Nasoethmoid Fractures Treatment & Management
- Author: David W Kim, MD; Chief Editor: Deepak Narayan, MD, FRCS more...
Stabilize the patient and treat serious insults to the airway, neurologic system, cervical spine, chest, and abdomen prior to definitive treatment of the maxillofacial bones. Address emergencies related to other maxillofacial trauma prior to definitive treatment. These include airway compromise and excessive bleeding.
Prior to definitive repair of naso-orbito-ethmoid (NOE) fractures, obtain a thorough understanding of all other facial fractures. Bony injuries that threaten vision or intracerebral structures must be addressed.
The objectives of definitive surgical treatment of NOE fractures are reduction and fixation of unstable fracture segments to stable structures. Treatment restores proper anatomic relationships. In particular, efforts must be directed to restore the functional and aesthetic baseline of the patient. The main goal of surgery is to restore the anatomic position of the MCT and the bony segment(s) to which it is attached. This prevents later complications related to lower lid laxity, epiphora, and aesthetic distortion. Delays promote scar formation and soft tissue retraction, making subsequent surgery more difficult and risky.
After all other more critical medical problems have been stabilized, the patient may be considered for repair of NOE injuries. Have adequate CT scan images available in the operating room for intraoperative guidance. A full complement of maxillofacial instruments, plates, wires, and screws must be available.
Prior to surgery, inform the patient of the implications of the anticipated procedures. The patient must understand the risks and possible complications of the procedure, including temporary or permanent paresthesia, CSF leak, meningitis, sinus infection or mucocele, anosmia, infection of implants, osteomyelitis, malunion or nonunion, external deformity, enophthalmos, extraocular motion dysfunction, blindness, and the possible need for additional surgery.
Preoperative photographs are important to document the degree of deformity. Analyze the deformity using measurements of the intercanthal, interpupillary, and interpalpebral distances. This allows the surgeon to estimate the distance of correction needed to approximate the preinjury state.
An open approach is required to adequately address fractures of the NOE complex. Several options are available for soft tissue incisions to access the NOE complex. If lacerations are located near the site of injury, they may be used to access the bony fragments.
In the classic protocol, a transcutaneous vertical Lynch incision is made medial to the medial canthal region in order to gain access to the fracture site. Although this approach allows for a very direct route to the area in question, the resultant vertical scar is in a visible area and is therefore potentially unsightly. Increasingly, efforts are being made to access facial fractures through less visible areas. In this region, several options exist for access through cosmetically inconspicuous incisions. These include the bicoronal incision, lower subciliary blepharoplasty incisions, lower lid transconjunctival incisions, and medial conjunctival incisions through or around the caruncle.
Bicoronal incisions have the advantage of camouflage behind the hairline. Dissect in a subperiosteal plane down to the orbital rim. Laterally, dissect deep to the superficial leaf of the deep temporal fascia so that the frontal branch of the facial nerve, which runs between the superficial temporal fascia and deep temporal fascia, remains uninjured.
Once at the superior orbital rims, the neurovascular bundles of the supraorbital and supratrochlear pedicles are identified and released from their grooves. If true foramina surround the structures, the inferior lip of bone may be removed in order to release the neurovascular bundles. Then, elevate the orbital contents in a subperiosteal plane to a point 2-3 cm posterior to the orbital rims along the roof and medial walls of the orbit. This degree of dissection is necessary to allow the scalp flap to relax enough to be reflected down to the level of the nasal bridge. Medial orbital wall dissection proceeds until all fracture segments are reached. The anterior ethmoidal artery may need to be controlled with suture ligation or cautery.
Subciliary incisions are a useful adjunct to the coronal approach in allowing for access to the inferior orbital rims. Corneal shields and/or a temporary tarsorrhaphy suture may be placed to protect the cornea. Make the incision approximately 2 mm inferior to the eyelash margin. Dissection may proceed medially on the deep surface of the Müller muscle under the preseptal and pretarsal orbicularis oculi to gain access to the posterior lacrimal crest. From this point, subperiosteal dissection exposes the fracture segments.
