Naso-orbitoethmoid (NOE) Complex Fracture

A naso-orbitoethmoid (NOE) complex fracture is a break of the thin bones in the middle of the face where the top of the nose meets the inner corner of the eye sockets and the small air cells (ethmoid sinus) between them. This area is crowded with important structures. It holds the medial canthal tendon (the tight band that anchors the inner corners of your eyelids), the tear-drainage sac, the thin walls of the eye socket, and the roof of the nasal cavity just below the skull base. When a strong blow pushes straight into the bridge of the nose, these thin bones can crack or shatter and move out of place. Because these bones are tied to the inner eyelid tendon and sit beside the eye, an NOE fracture can change how the eyes look (for example, the inner corners can drift apart), can change how tears drain, and can affect vision, smell, and breathing through the nose.

In simple terms: an NOE fracture is a central facial fracture at the root of the nose that often involves the inner corner of the eyelids, the tear system, and the medial (inner) wall of the eye socket. It is usually caused by high-energy blunt force, and it often occurs with other facial fractures. It needs careful checking because the injuries are close to the eyes and the brain.

Anatomy

• The ethmoid bones form small, honeycomb-like air cells between the nose and the eyes. They make up the inner wall of each eye socket and the roof of the nasal cavity.

• The medial canthal tendon (MCT) anchors the eyelids to the rim of the eye socket at the inner corner. If this tendon is ripped from its bony anchor, the eyelids pull apart and the eyes can look “wider apart” (called telecanthus).

• The lacrimal sac sits in a groove at the inner corner of the eye. It collects tears and drains them into the nose. This can tear or scar in NOE injuries, leading to constant tearing.

• The cribriform plate (part of the skull base) is just above the ethmoid sinus. If this part cracks, clear fluid from around the brain can leak into the nose (CSF leak).

• Nearby nerves (especially the frontal, supratrochlear, infratrochlear, and sometimes infraorbital branches of the trigeminal nerve) carry feeling from the forehead, inner eyelids, and upper cheek. These can be bruised or stretched in a fracture.

• The nasal bones, the frontal process of the maxilla, and the lacrimal bone all meet here. A break at this crossroads can spread in several directions and involve many structures at once.

Pathophysiology

A strong front-to-back force strikes the nasal bridge. The force pushes the central face backward, buckles the thin ethmoid walls, and can pull the medial canthal tendon off its bony anchor. Bones may break into one central piece or into many small pieces (comminution). Soft tissues swell and bruise. Blood collects inside the nose and sinuses. If the fracture line reaches the lacrimal sac, tears cannot drain normally. If the fracture line reaches the skull base, CSF may leak. If the fracture shifts the medial orbital wall, the eye muscles can get pinched, leading to double vision. If the globe is injured or the optic nerve is stretched, vision can blur. Because the bones are thin and tied to important soft tissues, even a small-looking cut can hide a deep and serious injury.

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Types of NOE fractures

By stability of the medial canthal tendon (Markowitz–Manson classification, explained simply):

1. Type I (single central fragment, tendon attached):
   The bones break but the inner eyelid tendon stays attached to a single central bone piece. The inner eyelid corner is usually stable. Telecanthus is mild or absent. Surgery, when needed, often repositions and fixes that single fragment.

2. Type II (comminuted central fragment, tendon still attached):
   The bones break into several pieces, but the tendon remains attached to some bone. The inner eyelid corner is less stable than in Type I. Telecanthus can be present. Surgery may need to rebuild the area and secure the tendon by fixing the bone pieces together or plating them to stable bone.

3. Type III (avulsion of the tendon from bone):
   The tendon is pulled free from its normal bony anchor. The inner eyelid corner is unstable and drifts outward, causing clear telecanthus. Reconstruction must reattach the tendon to strong bone, often with plates, screws, or small bone anchors. This is the most severe pattern.

By laterality:

• Unilateral NOE fracture: one side is broken.

• Bilateral NOE fracture: both sides are broken; facial widening is more likely.

