Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Naso-orbital-ethmoid Fractures A facial fracture is considered a naso-orbital-ethmoid (NOE) fracture if the fracture involves the bone to which the medial canthal tendon is attached. It is important to distinguish NOE fractures from isolated nasal fractures, orbital rim fractures, and fractures which involve only the ethmoid labyrinth. The medial canthal tendon provides globe support as part of a suspensory sling, which is in continuity with the lateral canthal tendon, and upper and lower tarsal plates. The tendon is also intimately associated with the lacrimal drainage apparatus. The main structural buttresses of the region are the frontal processes of the maxilla: these represent "pillars" to which other structures are attached. The classic physical findings are a flattened nasal dorsum and telecanthus, or widening of the interpalpebral distance. Telecanthus is not synonymous with hypertelorism, which is abnormal widening between the actual globes, and some authors refer to telecanthus as pseudohypertelorism. The normal intercanthal distance is 30 mm to 35 mm, which is half of the interpupillary distance (60 mm to 70 mm in an adult). Other physical findings commonly seen are rounding of the medial canthal angle, and periorbital ecchymoses secondary to bleeding from the ethmoid vessels. As in any case of midface trauma, the surrounding structures should be considered and evaluated: the cervical spine, the nasofrontal ostium, the lamina papyracae, the globes, and surrounding facial bones. The suspicion level should also be high for CSF rhinorrhea in all NOE fractures. Reflex watery rhinorrhea is often seen, however, and should be distinguished from CSF rhinorrhea. Most patients will have epiphora after NOE trauma secondary to edema alone, and the presence of epiphora is not a reliable sign of trauma to the nasolacrimal apparatus. To accurately assess the lacrimal system, the Jones tests should be performed. In the Jones I (or primary dye) test, a cotton-tipped applicator is placed under the inferior turbinate, and fluorescein dye is placed in the inferior cul-de-sac. Five minutes later, the presence of yellow dye on the cotton tip indicates no blockage of the nasolacrimal system: this is a positive Jones I test. If no dye is retrieved from the inferior meatus, some obstruction is present, and the degree and site of obstruction may be localized using a Jones II (or secondary dye) test. The remaining dye is irrigated from the cul-de-sac, the punctum is anesthetized and dilated, and an irrigation cannula is used to wash saline through the system. If dye is washed out onto a cotton pledget, the obstruction was partial only. Actually, up to 20% of normal subjects may demonstrate no dye with Jones I, but dye is irrigated with Jones II, so this combination may represent either incomplete obstruction or a variant of normal. If no fluid at all is retrieved from the nose with irrigation, this indicates a complete obstruction of the lower drainage system. If saline only, and not dilute dye, is seen in the inferior meatus, this indicates obstruction of the upper collecting system, because no dye was collected into the system, but saline can be irrigated through. Injury to the lacrimal system is not the rule with NOE fractures, however. A retrospective review of 46 patients with severe NOE fractures was reported by Gruss et al in 1985. Only 17% required eventual dacryocystorhinostomy (DCR). Many authors agree that the lacrimal system should be observed for several months and re-tested before the decision is made to perform DCR. The gold standard for evaluation of NOE fractures is the CT scan. CT is crucial in distinguishing nasal fractures or orbital fractures from true NOE fractures which involve the medial canthal tendon. In 1991 Markowitz and Manson reported a simple classification system which stresses the importance of the medial canthal tendon in decision-making. These authors use the term "central fragment" to describe the region of bone where the medial canthus attaches. Type I injuries are single segment fractures of the central fragment away from the maxilla and frontal bone. Type II injuries involve comminution of the central fragment, but the tendon is still attached to an intact piece of bone. In Type III injuries, the site of tendon attachment is comminuted, or more rarely, the canthal tendon is avulsed from the bone. As is true for other facial fractures, the management of NOE fractures has changed with changing technology. Most authors today advocate early open reduction and internal plate fixation of NOE fractures. Compression plating is usually not necessary in the maxillofacial skeleton, and monocortical fixation with plates and screws is sufficient. The miniplate and microplate systems are ideal for reconstruction of the naso-ethmoid region. The surgical approach used depends on the presence of other fractures and the presence of an existing laceration. If there is no need to manage other fractures, and there is no pre-existing laceration, either an extended bicoronal flap or an external ethmoidectomy-type incision may be used. If there is significant bony disruption or loss, especially at the nasal dorsum, bone grafting may be necessary, and split calvarium and rib are good sources. Isolated Type I injuries are rare, but require internal fixation of fracture sites only. In Type II injuries, reduction of the displaced canthal tendon is necessary. It is technically very difficult to achieve adequate reduction if the tendon is attached to bone on the same side as the fracture, and transnasal wire or suture fixation is recommended. The canthal tendon is attached to bone on the opposite side of the nose, and the wire is then tightened. In Type III injuries, a suture may be used for transnasal fixation, or the tendon may be sutured to a transnasal wire. Complications of NOE fractures include loss of nasal projection, telecanthus, lacrimal drainage problems, enophthalmos, diplopia, and ophthalmoplegia. CSF rhinorrhea may be an early or late complication of NOE fracture. Unrecognized injury to the nasofrontal ostia can result in frontal sinus mucocele, which may not present clinically for several years. Case Presentation On physical examination there was a laceration across the bridge of the nose, a depressed nasal dorsum, left periorbital edema, and telecanthus. On examination he had some diplopia, but otherwise had no visual complaints. Radiologic evaluation revealed a naso-orbital-ethmoid fracture mostly involving the left side and a left inferior orbital rim fracture. Using a transconjunctival approach he underwent open reduction and internal fixation of the left orbital rim fracture with a microplate and screws. The existing laceration was modified into an open-sky type approach. The nasal bones, frontal process of the left maxilla, and the area of attachment of the medial canthal tendon were comminuted, and there was no stable bone available for wire fixation. 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