Nasoorbitoethmoid Fractures Workup

  • Author: Travis T Tollefson, MD, MPH, FACS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 16, 2012
 

Laboratory Studies

  • Beta2-transferrin is the definitive test for CSF rhinorrhea. Collect 1 mL of the suspected fluid in a red top tube. Beta2-transferrin is a "send out" laboratory at most institutions. Watery rhinorrhea that is positive for beta2-transferrin is diagnostic for a CSF leak. Besides CSF, only the vitreous humor of the eye and the perilymph of the ear have been found to contain beta2-transferrin.
  • Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign. If CSF is present, it diffuses faster than blood and results in a clear halo around the central stain.
  • Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF.
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Imaging Studies

Plain radiographs have limited usefulness in aiding the diagnosis of nasoorbitoethmoid (NOE) fractures.

Thin-cut (1.5 mm) axial and coronal (when available) CT scans are the criterion standard for the diagnosis of NOE fractures. Axial CT scan image of comminuted NOE fracture is seen in the image below.

Axial CT scan demonstrates a comminuted nasoorbitoAxial CT scan demonstrates a comminuted nasoorbitoethmoid complex fracture.
  • Axial images reveal injury to the frontal sinus, lamina papyracea, ethmoid complex, nasal septum, and nasal bones.
  • Coronal images detail injuries to the cribriform plate, nasofrontal recess, orbital roof and floor, and lamina papyracea.
  • Contrast enhancement of the CSF can assist with the diagnosis of CSF fistula.
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Contributor Information and Disclosures
Author

Travis T Tollefson, MD, MPH, FACS  Associate Professor, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center

Travis T Tollefson, MD, MPH, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

E Bradley Strong, MD  Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of California at Davis

E Bradley Strong, MD is a member of the following medical societies: Alpha Omega Alpha and American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Jack A Coleman, MD  Consulting Staff, Franklin Surgical Associates

Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US

Disclosure: Accarent, Inc. Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Stephen G Batuello, MD  Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

References

  1. Sargent LA. Nasoethmoid orbital fractures: diagnosis and treatment. Plast Reconstr Surg. Dec 2007;120(7 Suppl 2):16S-31S. [Medline].

  2. Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg. May 1991;87(5):843-53. [Medline].

  3. Liau JY, Woodlief J, van Aalst JA. Pediatric nasoorbitoethmoid fractures. J Craniofac Surg. Sep 2011;22(5):1834-8. [Medline].

  4. Cultrara A, Turk JB, Har-El G. Midfacial degloving approach for repair of naso-orbital-ethmoid and midfacial fractures. Arch Facial Plast Surg. Mar-Apr 2004;6(2):133-5. [Medline].

  5. Potter JK, Muzaffar AR, Ellis E, Rohrich RJ, Hackney FL. Aesthetic management of the nasal component of naso-orbital ethmoid fractures. Plast Reconstr Surg. Jan 2006;117(1):10e-18e. [Medline].

  6. Herford AS, Ying T, Brown B. Outcomes of severely comminuted (type III) nasoorbitoethmoid fractures. J Oral Maxillofac Surg. Sep 2005;63(9):1266-77. [Medline].

  7. Hoffmann JF. Naso-orbital-ethmoid complex fracture management. Facial Plast Surg. 1998;14(1):67-76. [Medline].

  8. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: what the surgeon needs to know. Radiographics. May-Jun 2006;26(3):783-93. [Medline].

  9. Leipziger LS, Manson PN. Nasoethmoid orbital fractures. Current concepts and management principles. Clin Plast Surg. Jan 1992;19(1):167-93. [Medline].

  10. Sargent LA, Rogers GF. Nasoethmoid orbital fractures: diagnosis and management. The Journal of Cranio-Maxillofacial Trauma. 1999;5(1):19-27.

 
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A diagram of the nasoorbitoethmoid complex is shown. Note that the cribriform plate descends approximately 1 cm below the level of the ethmoid roof (fovea ethmoidalis).
Vertical buttresses of the nasoorbitoethmoid complex are depicted.
Horizontal buttresses of the nasoorbitoethmoid complex are depicted.
Anatomy of the medial canthal tendon is shown. The tendon splits around the lacrimal sac and attaches to the anterior and posterior lacrimal crests, as well as to the frontal process of the maxilla. The canthal tendon diverges to become the pretarsal, preseptal, and orbital orbicularis oculi muscle.
Midface dimensions are depicted. A normal intercanthal distance is 30-35 mm, which is approximately half of the interpupillary distance and is equivalent to the width of the nasal base.
Nasoorbitoethmoid complex fractures are classified according to 3 types. (A) Type I fractures involve a single, noncomminuted, central fragment without medial canthal tendon disruption (left-unilateral, right-bilateral). (B) Type II fractures involve comminution of the central fragment without medial canthal tendon disruption (left-unilateral, right-bilateral). (C) Type III fractures result in severe central fragment comminution with medial canthal tendon disruption (left-unilateral, right-bilateral).
Axial CT scan demonstrates a comminuted nasoorbitoethmoid complex fracture.
Illustration depicts the fascial planes of the forehead and temple. The temporal branch of the facial nerve runs within the superficial temporal fascia (temporoparietal fascia).
Illustration depicts the subciliary approach to the orbital floor and nasoorbitoethmoid complex.
(Above) Transnasal wires placed anterior to the lacrimal fossa result in rotation of the central fragment laterally, which results in postoperative telecanthus. (Below) Transnasal wires placed posterior and superior to the lacrimal fossa provide adequate support for the medial canthal tendon, and postoperative telecanthus is avoided.
Reconstruction of nasal dorsum with cantilevered calvarial bone graft is shown.
 
 
 
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