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. Naso-orbital Ethmoid Fractures Introduction. Suspect in Central Midfacial Trauma Failure of Diagnosis Leads to Significant Facial Deformities

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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 > 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


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