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

2. 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)

3. Diagnosis CT
Old photographs
Estimate intercanthal distance

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 6. Septal Reduction
Asch forceps

18. 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

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

20. 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