Management of Naso-Orbito-Ethmoid Fractures: A 10-Year Review
Management of Naso-Orbito-Ethmoid Fractures: A 10-Year Review
Management of Naso-Orbito-Ethmoid Fractures: A 10-Year Review
Received 2015 April 13; Revised 2015 October 20; Accepted 2015 October 31.
Abstract
Context: The naso-orbito-ethmoid (NOE) area is an intricate structure composed of the nasal, lacrimal, maxillary, frontal, and eth-
moid bones. The treatment of NOE fractures is one of the most challenging issues in the management of maxillofacial injuries. The
management of these fractures requires a thorough knowledge of midfacial anatomy, surgical techniques, and the available imple-
ments in order to obtain optimal aesthetic and functional results. The aim of this study was to review current knowledge (i.e., from
the past ten years) concerning NOE fractures and the related surgical techniques.
Evidence Acquisition: An extensive electronic literature search was performed via international and national databases, includ-
ing MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), DOAJ, Iranian Science Information database (SID),
Iranmedex, and Irandoc. Literature published between October 2004 and October 2014 was searched for using specific keywords.
The references from each study were also searched. Finally, all articles relevant to the selected keywords and the topic of the study
were reviewed.
Results: High-energy blunt or penetrating traumas are the most common cause of NOE fractures. NOE fractures account for some 5%
and 15% of adult and pediatric facial fractures, respectively. These fractures are characterized by three major post-injury symptoms,
namely increased intercanthal distance, diminished nasal projection, and impaired nasofrontal and lacrimal drainage. The prompt
management of NOE fractures is of the utmost importance in avoiding secondary deformities. Surgical treatment is guided by the
pattern and classification of the injury. The surgical approach also varies according to the fracture type and other concomitant facial
injuries. If the fractured fragment cannot be reduced satisfactorily by closed reduction, the operation should be converted into an
open reduction and internal fixation. The most common method for medial canthopexy is transnasal wiring.
Conclusions: Nowadays, advances in radiographic imaging along with the evolution in minimally invasive surgical techniques
have led to more conservative treatment modalities that may minimize post-injury complications and improve aesthetic outcomes.
Keywords: Maxillofacial Injuries, Facial Injuries, Naso-Orbito-Ethmoid, Medial Canthal Tendon, Canthopexy, Lacrimal Duct
Obstruction, Epiphoria
1. Context ally by the ethmoid air cells, and laterally by the orbit and
its contents.
The naso-orbito-ethmoid (NOE) complex is an intricate The NOE complex is responsible for the projection of
midface structure that consists of the nasal, lacrimal, max- some midfacial structures, as well as the normal posi-
illary, frontal, and ethmoid bones. This complex is bor- tion of the extraocular muscles and the medial canthal
dered anteriorly by the nasal bones, the frontal process of ligament, and it also provides support for the globe and
the maxilla, and the frontal bone. Moreover, the area’s infe- lacrimal system.
rior bound is the lower border of the ethmoidal labyrinth, One of the goals of the treatment of facial fractures is
while the lateral bound is formed by the lamina papyracea to reconstruct the pre-traumatic facial appearance, includ-
of the ethmoid bone and the lacrimal fossa. Understand- ing the facial width, projection, and height (1). The restora-
ing the anatomy of the NOE complex requires a familiarity tion of the normal function of the facial structures is an-
with the key structures of this region. The medial canthal other aim in facial fracture management (2). Secondary
tendon splits before inserting into the frontal process of or late reconstruction is much more difficult than the pri-
the maxilla. These two limbs of the tendon surround the mary treatment of NOE fractures (3). Therefore, the treat-
lacrimal fossa. This critical central fragment of the NOE ment of NOE fractures in a timely manner is helpful in cor-
complex is surrounded posteriorly by the lacrimal bone, recting aesthetic and functional defects (4). Moreover, the
anteriorly by the nasal bones and pyriform aperture, cra- early management of NOE fractures, even in the case of
nially by the frontal bone, inferiorly by the maxilla, medi- severely comminuted type III fractures, is of considerable
Copyright © 2016, Trauma Monthly. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International
License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is
properly cited.