By wound status:

• Closed: skin is intact; swelling and deformity may still be significant.

• Open: there is a cut or laceration over the fracture; higher infection risk; deeper structures may be exposed.

By associated structures:

• With lacrimal system injury: tearing problems are common.

• With skull base involvement: risk of CSF leak and meningitis.

• With ocular injury: risk to the globe, extraocular muscles, or optic nerve.

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Common causes

1. Motor vehicle collision (front-seat impact): the dashboard, steering wheel, or airbag hits the nasal bridge.

2. Motorcycle crash: the face meets the road or another object with high speed and force.

3. Bicycle crash: the handlebar or ground strikes the central face.

4. Pedestrian struck by a vehicle: direct blow to the face from bumper or ground.

5. High-level fall: landing face-first from a height drives force into the nasal bridge.

6. Ground-level fall in older adults: even a simple trip can cause a strong nose impact on hard floors.

7. Assault with a fist or object: a punch or blunt weapon hits the bridge of the nose.

8. Sports injury (boxing or MMA): repeated direct blows to the central face.

9. Sports injury (hockey, baseball, cricket): a puck or ball hits the nose-eye junction.

10. Sports injury (football/soccer): a head-to-head or elbow-to-face collision.

11. Industrial accident: a heavy tool or machine part strikes the midface.

12. Worksite fall onto equipment: face hits bars, scaffolds, or ladders.

13. Bicycle handlebar jab in children: smaller faces concentrate force over the ethmoid area.

14. E-scooter or skateboard fall: unprotected face meets pavement at speed.

15. Animal-related impact: a kick from a horse or a headbutt from large animals.

16. Explosive or blast wave: overpressure and debris injure the thin ethmoid bones.

17. Firework or projectile injury: small high-speed objects strike the nasal bridge.

18. Door or heavy object swing: the edge of a door hits the root of the nose.

19. Seizure-related fall: sudden fall forward onto a hard surface.

20. Iatrogenic or peri-operative trauma (rare): difficult nasal or orbital procedures accidentally stress the area.

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Common symptoms and signs

1. Swelling and bruising around the eyes and nose: the area looks puffy and discolored.

2. Flattening or widening of the nasal bridge: the nose looks pushed in or the face looks “wider” at the eyes.

3. Telecanthus (inner corners of the eyes look farther apart): the eyelid corners drift outward because the tendon is loose or the bone moved.

4. Nosebleed (epistaxis): blood flows from one or both nostrils after the impact.

5. Nasal blockage or stuffiness: swollen tissues and blood clots make breathing through the nose hard.

6. Clear, watery drip from the nose after trauma: this can be CSF leak, especially if salty tasting or worse with leaning forward.

7. Double vision (diplopia) or blurry vision: shifting bones or trapped muscles affect eye movement or focus.

8. Eye movement pain or restriction: looking to the side, up, or down hurts or feels stuck.

9. Tearing all the time (epiphora): damage to the lacrimal sac or duct stops normal tear drainage.

10. Numbness or tingling above the nose or inner eyelids: small sensory nerves are bruised.

11. Tenderness over the inner eye socket and nasal root: touching the area hurts.

12. Crepitus (crackling under the skin): air from sinuses leaks under the skin and makes a crackling feel.

13. Small cuts near the inner eye corner or along the nose: open wounds can overlie deeper fractures.

14. Headache or facial pressure: swelling in the sinuses and bruised bone cause deep ache.

15. Changes in smell: if the fracture extends to the skull base, smell can be reduced or altered.

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Diagnostic tests

A) Physical exam tests

1. Careful visual inspection of the nasal root and inner eye corners
   The clinician looks from the front and from above. They check the shape of the nasal bridge, the height and width of the root of the nose, and the position of the inner eye corners. They look for bruising, cuts, widening between inner eye corners (telecanthus), and flattening of the nasal root. This simple step often gives the first clue that an NOE pattern is present.

