Naso-orbital Ethmoid and Frontal Sinus Fractures

1. Naso-orbital Ethmoid and Frontal Sinus Fractures Grand Rounds Presentation Jim C. Grant, M.D. Byron J. Bailey, M.D. FACS April 29, 1998

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. Frontal Sinus FracturesSurgical Approaches Frontal Sinus Trephination Frontoethmoidectomy Osteoplastic Flap -- Most Commonly Employed Frontal Craniotomy

25. Frontal Sinus FracturesOperative Indications Anterior Table Displacement With an Aesthetic Forehead Deformity Nasofrontal Duct Involvement / Obstruction Displaced Posterior Table Fractures

26. 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

27. 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

28. 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

29. 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