What is Naso-Orbito-Ethmoid Fractures?
Naso-orbito-ethmoid (NOE) complex fractures are breaks in the bones that make up the NOE region, which includes the front part of the skull, the frontal bone above the eyes, the bones of the ethmoid and frontal sinuses, the nasal bones, and the eye sockets. These injuries can happen at the same time as other facial or body injuries, or they can happen on their own. The main causes are car accidents and fights, although the rates are changing because of improved vehicle and road safety.
Understanding the structure of this region is key to identifying and treating NOE fractures. The first step to treating patients with these injuries is advanced trauma life support, which is a procedure used to assess the severity of the injury. These patients might also have injuries to crucial parts like the airway, the brain, and the neck bone. Assessing these injuries often requires a thorough check-up and the use of imaging technology. The choice of surgical intervention will depend on how severe the NOE fracture is, which in turn depends on the state of the medial canthal tendon, a strong tissue that connects to the eyeball.
Accurate and detailed initial surgical correction is important for restoring the face’s looks and preventing future complications. Surgeons must find a balance between correcting the injury and avoiding causing more cosmetic damage.
What Causes Naso-Orbito-Ethmoid Fractures?
The NOE fracture pattern happens when a strong force hits the upper middle part of the face. Because this is usually a high-energy impact, these fractures often go hand in hand with injuries to other parts of the face and body. The most common cause is car accidents, especially ones involving motorcycles.
However, the good news is that NOE fractures seem to be becoming less common. The use of seatbelts and airbags have helped to lower the number of facial fractures overall. Other causes linked to this type of fracture include physical assault, sports injuries, and kicks from horses.
Risk Factors and Frequency for Naso-Orbito-Ethmoid Fractures
Nasal orbital ethmoid (NOE) fractures are injuries that occur in the face. They account for 5% of all facial fractures in adults and are most frequently found in young men. However, these types of fractures are more common in children, making up 16% of all facial fractures. In terms of economic impact, facial fractures cost about $1.06 billion per year in the United States, leading to 93,808 hospitalization days.
- NOE fractures account for 5% of all facial fractures in adults.
- Young males are most often affected by these fractures.
- In children, NOE fractures make up 16% of all facial fractures.
- Facial fractures cost the United States around $1.06 billion annually.
- These fractures result in 93,808 days in the hospital each year.
after a motor vehicle accident. He had open repair of his nasal fractures and
transnasal wires placed. He now presents with a complaint of intermittent
tearing from the right side since the surgery and a mucoid discharge from the
left side. Photos show appearance at time of injury (above) and appearance 12
months after repair.
Signs and Symptoms of Naso-Orbito-Ethmoid Fractures
If you suspect you might have facial trauma, doctors will approach your case using what’s known as an advanced trauma life support method. The main concerns here are making sure you can breathe properly, keeping your neck still, and stopping any major bleeding as 10% of bad facial fractures can bleed a lot. Doctors will also check your nerves and eyes because two-thirds of people with facial fractures might also have an eye injury.
To examine a part of your face called the NOE complex, doctors will first look at and feel the area. However, it might be hard to check because of severe swelling and bruising around the eyes. If you have too much tearing in your eye and face, it could be because your tear duct is damaged or blocked. Doctors can verify this with dye tests or a special X-ray called dacryocystography, especially if the tearing continues after surgery. Broken nose bones and the wall inside your nose can make it look like your nose is shorter and that the tip of your nose is turned upward. A bloody nose with a split in the lining may happen with or without a fluid called CSF draining from your nose if the bottom of the skull or the back of your forehead sinuses is fractured.
You can confirm the existence of CSF by testing for a substance called beta-2-transferrin, which is more accurate but slower than simply looking for a halo sign. The halo sign is when CSF fluid on a filter paper expands further out than the blood products, forming a halo pattern. Doctors can perform a quick check for nasal blockage by placing a metal object under your nostrils to look for condensation when you breathe out.
Checking the medial canthal tendon (MCT) is crucial in determining how severely the NOE complex is injured. A key sign of MCT damage is “telecanthus,” where the inner corners of your eyes seem to have moved further apart, but the distance between your pupils remains the same. On average, the distance between the inner corners of the eyes is around 30 to 31 mm, and the distance between pupils is 62 mm for women and 64 mm for men. If the distance between the inner corners of your eyes is over 40 mm, it’s visibly wide and may need surgery. Another way of checking the MCT is the “bow-string” test, where doctors test the eyelid’s tightness and feel for a broken piece while pulling down the eyelid to the side. If the MCT is injured, the eyelid will show more flexibility, and a broken piece might be felt.