2. Palpation for step-offs and bone movement
   With gloved hands, the clinician gently feels along the inner rim of the eye socket and the bridge of the nose. A “step-off” feels like a shelf where bone edges no longer line up. Mobility or crunching under the fingers suggests the bones are broken or the sinuses are full of air under the skin.

3. Anterior rhinoscopy (front-of-the-nose lighted exam)
   A small speculum and light are used to look inside the nostrils. The clinician checks for active bleeding, clots, tears in the lining, and a septal hematoma (a blood pocket in the septum that must be drained quickly). They also look for clear fluid suggestive of CSF.

4. Basic ocular exam: visual acuity and pupil responses
   Vision is checked with a handheld chart if possible. Pupils are checked for size, equality, and reaction to light. A relative afferent pupillary defect can suggest optic nerve trouble. This quick screen guides urgency and next tests.

5. Extraocular movement testing (follow-the-finger test)
   The patient follows a target in all directions. Pain or limited movement suggests swelling, muscle entrapment, or bone displacement at the medial wall or floor of the orbit. The test also checks if double vision appears in specific gaze positions.

B) Manual (bedside) tests

6. Measurement of the intercanthal distance (ICD) with a ruler or caliper
   The distance between the inner corners of the eyelids is measured and compared with normal values and with old photos if available. A clearly increased distance supports telecanthus from MCT injury.

7. Medial canthal tendon “pinch” or traction test
   The examiner gently pulls the inner eyelid skin and observes how firmly it springs back. Excessive laxity or displacement suggests that the tendon is no longer firmly attached to bone, pointing toward a Type II or Type III pattern.

8. Bimanual palpation (external and intranasal) of the NOE segment
   With one gloved finger inside the nose and the other hand outside on the nasal root, the examiner feels for abnormal motion of the central fragment. Abnormal “rocking” indicates segment instability that often needs surgical fixation.

9. Fluorescein dye disappearance test (simple tear-drain check)
   A drop of fluorescent dye is placed in the eye. After a few minutes, the examiner looks to see if the dye has drained. Persistent dye pooling suggests a blocked lacrimal system from NOE injury. This is a quick, bedside check.

10. Infraorbital and supratrochlear light-touch testing (sensory screen)
    A cotton wisp or soft swab is lightly touched to the skin above the nose, inner eyelids, and upper cheek. Reduced or asymmetric feeling can signal nerve bruising near the fracture.

C) Laboratory and pathological tests

11. Complete blood count (CBC)
    This looks for anemia from bleeding and checks infection markers if there is an open wound or sinus involvement. It helps with surgical planning and overall safety.

12. Coagulation profile (PT/INR, aPTT)
    This checks how well the blood clots. It is important if there is ongoing bleeding, if the patient uses blood thinners, or if surgery may be needed soon.

13. Beta-2 transferrin (or beta-trace protein) test for suspected CSF leak
    If clear fluid drips from the nose, a sample can be tested for beta-2 transferrin (or beta-trace protein). These markers are found in CSF but not in regular nasal secretions. A positive test confirms a CSF leak that needs careful management.

D) Electrodiagnostic tests

14. Visual evoked potentials (VEP) when optic nerve injury is suspected
    Flashes of light are used to stimulate the eye while electrodes on the scalp record the brain’s response. Delayed or reduced signals suggest the optic nerve is not conducting normally. This can be useful when exam cooperation is limited or swelling hides other signs.

15. Blink reflex electromyography (EMG) in selected nerve injuries
    Gentle electrical stimulation around the eye triggers a reflex blink. EMG measures the timing and strength of this reflex through facial muscles. Abnormal results can show damage along the trigeminal–facial reflex arc at the inner orbital region. This is rarely needed but can support complex nerve assessments.

E) Imaging tests

16. Thin-slice, non-contrast maxillofacial CT (gold standard)
    A CT scan with thin cuts through the midface shows the exact break lines, the number of fragments, and how far pieces have shifted. It clearly shows the medial orbital wall, the lacrimal sac region, and the bony attachment of the medial canthal tendon. Coronal and sagittal reformats are essential for surgical planning.