Etemadi Sh M et al.
importance to avoid secondary deformities (5). Finally, the stemming from motor vehicle accidents (10, 11), industrial
frontal sinus should be carefully evaluated radiographi- accidents, assault, and falls from height (9). Such fractures
cally (6). A recently published review study has explained pose a significant diagnostic and therapeutic challenge (12-
in detail the management of frontal sinus fractures result- 14). Other potential causes of NOE defects are relatively
ing from NOE fractures (7). rare, including neoplasms of the NOE region such as neu-
Recent advances in techniques for the reconstruction rofibromatosis, fibrous dysplasia, and retinoblastoma, as
of the craniofacial skeleton have resulted in a need to up- well as congenital deformities such as facial cleft, hyper-
date our knowledge regarding new methods for the man- telorism, lymphovenous malformation, and bilateral or-
agement of NOE fractures. bital frontal encephalocele. Fractures of the NOE complex
The aim of the present study was to review current account for approximately 5% of facial fractures in adults
knowledge regarding NOE fractures and the related surgi- (15). In children, the incidence is higher and NOE fractures
cal techniques based on literature published over the last account for nearly 15% of all facial fractures (6, 16). The dif-
ten years. ference can be attributed to the increased skull to face ra-
tio in children when compared to adults. Furthermore, the
frontal sinus does not appear until an individual is approx-
2. Evidence Acquisition
imately five years of age, increasing the incidence of skull
fracture and intracranial injury due to blunt trauma in this
We electronically searched international and national
period. Based on the literature, NOE fractures occur most
databases, including MEDLINE via PubMed, Cochrane Cen-
commonly in adult males and boys (9, 17-19).
tral Register of Controlled Trials (CENTRAL), DOAJ, Iranian
Science Information Database (SID) (http://www.sid.ir/),
3.2. Classification of NOE Fractures
Iranmedex (http://www.iranmedex.com/), and Iranian Re-
search Institute for Information Science and Technology The most common classification method for NOE frac-
(Irandoc) (http://www.irandoc.ac.ir) for articles published tures is based on the attachment of the medial canthal lig-
from October 2004 to October 2014 using specific key- ament and the comminuting intensity of the central frag-
words. The utilized keywords were “naso-orbito-ethmoid,” ment of bone (6). This scheme, which was suggested by
“naso-ethmoido-orbital,” “ethmoido-orbito-nasal,” “can- Markowitz et al. (2), is clinically useful for both the diag-
thopexy,” and “medial canthal ligament.” The references nosis and management of NOE fractures. Figure 1 demon-
from each study were also searched in order to identify strates this classification scheme (20). Type I fractures in-
any articles that were not found during our initial liter- clude a single-segment central fragment in which the me-
ature search. Only those articles relevant to the selected dial canthal ligament is attached to a relatively large seg-
keywords and the topic of the study were included. All ment of fractured bone. This is the most common type
of the retrieved papers and related review papers were of fracture (6). In type II fractures, the central fragment
evaluated and cited. is comminuted, although the fractures remain external to
Two authors (M.K. and P.S.) performed database the medial canthal ligament insertion. Type III fractures
searches, while the other two authors (M.E. and S.S.) per- are conditions in which the insertion of the medial can-
formed the data extraction procedure, independently. thal ligament is comminuted. According to Nguyen et al.’s
In the case of disagreement between the evaluators, the study, the least common fractures in this classification are
disagreement was resolved by discussion and a final type III fractures, accounting for 1% - 5% of all NOE fractures
consensus was agreed on. (6).
Another classification for NOE fractures concerns uni-
lateral or bilateral fractures. The unilateral involvement of
3. Results the NOE complex is more common (17, 21).
NOE fractures can also be classified based on concomi-
3.1. Etiology and Prevalence of NOE Defects tance with other facial fractures (22). This can include
The bony structures of the NOE complex, particularly the occurrence of NOE fractures and orbitozygomatic frac-
the delicate bones of the medial orbit, are highly suscepti- tures, NOE fractures and craniofacial fractures, NOE frac-
ble to fractures. High-energy blunt or penetrating traumas tures and panfacial fractures, and isolated NOE fractures.
are the most common cause of NOE fractures. Different eti- Although the classification system introduced by
ological factors may be associated with defects in the NOE Markowitz et al. (2) is the most widely used system
region, including trauma and congenital deformities, of among maxillofacial trauma surgeons, it may not take
which trauma is the most common etiological factor. NOE into account the differences in midface-skull propor-
fractures usually occur due to blunt trauma (8, 9), mostly tions and frontal sinus pneumatization between children
Figure 1. Markowitz type I fractures include a single-segment central fragment in which the medial canthal ligament is attached to a relatively large segment of fractured
bone. Markowitz type II fractures include the comminuted central fragment with the medial canthal tendon still attached. Markowitz type III fractures are conditions in
which the insertion of the medial canthal ligament is comminuted (Reprinted with permission from Hopper et al.’s study (20)).