Alternatively, a transconjunctival lower lid approach may be used. Make an incision through the lower conjunctiva just below the inferior border of the free tarsal plate. Dissection may then proceed in a preseptal plane on the undersurface of the orbicularis muscle as in the subciliary approach.
In order to gain additional exposure, medial conjunctival incisions may be added to the lower lid incisions. The transcaruncular approach involves incising through the caruncle to gain access to the Müller muscle and then to the medial orbital wall. The paracaruncular approach involves using an incision through the superomedial and inferomedial borders of the caruncle. This approach is advantageous because it allows access to the tissue plane between the caruncle and surrounding tissue, resulting in reduced bleeding and postoperative edema.
Once adequate exposure is achieved, make efforts to identify the MCT and characterize the degree of comminution of associated bony segments. The MCT is usually attached to a bony segment rather than totally avulsed from bone. Identification of this segment and its restoration to an acceptable position are crucial for restoring cosmetic relationships. If the MCT is damaged or avulsed, place a suture tag on the thicker, anterior leaf of the tendon for later canthopexy. Some surgeons advocate relaxing the lateral canthal tendon through a brow incision or through the coronal approach to provide more laxity of the MCT and allow for overcorrection. The tendon can then be resuspended after MCT stabilization is completed. At this point, the class of NOE injury and, thus, how to proceed, should be clear.
Type I fractures
Once exposure is achieved, the exact geometry of the fracture can be determined. Perform reduction by hand or with a penetrating towel clamp or other bone-grasping instrument. To prevent lateral migration of the bony segment and MCT, the reduction must be held in place until fixation is complete.
For patients in whom the fracture segment involves the frontal process of the maxilla and inferior orbital rim, small miniplates with self-tapping monocortical screws to each of these structures are appropriate for fixation. If the conjoining bony segment is only a small piece of lacrimal bone, it may be wired to its normal position using a 28-gauge steel wire.
In those rare patients in whom the MCT is avulsed or severed completely from the bone, perform reattachment to the lacrimal crest. Drill a small hole through the superior aspect of the posterior lacrimal crest with a minidriver and Kirchner wire. Then, guide a 30-gauge steel wire through a thick portion of the MCT and loop it through the hole placed in the posterior lacrimal crest. Slight overcorrection allows for optimal restoration of the vector pull of the MCT in the medial, superior, and posterior directions. See the images below.
Type II fractures
Prepare the patient and achieve exposure as for type I fractures. Additional exposure of the contralateral medial orbital wall is required for fixation. Again, meticulous dissection in a subperiosteal plane is needed to isolate the MCT and associated bone fragment. The comminuted nature of this injury makes this process more difficult and may require piece-meal incision and elevation of periosteum. The medial rectus and superior oblique muscles may be entrapped through narrow rents in the medial orbital wall.
The difficulty in repairing type II and III fractures is in finding a stable anchoring point for the MCT and bone fragment. Fixation to the ipsilateral frontal or nasal bone results in an inaccurate vector pull of the MCT (too anterior) and subsequent dysfunction of the nasolacrimal apparatus.
Transnasal wiring provides a stable source of fixation. Accomplish this by using thin-gauge steel wire (28- 30-gauge) passed through small drill holes placed through the bony segment attached to the MCT. Place the holes just above and below the insertion of the MCT. Pass the wire through one of the holes of the MCT bone segment and then secure it to a large curved needle, which is then passed through the ipsilateral lacrimal bone defect, the nasal septum, and the contralateral lacrimal bone anterior to the posterior lacrimal crest. See the image below.
Pass the needle and wire back to the ipsilateral side, first posterior to the contralateral posterior lacrimal crest and nasal septum, through the ipsilateral defect, and through the other hole of the MCT bone segment. If the opposite side is involved, with fracture of the medial orbital wall, the wires may be secured to a miniplate or screw-fixed on the contralateral superior orbital rim.
