NOE: Complications and Treatment Craniofacial Rounds Thursday May 5, 2011

Anatomic considerations Medial canthal tendon Bones: frontal, nasal, maxilla, lacrimal, ethmoid Medial orbital wall or orbital floor fractures Anterior cranial fossa Vessels: Supraorbital, supratrochlear, infratrochlear, anterior and posterior ethmoidal arteries Eye: Globe, optic nerve Lacrimal apparatus Cannaliculi DM – Type II – useful to separate this comminution by A and B. Important if it’s a nasal comminution (bone graft) vs medial buttress (orbital wall repair)

Diagnosis CT Old photographs Estimate intercanthal distance

Physical Exam Swelling Intercanthal distance Eyelid traction Approx half interpupillary distance >40 mm Eyelid traction Bimanual exam CSF rhinorrhea Eye exam Enophthalmos 20-25% ocular injury Holt and Holt Holt GR, Holt JE: Incidence of eye injuries in facial fractures: An analysis of 717 cases. Otolaryngol Head Neck Surg 91: 276, 1983

Facial Deformity Telecanthus Shortened palpebral fissures Enophthalmos Shortened/retruded nose Flattening, collapse, inward telescoping of nasal bones Ocular dystopia Ocular dystopia – inferior globe displacement (vertical or horizontal) Enophthalmos – posterior displacement of the globe, 1 cm^2 volume expansion per 1 mm displacement Telecanthus – distance between the inner corner of each eye exceeds the width of the eye with normal interpupillary distance Vs Hypertelorism – increased interpupillary distance

Treatment Indications All displaced fractures Medial canthal tendon insertion displacement/ disinsertion Telecanthus Facial deformity Nasal airway Tear drainage disruption 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 87:843, 1991

Fixation Closed reduction, external splinting, wires Indications Pros Simple fractures Pros Simple Cons Cannot correct medial canthal displacement/ disinsertion Unable to reduce medial orbital wall/rim Collapse, flattening, telescoping of nose Converse JM, Smith B: Naso-orbital fractures. Trans Am Acad Ophthalmol Otolaryngol 67:622, 1963 Adams M: Internal wiring fixation of facial fractures. Surgery 12:523, 1942 Fielding JF: A spring wire clip for fixation of naso-orbital fractures. Plast Reconstr Surg 39:313, 1967

Fixation Open reduction, internal fixation Mustarde 1964, Dingman 1964 Medial canthal tendon insertion Stranc 1970 Canthopexy Suture/wire Mustarde JC: Epicanthus and telccarnhus, Int Ophthalmol C1in 4:359, 1964 Dingman RO, Natvig P: Surgery of Facial Fractures, Philadelphia, PA, Saunders, 1964 Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970

Approaches Approaches Existing lacerations Local incisions Midline vertical (Stranc) Open sky (Converse 1970) W incision Coronal incision Lower lid incision Upper gingivobuccal sulcus incision Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970 Converse JM. Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 46:396, 1970

Repair Bony rim exposure MCT insertion exposure Reduction medial orbital rim Reconstruction medial orbital wall MCT canthopexy Septal reduction Nasal dorsum augmentation Soft Tissue Readaption From Ellis JOMFS 1993

1. Bony Rim Exposure Exposure Orbital rims Medial orbital wall Anterior ethmoidal arteries – cauterize Posterior ethmoidal arteries – optic nerve just a few mm posterior!! Nasal bridge Careful not to detach MCT insertion MCT ID fragment of insertion Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970 Converse JM. Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 46:396, 1970

2. MCT Insertion Exposure Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970 Converse JM. Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 46:396, 1970

3. Reduction Medial Orbital Rim Reduce/recon medial orbital rim Transnasal reduction of MCT-bearing bone fragment Simple

Transnasal wiring A: Coronal view, horizontal mattress B: Improper placement (too anterior, lateral displacement) C: Proper placement From Ellis JOMFS 1993 Ideally place one wire posterior or superior to lacrimal fossa Hard to access – Ellis: can distract segment laterally and drill from nasal surface

4. Reconstruction Medial Orbital Wall Alloplastic Titanium mesh, medpor Autologous Bone (rib, calvarium Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970 Converse JM. Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 46:396, 1970

5. MCT Canthopexy Stranc MF: Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 23:8, 1970 Converse JM. Hogan VM: Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 46:396, 1970

6. Septal Reduction Asch forceps

7. Nasal Dorsum Augmentation Dorsal nasal support to prevent secondary deformities Primary bone grafting Indicated with a severely comminuted septum Risks dorsal support weakness DM – primary bone grafting in a badly comminuted septum, prevents secondary deformity - difficult to determine position of the nasal bones as it’s usually driven into the frontal sinus and comminuted. Often still depressed. Could consider bone graft

8. Soft Tissue Readaption Recreate the naso-orbital “valley” Stents or bolsters Transnasal wiring for comminuted/severe cases

Conclusion NOE – complex anatomy Secondary deformities difficult to treat Early repair, ORIF Restoration of intercanthal width Proper reduction of canthal tendon bearing fragment Early bone grafting to prevent secondary deformity DM – Frontal sinus is probably still going to be obstructed at the level of the nasolacrimal ducts… may have obstruction in future. No literature or evidence to discuss dealing with frontal sinus