Nasoorbitoethmoid Fractures Treatment & Management

General goals of surgical therapy include protection of orbital and intracranial contents, prevention of early and late complications (eg, blindness, epiphora), and restoration of aesthetic facial contour (eg, normal intercanthal distance, orbital volume). ^[2]

The insertion of the medial canthal tendon onto the bony central fragment is the focal point of nasoorbitoethmoid (NOE) complex reconstruction. The medial canthal tendon-central fragment complex maintains the normal intercanthal distance and outward appearance of the midface. ^[9]

NOE injuries are the most challenging of all facial fractures, and surgical repair is often complex and arduous. Inadequate surgical exposure, imprecise fracture reduction, or poor medial canthal tendon repair almost certainly yields suboptimal results.

Inform all patients undergoing nasoorbitoethmoid (NOE) complex repair of the following risks:

• Scarring, particularly in patients with male-pattern baldness

• Bleeding

• Infection

• Forehead paresthesias

• External deformity (eg, telecanthus, nasal deformity)

• Enophthalmos, diplopia, blindness

• Epiphora

• Anosmia

• CSF leak, meningitis

• Sinusitis

• Death

Surgical exposure can be obtained through coronal incision, subciliary incision, sublabial incision, or canthal stab incision. Although not commonly used, the midface degloving approach has been reported to provide adequate access for nasoorbitoethmoid and other midfacial fractures. ^[3]

Coronal incision

The coronal incision exposes the frontal bone, nasal bones, superior orbital rims, orbital roof, and frontomaxillary buttress.

The patient is positioned 180° away from the anesthesia. Facial lacerations should be explored to augment surgical access. Unfortunately, lacerations alone are usually inadequate for exposure, diagnosis, and repair of nasoorbitoethmoid (NOE) fractures. The hair is parted in a widows-peak pattern 4-6 cm behind the anterior hairline. The hair can be shaved along the incision site in a 1-2 cm strip, although this is not necessary. The scalp is incised and elevated in a subperiosteal plane. A subgaleal plane is used if a dural repair is anticipated (eg, posterior table frontal sinus fracture, known CSF leak). The pericranial flap then can be used for closure of the CSF leak.

Lateral flap dissection is performed between the temporoparietal fascia (superficial temporal fascia) and the temporalis muscle fascia (deep temporal fascia). The fascial planes of the forehead and temple are seen in the image below.

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).

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The temporoparietal fascia and frontal branch of the facial nerve are elevated with the flap. The supraorbital and supratrochlear neurovascular pedicles are identified and protected. Exposure over the glabella, nasal bones, superior orbital rims, and orbital roof may require release of the supraorbital and supratrochlear neurovascular pedicles. The pedicles are released by outfracturing the inferior portion of the foramina with a fine osteotome.

After completion of the bony repair, the galea aponeurosis and skin are closed in a layered fashion. The periosteum is resuspended carefully at the orbital rims and over the zygomatic arches to avoid postoperative ptosis. Two Penrose drains and a pressure dressing are applied, and care is taken to assure that the ears are not rolled forward under the pressure dressing.

Subciliary incision

The subciliary incision as seen in the image below exposes the inferior orbital rim, orbital floor, a portion of the medial orbital wall, the frontomaxillary buttress, and the lateral nasal bones.

Illustration depicts the subciliary approach to the orbital floor and nasoorbitoethmoid complex.

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Corneal shields are placed over the eyes bilaterally. A small amount of local anesthesia is infiltrated into the lower lid just below the lash line. A 4-0 silk retention suture is placed through the gray line of the lower eyelid. Superior tension is applied to stabilize the lower eyelid. A subciliary incision is placed parallel to, and 2 mm below, the lash line. The incision extends from the medial lash margin to the lateral canthus. Westcott scissors are used to form a tunnel beneath the orbicularis oculi muscle but superficial to the orbital septum. One blade of the scissors then is placed in the tunnel, and the preseptal space is opened 2-3 cm below the skin incision. This incision preserves a strip of pretarsal orbicularis oculi muscle to support the lower eyelid and reduce the risk of postoperative ectropion.