and adults (23). Burstein et al.’s classification provides a (22). Although post-traumatic cerebrospinal fluid leaks re-
more thorough appreciation of pediatric NOE fracture sulting from maxillofacial fractures are uncommon (26),
patterns with concomitant skull fractures (24). It incorpo- if such leaks are suspected on clinical examination, then
rates the aforementioned anatomic differences and the beta-2 transferrin testing of clear rhinorrhea can confirm
greater involvement of the frontal basilar skull. Figure 2 the leakage (27).
demonstrates the Burstein classification in more detail
(23). 3.4. Surgical Approaches
The goal of NOE fracture treatment is the obviation of
3.3. Diagnosis of NOE Fractures
three major issues, namely the establishment of proper
The best way to confirm the diagnosis of NOE fractures nasal projection, narrowing of the intercanthal distance,
is a combination of clinical examination and computed to- and the establishment of the nasofrontal and lacrimal
mography (CT) scan (3). A maxillofacial CT scan with 1 - fluid route (22). External plates and splints were once used
2 mm slices can ascertain midfacial fractures (9). Three- for the management of NOE fractures (9). However, cur-
dimensional (3-D) reconstructions are also useful in com- rent treatments are mostly based on open reduction and
bination with traditional two-dimensional views, since 3- internal fixation. It should be noted that prompt surgery
D reconstructions may offer increased accuracy in the de- and initial correction of the NOE anatomical region yields
tection of fractures of the NOE region at the piriform aper- much better results when compared to late revision surg-
ture (25). The medial orbital region and the lacrimal fossa eries. However, most authors have advocated the post-
are two of the key areas to assess in radiographic images. ponement of surgery for 3 - 7 days to allow for the recession
The assessment of the axial cuts in cross-sectional images of edema (22). Surgical approaches for accessing the NOE
can also provide important information about the NOE region are inferior lid incisions including subciliary and
complex as well as the degree of disruption in the region transconjunctival approaches. If NOE fractures are con-
of the medial canthal tendon attachment (7). Subjective comitant with midfacial fractures, inferior lid incisions
signs of NOE fractures include edema of the medial can- can be applied with a transoral approach. Moreover, on
thal region, nasolacrimal duct obstruction, diplopia, anos- the condition that the NOE fractures are accompanied by a
mia, and nasal congestion. Objective signs of NOE frac- fracture of the upper third of the face, a coronal approach
tures include the mobility of the intercanthal region in pal- is indicated. Generally, the fracture treatment principles in
pation, rounding of the medial canthus, widening of the pediatric patients remain the same as those for adults (7).
nasal bridge, and telecanthus. In cases of suspected NOE The surgical treatment of NOE fractures is guided by
fractures, telecanthus and loss of nasal projection are hall- the pattern and classification of injury. The surgical ap-
mark clinical findings. Telecanthus refers to an increased proach also varies according to the fracture type and other
intercanthal distance, with a normal intercanthal distance concomitant facial injuries. Non-displaced type I fractures
in Caucasian individuals being approximately 35 mm (7, with a single central fragment and an intact medial can-
9). A distance exceeding 40 mm is classified as telecanthus thal tendon attachment often require no surgical interven-
and it may indicate that surgical treatment is required tion, and the patients can be followed clinically. However,
Figure 2. A, a Burstein type I fracture is localized to the upper NOE complex and frontal bone, while medial to the superior orbital foramen; B, a Burstein type II fracture
involves half of the superior orbital wall, although it does not involve the NOE; C, a Burstein type III fracture is bilateral and involves the superior orbital walls, upper NOE, and
bilateral frontal bones (Reprinted with permission from Liau et al.’s study (23))
displaced and/or unstable type I fractures will require open out complications such as telecanthus, diplopia, and a con-
reduction and internal fixation, which can be managed siderable scar (29).
