Naso-Orbito-ethmoidal Fractures Seminar Abhijit Joshi (Nxpowerlite) / Orthodontic Courses by Indian Dental Academy

Abhijit Joshi
INDIAN DENTAL ACADEMY

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Abhijit Joshi
NASO-ORBITO-ETHMOIDAL
FRACTURES
Abhijit Joshi
Contents :
Significance of NOE region & applied anatomy
Classification of NOE fractures.
Clinical features and pictures
Radiology.
Assessment of lacrimal drainage.
CSF leaks and management.
Steps in managing a NOE fracture
Managing a Post traumatic nasal deformity.
Abhijit Joshi
NOE complex
Intricate anatomical structure.

At anatomical crossroads.

4 cavities involved:
Cranium
Orbits
Nasal
maxilla

4 bones involved:
Paired nasal
Frontal process of maxilla
Ethmoids
Lacrimal bones.

Abhijit Joshi
NOE complex
Wedged in interorbital space.

Basically weak

Strength :
Vertical buttress : frontal pr of
max
Horizontal : sup/inf orbital
rims

Additional strength:
Lattice network of bones
Articulation at various angles.

Abhijit Joshi
Anatomy and applied aspects:
Osteology
Soft tissue anatomy
Abhijit Joshi
Osteology
Nasal bones
Ethmoid
Medial orbital rim and wall

Other bones involved:
Perpendicular and Cribriform plate of ethmoid.
Nasal process of frontal bone.
Sphenoid bone

Abhijit Joshi
Nasal bones
Abhijit Joshi
Anteriorly: frontal process of max + max proc of frontal.

Lacrimal fossa :
depression on inferomedial orb rim.
Formed by max and lacrimal bones
Bound by Ant lacrimal and Post lacrimal crests.
16mm high x 4-9mm wide x 2mm deep
Max-lacrimal suture: confluence of the 2 bones
Mean thickness of lacrimal bone here : 106microm easy perforation
Abhijit Joshi
Sutura notha/ sutura longitudinalis imperfecta of weber:

Fine groove on frontal process of maxilla
Anterior to ant lacrimal crest
Contains small branches of infraorbital artery.
Anticipate their presence during dissection
Abhijit Joshi
Medial orbital wall

Paper thin lamina papyracea
Strength from ethmoid air cells dessipation.

Medial blow out # assoc with orb floor # in
50% cases.

Traversed by:
ant ethmoid art 24mm
Post ethmoid art 34mm
Care taken to identify these vessels can
contribute to Retro Bulbar Hemorrhage

Entrapment of orbital fat media horizontal
diplopia restriction of abduction-retraction of
globe
Abhijit Joshi
Ethmoid bone
Abhijit Joshi
Abhijit Joshi
Ethmoid :
Abhijit Joshi
Soft tissue anatomy:
medial canthal ligament
Lacrimal drainage apparatus
Associated vessels etc.
Abhijit Joshi
Soft tissues.
Right eye in primary position
Abhijit Joshi
The U/L are suspended in space, tethered medially and laterally by canthal ligaments
Orb. oculi attaches to the medial orbital wall via MCL
Fibrous diamond shaped, Tripartite arrangement.
Greater horizontally with Ant and post limbs
Abhijit Joshi
Medial canthal ligament (MCL):
Complex, strong interlocking 3-D arrangment of indivisual
components and structures.

Strength derived from complex
anatomy.

Intimately related to
lacrimal drainage apparatus.
lacrimal bone
reinforces.

Abhijit Joshi
Anterior limb:
11.7mm length/4.9mm width longer and more prominent.
medial attachment :
Frontal process of maxilla just lateral to suture with nasal
bone.
Superior aspect of Ant lacrimal crest and beyond (zide).

superior branch periosteum of frontal bone(corrugator super cilli)
Abhijit Joshi
Posterior limb of MCL
Small and poorly defined.
Attaches to posterior lacrimal crest.
Periosteum in this region is thicker and extends till
anterior lacrimal crest in a triangular fashion
Applied :
makes post attachment strong.
Strengthens the whole structure.
Hence important to reconstruct the post segment.