A Westcott scissor and a cotton swab are used for sharp and blunt dissection between the orbicularis oculi muscle and the orbital septum. The proper plane is relatively avascular. Minor bleeding can be controlled with bipolar cautery. If the dissection is performed too deeply, the orbital septum is violated and orbital fat is exposed. If the dissection is performed too superficially, the orbicularis oculi muscle is cut, which results in increased bleeding, possible skin perforation, and an increased risk of postoperative ectropion.

Once the orbital rim is exposed, the periosteum is incised with a monopolar needle cautery. Careful subperiosteal dissection is performed to expose the orbital floor, medial orbital wall, and frontomaxillary buttress, as necessary. The medial dissection must remain on the orbital rim to avoid injuring the lacrimal apparatus. After reduction and plating of the NOE complex fractures, the periosteum is closed with 4-0 polyglycolic suture. The skin muscle flap is redraped, and the skin incisions are closed with 6-0 absorbable suture. Patients with lower lid laxity may require a lateral tacking stitch from the pretarsal/preseptal orbicularis oculi muscle to the lateral orbital rim.

Transconjunctival incision

Transconjunctival exposure of the orbit: The transconjunctival incision eliminates an external scar and reduces the risk of postoperative ectropion. Unfortunately, the lacrimal apparatus limits the exposure of the medial orbital wall and nasal nasomaxillary buttress. When using a transconjunctival approach (which the author prefers) the author often makes a 8-mm stab incision in the medial lower lid (in a natural skin crease) to obtain access to the nasomaxillary buttress. The palpebral conjunctiva is first infiltrated with a small amount of local anesthesia. Two 4-0 silk sutures are placed through the gray line to retract the lid inferiorly. A lateral canthotomy is performed using a scalpel. An inferior cantholysis is performed using Westcott scissors and microforceps.

Bleeding is controlled with bipolar cautery. The Westcott scissors are used to elevate a transconjunctival plane deep to the lower lid retractors but superficial to the orbital septum. The scissors are then inserted and the conjunctiva is tented upward. A needlepoint electrocautery is used (on very low power) to cauterize the conjunctiva at the proposed incision site. The scissors are used to incise the area. The exposure is carried medially to a point just lateral to the lower lid punctum. Dissection to the orbital rim is completed with the Westcott scissors and a cotton swab. The correct dissection plane is relatively avascular.

Once the orbital rim is reached, the needlepoint cautery is used to expose the rim, and the dissection is carried along the floor and medial orbital wall. Once the repair is complete, the conjunctiva is closed with a running 6-0 fast absorbing gut, the lateral canthotomy is closed with a 5-0 absorbing monofilament suture, and the skin is closed with 6-0 nylon.

Sublabial incision

The sublabial incision provides exposure of the piriform aperture, the face of the maxilla, and the frontomaxillary buttress.

The gingivobuccal sulcus is infiltrated with local anesthetic, and electrocautery is used to incise the mucosa. The incision is placed 1-2 cm above the gingival margin and extends from the midline to the canine fossa, leaving an adequate gingival cuff for closure of the incision. The incision can be extended laterally for greater exposure; however, take care not to enter the buccal fat pad, which obstructs the field of view. The dissection is carried to the face of the maxilla. A periosteal elevator is used to expose the face of the maxilla, piriform aperture, maxillary branch of the trigeminal nerve, inferior orbital rim, and the frontomaxillary buttress. After completion of the bony repair, the incision is closed with running, locking, 3-0 chromic suture.

Canthal stab incision

The canthal stab incision allows identification of a severed medial canthal tendon. Local anesthetic is infiltrated over the medial canthal tendon. A 3- to 4-mm horizontal stab incision is placed approximately 5 mm medial to the medial palpebral fissure, and the fibrous tissue making up the medial canthal tendon is dissected free. After medial canthal tendon repair, the wound is closed with deep 4-0 interrupted polyglycolic sutures, and the skin is closed with 6-0 interrupted nylon sutures.

Other exposures

Transcaruncular exposure of the orbit

The transcaruncular approach allows excellent exposure of the medial orbital wall, but it does not allow exposure of the nasal bones or medial canthal tendon. A study by Imaizumi et al of six patients with type I NOE fractures and two with Le Fort II fractures reported the extended transcaruncular approach to be a promising technique for repair of these injuries and a means of avoiding the drawbacks of skin incisions. Excellent fracture realignment was achieved in each case, although complications associated with the extended transcaruncular approach occurred in two cases. ^[10]

Glabellar and open-sky incision

This incision is generally avoided because of unfavorable external scars and postoperative paresthesias.