through a maxillary transvestibular approach, possibly in
combination with a transorbital approach (transconjunc- 3.4.3. Using Micro-Anchor Devices
tival or transcutaneous). These fractures often require frac- This method involves a nickel-titanium (nitinol) an-
ture reduction and mini-plate fixation of the frontal pro- chor (1.3 mm in diameter and 3.7 mm in height), 4 - 0 Ethi-
cess of the maxilla (7). Figure 3 depicts a case of a type II bond suture, and the associated inserter and perforator de-
NOE fracture accompanied by a Le Fort II fracture that was vices. After making a cutaneous incision anterior to the
fixed using mini-plates. In type II and especially type III medial canthal ligament, subperiosteal dissection is con-
fractures, after reduction and fixation of the fractured seg- tinued to the lacrimal crest. A hole is created posterior and
ments, medial canthopexy should be carried out in order superior to the lacrimal crest using the perforator device.
to reposition the medial canthal ligament. The most com- Thereafter, the micro-anchor is placed by the inserter de-
mon method for medial canthopexy is transnasal wiring vice and held by the suture. This technique has the advan-
(Figure 4). However, in the present review we mostly tage of eliminating the dissection of the contralateral side
sought to focus on new and novel modified treatment tech- (30).
niques. Hence, novel techniques for medial canthopexy
are discussed in detail below.
3.4.4. Unitransnasal Canthopexy
After making an incision 2 mm from the medial can-
3.4.1. Using the Frontoglabellar Area for Wire Fixation thal ligament, two holes are created 2 mm apart from each
After the reflection of a coronal flap, a shallow hole is other into the nose. Polypropylene suture is then passed
created in the glabellar area of the frontal bone using a through each hole using a No. 14 angiocatheter. The end of
bur. Then, the medial canthal ligament is located and a the suture is held by the insertion of a hemostat into the
wire is passed through it. Two holes are created in the fron- nose and evicted. The ends of the suture are tied. There-
toglabellar region and the wires are fastened. The advan- after, the medial canthal ligament is held in place by the
tages of this approach include the elimination of bolster, other end of the sutures. When using this method, the
the prevention of injury to contralateral delicate bones nasal bone and orbit of the contralateral side remain un-
and lacrimal apparatus, and the invisibility of the wires damaged (31).
due to the presence of thick soft tissue (28).
3.4.5. Transcaruncular-Transnasal Suture
3.4.2. Transcutaneous Medial Canthal Tendon Incision to the After the reflection of the coronal flap, the NOE region
Medial Orbit is exposed. Vicryl or polydioxanone suture is inserted into
An incision some 1.5 - 2 cm in length is made anterior the periosteum in the region of the attachment capsule
to the anterior part of the medial canthal ligament. Then, of the medial canthal ligament and then evicted from the
the anterior part of the medial canthal ligament, the me- caruncle. Next, it is again passed from the caruncle to-
dial wall of the orbit, and the nasal bridge are exposed. The wards the attachment. Finally, the suture is tied. This ap-
incision used in this approach is more posterior, smaller proach provides benefits such as requiring less operation
in size, and more esthetic than a Lynch incision. Moreover, time, excellent control of the magnitude of canthopexy,
this approach allows the management of the fracture with- and the elimination of foreign body reaction (21).
Figure 3. Preoperative CTs of a patient in A and B, axial and C, coronal views depict the nasal bone and nasal bridge fracture as well as the NOE and Le Fort fracture; D, the afore-
mentioned fractures can also be traced in a three-dimensional CT; E, surgical exposure of the NOE fracture. F, plates and screws used for fracture reduction and stabilization;
G, postoperative Waters projection showing the fixation of the facial fractures (Courtesy of Dr. Mehrnoush Momeni)
3.4.6. Precaruncular Medial Canthopexy tinued above the Horner muscle to the posterior lacrimal
After the placement of the eye-shield, a conjunctival in- crest. Periorbital tissue is reflected from the medial wall.
cision is made anterior to the caruncle. Dissection is con-
Figure 4. The Central Bone Segments or Medial Canthal Tendons are Stabilized to Each Other With Different Transnasal Wiring Techniques
Figure 5. Medial Canthopexy Using a Unilateral Technique With a Transcaruncular Barb Secured to a Mini-Plate
One of the most common complications stemming etrate into the anterior cranial fossa (49). Cerebrospinal
from NOE fractures is traumatic telecanthus (10, 37) due fluid rhinorrhea may also occur traumatically due to NOE
to injury and the avulsion of the medial canthal ligament fractures (11, 50).