Both ant and post limbs envelope the lacrimal sac.

Abhijit Joshi
Lacrimal drainage:
Abhijit Joshi
Abhijit Joshi
Relationship betw excretory system and MCL
Sac is wrapped by lacrimal fascia ( split periorbita)
Wrapped by MCL ant and post limbs
Deep portion of Pretarsal orb oculi horner-duverney
muscle passes posterior to post limb of MCL and attaches to
upper portion of PLC.

Abhijit Joshi
Other Relations:
MCL to ant cranial fossa:
Mean vertical dimension betw MCL and level of cribriform plate
: 17mm +/- 4mm
McCann1998 Invest Opthal

Distance between common internal punctum and most ant part
of cribriform plate is 25mm
botek 93 Opthal Surgery

MCL and Angular art and vein:
Superficial to MCL
5-8mm anteromedial to ant lacrimal crest
Anticipate bleeding.
Abhijit Joshi
Type I central fragment

Type II comminuted fracture
with lateral extension not
involving MCL

Type III comminuted fracture
with extension into MCL
Markowitz and Manson
Abhijit Joshi
Classification - Ayliffe
Type I en bloc minimum
displaced fractures of the entire
NOE complex

Type II en bloc displaced
fractures, usually associated with
large pneumatized sinus and
minimal fragmentation
Abhijit Joshi
Type III comminuted fracture
but canthal ligament firmly
attached with bone fragments
which are big enough to plate

Type IV comminuted fracture
with free canthal ligament not
large enough to be plated

Abhijit Joshi
Type V gross comminution needing bone grafting

Abhijit Joshi
Ideal proportions
The ideal nasofrontal angle 115 to 130 The ideal nasal project 1:1.
ideal intercanthal distance should be approximately 1/3.
Abhijit Joshi
In a NOE fracture
Direct blow to nasal bony dorsum

Crushing of Fragile perpendicular
plate, ethmoidal air cells

post displacement

Removes dorsal support for nose.
Medial canthal ligament detaches /
disarticulation of bone containing
attachement

Rounding of medial canthal angle
Widening of intercanthal distance.
Adherent dura , Crista Galli/ cribriform plate
move as a unit olfactory damage.

CSF leak

Abhijit Joshi
Clinical features:
Reduced Dorsal nasal projection , Upturned nasal tip
Accentuation of Naso-Frontal angle.
Accentuated naso-jugal fold.
Inward Telescoping medial wall into ethmoid.

Traumatic telecanthus (loss of stabilization of MCL).
Traumatic hypertelorism
Orbital dystopia
Mongoloid slant

Cerebrospinal fluid leakage.
Nasolacrimal duct obstruction/severage epiphora .
Anosmia
Nasal airway obstruction

Pig snout.
Abhijit Joshi
accentuated N-F angle
Decreased dorsal nasal projection.
Upturned nasal tip.
traumatic telecanthus

Abhijit Joshi
Edema, emphysema, echymosis
Traumatic telecanthus
Orbital dystopia
rounding of medial canthal angle
Mongoloid slant www.indiandentalacademy.com
Abhijit Joshi
Subconjunctival emphysema
In a patient with medial wall fracture assc with NOE #
(after blowing his nose)
Abhijit Joshi
Injury to lacrimal drainage:
Abhijit Joshi
Clinical assessment.
Firm palpation of ant. Lacrimal crest and
frontal process of maxilla
Firm compression of MC region to displace
the edema with thumb and forefinger while
displacing lateral canthus laterally allows
palpation of
fractured fragment,
mobility of MCL attachment
Mobility of adjacent bone
Principles of management of complex
craniofacial trauma; Marciani et al, JOMS 93
Abhijit Joshi
Physical examination
Eyelid traction test / Furnas traction test
Furnas DW, Bircoll
MJ Plast Reconstr Surg. 1973 Sep;52(3):315-7

Bimanual palpation by placing an instrument into the
nose to determine canthal bearing bone fragment
displaced and mobile
Abhijit Joshi
Diagnostic Imaging.
Conventional : standard PNS view
Plain films are of ALMOST NO USE in diagnosing NOE fractures
because most will be undetected;
Edward ellis ;Sequencing treatment for NOE
fractures JOMS 93
Abhijit Joshi
CT
Is of greatest value

HRCT adds to the existing value

What to ask for?
1-2 mm Axial and coronal slices with 3D recon.
Top of skull-frontal sinus-orbits-maxilla
Bone window NOE bony complex
Soft tissue window brain/ocular adnexa.