Fracture repair

Surgical repair of facial fractures should be performed from the periphery (ie, the skull base, which is stable) toward the central facial skeleton. Any maxillary or frontal bone fractures should be reduced and plated to provide an accurate template for NOE fracture repair.

• Type I fractures

  • Nondisplaced single fragment injuries do not require surgical repair.

  • Displaced type I fractures usually require coronal, transconjunctival, and sublabial exposures.

  • Two separate microplates (1-1.2 mm) are applied from the frontal bone to the central fragment and from the maxilla to the central fragment.

  • An accurate reduction must be maintained until both plates are placed, or the lateral pull of the medial canthal tendon may result in central fragment lateralization and subsequent telecanthus.

  • Application of a single microplate from the frontal bone, across the entire central fragment, and onto the maxilla should be avoided, if possible. Such placement requires more elevation of the periosteum on the central fragment, which may disrupt the medial canthal tendon. Plates placed in this region also may widen the nasal root.

• Type II fractures

  • Comminuted fractures require more extensive surgical exposure, microplate reduction, and transnasal wiring.

  • Sublabial, transconjunctival, and coronal incisions are used routinely.

  • A subperiosteal dissection is used to locate, but not avulse, the medial canthal tendon.

  • Holes are drilled in the central fragment above and below the medial canthal tendon. Nonabsorbable suture or 28-gauge stainless steel wire is passed lateral to medial through the central fragment and twisted tightly on the medial aspect of the central fragment. Separate holes are drilled through the medial orbital wall posterior and superior to the lacrimal fossa.

  • Holes drilled anterior to the lacrimal fossa result in lateral rotation of the central fragment and telecanthus as seen in the image below. Drilling above the frontoethmoid suture line should be avoided to decrease the risk of intracranial entry. The cribriform plate lies inferior to the roof of the fovea ethmoidalis. Exit holes are drilled on the contralateral side.

    (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.

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  • A large spinal needle is passed retrograde through the holes toward the NOE injury. The transnasal wires are passed through the lumen of the needle, and the needle is extracted. The wires are secured to a microscrew or plate on the contralateral superior orbital rim. Microplates are applied to rigidly fixate the central fragment to stable medial orbital bone.

• Type III fractures

  • Type III fractures are associated with more severe trauma and may require primary bone grafting.

  • Sublabial, transconjunctival, and coronal incisions routinely are required.

  • A higher risk of lacrimal duct injury occurs with type III fractures. If frank nasolacrimal injury is present, the nasolacrimal apparatus should be cannulated and stented.

  • After adequate surgical exposure is obtained, the medial canthal tendon remnant is identified. A medial canthal incision can be used to identify the medial canthal tendon, if necessary. The author has generally been able to identify the tendon via a coronal incision by placing a 27-gauge wire transcutaneously at the medial canthus and identifying the tip of the needle internally. A 28-gauge wire or nonabsorbable suture is then passed through the stump twice and to secure the medial canthal tendon. The bony central fragment is identified, and 2 holes are drilled for insertion of transnasal wires.

  • If the central fragment cannot be identified or reconstituted with a suitable bone fragment in the surgical field (ethmoid or maxillary bone), an outer table calvarial bone graft can be used. Bone grafts must be of adequate size to fill the medial canthal defect. The wire (previously attached to the medial canthal tendon) is passed through the central fragment and twisted securely. The wire then is passed transnasally and fixated as previously described (see Type II fractures). Microplates are applied to rigidly fixate the central fragment to stable medial orbital bone.

  • Type III injuries that result in significant loss of nasal projection are repaired primarily with a calvarial bone graft. After medial canthal tendon reconstruction is complete, an outer table calvarial bone graft is harvested to reconstruct the nasal dorsum.