(38). Another esthetic imperfection associated with NOE Concomitant infection is rarely reported in NOE frac-
fractures is nasal deformity (39) owing to the loss of nasal tures. In a study of 1239 cases of maxillofacial fractures,
support (40). Moreover, enophthalmos (8) and midface Kyrgidis et al. reported seven cases of infection in NOE frac-
retrusion (36) are other cosmetic defects that arise from tures together with panfacial fractures (17).
NOE fractures. Pediatric NOE fracture is a challenging complication
Epiphoria may occur as a result of nasolacrimal sys- among all the maxillofacial fractures. Rigid fixation has
tem obstruction or post-operative eyelid malposition (18, been shown to result in growth restriction in animal mod-
41, 42). It has a prevalence of about 47% (18, 43). If this con- els. Techniques utilizing absorbable plating systems are
dition has not been remedied after a follow-up period of now commonly used for craniofacial surgery in pediatric
three to six months, external dacryocystorhinostomy may patients, which obviates the potential need for plate re-
be required (18, 41). moval, although no studies document the use of this tech-
Diplopia may be another sequela of fractures of the nique in pediatric NOE fractures (9). Despite the poten-
NOE complex, and it may occur due to the lateral displace- tially increased incidence of nasolacrimal duct obstruc-
ment of medial orbital wall fragments into the orbit (blow- tion causing epiphoria, transnasal wiring remains the
in fracture) or the medial displacement of ethmoid bone treatment modality of choice for medial canthal stabiliza-
fragments (blow-out fracture) (44). Other visual impair- tion in type II and type III NOE fractures in pediatric pa-
ments and blindness can also occur in NOE fractures (8, tients (9, 24).
10, 45, 46). In his 19-year retrospective study, Ansari re-
ported only one case of blindness among 19 patients with 4. Conclusions
NOE fractures, which is the facial fracture type involving
the least ocular injuries (47). In a review study conducted Although surgical access has not changed dramatically
by Bossert and Girotto, the incidence of blindness-related over the past decade, technological progress has led to
facial fractures was reported to be around 3% (48). new and efficient tools being added to the surgeon’s ar-
Brain injury can be a life-threatening consequence of mamentarium, including improved surgical instrumenta-
NOE fracture (11, 42) that occurs when bony fragments pen- tion, presurgical computerized planning and manufactur-
ing processes, and intraoperative CT scanning for the real- 14. Paskert JP, Manson PN. The bimanual examination for assessing
time verification of surgical reduction. Advances in sophis- instability in naso-orbitoethmoidal injuries. Plast Reconstr Surg.
1989;83(1):165–7. [PubMed: 2909061].
ticated imaging along with the evolution in minimally in-
15. Kelley P, Crawford M, Higuera S, Hollier LH. Two hundred ninety-
vasive surgical techniques have led to more conservative four consecutive facial fractures in an urban trauma center: lessons
options that may provide better patient outcomes while learned. Plast Reconstr Surg. 2005;116(3):42e–9e. [PubMed: 16141803].
minimizing the risks and morbidity associated with more 16. Chapman VM, Fenton LZ, Gao D, Strain JD. Facial fractures in children:
unique patterns of injury observed by computed tomography. J Com-
traditional treatment approaches. put Assist Tomogr. 2009;33(1):70–2. doi: 10.1097/RCT.0b013e318169bfdc.
[PubMed: 19188788].
17. Kyrgidis A, Koloutsos G, Kommata A, Lazarides N, Antoniades K. Inci-
Acknowledgments dence, aetiology, treatment outcome and complications of maxillo-
facial fractures. A retrospective study from Northern Greece. J Cran-
The authors would like to extend their sincere thanks iomaxillofac Surg. 2013;41(7):637–43. doi: 10.1016/j.jcms.2012.11.046.
to Omid Nazari for providing the schematic figures [PubMed: 23332470].
18. Becelli R, Renzi G, Mannino G, Cerulli G, Iannetti G. Posttraumatic ob-
for the present study. Special gratitude must also go
struction of lacrimal pathways: a retrospective analysis of 58 consec-
to Mehrnoush Momeni, Mani Arashrad, and Amirsalar utive naso-orbitoethmoid fractures. J Craniofac Surg. 2004;15(1):29–33.
Sayedyahossein for providing the photographs of the [PubMed: 14704558].
clinical cases. 19. Spinelli HM, Shapiro MD, Wei LL, Elahi E, Hirmand H. The role of
lacrimal intubation in the management of facial trauma and tumor
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