NASO-ORBITO

ETHMOID FRACTURES
CONTENTS
• INTRODUCTION
• ANATOMY
• DEFINITION
• CLASSIFICATION
• DIAGNOSIS
• EXAMINATION
• TREATMENT
• COMPLICATION
• ADVANCES
INTRODUCTION
• Epker coined the term.

• Most challenging scenario

• Fracture results in severe facial dysfunction and

malformation.

• 5%- adult and 15%- pediatric

ANATOMY
• NOE complex
• In central upper mid face

• Osteology

• Soft tissue component

• Medial canthal tendon
• Arises from anterior and posterior lacrimal crests and
frontal process of maxilla

• Diverges to become orbicularis oculi muscle, tarsal plate

and suspensory ligaments of eyelid
• Lacrimal drainage apparatus
• Littles area
• Butresses
• Blood supply

• Nerve supply
DEFINITION

• NOE fractures- injuries involving the area of confluence of

the nose, orbit, ethmoids, the base of frontal sinus and the
floor of the anterior cranial fossa and this area includes
the insertion of medial canthal tendons.
CLASSIFICATION
• Markowitz classification
DIAGNOSIS
• CLINICAL EXAMINATION
• Gross edema
• Laceration
• Eye, forehead, nose pain
• Forehead paresthesia
• Mongoloid slant
• Enophthalmos
• Diplopia
• Loss of globe integrity
• Circum orbital edema, ecchymosis
• Subconjunctival hemorrhage
EXAMINATION
• Examine nasal cavity for csf and septal hematoma
• Watery rhinorrhea or salty post nasal drippage
• Test for csf
• Examine lacerations under sterile conditions
• Measure telecanthus
• Palpate nasal bone
• Evaluate degree of nasal or midface retrusion
Csf leakage
TESTS FOR MEDIAL CANTHAL
LIGAMENT
• Furness test
• IMAGING
TREATMENT
• ORIF- Dingman and Natvig

• Mustrade- transnasal wiring

• Overcorrected because secondary deformities difficult to

correct.
• ELLIS 8 KEY STEPS:
• Surgical exposure

• Identification of medial canthal tendon and tendon bearing

bone fragment.

• Reduction and reconstruction of medial orbital rim

• Reconstruction of medial orbital wall

• Transnasal canthopexy

• Reduction of septal fracture

• Nasal dorsum reconstruction and augmentation

• Soft tissue adaptation.

• Lynch incision / medial canthal incision
• Mid facial degloving approach
Surgical landmarks
Along medial orbital wall:
• Anterior lacrimal crest

• Anterior ethmoidal artery -15 mm

• Posterior ethmoidal artery – 25 mm

• Stop dissection at this point.

• Optic nerve at optic foramen 35-40 mm

REPAIR OF BONY SKELETON
• Medial canthal ligament must be identified before
repairing bony skeleton.

• Activity of lacrimal system to be assessed

• Trans nasal canthopexy
Alternative support for transnasal
canthopexy wire
Dorsum reconstruction
External splint
Post operative management
• Nose blowing avoided- 10 days

• Ophthalmic ointments, steroids, antibiotics and analgesics

• Ophthalmologic evaluation
Patency of lacrimal apparatus
Nasolacrimal apparatus repair
• 5%- 21%

• Delayed assessment is recommended

• Secondary dacryocystorhinostomy.
COMPLICATIONS
• Persistant telecanthus
• Epiphora
• Deviated nasal prominence
• Saddle nose appearance
• Malunion
• Csf leak
• Globe injuries
Advances
• 3 D pre bent Ti implant
• Ultra high molecular weight poly ethylene
• Bone tissue engineering
•
• Scaffold, signal and cells

• Scaffold-CAD/CAM

• Signals –BMP

• Cells- bone marrow derived and adipose derived

mesenchymal stem cells can differentiate into osteoblasts