Testing for Naso-Orbito-Ethmoid Fractures
If there’s suspected serious injury and severe facial swelling, an initial physical exam may be tricky. Here’s where a computed tomography (CT) scan of the head, without contrast, comes in handy. It can provide a clear picture of any damage to the bones and soft tissue. The CT scan can create 2D and 3D images, viewed from different angles, which can help doctors diagnose and plan to treat complex nose and eye socket fractures.
These 3D images are also helpful in showing family members the extent of injuries if they’re not familiar with anatomy. Based on the results of the CT scan, doctors can decide on the best surgical approach, level of exposure needed, and equipment required. Additionally, the scan can expose other injuries in the head. In situations involving multiple injuries, a CT scan could be done as soon as doctors ensure the patient is stable.
When it comes to nose and eye socket fractures, doctors often use the Markowitz and Manson system. This is because it helps determine the complexity of the reconstruction required, based on the condition of the Medial Canthal Tendon (MCT), a key structure involved in these fractures. Doctors decide on the classification using a combination of CT scan results and clinical examination:
- Type 1: The MCT is still attached to a large bone fragment.
- Type 2: The MCT is still attached, but to a shattered bone fragment.
- Type 3: The MCT has been ripped from the bone.
Treatment Options for Naso-Orbito-Ethmoid Fractures
Fractures to the area of the face that includes the nose, eyes, and the forehead’s sides, referred to as the naso-orbito-ethmoid complex, need surgery to correct. The aim of this surgery is to restore the natural look and proportions of the face. A particular detail is the repair of a detached structure near the innercorners of the eyes called the medial canthal tendon. Examining pictures taken before the injury can guide surgeons to restore the face’s original appearance as closely as possible. The best surgical approach will be chosen based on how severe and widespread the fractures are, with the intent to leave the smallest scar possible. Sometimes, existing facial scars or cuts can be used to access the area.
The most common surgical incision for these fractures involves a cut from ear to ear over the top of the scalp. This incision gives the surgeon good visibility of the upper middle part of the face and it’s vastly used when the fractures involve the forehead’s sinus. However, for fractures involving the lower middle part of the face, a different approach might be used, but this carries risks like post-operative numbness and changes to the shape of the nose. Once the fractures are exposed fully, repairing and securing the broken bone parts is the primary step. Depending on the type of fracture, surgeons can perform a ‘closed’ repair without needing to expose the broken parts, or an ‘open’ repair, where the bone parts are exposed, secured, and sometimes reinforced with a mesh. This mesh can be made from titanium or materials that can be absorbed by the body. Smaller plates and screws can also be used to secure the bone fragments and restore the key parts supporting the facial structure. If the forehead’s sinus is involved, additional steps might be required, but this is complex and detailed.
In severe NOE complex fractures, the detached medial canthal tendon can be repaired and held in place using a wire inserted through a small hole drilled into the medial wall of the eye socket. Sometimes, when the fractures of the medial wall of the eye socket are unstable, a needle can be used instead of a drill. It’s important that the distance between the inner corners of eyes is slightly shortened during the operation to compensate for a predictable widening that occurs after surgery.
Injury to the tear duct system of the eyes is a usual complication of facial trauma, which may cause excessive tearing immediately after surgery. However, this issue usually resolves with time, and a long-term excessive tearing is relatively uncommon. But should this issue persist six months after the operation, a procedure to correct the tear-flow and prevent the buildup of mucus might be recommended.
What else can Naso-Orbito-Ethmoid Fractures be?
Naso-orbito-ethmoid complex fractures, which affect the nose, eyes, and forehead, are rarely just by themselves. Other fractures on the face or body often accompany them. There are some other types of facial fractures that can go hand in hand with these, such as:
- Zygomaticomaxillary complex fractures: These fractures can occur on their own or with naso-orbito-ethmoid fractures. They’re typically the result of a strong sideways blow to the middle or lower part of the face.
