Nasoorbitoethmoid Fractures Workup

Initial evaluation

This is carried out as follows:

• Establish ABCs.
• Diagnose any associated injuries.
• After stabilization, perform a thorough head and neck examination to reveal injuries to the brain, spine, orbits, and facial skeleton.
• A team approach involving the otolaryngologist/plastic surgeon, neurosurgeon, and ophthalmologist is recommended.
• Ophthalmologic consultation is mandatory.

Direct examination of the NOE complex

This is performed as follows:

• Examine the nasal cavity for the presence of CSF.
• Query all conscious patients about the presence of watery rhinorrhea or salty postnasal drainage.
• Test bloody fluid that is suspicious for CSF rhinorrhea (see Lab Studies).
• Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation.
• To evaluate the integrity of the medial canthal tendon, place the thumb and index finger over the nasal root and carefully apply lateral tension to each lower lid. Normally, a defined endpoint to the maneuver is evident without palpable motion at the medial canthus. A lax medial canthal tendon or medial orbital wall motion is consistent with an NOE complex fracture. A periosteal elevator also can be inserted through the nose to palpate the stability of the medial canthal tendon complex. The clinical medial canthal integrity should be compared with the CT evidence to classify the fracture and associated injuries and used to develop an early comprehensive management plan. ^[7]
• Measure and document telecanthus and enophthalmos.
• Assess and document pupil responses and extraocular muscle mobility.
• Palpate the nasal bones for crepitus and comminution.
• Evaluate the septum for septal hematoma.
• Evaluate the degree of nasal or midface retrusion. Preinjury photographs may be helpful.

See the list below:

• 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.

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 nasoorbitoethmoid complex fracture.

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See the list below:

• 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.

A study by Nissen et al, using a retrospective analysis of CT scans from patients at a level I trauma center, suggested that in individuals with zygoma fractures, concomitant NOE fractures are underdiagnosed. The investigators found the incidence of concomitant NOE fractures in zygoma fractures to be 30.6%. However, in radiology, plastic surgery, and operative notes, the rates of NOE documentation were 0%, 3.7%, and 8.3%, respectively. Significantly displaced NOE fractures (found in 16.9% of zygoma fractures) had documentation rates of 0%, 6.7%, and 16.8%, respectively. ^[8]