Abhijit Joshi
Axial cuts.
Position and status of frontal
process of maxilla central
fragment.
Medial walls of orbit if they are
blown in nasally,
Anterior and posterior tables of
frontal bone
Nasolacrimal system
Abhijit Joshi
Coronal cuts
Cuts taken from nasal
bridge to orbital apex
junction of floor to medial
wall assessed.
Disruption of ant. Cranial
fossa around cribriform
plate.
CSF leak CT value
localization of CSF leaks.
Abhijit Joshi
3D CT
Abhijit Joshi
Tests for Secretory
system
Tests for drainage/excretory
system
Schirmers test
basal tear secretion test
primary dye test
Investigations of the lacrimal system

Dye disappearance test
Jones 1 and Jones 2
DCG
HRCT
Tc 99 scan

Abhijit Joshi
Dye disappearance test:
Simplest of tests.

Flouriscine dye placed on
conjunctival fornix

Dye disappears.

Patency of system

Abhijit Joshi
Jones test
Jones 1.
1 drop fluorescein dye placed into conjunctuval sac.
Cotton bud soaked in LA placed in inf meatus.
Wait for 5 min and remove the bud.
If bud stained with dye test +ve
Abhijit Joshi
If ve then proceed to jones 2:
Clear saline irrigated thru cannula
inserted into inf canaliculus
Patient bends forward
1. Nothing frm nostril
Complete obstr.
distal to tip
2. Fluid regurgutates
opp. punctum
Patency of both canaliculi till
int canaliculus
3. Clear fluid from nose
Dye not entered canaliculi
Blocked punctum/canaliculi
Stained fluid
+ve test
Abhijit Joshi
Dacrocystography:
Radioactive oilbased dye injected into lacrimal
drainage.
Radiographed to know the course of duct
CT used for imaging CT dacrocystography.
Abhijit Joshi
CSF leak and management.
Abhijit Joshi
Cerebrospinal fluid.
CSF is essentially an ultrafiltrate of plasma

Clear colourless fluid bathes brain and spinal cord.

Fills ventricles within the subarachnoid space.

Main funtion:
Cushions brain against trauma (sp. Gravity of brains
within 4% of that of CSF brain floats !!)
nourishment.
Removal of waste products.

Abhijit Joshi
Production and composition.
Production :
Choroid plexus and ventricular ependyma
@ 500cc/day.
Volume : 150cc turnover is TID
Pressure mantained at 60-150mm H
2
O valsalva,
coughing, straining.

Composition:
Insoluble salts.
Ph 7.33
Total proteins content: 20.0mg/dl
Glucose : 64.0mg/dl
Beta transferrin.

Abhijit Joshi
CSF leaks
Barriers to contain CSF and
prevent its communication
with external:
Dura,
Skull
Periosteum
Galea and skin.

Barriers violated CSF leak.

Risk of meningitis 4-50%
Abhijit Joshi
CSF leaks.
Traumatic Atraumatic - 3-4%
spontaneous
High-pressure

Normal-pressure
Surgical
16%
Non-surgical
80%
3% closed head injuries
9% penetrating head injuries
10-30% basilar skull fractures
Abhijit Joshi
Common sites for CSF leak
Cribriform plate, frontal sinus, Ant. Eth. roof.
posterior ethmoid roof,
sphenoid sinus.
temporal bone (pseudorhinoliquorrhea).

Abhijit Joshi
Simple bed side procedure nonspecific.
Performed upon patient arising in the
morning.
Place patients chin to chest for 1min.
Copious leakage thru nose like an open
faucet.
Intermittent drainage:
Use Ipratropium bromide
Nasal secretions will stop
CSF leaks continue.

Reservoir sign
Abhijit Joshi
Salty taste:

Handkerchief sign:
mucous stiffens linen on drying but csf keeps it soft
distinguishes from allergic rhinitis.

