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Naso-Orbital Ethmoid Fractures

Resident Physician: S. Ross Patton, MD


Faculty Mentor: Michael P. Underbrink, MD, MBA, FACS
The University of Texas Medical Branch – UTMB Health
Department of Otolaryngology
Grand Rounds Presentation
November 19, 2014

Series Editor: Francis B. Quinn, Jr., MD, FACS -- Archivist: Melinda Stoner Quinn, MSICS
Objectives

1. Review relevant facial anatomy for NOE fractures

2. Review definition and classification of NOE fractures

3. Review surgical approaches and treatment of NOE fractures


Background

http://dentoclub.webs.com/apps/photos/photo?photoid=66406077
NOE Definition
NOE Region

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM
!/?segment=Midface&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-
Diagnosis/noe.jsp
Anatomy of NOE Region
Lacrimal Fossa

-http://en.wikipedia.org/wiki/Lacrimal_bone
Orbital Anatomy- Important Distances to Know

Published in Grand Rounds given by AH Muir from UCSF


Medial Canthal Tendon

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html
Relationship to Other Important Structures

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html
Midface Buttress System

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html
Nomenclature

NOE - naso-orbital ethmoid


NEC - naso-ethmoid complex

Naso ethmoid orbital


Naso-orbital ethmoidal
Mechanism Of Injury

http://www.iihs.org/iktopnews/negative-publicity-about-airbags-obscuring-their-
benefit-institute-aihs/news/desdvises-against-disconnecting-airbags-except-in-rare-
cases
http://www.iihs.org/iihs/news/desktopnews/negative-publicity-about-airbags-
obscuring-their-benefit-institute-advises-against-disconnecting-airbags-except-in-
rare-cases
Pathophysiology of NOE

http://www.sciencedirect.com/science/article/pii/S1042369908001155
Classification
Markowitz Type I

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Midf
ace&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-Diagnosis/noe.jsp
Markowitz Unilateral Type II

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Midf
ace&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-Diagnosis/noe.jsp
Bilateral Type II Fracture

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Midf
ace&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-Diagnosis/noe.jsp
Markowitz Type III

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Midf
ace&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-Diagnosis/noe.jsp
Why So Difficult?
Management
Management: Clinical Presentation in the Trauma Bay

Linnau et al 2003
Management: Diagnosis by Exam and Imaging
Physical Exam: Telecanthus

http://dentoclub.webs.com/apps/photos/photo?photoid=66406077
Bowstring Sign Palpation/Instrument

https://www2.aofoundation.org/wps/portal/!ut/p/c0/ https://www2.aofoundation.org/wps/portal/!ut/p/c0/
Physical Exam: Loss of nasal dorsal Height

Pigsnout
Deformity

Sargent 2007
Sargent 2007
Physical Exam: Epicanthal Folds

http://www.technologybloggers.org/science/is-your-computer-damaging-your-
eyes/
Physical Exam: Globe

--http://www.eyecalcs.com/DWAN/pages/v5/ch087/012f.html
Imaging
Plain Films

Caldwell View
Water’s View

http://www.bcm.edu/oto/index.cfm?pmid=15481

http://www.bcm.edu/oto/index.cfm?pmid=15481
Coronal CT

http://radiographics.rsna.org/content/26/3/783.figures-only
Axial CT

Nguyen et al 2010
Axial CT- Finding the lacrimal Fossa

-http://www.ajnr.org/content/22/5/845/F4.expansion.html

-http://www.images.missionforvisionusa.org/anatomy/2005/10/orbit-ct-images.html
Management-Acute Management of Related
Problems: Intracranial trauma

-http://neurosciencenews.com/neurology-children-tbi-concussion-research-263/brain-big-bandaid-public/
Management-Acute Management of Related
Problems: Epistaxis
Planum Sphenoidale

Superior orbital Fissure


Syndrome

Blindness

Epistaxis
-internal carotid

http://emedicine.medscape.com/article/882627-overview#aw2aab6b3
Nasolacrimal Duct Injury

http://care.american-rhinologic.org/epiphora
CSF Leak

http://www.drpaulose.com/general/csf-leak-from-the-nose-how-to-treat
Management: Surgical Planning Once Stabilized
Timing of Operation
Picking a Surgical Approach
Open Sky Approach
Midface Degloving
Bicoronal Flap
Layers of the Scalp

AO Surgery. Bicoronal Flap. https://www2.aofoundation.org/wps/portal/surgery?showPage=approach&contentUrl=srg/92/04-


Approaches/A70_Coronal-approach.jsp&bone=CMF&segment=Midface&approach=Coronal%20approach&Language=en
Video - Bicoronal Approach

http://youtu.be/gVWGklBtZTA
Additional Incision to approach inferior orbit

https://www2.aofoundation.org/wps/portal/surgery/?contentUrl=%2Fsrg%2F92%2F04-Approaches%2FA30_1-lower-eyelid-
transcutan.jsp&bone=CMF&segment=Midface&showPage=approach&approach=Transcutaneous%20lower-eyelid%20approaches
Surgical Repair
General Principles

Which fractures need surgery? ***Almost all- (type I)

Goals of Surgery: Restore pre-injury


appearance/function (if possible)

Other fractures: Treat other fx first


Type I Repair

Plating Only

Sargent 2007
Type II Repair

Plating and trans-nasal


wiring

Sargent 2007
Type II Repair- Trans-nasal wiring

Sargent 2007
Type II Repair- Trans-nasal wiring
Type II Repair- Trans-nasal wiring

Pitfall- don’t drill into the brain


Type II Repair- Trans-nasal wiring
Type II Repair- Trans-nasal wiring

Unilateral Repair
Type II Repair- Trans-nasal wiring

Bilateral Repair
Type II Repair- Trans-nasal wiring
Pitfall: Placement of wires

Type II Repair

Papel-2nd edition
Type III Repair- Trans-nasal wiring
Type III Repair
Nasal Reconstruction

Papadopolous et al 2009
Nasal Reconstruction: Cantilevered Bone Graft
Soft tissue bolsters

Sargent 2007
Sources

AO Foundation. “Nasal/NOE”. https://www2.aofoundation.org/


wps/portal/!utc1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN39yBTAyMvLwOLUA93I4MQE6B8JJK8haGF
gYFnqKezn7GTn4GBgQkB3X4e-bmp-
gW5EeUAmUJP3w!!/dl2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwRzFFMTBJREZMVUlRUDEwMDA!/?sho
wPage=diagnosis&bone=CMF&segment=Midface

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Bailey BJ. Nasal Fractures. Head & Neck Surgery- Otolaryngology 4th Edition. Ch 71

Papel ID. Frontal Sinus and Nasoorbitoethmoid Complex Fractures. Facial Plastic and Reconstructive Surgery 2nd
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Donald PJ. Frontal sinus and nasofrontoethmoidal complex fractures. SIPAC. 2002.

Shibuya TY. Chen VY. Oh YS. Naso-orbito-ethmoid fracture management. Operative Techniques in Otolaryngology.
2008;19:140-44.

Naso-orbital ethmoid fractures. Medscape Reference. 2/1/2013. http://emedicine.medscape.com/article/869330-


overview

Nguyen M. Koshy JC. Hollier LH. Pearls of Nasoorbitoethmoid trauma Management. Seminars in Plastic Surgery.
24:4:2010.

Papadopoulos H. Salib NK. Management of Naso-Orbital-Ethmoidal Fractures. Oral Maxillofacial Surg Clin N Am
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