Nasoorbitoethmoid (NOE) Fracture

Back To Search

Nasoorbitoethmoid (NOE) Fracture

Trauma
Author Credentials 

Jon Robitschek, MD
Assistant Professor
Chief of Facial Plastic Surgery
Department of Otolaryngology – Head & Neck Surgery
Brooke Army Medical Center
3551 Roger Brooke Dr
San Antonio, TX 78219

Module Summary

Fractures of the nasoethmoidal (NOE) complex constitute one of the more profound challenges in the management of craniofacial trauma. The nasoethmoidal complex serves as a junctional buttress between the nasal bone, medial canthal region of the orbit, anterior skull base, and the frontal bone. Additional clinical considerations include frontal sinus involvement, cerebral spinal fluid (CSF) leak, and integrity of the lacrimal system.
Successful initial surgical intervention is critical to establishing an optimal outcome in NOE fracture patients. Tenets of operative management encompass accurate fracture classification and stabilization with rigid fixation when indicated. Specifically, establishing anatomic medial canthal and radix position with associated nasal dorsal projection are core surgical concepts. Failure to appropriately manage these complex fractures in the initial presentation often lead to persistent functional as well as aesthetic sequelae. Surgical correction of these persistent deformities is particularly daunting given a constricted soft tissue envelope and loss of bony support.

Module Learning Objectives 

 

  1. Diagnose the symptoms, physical exam presentation, and radiographic findings associated with NOE fractures.
  2. Accurately employ a classification system in assessing NOE fractures.
  3. Explain the clinical indications for operative intervention with regard to classification of fractures.
  4. Accurately diagnose and manage associated lacrimal system injury, frontal sinus involvement, and CSF leak.
  5. Describe the various surgical approaches employed in the management of NOE fractures.
  6. Recognize the utility of nasal dorsal augmentation in the management of these patients.
  7. Review the complications and residual deformities in patients with NOE fractures.

Anatomy

Learning Objectives 
  1. Understand the nasal, orbital, ethmoid and lacrimal structures involved with NOE fractures.
  2. Grasp the anatomic basis for the three tiered NOE fracture classification scheme.
  3. Provide a detailed description of the normal soft tissue anatomy of the medial canthal region of the orbit.
References 
  1. Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg. 1991 May;87(5):843-53.
  2. Morrison AD, Gregoire CE. Management of fractures of the nasofrontal complex. Oral Maxillofac Surg Clin North Am. 2013 Nov;25(4):637-48.
  3. Pawar SS, Rhee JS. Frontal sinus and naso-orbital-ethmoid fractures. JAMA Facial Plast Surg. 2014 Jul-Aug;16(4):284-9.

Pathogenesis

Learning Objectives 

Understand the biomechanics associated with nasoethmoidal injuries.

References 
  1. Pappachan B, Alexander M. Biomechanics of Cranio-Maxillofacial Trauma. Journal of Maxillofacial & Oral Surgery. 2012;11(2):224-230.

Incidence

Learning Objectives 

Be familiar with the incidence of NOE fractures.

References 
  1. Nguyen M, Koshy JC, Hollier LH. Pearls of Nasoorbitoethmoid Trauma Management. Seminars in Plastic Surgery. 2010;24(4):383-388. doi:10.1055/s-0030-1269767.

Patient Evaluation

Learning Objectives 
  1. Describe the typical physical findings in a patient with a NOE fracture.
  2. Know normal and abnormal parameters for intercanthal distance.
  3. Understand how to accurately assess the integrity of the medial canthal tendons.
  4. Know how to distinguish among type I, II, and III injuries.
  5. Grasp the relative indications for ophthalmologic and/or neurosurgical consultation.
References 
  1. Hoffman JF: Naso-orbital-ethmoid complex fracture management. Facial Plast Surg Clin North Am. 1998;14:67-76.
  2. Vora NM, Fedok FG. Management of the central nasal support in naso-orbital-ethmoid fractures. Facial Plast Surg Clin North Am. 2000;16:181-91.

Imaging

Learning Objectives 

Understand the appropriate radiologic studies for evaluation of NOE fractures.

References 
  1. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: what the surgeon needs to know. Radiographics. 2006 May-Jun. 26(3):783-93.

Treatment

Learning Objectives 

Understand the basic indications, timing, and technique of repair of lacrimal drainage injuries.

References 
  1. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg. 1985 Jan;38(1):116-21.
  2. Osguthorpe JD, Hoang G. Nasolacrimal injuries. Otolaryngol Clin North Am. 1991;24:59-78.
  3. Iwai T, Yasumura K, Yabuki Y, Omura S, Matsui Y, Kobayashi S, Fujimaki R, Okubo M, Tohnai I, Maegawa J. Intraoperative lacrimal intubation to prevent epiphora as a result of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex. Br J Oral Maxillofac Surg. 2013 Oct;51(7):e165-8.

