries. architecture with as little underlying hardware as possible.
• Inadequate projection of the nasal dorsum will create the illusion
of telecanthus (pseudo-telecanthus), whereas a well-projected
nasal dorsum will camouflage existing telecanthus.
POSTOPERATIVE CARE • Lacrimal dysfunction is surprisingly rare following bony NOE
Postoperative management of the NOE repair should include routine injury.16 Unless an obvious lacrimal injury is noted, such as a
vision checks, especially if the orbit was involved. If nasal cartilage laceration through the medial third of the eyelid, routine lacrimal
exploration or intubation does not diminish the incidence of
and septum were injured, temporary intranasal support with splint-
postoperative epiphora and is not indicated.
ing can be valuable. Bilateral soft intranasal support, such as the • When performing medial canthopexy, the MCT should be
Doyle splint, may be tolerated better than intranasal packing with reduced into a position slightly posterior and superior to the
gauze. Intranasal splinting for at least 2 weeks will help minimize posterior lacrimal crest.
synechiae and maintain patency; patients have difficulty tolerating • During dissection, close attention should be paid to the MCT
splints much longer than this. and care taken to not detach it from its bony insertion.
Partial resolution of NOE edema can take several weeks, and • The more hardware placed in the NOE region, the greater the
total resolution may take more than 6 months. The final result cannot potential for chronic inflammation from loose screws and plates.
be judged for at least 6 months. Some authors believe that several Piecing together every small fragment of bone with plates and
weeks of external nasal splinting minimizes edema and results in screws is not necessary.
• Delayed or secondary repair of NOE injuries is associated with
better final soft tissue contour.12
notoriously poor outcomes. The first operation is the best and
If the initial outcome is obviously substandard, secondary repair only chance to achieve a great result.
should not be delayed excessively.
346 Current Therapy in Oral and Maxillofacial Surgery
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