17. 3-D CT reconstruction for operative planning
    The same CT data are processed to create a 3-D model of the fractured bones. Surgeons use this to understand the deformity, plan the direction of reductions, choose plate sizes, and anticipate how to reattach the tendon.

18. MRI of the orbits and skull base (problem-focused)
    MRI shows soft tissues better than CT. It helps when there is suspected optic nerve injury, muscle entrapment not clear on CT, lacrimal sac soft-tissue damage, or concern for brain or meningeal involvement. MRI is also useful if a CSF leak is suspected and CT does not show the exact site.

19. Dacryocystography or dacryoscintigraphy (tear-drainage imaging)
    Contrast dye or a tracer is placed in the tear duct, and images show whether the lacrimal system is open or blocked. This helps decide if simple stenting may work or if a more complex reconstruction is needed.

20. Ocular ultrasound (B-scan) when the globe is closed and CT is inconclusive
    If the eyeball is intact (no open-globe injury), a B-scan can look for retinal detachment or vitreous hemorrhage that may explain sudden vision loss. It is not used when a globe rupture is suspected.

Non-pharmacological treatments

These are the day-to-day, no-pill measures used alone in minor, stable injuries or alongside surgery in more serious cases. Each item lists its description, purpose, and mechanism in simple terms.

1. Head elevation (30–45°) while resting and sleeping.
   Purpose: Reduce swelling and pressure.
   Mechanism: Gravity improves venous/lymphatic drainage from the midface and orbit, easing edema and discomfort.

2. Cold compresses in the first 24–48 hours (10–20 minutes on, then off).
   Purpose: Calm pain and swelling.
   Mechanism: Cooling causes surface blood vessels to constrict, limiting fluid leak into tissues and numbing nerve endings.

3. Strict “sinus precautions.”
   Purpose: Prevent air/pressure from being forced through the fracture lines and sinuses.
   Mechanism: Do not blow your nose, don’t use straws, sneeze with your mouth open, avoid scuba/air travel early, avoid wind instruments. These steps limit pressure spikes that can drive air or bacteria into wounds or eye socket. University of Michigan Medical SchoolArizona Oral & Maxillofacial Surgeonsadvancedoralsurgerymi.com

4. Eye protection and ocular surface care.
   Purpose: Shield a bruised eye and protect the cornea if eyelid closure is incomplete.
   Mechanism: A clear shield at night and lubricating drops/gel keep the eye surface moist and protected while soft tissues heal.

5. Short-term eye patching for distressing double vision (if advised).
   Purpose: Reduce nausea/headache from diplopia before definitive care.
   Mechanism: Occluding one eye eliminates conflicting images until swelling settles or surgery is performed.

6. Gentle nasal saline spray or irrigations (when permitted).
   Purpose: Keep nasal cavities moist/flushed without force.
   Mechanism: Isotonic saline loosens crusts and reduces infection risk; never forceful irrigation early if skull base breach is suspected. (Your surgeon will advise when it’s safe.) Medscape

7. Wound care for facial lacerations.
   Purpose: Lower infection risk.
   Mechanism: Soap-and-water cleansing around—but not scrubbing—sutures, plus petroleum or antibiotic ointment as directed, keeps edges moist and clean.

8. Avoid nasal intubation and traumatic nasal instrumentation until cleared.
   Purpose: Protect fractured midface/skull base.
   Mechanism: In unstable midface or suspected basilar skull fractures, nasal tubes can track intracranially; alternative airways are preferred. (Anesthesia teams individualize this.) MedscapeNCBI

9. Soft, non-chewy diet for 2–3 weeks.
   Purpose: Limit strain on midface buttresses and reduce pain.
   Mechanism: Soft foods avoid heavy bite forces transmitted to fracture lines.

10. Smoking cessation and alcohol avoidance.
    Purpose: Improve healing and lower infection/bleeding risks.
    Mechanism: Nicotine reduces blood flow and collagen formation; alcohol impairs immunity and raises bleeding risk.