If feasible, in addition to transnasal stabilization, use microplates to fix the MCT bony fragment to adjacent stable bone. Other bony fragments (not attached to the MCT), if adequately sized, may be fixed rigidly to stable bone with miniplates or wires.
Type III fractures
These are the most severe of the NOE fractures, are usually bilateral, and are associated with significant comminution and distortion. A higher incidence of associated injuries to the dura, skull base, and intraorbital contents are present with type III fractures.
After careful dissections are performed on both medial orbital walls, perform bilateral intercanthal tendon fixation. Assess the MCT on both sides. Typically, the tendon is attached to a small bony remnant. (For type II fractures, use a small-gauge wire transnasally for fixation.) If the associated MCT bony segment is too small for drill holes, the wire may be passed directly through a thickened portion of the MCT.
Both free ends on the wire are then passed through the lacrimal defect on the first side, through the nasal septum, and through the opposite lacrimal defect. Use the free ends to secure the opposite MCT and bony segment. As the wire is tightened, the MCTs of each side are pulled medially toward each other. To ensure a proper superior and posterior component of pull, take care to pass the wire through a superior and posterior aspect of the nasal septum. Otherwise, poor apposition of the lower lids to the globe may ensue.
If the lacrimal bony defects are much larger than the MCT bony segment, as may occur in severe comminution, primary bone grafting may be indicated to repair the bone loss. A monocortical calvarial bone graft may be used to restore bony continuity and provide anchoring for the MCT wire fixation.
As with other NOE fractures, repair sizable fracture segments that are adjacent to stable structures with miniplates or wire fixation. In severe cases in which a loss of bony nasal dorsal profile occurs, nasal dorsal grafting augmentation may be indicated. Repair of extensive nasolacrimal system injury is described in the article Laceration, Canalicular.
To remind the patient to not manipulate the operated site, a nasal splint dressing may be placed over the nasal dorsum. If a coronal incision was used, place Penrose drains (removed the next day) and a pressure dressing.
Surgeons are divided on the need for postoperative antibiotics. If the original fracture sites were open to the external environment or in communication with intraoral or intranasal spaces, implement prophylactic antibiotics covering gram-positive and anaerobic organisms for 5-10 days.
Observe the patient for 24 hours to watch for possible elevation of intraorbital tension. Perform serial eye examinations during the first postoperative day.
Perform follow-up evaluations at 5-7 days (skin sutures may be removed at this time), 2-4 weeks, 6-8 weeks, and 3-6 months. Longer-term follow-up care may be needed to monitor postoperative complications or deformity.
Persistent telecanthus represents a difficult problem that is avoided by early treatment and precise attachment of the MCT. Pronounced postoperative telecanthus implies inadequacy of the original technique or detachment of the transnasal wire. Reexploration is indicated in such instances. A study by Elbarbary and Ali describes a modified procedure for treating traumatic telecanthus resulting from NOE complex injury, after primary treatment has been delayed or inadequately performed. The technique, performed on 13 patients at least 6 months after they had suffered NOE fractures, involved transnasal canthopexy, with two wires used to hold independently the anterior and posterior limbs of the MCT. Each wire was passed through a single hole in the lacrimal bones (rather than two holes, to keep from weakening the bones), after which the wire was fixed to titanium mesh that had been attached to the contralateral medial orbital rim.
Injury to the lacrimal system may be avoided by intraoperative stenting of the lacrimal puncta and duct. Injury to these structures causes obstruction and epiphora. Additionally, care should be made to avoid securing wires too low on the medial nasal wall and lacrimal crests so they do not impinge on the lacrimal sac. Conjunctivodacryocystorhinostomy may be required to repair such problems.
Nasofrontal duct impingement may ensue following transnasal wiring. In such cases, the wires pull orbital soft tissue into the ethmoid sinus. Patients present with progressive frontal pressure and possible proptosis. CT scan evaluation followed by reconstruction of the duct or, in severe cases, obliteration of the frontal sinus, may be necessary.
