Naso-orbital Ethmoid and Frontal Sinus Fractures

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Naso-orbital Ethmoid and Frontal Sinus Fractures

• Grand Rounds Presentation
• Jim C. Grant, M.D.
• Byron J. Bailey, M.D. FACS
• April 29, 1998

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Naso-orbital Ethmoid FracturesIntroduction

• Suspect in Central Midfacial Trauma
• Failure of Diagnosis Leads to Significant Facial
  Deformities
• Isolation of Lower 2/3 Medial Orbital Rim
• Lateral Nose
• Medial Orbital Wall
• Nasomaxillary Buttress
• Frontal Process of Maxilla / Maxillary Process
  of Frontal Bone

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Basic Principles in Craniomaxillofacial Management

• Early One Stage Repair
• Exposure of All Fracture Fragments
• Precise Anatomic Rigid Fixation
• Immediate Bone Grafting as Indicated for Bony
  Loss
• Definitive Soft Tissue Management

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Naso-Orbital Ethmoid Region Bony Anatomy

• Limits of the Naso-orbital Ethmoid Region
• Horizontal Buttress
• Vertical Buttress -- Central Fragment
• Medial Orbital Wall
• Nasal Bones
• Ethmoid Labyrinth / Perpendicular Plate

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Naso-orbital Ethmoid AnatomySoft Tissue
Structures

• Medial Canthal Tendon
• Anterior / Posterior / Superior Limbs
• Function
• Nasolacrimal Collecting System
• Ensheathed Partially by Superior and Anterior
  Limbs
• Inferior Aspect Prone to Injury

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Naso-orbital Ethmoid FracturesSigns and
Examination

• Medial Canthal Tendon Displacement
• Traumatic Telecanthus (IC/IP gt 1/2)
• Lack of Eyelid Tension -- Positive Bowstring
  Test
• Rounding of the Medial Canthus
• Shortened Palpebral Fissure

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Naso-orbital Ethmoid FractureSigns and
Examination

• Lacrimal System
• Inspect With Loupes if Laceration in Area\
• Damaged Area Canulated
• Associated Ocular Injury
• Enophthalmos
• Diplopia
• Entrapment
• Vertical Dystopia
• Loss of Globe Integrity

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Naso-orbital Ethmoid FracturesSigns and
Examination

• Nasal Deformity -- pushed between the eyes
• Reduced Nasal Projection and Height
• Flattened Nasal Dorsum
• Septal Deviation / Dislocation
• Intracranial Involvement
• Cerebrospinal Fistula
• Pneumocephalus
• Frontal Sinus Involvement

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Naso-orbital Ethmoid FracturesSigns and
Examination

• Palpation of Nasal Bones
• Allows Assessment of Integrity of Dorsal Nasal
  Height
• Collapse Implies Absence of Support
• Click on Pressing Inward at the Medial Canthal
  Ligament
• Bimanual Examination

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Naso-orbital Ethmoid FracturesClassification

• Type I-- Involves Single Segment Central Fragment
  Fractures
• Type II -- Comminuted Central Fragment With
  Fracture Lines Remaining Peripheral to the Medial
  Canthal Tendon Insertion
• Type III -- Comminuted Central Fragment With
  Fracture Lines Extending Beneath the Medial
  Canthal Tendon Insertion

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Naso-orbital Ethmoid FracturesGoals of Management

• Reconstitution of the Skeletal Framework of the
  Naso-orbital Ethmoid Region
• Stabilization of the Intercanthal Width and
  Medial Canthal Tendons
• Orbital Reconstruction
• Establishment of Nasal Support
• Reconstitution of Other Craniofacial Injuries
  Including Frontal Sinus
• Soft Tissue Repair

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Naso-orbital Ethmoid FracturesType I Incomplete
Repair

• No Requirement for Superior Surgical Approach
• Inferior Approach via Gingivobuccal Sulcus
  Incision and Transconjunctival / Subciliary
• Reduction and Rigid Fixation at Inferior Orbital
  Rim and Pyriform Aperture

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Naso-orbital Ethmoid Fractures Type I Complete

• Displaced Superior Fragment Requires Superior
  Approach via Coronal Flap With Reduction and
  Stabilization at the Superior Medial Orbital Rim
• Inferior Approach With Reduction and
  Stabilization at Inferior Orbital Rim and
  Pyriform Aperture
• Unless Severe Lateral Displacement --Transnasal
  Wiring Not Indicated

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Naso-orbital Ethmoid FracturesType II Repair