11. Oral hygiene focus.
    Purpose: Reduce bacterial load that can seed sinus/soft-tissue infections.
    Mechanism: Twice-daily brushing (gentle near incisions), salt-water rinses, and flossing where comfortable. University of Michigan Medical School

12. Activity modification.
    Purpose: Prevent re-injury.
    Mechanism: No contact sports, heavy lifting, or bending/straining for several weeks, as Valsalva surges and impacts can displace repairs. northernmontanaoms.com

13. Vision safety checks (home “red flags”).
    Purpose: Catch emergencies early.
    Mechanism: Monitor for sudden vision drop, severe eye pain, proptosis (bulging), or a dilated/non-reactive pupil—symptoms of orbital compartment syndrome needing immediate care. EyeWikiMedscape

14. Humidified room air.
    Purpose: Ease nasal dryness, crusting, and bleeding.
    Mechanism: Moist air keeps mucosa supple while sinuses heal.

15. Sleep hygiene and adequate rest.
    Purpose: Support immune function and repair.
    Mechanism: Sleep improves growth hormone pulses and tissue healing dynamics.

16. Nasal external splints or internal packs (if your surgeon placed them).
    Purpose: Stabilize reduced bones and control bleeding.
    Mechanism: Provides temporary scaffolding to maintain alignment; packs also tamponade bleeding surfaces. (Only clinician removes/adjusts.)

17. Tear-duct stents after lacrimal repair (when indicated).
    Purpose: Keep the new tear-drain channel open while tissues scar.
    Mechanism: Soft silicone tubes are left for weeks to months and then removed in clinic. mft.nhs.ukRSUTaylor & Francis Online

18. Facial scar care once incisions close.
    Purpose: Optimize scar appearance.
    Mechanism: Daily sunscreen, silicone gel/sheets, and gentle massage remodel collagen over 3–6 months.

19. Nutritional optimization (see “What to eat”).
    Purpose: Provide building blocks for bone and soft-tissue healing.
    Mechanism: Adequate protein and micronutrients support collagen cross-linking and osteogenesis.

20. Scheduled follow-ups and imaging (as advised).
    Purpose: Ensure alignment holds and eye corner position remains symmetric.
    Mechanism: Surgeons reassess the medial canthal tendon position and, when needed, repeat CT to confirm stability. Lippincott Journals

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Drug treatments

Important: Doses below are typical adult ranges and must be individualized by your clinician based on age, kidney/liver function, allergies, and the exact fracture pattern.

1. Acetaminophen (paracetamol) — analgesic/antipyretic.
   Dose/Time: 500–1,000 mg every 6–8 h; do not exceed 3,000–4,000 mg/day (lower if liver disease).
   Purpose/Mechanism: Central COX inhibition for pain/fever relief; foundation of multimodal analgesia.

2. NSAIDs (e.g., ibuprofen 400–600 mg q6–8h, naproxen 250–500 mg q12h) — anti-inflammatory analgesics.
   Purpose/Mechanism: COX-1/2 inhibition reduces prostaglandin-mediated pain and swelling.
   Notes: Can worsen bleeding or gastric/renal issues; discuss with your surgeon in the first 48–72 h if epistaxis risk is high.

3. Short-course opioids (e.g., oxycodone 2.5–5 mg q6h PRN for ≤3–5 days) — rescue analgesia.
   Purpose/Mechanism: μ-opioid receptor agonism for severe breakthrough pain.
   Notes: Use the lowest effective dose; avoid driving and combine with stool softeners.

4. Antibiotic prophylaxis (selected cases only).
   When: Open fractures (through skin), fractures involving sinus/nasal mucosa, or operative cases—often limited to pre-op dose and ≤24 h post-op per many trauma guidelines. Closed, clean fractures generally do not need antibiotics.
   Typical choices: Cefazolin peri-op; amoxicillin-clavulanate (e.g., 875/125 mg q12h) when sinus contamination is a concern; clindamycin if β-lactam–allergic.
   Mechanism: Reduce bacterial load introduced at surgery or via sinus tracts. Duration beyond 24 h shows no added benefit in most facial fractures. MedscapeLippincott JournalsWVU Medicine

5. Topical ocular lubricants (carboxymethylcellulose gel/drops).
   Purpose/Mechanism: Protect cornea if lid closure is incomplete; reduces exposure symptoms by forming a moisture layer.