- LeFort fractures: These fractures refer to instances when the middle part of the face gets detached from the base of the skull. There are 3 levels of severity, with one being the least severe and most common, and 3 where the face gets entirely separated from the rest of the skull. This type of fracture always involves the middle part of the face, and type 3 always includes a naso-orbito-ethmoid fracture.
- Orbital floor fractures, also known as blowout fractures: These happen when a blow to the eye causes a break in the thin bone that separates the cheek sinus from the eye socket. Sometimes, eye muscle or fat can slip through this break, causing double vision and difficulty in moving the eye.
- Pan-facial fractures: These refer to fractures that involve the top, middle, and bottom parts of the face.
What to expect with Naso-Orbito-Ethmoid Fractures
Most patients who undergo primary corrective surgery end up with satisfactory cosmetic results. However, in cases of severe type 3 fractures, some patients may still have persistent nose deformation. If the first surgical attempt does not fully correct telecanthus, which is an abnormal increase in the distance between the eyes, any further correction attempts can be very difficult.
Possible Complications When Diagnosed with Naso-Orbito-Ethmoid Fractures
Some complications arise from disrupting the nasofrontal duct or nasolacrimal duct through direct damage, displaced fracture segments, or unintentional injury during treatment. This could result in facial deformity. Fully correcting issues such as telecanthus (excessive distance between the inner corners of the eyes) or nasal depression may be challenging, and some level of asymmetry might persist. Depending on the surgery, patients might temporarily or permanently lose sensation or movement in the forehead. Forehead scars might remain prominent over time, especially if there’s tissue removal, infection, or involvement of sebaceous glabellar skin (the skin between eyebrows).
Furthermore, there’s a risk of infection at the surgical site, in soft tissues, and in the meninges (membranes around the brain and spinal cord). Formation of mucoceles (fluid-filled sacs) is another complication that comes with disruption of sinus or lacrimal drainage. These mucoceles can become infected, turning into mucopyoceles.
Last but not least, mental health issues are a potential concern. Patients with facial injuries have higher risks of developing post-traumatic stress disorder or anxiety-related disorders, particularly those who have been victims of assault.
Recovery from Naso-Orbito-Ethmoid Fractures
The selection of antibiotics before, during, and after surgery largely depends on the type and cause of injury, as well as the surgeon’s preference. In cases where the wounds are contaminated or the protective layers around the brain and spinal cord are exposed, or if there’s a leak of spinal fluid, preventive antibiotics are typically given to avoid wound infection and bacterial meningitis. After surgery, doctors may use imaging techniques to make sure the bone has properly been realigned. A soft padding is usually placed over the nose and inner corner of the eye to help keep the shape of the surrounding soft tissue steady and to prevent any buildup of fluid.
After surgery, it is important to keep an eye on the patient’s breathing, brain function, and eye health. This is especially true for patients who have suffered multiple injuries. Regular outpatient check-ups are necessary over the first several months after the procedure to monitor how the wound is healing, to observe the shape of the soft tissue, and to track the overall health status of the patient. Generally, patients receive eye drops to keep the cornea moist and steady the layer of tears. Until the patient can swallow safely, they may need to receive fluids through a vein. Some patients may require dietary supplements to improve their nutritional intake.
Patients who have had corrective surgery are advised against blowing their nose for at least ten days to prevent the spread of air in the eye sockets and forehead. Tasks involving heavy lifting, strenuous efforts, and intense exercise should be avoided after surgery as these can increase the likelihood of swelling, bruising, and bleeding. Pain and nausea should be managed appropriately to prevent discomfort. To avoid any straining, it’s also recommended that patients use stool softeners.
Preventing Naso-Orbito-Ethmoid Fractures
Improvements in car safety have helped to decrease the number and seriousness of facial injuries in developed countries. The wide use of airbags has been crucial in this progress. Increasing education and awareness can play a vital role, especially in groups that are more susceptible to severe facial injuries. This may help to lower injury rates and severity even further.
A key area to target is young drivers. Informing them about the potential long-term consequences of personal violence may make a big difference in reducing these injuries. Wearing helmets can also help. This is particularly important for people who ride motorcycles and all-terrain vehicles or participate in sports where hard balls are flying around, such as baseball, cricket, jai-alai etc. Helmets can greatly reduce the chance and seriousness of face injuries in these scenarios.