• Repair Requirements Include
• Transnasal Reduction of Medial Canthal
  Tendon-Bearing Bone Fragments
• Interfragment Wiring to Link All Fragments
• Rigid Fixation After Reduction
• Transnasal Wire Must be Placed Superior and
  Posterior to the Medial Canthal Tendon on the
  Central Fragment

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Naso-orbital Ethmoid FracturesType III Repair

• Same Basic Principles of a Type II Repair
• Comminuted Fractures Not Suitable for
  Reconstruction -- Medial Canthal Tendon Detached
• Bone Grafts May Be Required
• Medial Canthal Tendon Secured To Second Set of
  Transnasal Wires -- Point of Attachment is
  Superior and Posterior

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Naso-orbital Ethmoid FracturesNasal Support
Repair

• Dorsal Bone Grafting
• Reduction of Septal Fracture
• Possible Use of Medial Crura Strut for Columellar
  Support
• Placement of Canilevered Graft Under the Dome

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Naso-orbital Ethmoid FractureLacrimal System
Repair

• Routine Exploration With Canalicular Probing Not
  Indicated
• Identifiable Disruption -- Canulate and Suture
• Only 5 Incidence of Cases Require DCR Later

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Naso-orbital Ethmoid FracturesSoft Tissue Repair

• Padded Bolsters Placed
• Secured Through Transnasal Wiring
• Lack of Bolstering Leads to Thickened Skin in
  this Area Increasing the Intercanthal Soft Tissue
  Difference

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Naso-orbital Ethmoid FracturesOrbital Repair

• Restoration of Orbital Volume and Contour Must be
  Addressed
• Use of Bone Grafts and Alloplastic Materials in
  the Orbital Floor

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Naso-orbital Ethmoid FracturesComplications

• Persistent Telecanthus
• Anteriorly Placed Transnasal Wires
• Inadvertent Elevation of Tendon
• Inadequate Reduction and Stabilization of
  Central Fragment
• Lack of Adequate Repair of the Orbit
• Lack of Adequate Repair of Nasal Support
• Soft Tissue Thickness Secondary to Inadequate
  Bolstering

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Frontal Sinus FracturesIntroduction

• Incidence -- 5 - 12 Craniofacial Injuries
• High Morbidity and Mortality
• Management Goals
• Avoidance of Early and Late Complications
• Cosmetic Reconstruction
• Progresses of Frontal Sinus Surgery

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Frontal Sinus FracturesAnatomy

• Frontal Sinus Development
• Anterior versus Posterior Table
• Nasofrontal Duct
• Arterial / Venous Blood Supply
• Sensory Innervation

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Frontal Sinus FracturesDiagnosis

• Physical Examination
• Assess for Associated Ocular Injuries
• Assess for Associated Intracranial Injury
• Assess for Associated Craniofacial Injury --
  Naso-orbital Region
• CT Scanning
• Difficult to Assess Patency of Nasofrontal Duct

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Frontal Sinus FracturesSurgical Approaches

• Frontal Sinus Trephination
• Frontoethmoidectomy
• Osteoplastic Flap -- Most Commonly Employed
• Frontal Craniotomy

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Frontal Sinus FracturesOperative Indications

• Anterior Table Displacement With an Aesthetic
  Forehead Deformity
• Nasofrontal Duct Involvement / Obstruction
• Displaced Posterior Table Fractures

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Frontal Sinus FracturesAnterior Table Fractures

• Nondisplaced Anterior Table Fracture
• Displaced Anterior Table Fracture
• Status of Nasofrontal Duct
• Sinus Preservation
• Sinus Obliteration
• Removal of Mucosa
• NF Duct Obstruction
• Sinus Packing

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Frontal Sinus FracturesNasofrontal Duct
Reconstruction

• Intersinus Removal Allowing Drainage Through
  Contralateral Duct
• Placement of Catheter Through Traumatized
  Nasofrontal Duct
• Frontoethmoidectomy Approach When Posterior Table
  Not Requiring Repair

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Frontal Sinus FracturesPosterior Table Repair

• Nondisplaced Posterior Table Fractures
• Minimally Displaced Posterior Table Fractures--
  Less than One Width
• Displaced Posterior Table Fracture
• Nasofrontal Duct Status
• Cerebrospinal Fluid Leak
• Degree of Comminution

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Frontal Sinus FracturesCranialization

• Coronal Incision -- Osteoplastic / Frontal
  Craniotomy
• Preservation of Anterior Pericranium
• Intersinus Septum Removal / Posterior Table
  Removal
• Debridement of Necrotic Tissue / Repair of Dural
  Tears
• Sinus Mucosa Removal
• Nasofrontal Duct Obliteration
• Interposition Pericranial Flap to Floor