Halo sign/double ring sign:
blood CSF mixture spreads on linen.
Dark ring of blood encircles more lightly stained CSF

Abhijit Joshi
Tramline effect:
occurs when CSF mixed with blood.
CSf appears later as yellowish discharge mixes
with blood.
CSF higher protein content.
More viscous CSF forms central track with blood on
either side which diffuses to edge.
Abhijit Joshi
Laboratory diagnosis
Glucose test
Protein analysis
Beta transferrin test
beta-Trace Protein
Electronic nose
Abhijit Joshi
Glucose test : CSF collected in vial and if glucose
levels are > 45mg/dl CFS existence.
Abhijit Joshi
glucose oxidase stick technique

Normally nasal secretions are devoid of glucose
whereas CSF has a glucose level related to the plasma
glucose. The literature generally supports a glucose
value of 30 mg/dL in rhinorrhea fluid as indicative of
CSF. However, there are opportunities for false-
positives and false-negatives. For example, a post-
surgical patient may have a serous exudate which
physiologically contains glucose.

To measure the glucose concentration of nasal
secretions in the absence or presence of rhinorrhoea

Abhijit Joshi
Beta transferrin test
This protein is found in only three bodily fluids CSF,
perilymph, and vitreous humor .

Unless a patient has an open globe, ongoing production of
clear nasal discharge that is positive for beta-2-transferrin
is highly diagnostic for CSF

Is a protein produced by neuraminidase activity
Abhijit Joshi
b-2 transferrin

Immunofixation electrophoresis of nasal secretions in
the laboratory used to detect b-2
This test is not sufficiently rapid to provide support for
clinical decision making in emergency departments
and may not be available in all hospitals, particularly
in developing countries

Abhijit Joshi
Beta Trace protein.
B-TP is a naturally occurring secretory enzyme present in
human CSF concentration of 15 to 20 mg/L.

The CSF to serum ratio of b-TP (33:1) highest of all CSF
specific proteins

Ideal marker for the detection of CSF traces.

Most abundant protein in human CSF, (also in prealbumin,
albumin, Ig G).

Also in urine, aqueous humor, and inner ear fluids,glomerular filtr.

In healthy subjects, the serum concentration of B-TP is 0.3 mg/L.

Abhijit Joshi
Immunoelectrophoresis / Nephelometric assay used.
In comparison to the 2-transferrin test, the b-TP
assay superior higher predictive values.
Test can be performed within 20 minutes
Smallest traces of CSF (5%) can be detected by B-TP.
Limitation : Pts with acute glomerulonephritis or
terminal renal insufficiency; in these patients, the B-
TP concentration increases in the serum.
Bachmann et al

Predictive Values of -Trace Protein by Use of Laser-Nephelometry
Assay for the Identification of Cerebrospinal Fluid Neurosurgery, Vol. 50, No. 3,
March 2002

Abhijit Joshi
Nephelometer
It does so by employing a light beam (source beam)
and a light detector set to one side of the source
beam.
Particle density is then a function of the light reflected
into the detector from the particles.
How much light reflects dependent upon properties
of the particles shape, color, and reflectivity.

An assay is a procedure where the concentration of a component
part of a mixture is determined
An apparatus used to measure the size and concentration of
particles in a liquid by analysis of light scattered by the
liquid.`
Abhijit Joshi
Electronic nose
Vapor-sensing devises used primarily in the food and
beverage industries.
Numerous publications have addressed the medical utility
of such devices.
Electronic nose technology has been used for breath
analysis to identify:
Campylobacter pylori in the stomach,
Study lactose malabsorption,
Vapor pressure in sweat analysis in screening for
cystic fibrosis.