If the transnasal wires pass too low on the septum in repair of a type III fracture, the wires may pull the MCT inferiorly and result in scleral show and lid laxity. Repair requires repositioning of the wires to a higher point on the nasal septum.
Soft tissue complications result from technical pitfalls or problems with wound healing. In general, unfavorable scarring may be avoided by closing facial incisions in a 2-layered fashion, with deeper subcutaneous absorbable sutures placed to remove tension from the skin closure. Skin closure should be performed with nontraumatic handling of wound edges and should result in slightly everted wound edges. Scarring from medial canthal incisions may lead to unsightly webbing. The problem may be avoided by designing nonlinear incisions. Revision of scars at this site may be accomplished with Z-plasty or excision and geometric broken-line closure.
Lower lid ectropion may follow a subciliary approach. This complication may be avoided by performing meticulous dissection between the orbital septum and orbicularis oculi muscle and, for patients in whom laxity is present, superolateral suspension of the muscle to the periosteum of the lateral orbital wall. Preserving a strip of pretarsal orbicularis oculi adds support to the lower lid and may reduce the risk of ectropion. If severe ectropion occurs, breaking up the scar with Z-plasty or skin grafting from the opposite lid skin may be necessary.
Nerve injury may have occurred prior to surgery from the initial traumatic insult. Therefore, the status of the main sensory and motor nerves of the face and forehead must be documented prior to surgery. Care should be taken to identify and preserve the supraorbital and infraorbital neurovascular pedicles while the soft tissue flaps are raised. More commonly, supraorbital nerve injury results from nerve stretching when retracting the soft tissue and orbital tissues to gain access to the superior and medial orbital rims.
The frontal branch of the facial nerve may be injured from excess traction on the forehead flap. Anatomic disruption of the nerve may occur if the improper plane is used to raise the lateral aspect of the coronal flap. The nerve is known to cross the arch superficially to the superficial layer of the deep temporalis fascia. Therefore, dissection should be performed deep to this layer. The appropriate plane is accessed by incising the temporalis and dissecting deep to the fascia. Nerve injury is often incomplete and temporary.
Postoperative infections are more apt to occur in the setting of extensive soft tissue injury, contaminated wounds, open fractures, fractures communicating with intranasal or intraoral spaces, or nonevacuated sinus blood. (For more resources on wound care, visit Medscape’s Wound Management Resource Center.) If empiric antibiotic therapy does not clear the infection, debridement and drainage may be required. Cultures should be obtained if purulent material is encountered, and specific antibiotic treatment should be instituted. Long-term unchecked infection may cause osteomyelitis around the sites of the screws or wires. Removal of these implants and debridement of bone may be necessary if antibiotics are unsuccessful.
Outcome and Prognosis
A lack of prospective studies on trauma patients makes assessment of outcome measures for patients treated for naso-orbito-ethmoid (NOE) fractures difficult. Repair of simple fractures typically restores bony aesthetic contour and function; however, complex fractures often leave the patient with some long-term cosmetic and functional deficits. Adjuvant nasal dorsal augmentation may improve residual cosmetic deformity. Early and meticulous surgery is most likely to produce results that restore the patient to the pretrauma state.
Future and Controversies
Absorbable plating systems composed of polylactic acids have recently become available and are gaining popularity for maxillofacial repair. These systems have the advantage of providing rigid osseous fixation without permanent foreign body implantation. This theoretically reduces the risk of infection and plate exposure. The other main advantage of these systems is the ability to contour plates with thermal manipulation (eg, hot saline sponge, specialized heated instruments), even after the plates have been positioned in situ. This facilitates contouring plates to a precise and appropriate shape across fracture lines.
Recent efforts to apply endoscopic techniques in the treatment of facial fractures are promising. As yet, a reliable endoscopic technique to restore accurate repositioning of the MCT and associated bony segments has not been described. Due to the relatively small area involved in these injuries, using endoscopy may prove to be a challenge. Further, with the trend toward more aesthetically favorable incisions that can still provide excellent exposure, the advantages afforded with an endoscopic approach in this area remain unclear.
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