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
Diagnosis
• CT
• Old photographs
– Estimate intercanthal distance
Physical Exam
• Swelling
• Intercanthal distance
– Approx half interpupillary distance
– >40 mm
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•
•
•
Eyelid traction
Bimanual exam
CSF rhinorrhea
Eye exam
– Enophthalmos
– 20-25% ocular injury
Facial Deformity
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•
•
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Telecanthus
Shortened palpebral fissures
Enophthalmos
Shortened/retruded nose
– Flattening, collapse, inward telescoping of
nasal bones
• Ocular dystopia
Treatment Indications
• All displaced fractures
• Medial canthal tendon insertion
displacement/ disinsertion
– Telecanthus
• Facial deformity
• Nasal airway
• Tear drainage disruption
Fixation
- Closed reduction, external splinting, wires
- Indications
- Simple fractures
- Pros
- Simple
- Cons
- Cannot correct medial canthal displacement/ disinsertion
- Unable to reduce medial orbital wall/rim
- Collapse, flattening, telescoping of nose
Fixation
- Open reduction, internal fixation
- Mustarde 1964, Dingman 1964
- Medial canthal tendon insertion
- Stranc 1970
- Canthopexy
- Suture/wire
Approaches
• Approaches
– Existing lacerations
– Local incisions
• Midline vertical (Stranc)
• Open sky (Converse 1970)
• W incision
– Coronal incision
– Lower lid incision
– Upper gingivobuccal sulcus incision
Repair
1.
2.
3.
4.
5.
6.
7.
8.
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
2. MCT Insertion Exposure
• MCT insertion
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
4. Reconstruction Medial Orbital
Wall
• Alloplastic
– Titanium mesh, medpor
• Autologous
– Bone (rib, calvarium
5. MCT Canthopexy
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
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