6. Topical ophthalmic antibiotics (e.g., erythromycin ointment) if corneal abrasion is present.
   Purpose/Mechanism: Lower infection risk on a denuded corneal surface (only when an abrasion is confirmed).

7. Short-course nasal decongestant spray (e.g., oxymetazoline 0.05%, up to 3 days).
   Purpose/Mechanism: Alpha-agonist vasoconstriction shrinks mucosa to ease nasal breathing and reduce epistaxis—use sparingly to avoid rebound.

8. Antiemetics (ondansetron 4–8 mg q8h PRN).
   Purpose/Mechanism: Serotonin-3 antagonism reduces nausea that can increase facial pressure with retching.

9. Tetanus prophylaxis (vaccine ± immune globulin).
   When: Booster if last tetanus vaccine ≥10 years (clean wounds) or ≥5 years (dirty/major wounds). Add tetanus immune globulin for certain under-immunized or immunocompromised patients. CDC+1

10. Systemic corticosteroids (selected peri-operative use only, specialist-guided).
    Purpose/Mechanism: Reduce postoperative edema and nausea; evidence is mixed/weak and must be balanced against impaired wound healing risk. PubMedSAGE Journals

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Dietary molecular supplements

Always clear supplements with your surgeon—some affect bleeding or anesthesia.

1. Protein (1.0–1.5 g/kg/day) — building blocks for collagen/bone matrix; supports immune cells.

2. Vitamin C (ascorbic acid 200–500 mg/day) — cofactor for collagen cross-linking; antioxidant for wound healing.

3. Vitamin D3 (cholecalciferol 800–2,000 IU/day, individualized) — supports calcium absorption and bone remodeling.

4. Calcium (dietary to ~1,000–1,200 mg/day total) — mineral for callus formation; pair with vitamin D.

5. Zinc (8–15 mg/day) — supports DNA synthesis and epithelial repair.

6. Vitamin A (2,500–5,000 IU/day from diet; avoid megadoses) — epithelial integrity and immune function.

7. Vitamin K2 (MK-7, ~90–120 µg/day) — helps direct calcium into bone (adjunctive role).

8. Magnesium (200–400 mg/day as citrate or glycinate) — cofactor in bone metabolism and muscle relaxation.

9. Arginine (3–6 g/day) or arginine-rich foods — substrate for nitric oxide; may aid wound immune response.

10. Bromelain (e.g., 200–400 mg/day standardized) — pineapple enzyme studied for postoperative edema; stop before surgery due to bleeding concerns.

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Regenerative / biologic” therapies

These are advanced or selectively used options; several remain off-label in facial fractures and should only be considered by experienced teams.

1. Tdap/Td booster (vaccine).
   Dose: One booster per CDC intervals (see above).
   Function/Mechanism: Trains immune memory against tetanus toxin to prevent life-threatening tetanus from contaminated wounds. CDC

2. Human tetanus immune globulin (TIG) 250 IU IM (when indicated).
   Function/Mechanism: Passive antibodies neutralize circulating tetanus toxin after high-risk wounds in under-immunized patients. CDC

3. Platelet-rich plasma (PRP) / platelet-rich fibrin (PRF) — procedure, not a pill.
   Function/Mechanism: Concentrated platelets release growth factors (PDGF, TGF-β) that may enhance soft-tissue healing; evidence in craniofacial trauma varies.

4. Demineralized bone matrix (DBM) or bone graft substitutes used during reconstruction.
   Function/Mechanism: Provide osteoconductive scaffold; some products are osteoinductive.

5. Recombinant human BMP-2 (very selective, off-label in many craniofacial sites).
   Function/Mechanism: Osteoinductive signaling to promote new bone; balanced against swelling or heterotopic bone risks in the face. (Surgeon-only decision.)