Surgical Therapies

Learning Objectives 
  1. Understand the indications for surgical intervention, based on the NOE fracture classification scheme.
  2. Describe the various surgical approaches to the NOE complex.
  3. Understand the technical steps necessary for successful transnasal wire placement
  4. Recognize the indications and techniques for dorsal graft augmentation.
References 
  1. Leipziger LS, Manson PN. Nasoethmoid orbital fractures. Clin Plast Surg. 1992;19:167-92.
  2. Vora NM, Fedok FG. Management of the central nasal support in naso-orbital ethmoid fractures. Facial Plast Surg Clin North Am. 2000;16:181-91.
  3. Cultrara A, Turk JB, Har-El G. Midfacial degloving approach for repair of naso-orbital-ethmoid and midfacial fractures. Arch Facial Plast Surg. 2004 Mar-Apr. 6(2):133-5.
  4. Potter JK, Muzaffar AR, Ellis E, Rohrich RJ, Hackney FL. Aesthetic management of the nasal component of naso-orbital ethmoid fractures. Plast Reconstr Surg. 2006 Jan;117(1):10e-18e.
  5. Baliga SD, Urolagin SB. Transnasal Fixation of NOE Fracture: Minimally Invasive Approach. Journal of Maxillofacial & Oral Surgery. 2012;11(1):34-37. doi:10.1007/s12663-011-0305-y.
  6. Imaizumi A, Ishida K, Nishizeki O. An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair. J Craniomaxillofac Surg. 2016 Dec;44(12):1922-1928.

Staging

Learning Objectives 

Describe the classification system used in nasoethmoid fracture.

References 
  1. Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg. 1991 May;87(5):843-53.

Case Studies

  1. A 33 year old female sustains blunt trauma to the nasal bridge with transient loss of consciousness. She presents to the Emergency Department (ED) with a Glasgow coma scale (GSW) of 15 and on physical exam has copious secretions form the nose, moderate depression of the nasal dorsum, and blunting left medial canthus. The intercanthal distance is measured at 33mm. Computed tomography (CT) demonstrated a type I nasoethmoid (NOE) fracture.
    • Management Considerations: Concern for possible CSF should be evaluated with beta-2 transferrin assay and possible neurosurgical consultation in addition to ophthalmology. Typical exposure for surgical treatment of a type I NOE fracture may include a coronal, sublabial, and/or transcaruncular approach. Options for fixation include mini-plates, titanium mesh, and possibly transnasal wiring if indicated. Dorsal augmentation with a cantilevered calvarial bone graft may also be considered.
  2. A 19 year old male was an unrestrained passenger in a motor vehicle accident. On exam in the ED, his intercanthal distance is measured at 40mm with a large lacerations traversing a depressed nasal dorsum and extending to the medial canthal region on the left. There is laxity of the left medial canthal tendon and CT imagining demonstrates a type III nasoethmoid (NOE) fracture.
    • Management Considerations: Formal ophthalmology consult should be obtained with exploration and possible stenting of the lacrimal system on the left. Exposure for a type III NOE fracture often requires a combination of coronal, sublabial, and transcaruncular approach. Utilizing the laceration for access in this particular case should also be considered. The avulsed medial canthal tendon will require transnasal wiring to the contralateral orbit; employing a posterior / superior vector in proximity to the posterior lacrimal crest. Options for fixation include mini-plates and titanium mesh. Dorsal augmentation with a cantilevered calvarial bone graft should also be considered.

Complications

Learning Objectives 
  1. Recognize common sequelae of NOE fractures.
  2. Understand the incidence of persistent lacrimal system dysfunction and management options.
References 
  1. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg. 1985 Jan;38(1):116-21.
  2. Osguthorpe JD, Hoang G. Nasolacrimal injuries. Otolaryngol Clin North Am.1991;24:59-78.
  3. Elbarbary AS, Ali A. Medial canthopexy of old unrepaired naso-orbito-ethmoidal (noe) traumatic telecanthus. J Craniomaxillofac Surg. 2014 Mar;42 (2):106-12.
  4. Herford AS, Ying T, Brown B. Outcomes of severely comminuted (type III) nasoorbitoethmoid fractures. J Oral Maxillofac Surg. 2005 Sep;63(9):1266-77.
  5. Wolff J, Sándor GK, Pyysalo M, Miettinen A, Koivumäki AV, Kainulainen VT. Late reconstruction of orbital and naso-orbital deformities. Oral Maxillofac Surg Clin North Am. 2013 Nov;25(4):683-95.

Review

Review Questions 
  1. What are physical signs and symptoms associated with NOE fractures?
  2. Characterize the classification system used in stratifying these fractures?
  3. What are the normal parameters used for intercanthal distance?
  4. How do you evaluate the integrity of the medial canthal tendon insertion?
  5. What are the common surgical approaches used in the repair of NOE fractures?
  6. What are the indications and technical details involved with open reduction and internal fixation of NOE fractures?
  7. What are the technical steps involved in successful transnasal wiring?
  8. What are the most common complications following NOE fractures?
  9. What is the most common facial deformity following treatment of these injuries and how is it avoided/managed?
  10. Under what circumstance would one consider a cantilevered split calvarial bone graft?