naso-orbital ethmoid · pdf filenaso-orbital ethmoid fractures ......

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Naso-Orbital Ethmoid Fractures

Resident Physician: S. Ross Patton, MD

Faculty Mentor: Michael P. Underbrink, MD, MBA, FACS

The University of Texas Medical Branch – UTMB Health

Department of Otolaryngology

Grand Rounds Presentation

November 19, 2014

Series Editor: Francis B. Quinn, Jr., MD, FACS -- Archivist: Melinda Stoner Quinn, MSICS

Objectives

1. Review relevant facial anatomy for NOE fractures

2. Review definition and classification of NOE fractures

3. Review surgical approaches and treatment of NOE fractures

http://dentoclub.webs.com/apps/photos/photo?photoid=66406077

Background

NOE Definition

NOE Region

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM

!/?segment=Midface&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-

Diagnosis/noe.jsp

Anatomy of NOE Region

Lacrimal Fossa

-http://en.wikipedia.org/wiki/Lacrimal_bone

Orbital Anatomy- Important Distances to Know

Published in Grand Rounds given by AH Muir from UCSF

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html

Medial Canthal Tendon

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html

Relationship to Other Important Structures

http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html http://oralmaxillo-facialsurgery.blogspot.com/2010/05/nasoorbitoethmoid-fractures.html

Midface Buttress System

Nomenclature

NOE - naso-orbital ethmoid

NEC - naso-ethmoid complex

Naso ethmoid orbital

Naso-orbital ethmoidal

http://www.iihs.org/iktopnews/negative-publicity-about-airbags-obscuring-their-benefit-institute-aihs/news/desdvises-against-disconnecting-airbags-except-in-rare-cases

Mechanism Of Injury

http://www.iihs.org/iihs/news/desktopnews/negative-publicity-about-airbags-obscuring-their-benefit-institute-advises-against-disconnecting-airbags-except-in-rare-cases

http://www.sciencedirect.com/science/article/pii/S1042369908001155

Pathophysiology of NOE

Classification

Markowitz Type I

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Midf

ace&bone=CMF&classification=92-Nasal%2FNOE%2C%20NOE&teaserTitle=&showPage=diagnosis&contentUrl=/srg/92/01-Diagnosis/noe.jsp

Markowitz Unilateral Type II



Bilateral Type II Fracture





Markowitz Type III

Why So Difficult?

Management

Linnau et al 2003

Management: Clinical Presentation in the Trauma Bay

Management: Diagnosis by Exam and Imaging

Physical Exam: Telecanthus

http://dentoclub.webs.com/apps/photos/photo?photoid=66406077

https://www2.aofoundation.org/wps/portal/!ut/p/c0/

Bowstring Sign Palpation/Instrument

https://www2.aofoundation.org/wps/portal/!ut/p/c0/

Physical Exam: Loss of nasal dorsal Height

Sargent 2007 Sargent 2007

Pigsnout

Deformity

http://www.technologybloggers.org/science/is-your-computer-damaging-your-

eyes/

Physical Exam: Epicanthal Folds

Physical Exam: Globe

--http://www.eyecalcs.com/DWAN/pages/v5/ch087/012f.html

Imaging

Plain Films

http://www.bcm.edu/oto/index.cfm?pmid=15481

Water’s ViewCaldwell View

http://www.bcm.edu/oto/index.cfm?pmid=15481

http://radiographics.rsna.org/content/26/3/783.figures-only

Coronal CT

Nguyen et al 2010

Axial CT

Axial CT- Finding the lacrimal Fossa

-http://www.ajnr.org/content/22/5/845/F4.expansion.html

-http://www.images.missionforvisionusa.org/anatomy/2005/10/orbit-ct-images.html

Management-Acute Management of Related

Problems: Intracranial trauma

-http://neurosciencenews.com/neurology-children-tbi-concussion-research-263/brain-big-bandaid-public/

Management-Acute Management of Related

Problems: Epistaxis

Planum Sphenoidale

Superior orbital Fissure

Syndrome

Blindness

Epistaxis

-internal carotid

http://emedicine.medscape.com/article/882627-overview#aw2aab6b3

Nasolacrimal Duct Injury

http://care.american-rhinologic.org/epiphora

http://www.drpaulose.com/general/csf-leak-from-the-nose-how-to-treat

CSF Leak

Management: Surgical Planning Once Stabilized

Timing of Operation

Picking a Surgical Approach

Open Sky Approach

Midface Degloving

Bicoronal Flap

Layers of the Scalp

AO Surgery. Bicoronal Flap. https://www2.aofoundation.org/wps/portal/surgery?showPage=approach&contentUrl=srg/92/04-Approaches/A70_Coronal-approach.jsp&bone=CMF&segment=Midface&approach=Coronal%20approach&Language=en

Video - Bicoronal Approach

http://youtu.be/gVWGklBtZTA

http://youtu.be/gVWGklBtZTA

https://www2.aofoundation.org/wps/portal/surgery/?contentUrl=%2Fsrg%2F92%2F04-Approaches%2FA30_1-lower-eyelid-

transcutan.jsp&bone=CMF&segment=Midface&showPage=approach&approach=Transcutaneous%20lower-eyelid%20approaches

Additional Incision to approach inferior orbit

Surgical Repair

General Principles

Which fractures need surgery? ***Almost all- (type I)

Goals of Surgery: Restore pre-injury

appearance/function (if possible)

Other fractures: Treat other fx first

Type I Repair

Sargent 2007

Plating Only

Type II Repair

Sargent 2007

Plating and trans-nasal

wiring

Type II Repair- Trans-nasal wiring

Sargent 2007


Pitfall- don’t drill into the brain


Unilateral Repair


Bilateral Repair

Type II Repair

Papel-2nd edition


Pitfall: Placement of wires

Type III Repair- Trans-nasal wiring

Type III Repair

Papadopolous et al 2009

Nasal Reconstruction

Nasal Reconstruction: Cantilevered Bone Graft

Sargent 2007

Soft tissue bolsters

Sources

AO Foundation. “Nasal/NOE”. https://www2.aofoundation.org/

wps/portal/!utc1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN39yBTAyMvLwOLUA93I4MQE6B8JJK8haGF

gYFnqKezn7GTn4GBgQkB3X4e-bmp-

gW5EeUAmUJP3w!!/dl2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwRzFFMTBJREZMVUlRUDEwMDA!/?sho

wPage=diagnosis&bone=CMF&segment=Midface

Kellman RM. Maxillofacial Trauma. Cummings Otolaryngology 5th Edition. Ch 23

Bailey BJ. Nasal Fractures. Head & Neck Surgery- Otolaryngology 4th Edition. Ch 71

Papel ID. Frontal Sinus and Nasoorbitoethmoid Complex Fractures. Facial Plastic and Reconstructive Surgery 2nd

edition.

Donald PJ. Frontal sinus and nasofrontoethmoidal complex fractures. SIPAC. 2002.

Shibuya TY. Chen VY. Oh YS. Naso-orbito-ethmoid fracture management. Operative Techniques in Otolaryngology.

2008;19:140-44.

Naso-orbital ethmoid fractures. Medscape Reference. 2/1/2013. http://emedicine.medscape.com/article/869330-

overview

Nguyen M. Koshy JC. Hollier LH. Pearls of Nasoorbitoethmoid trauma Management. Seminars in Plastic Surgery.

24:4:2010.

Papadopoulos H. Salib NK. Management of Naso-Orbital-Ethmoidal Fractures. Oral Maxillofacial Surg Clin N Am

21(2009) 221-225

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