6. Parathyroid hormone analogs (e.g., teriparatide 20 µg SC daily, time-limited) in specific fracture-healing contexts.
   Function/Mechanism: Intermittent PTH signaling can stimulate osteoblasts and has shown mixed evidence in improving fracture healing in selected populations; not routine for facial fractures. PMCPLOS

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Surgeries

1. Open reduction and internal fixation (ORIF) of the NOE complex.
   What happens: Through carefully planned incisions (often a coronal scalp incision with hidden scars and/or transconjunctival/transcaruncular approaches), the surgeon repositions bone fragments and secures them with microplates/screws.
   Why: Restore the three-dimensional contour of nose–orbit–ethmoid, re-establish buttress support, and open compressed sinus pathways. surgeryreference.aofoundation.org

2. Transnasal canthopexy (medial canthal tendon repair).
   What happens: A wire/suture or plate-assisted system anchors the tendon back to the posterior lacrimal crest (its normal footprint).
   Why: Correct telecanthus, re-establish eyelid apposition and lacrimal pump function; essential in Type III injuries. surgeryreference.aofoundation.orgLippincott Journals

3. Medial orbital wall / floor reconstruction (open or endoscopic-assisted).
   What happens: The surgeon reduces bone and, if needed, places a thin implant (e.g., titanium mesh or porous polyethylene) to rebuild the wall.
   Why: Restore orbital volume and prevent enophthalmos or persistent double vision.

4. Lacrimal system repair (stenting) or dacryocystorhinostomy (DCR).
   What happens: If the tear duct is lacerated/blocked, microsurgical repair with silicone stenting is performed; when scarring obstructs the nasolacrimal duct, a DCR creates a new drainage route into the nose.
   Why: Stop chronic tearing and infections from nasolacrimal blockage after trauma. PMC

5. Secondary rhinoplasty/septorhinoplasty or grafting (when needed).
   What happens: After initial healing, contour refinements of the nasal dorsum/sidewalls and septal straightening restore airflow and appearance.
   Why: Address residual deformity or obstruction that conservative measures cannot fix.

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Prevention tips

1. Always wear a seatbelt; use age-appropriate child restraints.

2. Wear helmets/face shields for bikes, motorcycles, skating, construction, and contact sports.

3. Avoid drunk or distracted driving.

4. Use workplace PPE (eye/face protection) for high-velocity tools.

5. Fall-proof your home (good lighting, non-slip mats, railings).

6. Practice violence prevention and seek help if unsafe at home.

7. Eye protection for racquet sports, hockey, baseball, and similar. American Osteopathic Association

8. Secure ladders and use spotters.

9. Keep vision prescriptions current; impaired depth perception raises fall risk.

10. Maintain bone health (dietary protein, vitamin D, weight-bearing exercise, quit smoking).

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When to see a doctor urgently

• Sudden vision changes, new or worsening double vision, eye bulging, or a pupil that doesn’t react. These can signal orbital compartment syndrome, an emergency that can cause permanent vision loss without rapid treatment. EyeWiki

• Clear, watery fluid dripping from the nose with a salty/metallic taste—especially when leaning forward—may be CSF rhinorrhea and needs prompt evaluation. A beta-2 transferrin test on the nasal fluid helps confirm this. ARUP Consult

• Worsening facial pain, fever, foul discharge, or spreading redness (infection).

• Persistent heavy nosebleed, repeated vomiting, severe headache, confusion, or neck stiffness.

• Any change in eyelid position or widening of the inner eye corners (telecanthus) after a blow to the face.

