Fractures of the naso-orbital-ethmoid (NOE) complex

Fractures of the naso-orbital-ethmoid (NOE) complex involve the bones that form the NOE confluence, which includes the anterior cranial fossa, frontal bone, bones of the ethmoid and frontal sinuses, nasal bones, and orbits. They often occur alongside injuries to other parts of the face and body but can occur in isolation. Road traffic accidents and physical violence are the leading causes of these injuries, but this picture is changing with improved vehicle and road safety.

Knowledge of regional anatomy is fundamental in understanding assessment and management. The approach to these injuries starts with the advanced trauma life support approach, as these patients can have injuries to critical structures such as the airway. Further assessment relies on thorough clinical assessment aided by radiological imaging. The operative intervention depends on the classification of the NOE complex fracture, which is based on the status of the medial canthal tendon. Meticulous primary surgical correction is key in restoring aesthetic features and preventing future complications of trauma. Operative approach and exposure is carefully considered to balance the need to correct the deformities but also to prevent further aesthetic disruption and complications.

Pathophysiology

The naso-orbital-ethmoid complex is a confluence of structures made up of the nasal bones, nasal process of the frontal bone, frontal process of the maxilla, lacrimal bone, lamina papyracea of the ethmoid bone, and sphenoid bone. The medial canthal tendon (MCT), also called medial palpebral tendon, is a band of fibrous tissue originating from the medial palpebral part of the orbicularis oculi muscle as well as the superior and inferior tarsus of the eyelids. The MCT splits and surrounds the lacrimal fossa, which includes the lacrimal duct before inserting into the lacrimal crest of the maxilla anteriorly and the lacrimal bone posteriorly. The facial skeleton is formed of four paired vertical and four horizontal buttresses, which are columns of bone that provide structure to surrounding tissues and help provide a form to the face. The NOE complex incorporates the medial vertical and inferior and superior transverse buttresses. These become the focus during surgical fixation. It has been suggested that NOE fractures are the result of facial bone design. The nasal bones transmit a force posteriorly to thinner bones, which crumple to transmit the force to the ethmoid sinuses, thus sparing the contents of the cranial vault and orbital contents. However, there is disagreement on whether facial bone fractures provide any protection to the brain itself.

Sensory innervation to the NOE region is by the ophthalmic and maxillary branches of the trigeminal nerve. Motor innervation is by the zygomatic branches of the facial nerve. Autonomic supply consisting of sympathetic and parasympathetic fibers innervate both intraocular and external structures. The lacrimal nerve transmits both fiber types to the lacrimal gland. Sympathetic fibers also provide innervation to the smooth muscle of the lids widening the palpebral fissure when stimulated.

Arterial supply to the region originates from the internal and external carotid arteries. The facial and maxillary arteries are given off by the external carotid artery and supply the majority of the face. The ophthalmic artery originating from the internal carotid supplies the orbital structures. The ophthalmic artery also gives rise to the anterior and posterior ethmoidal arteries which supply the ethmoid sinus and terminate in the nasal cavity where they anastomose with the sphenopalatine artery to form Little’s area which is prone to bleeding. Venous drainage follows a similar pattern to the arterial supply. The venous blood drains into the cavernous sinus, which can produce complications from thrombosis secondary to trauma or infection.

Classification of Fractures of the naso-orbital-ethmoid

The Markowitz and Manson system is the most widely used classification system of NOE complex fractures and has replaced other systems by making the integrity of the MCT a key feature of fracture severity. This classification system relies on both CT scan and clinical examination which outline the status of NOE complex bony structures and MCT integrity, respectively:

  • Type 1: The MCT is attached to a central fracture segment.
  • Type 2: The MCT is attached to a comminuted central fracture segment.
  • Type 3: The MCT is detached from a comminuted central fracture segment.

Causes of Fractures of the naso-orbital-ethmoid

  • The NOE fracture pattern is caused by forceful, direct trauma to the central midface. Due to the high energy involved, these fractures often occur in combination with injuries to other parts of the face and body.
  • The road traffic collision is the most common cause of NOE fractures, especially with motorcycles.. Fortunately, it appears to have reduced in frequency.
  • The introduction of seatbelts and airbags has helped to decrease the incidence of facial fractures. Physical assault, sport, and horse kicks have also been associated with this fracture pattern.

Symptoms Of Fractures of the naso-orbital-ethmoid

Symptoms bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.

  • Pain or tenderness, especially when touching your nose
  • Swelling of your nose and surrounding areas
  • Bleeding from your nose
  • Bruising around your nose or eyes
  • Bruising, swelling and tenderness around the nose
  • A deformed, twisted or crooked nose
  • Blockage of one or both nostrils
  • A deviated septum
  • A bruise-like discoloration under the eyes
  • Crooked or misshapen nose
  • Difficulty breathing through your nose
  • Discharge of mucus from your nose
  • Feeling that one or both of your nasal passages are blocked
  • Gross facial edema may show firstly in the early stage of fracture, which will result in distortion of soft tissue landmarks.
  • Ophthalmic symptoms include diplopia, telecanthus, enophthalmos, epiphora, and shortened palpebral fissure, which result from orbit wall or medal canthal tendon malformation.
  • Moreover, the nasal symptoms include retrusion of the nasal bridge, anosmia caused by damage to the cribriform plate, and nasal congestion secondary to septal hematoma or bony/cartilaginous deformity. Cerebrospinal fluid leak (CSF) may also present, which needs to be highly valued.