Abhijit Joshi
A. Headspace over a liquid sample is
aspirated into an analyzer (electronic
nose).
B. Headspace gas (containing the sample
aroma) is allowed to interact with
array of 32 conducting polymers with
differing sensitivities to specific
chemical types (eg, alcohols,
ketones).
C. Electrical resistance of each of the
conducting polymers changes
reproducibly after exposure to an
aroma, allowing the aroma to be
represented as a point in a 32-
dimensional space
Abhijit Joshi
Efficacy of electronic nose

The amount required,0.3 mL, may be obtained with
only a few drops of nasal discharge

The electronic nose was also able to reliably place
unknown specimens in the appropriate category of
CSF or serum
Anna Aronzon et al OtolaryngologyHead and Neck Surgery
(2005) 133, 16-19

Abhijit Joshi
Radiographic evaluation:
High resolution CT : bone defect is filled with CSF
density fluid extracranially.

CT cisternography

Radionuclide cisternography

Intrathecal flourscien

MRI cisternography
Abhijit Joshi
CT Cisternography
Contrast dye oil based, nonionic (metrizimide)used.
Lumbar puncture into subarachnoid space.
Trendelenburg position.
Subject to CT scan.
High resolution CT Coronal 2mm slices obtained :
confirm CSF leak
Locate site of leak.
Abhijit Joshi
CSF fistulas
Metrizamide CT scan showing CSF leak in left frontal sinus
s/p SW to left orbit.
CSF leak
Abhijit Joshi
Use of low concentration flourescein dye
Cotton pledgets placed in the nose.
Sterile dilution of 0.3ml flourescein + 10cc CSF made.
Infused intrathecally.
Pledgets removed after 30min to 1hr
Analyzed under ultraviolet light.

can be given simultaneously with contrast material, and thus
one can use CT cisternography and endoscopic examination
in a complementary fashion .
Abhijit Joshi
Nuclear cisternography
Sensitive method to evaluate CSF leaks
Indium 111 (bonds to CSF protiens) used life of
48hrs delayed imaging.
Injected intrathecaly.
Tracer takes 2-4hrs to reach basal cisterns
Intranasal pledgets Endoscopically placed in the
middle meatus and sphenoethmoidal
Abhijit Joshi
Abhijit Joshi
Treatment :
Tailored to individual

Intracranial versus extracranial

Endoscopic versus microscopic

Abhijit Joshi
Intracranial approach.
Advantages :
direct visualization,
ability to repair adjacent cortex,
Better chance of repairing a leak caused by
increased intracranial pressure.

Disadvantages:
increased morbidity,
longer hospitalization,
higher incidence of post-operative anosmia.
Abhijit Joshi
extracranial repair
has decreased morbidity and anosmia,
superior exposure of the posterior ethmoid,
parasellar, and sphenoid regions.

Disadv: less suited for defects in the frontal sinuses
with prominent lateral extension and is less
successful in high-pressure leaks

Abhijit Joshi
Grafts :
Free nasal mucosa,Pedicled nasal mucosa,
bone grafts harvested from the nasal septum or middle
turbinate
Temporalis fascia,muscle ,Adipose tissue.
Vascularized free flap.

Graft stabilization:
with cyanoacrylate glue/fibrin glue

Packing
Microfibrillar collagen(over the graft),
Absorbable gelatin sponges
Oxidized cellulose.
All repairs intraoperatively tested Valsalva maneuver.

Abhijit Joshi
What can be used??
Grafts/flaps
fat, fascia, muscle, cartilage,
mucosa
simple or composite

Biological glue
collagen, fibrin,
cyanoacrylate
Gelfoam, Merocel

Abhijit Joshi
Skull Base (extracranial) approaches:

Cribiform plate fistula: Transethmoidal repair
Nasal septal mucosal flap to cover ethmoid sinus.

Sphenoid sinus fistula: Transseptal transsphenoidal
approach
Recent endoscopic advances allow for a fully
endoscopic transsphenoidal approach

Primary repair of dural opening is attempted
Grafts of pericardium, fascia lata, or endogenous fat

Abhijit Joshi
Endoscopic approach to a CSF leak.
CSF leak
Abhijit Joshi
Final word on CSF.
CSF fistulae arise from a variety of etologies.

Diagnosis based on physical, laboratory and radiologic
techniques

Treatment divided into surigical and non-surgical.

Future holds refinement of existing techniques,
development of new ones

Abhijit Joshi

Abhijit Joshi

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Abhijit Joshi
Thank you
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