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What to eat (and what to avoid) during recovery

Eat more of:

1. Soft, protein-rich foods (eggs, yogurt, fish, tofu, dal, tender chicken, smoothies).

2. Vitamin-C-rich produce (guava, citrus, kiwi, berries) for collagen.

3. Dairy or fortified alternatives for calcium; add leafy greens and sesame.

4. Vitamin D sources (fortified milk, egg yolk; consider safe sun exposure per local guidance).

5. Zinc sources (lentils, chickpeas, nuts, seeds, meat).

Limit/avoid:

1. Hard, crunchy, or chewy foods (nuts, crusty bread, tough meat) in early weeks to avoid midface strain.
2. Very hot/spicy foods if they trigger nose running or sneezing.
3. Alcohol (impairs immunity and increases bleeding risk).
4. Smoking/vaping (impairs blood flow and healing).
5. Herbal “blood thinners” (e.g., high-dose fish oil, ginkgo) before surgery—only with surgeon approval.

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Frequently asked questions

1) How is an NOE fracture different from a “simple” broken nose?
A nasal fracture involves the nasal bones only. NOE fractures extend into the inner orbital wall and ethmoid region and may disrupt the eyelid tendon, which changes eye corner position and tear drainage. This is why NOE injuries often need specialized surgery. surgeryreference.aofoundation.org

2) Do all NOE fractures need surgery?
No. Nondisplaced fractures with a normal inner eye corner and patent tear drainage may be observed with precautions. Displaced fractures or tendon avulsion typically need ORIF and canthopexy to restore function and appearance. surgeryreference.aofoundation.org

3) What scan do I need?
A thin-slice CT (often 0.6–1.5 mm) with coronal/sagittal reconstructions—and sometimes 3D views—maps fragments and guides surgery. MRI is reserved for soft-tissue or brain concerns. EPOSResearchGate

4) What is telecanthus?
It’s the widening of the inner eye corner distance with normal pupil distance—classic when the medial canthal tendon is disrupted. MD Searchlight

5) My eye keeps tearing after injury—why?
The nasolacrimal duct can scar or kink. Doctors use simple tests like the fluorescein dye disappearance test and may perform stenting or a DCR to restore flow if the blockage persists. Lippincott Journalsmft.nhs.uk

6) What is transnasal canthopexy?
A technique to re-anchor the medial canthal tendon to the posterior lacrimal crest, often with a transnasal wire or a plate-assisted method, to correct telecanthus. surgeryreference.aofoundation.orgLippincott Journals

7) Are antibiotics always required?
No. Many closed facial fractures don’t need antibiotics. When fractures are open, involve sinus/nasal mucosa, or are operated, a brief (≤24 h) prophylaxis is common; longer courses rarely help and may harm. Follow your team’s protocol. WVU MedicineLippincott Journals

8) Should I take steroids to reduce swelling?
Only if your surgeon recommends. Steroids can reduce swelling and pain but carry risks (impaired healing, infection). Evidence is mixed. PubMed

9) Can nose blowing really be dangerous after this injury?
Yes. It can force air and bacteria into the tissues and through fracture lines—avoid nose blowing, use tissues, sneeze with your mouth open, and avoid straws until cleared. University of Michigan Medical School

10) What is a CSF leak and how is it tested?
Clear fluid from the nose after face/skull trauma can be CSF. Labs detect beta-2 transferrin, a protein found almost only in CSF, to confirm. This needs prompt specialty care. ARUP Consult

11) Is nasotracheal intubation safe if I need anesthesia?
With midface instability or skull-base fracture, nasal intubation is contraindicated; anesthesiologists choose safer alternatives. This is individualized by the team. Medscape

12) How long does healing take?
Bone consolidation begins over 6–8 weeks; soft-tissue remodeling and final scar maturation continue for months. Complex reconstructions may need staged revisions.

13) Will I look the same again?
That is the goal of modern NOE surgery—restore the eyelid tendon position and 3-D contours. Pre-injury photos help surgeons match symmetry. NCBI

14) Can supplements speed bone healing?
Good nutrition (protein, vitamin D, calcium) supports healing. Some agents (e.g., teriparatide) show mixed evidence and are not routine for facial fractures. PLOS

15) When can I fly or return to sports?
Discuss with your surgeon. As a rule, avoid pressure changes and contact sports until fractures have stabilized and sinuses/orbits are cleared. Many patients wait several weeks for flying, longer for contact sports.

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The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: August 14, 2025.