    • The graft should be positioned to allow for reconstitution of the premorbid nasofrontal angle and extended as far as necessary to provide adequate tip support. The graft is cantilevered off the frontal bone with a miniplate or with 2 position screws as seen in the image below. Both the functional and aesthetic characteristics of the nasal architecture should be restored with attention to the nasal dorsal height, tip projection, lateral nasal wall correction and stability of the nasal bone fractures. ^[11]

      Reconstruction of nasal dorsum with cantilevered calvarial bone graft is shown.

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  • After surgical repair, external bolsters are required to prevent hematoma formation, widening of the nasion, and pseudotelecanthus. Thermally activated external nasal bolsters, commonly used for nasal fractures, can be wrapped in Xeroform gauze and applied to the lateral nasal sidewall. Transnasal wires are passed through the medial canthal region and back through the nose just inferior to the nasal bones. The wires are twisted to apply pressure and reduce soft tissue edema. The underlying tissue is closely observed to avoid tissue necrosis.

Postoperative ophthalmologic examination is recommended, as well as gross visual acuity checks every 6 hours for a 24-hour period. The Penrose drains are removed from the scalp at 24 hours, and the pressure dressing is discontinued after 3 days. The lead bolsters and scalp sutures are removed at 10 days postoperatively. The patient should be examined and queried again, looking for any evidence of a CSF leak. Patients should be asked to perform standard nasal hygiene (nasal saline irrigations and no nose blowing).

Routine follow-up care is performed postoperatively at 2 weeks, 1 month, 3 months, 6 months, and then as needed if revision procedures are necessary. Long-term follow-up care can be difficult in this patient population.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Facial Fracture and Broken Nose.

Persistent lower lid ectropion is an uncommon complication of the subciliary approach and is best avoided by the following:

• Precise surgical incisions and dissection between the orbital septum and the orbicularis oculi muscle

• Maintenance of a pretarsal strip of orbicularis oculi muscle below the skin incision

• Minimizing the use of electrocautery

• Precise surgical closure with lateral suspension of the orbicularis oculi muscle when lower lid laxity is present

Postoperative telecanthus is a relatively common complication of nasoorbitoethmoid (NOE) fracture repair and is best avoided by the following:

• Obtaining adequate surgical exposure

• Precise reduction of the medial canthal tendon and the bony central fragment

A study by Elbarbary and Ali described 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 medial canthal tendon. 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. ^[12]

Pseudotelecanthus is defined as widening of the nasion with normal intercanthal distance. Pseudotelecanthus occurs when the medial canthal tendon and central fragment are repaired accurately, but the treatment of nasal fractures and the overlying soft tissue is inadequate. This complication is best avoided by the following:

• Accurate diagnosis and treatment of nasal fractures

• Appropriate use of lead bolsters and transnasal wires

Enophthalmos results from inadequate repair of the medial orbital wall or orbital floor. This complication is best avoided by the following:

• Accurate diagnosis of orbital blow-out fractures on the preoperative CT scan

• Adequate surgical exposure and repair of significant orbital blow-out fractures

Midface retrusion may occur but is best avoided by the following:

• Accurate intraoperative assessment of nasal dorsal height (often difficult because of soft tissue edema) and judicious use of primary bone grafting to the nasal dorsum

• Accurate reduction of associated mid-facial fractures and adequate fixation of the fracture segments with bone plates and screws

Disruption of the delicate ethmoid complex and comminution of the nasal bones can make the repair of nasoorbitoethmoid (NOE) complex fractures extremely difficult. These injuries often test the capabilities of even the most experienced surgeons. To obtain an aesthetic surgical result, the surgeon must meticulously identify, accurately reduce, and rigidly fixate the medial canthal tendon and central fragment. Special attention also must be focused on the overlying soft tissue to avoid hematoma, chronic induration, and pseudotelecanthus.

A retrospective study by Lopez et al of pediatric patients with nasoorbitoethmoid (NOE) fractures indicated that transnasal wiring can effectively prevent type III fracture–related telecanthus, with none of the type III patients in the study who underwent this procedure developing the condition postoperatively. ^[13]

Aesthetic reconstruction of the nasal root and medial canthal region continues to be a significant surgical challenge. Future advances may address this issue with the use of surgical navigation systems and/or intraoperative imaging, which returns the bony architecture to its premorbid state more accurately.