Diagnosis of Fractures of the naso-orbital-ethmoid

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical Examination

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side.
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Examination of the NOE complex begins with a visual and manual inspection, which often will reveal severe swelling and periorbital ecchymosis, which sometimes make examination challenge. Excessive tear overflow in the eye and face (epiphora) can be associated with lacrimal duct damage or obstruction. A more reliable assessment of lacrimal duct function is using dye tests or dacryocystography (radiological contrast assessment of the lacrimal apparatus) if epiphora is persistent following surgery. Nasal bone fracture and depression can result in a decreased nasal dorsal projection with an associated upturn of the nasal tip. Epistaxis with associated mucosal nasal tearing may be present with or without cerebral spinal fluid (CSF) rhinorrhoea, as a result of anterior cranial fossa fracture. CSF presence can be confirmed with a beta-transferrin test, which is more accurate than the halo sign (CSF fluid on filter paper forming a halo pattern). Nasal patency can be crudely assessed with a metal object placed under each nostril.

Assessment of the MCT is a fundamental aspect of discerning the severity of an NOE complex injury. Telecanthus (increased distance between to the two medical canthi) with equal interpupillary distance is a sign of MCT rupture. Intercanthal distance is on average 30 to 31 mm, and the interpupillary distance is 60 to 61 mm. An intercanthal distance greater than 40 mm is noticeable, and an indication for surgical correction. The bow-string test involves palpating the nasal root whilst retracting the eyelid inferior-laterally, the eyelid will have greater laxity, and a fractured segment may be palpable if the MCT is compromised.

Evaluation

Investigations

The examination may be initially limited by severe pain and gross swelling of facial structures. Computed tomography (CT) scan of the head provides definitive details of soft tissue and bony injuries. The use of both 2D and 3D images on coronal and axial views aids the diagnosis and staging of NOE complex fractures and assists the operating team in planning corrective operations. The approach, degree of exposure, and equipment required are highly dependent on the CT scan. The study also outlines injuries of other structures in the head. In a trauma setting, it is likely to be performed early once the patient is stabilized with an advanced trauma life support approach.

Preoperative blood work should include CBC, electrolytes, coagulation profile, and a pregnancy test.

Imaging should provide useful information to differentiate orbital floor fractures from any of the following:

  • Medial or lateral wall fractures
  • Orbito-zygomatic fractures
  • LeFort I, II, and III fractures
  • Naso-orbital ethmoidal fractures (Markowitz fractures)

Clinical examination has to eliminate the need for acute intervention under the following conditions:

  • Large fractures with a high risk of enophthalmos
  • Entrapment of infra-orbital structures
  • Optical neuropathy

Computed tomography scan

Computed tomography (CT) is the imaging modality of choice if a blowout fracture is suspected after blunt orbital trauma. Some symptoms include double vision, pain with eye movements, and restriction of extraocular muscle movements. A CT scan often reveals herniation of orbital fat or the inferior rectus muscle, into the maxillary sinus. Such a scan can also detect occult tears and retained foreign bodies if any are present.

Plain Radiograph

Can help suspect an orbital floor fracture in the presence of the following:

  • Subcutaneous emphysema
  • Soft-tissue teardrop along the roof of the maxillary sinus
  • Air-fluid level in the maxillary sinus

Treatment of Fractures of the naso-orbital-ethmoid

NOE fractures require surgical fixation and/or reduction to restore the aesthetic features of the face. If the medial canthal tendon is avulsed, then this will need to be reduced. The approach will depend on the severity and distribution of fractures, and an effort is made to use the smallest incision to provide the greatest exposure of tissue and bone. The consideration of the incision site is very important as it can have a great aesthetic impact. Sometimes facial lacerations or pre-existing scars can be utilized. Pre-injury photographs can be of assistance to surgeons in planning reduction and fixation as so to return, as close as possible, the face back to its original form.

The coronal incision provides good exposure of the mid-upper face and is the gold standard approach to NOE fractures involving the frontal sinus. The midface degloving approach provides greater exposure of the midface. This technique, however, is associated with a number of complications, such as anesthesia and nasal deformity. Reduction and fixation of bony segments are sought before soft tissues are corrected. In type 1 NOE fractures, closed reduction can be achieved. Type 2 and type 3 fractures will require exposure of the fractured segments with open reduction and internal fixation. A titanium mesh is used to stabilize the medial orbital wall, however, absorbable meshes can be used. Microplates and screws are used to fix and stabilize bones and ensure the stabilization of the horizontal and vertical buttresses. Frontal sinus involvement requires additional repair of fractured walls and repair of open meninges if present. The sinuses are obliterated to avoid future mucocele formation with a variety of techniques. Pedicled flaps, autologous grafts (adipose tissue, bones, and muscles), xenografts, and biomaterial can be used for this purpose. Alternatively, in more severe sinus injuries, cranialization can be utilized – this is the removal of the posterior frontal sinus wall allowing brian tissue to fill the space.

In type 3 NOE complex fractures reduction of the MCT (canthopexy) is achieved by transnasal wiring, which is performed by drilling a small hole into the medial orbital wall and tethering the MCT with a wire. The use of a needle to secure the MCT in lieu of a drill is sometimes required for unstable comminuted fractures of the medial orbital wall.

Disruption to the lacrimal pathways is a common complication of midfacial trauma, with epiphora reported in nearly half of cases immediately postoperatively. However, permanent epiphora is relatively uncommon. As such, secondary correction with dacryocystorhinostomy is preferred six months after fracture fixation. The aim is to correct tear drainage and prevent future mucocele formation.

Do no HARM for 72 hours after injury

  • Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running, and walking may cause further damage, and causes healing delay.
  • Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

References

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