Naso-orbital-ethmoid injury: Report of a case and review of the literature R. Donald Heine, D.M.D.,a Guy A. Catone, D.IV.D.,~ J. Bruce Bavitz, D.M.D.,’ Mark R. Grenadier, D.D.S.,d Pittsburgh, Pa. ALLEGHENY
GENERAL
and
HOSPITAL
Trauma to the midface severe enough to cause nasal fractures will often result in fractures of the bony naso-orbital-ethmoid (NOE) complex. Extensive damage may be encountered in the interorbital area because of the fragility of the bony framework. The medial orbital walls, ethmoid sinuses, and cribriform area of the anterior cranial fossa can resist a maximum compressive force of only 30 g. NOE injuries are usually the result of either a direct blow sustained during an altercation or of a high-velocity motor vehicle accident. Quite often multiple systemic injuries serve to complicate treatment. NOE fractures present the surgeon with numerous challenges during repair. The delicate bony architecture, anatomic framework, and cosmetic expectations indicate comprehensive, thorough treatment. Damage to the eye, which is basically an extension of the brain, is of major concern. Pupillary discrepancies, retrobulbar hematoma, and damage to the optic nerve must be ruled out. Early surgical management is indicated because delayed repair or inadequate treatment prediposes the patient to defects that may be extremely difficult if not impossible to correct with secondary procedures. Numerous articles have been published describing the NOE injury. The multifaceted array of fractures seen in NOE injuries has been formulated into a comprehensive classification by Gruss. (ORAL SURG ORAL MED ORAL PATHOL 1990;69:542-9)
T
he intent of this article is to present the diagnosis and treatment of a patient who had sustained a severe naso-orbital-ethmoid (NOE) injury. A brief review of anatomy and treatment rationale will be presented. ANATOMY
The nasal, orbital, and cranial cavities are separated by the NOE complex. The medial orbital wall is formed by the lacrimal bone anteriorly and the lamina papyracea of the ethmoid posteriorly (Fig 1). The extreme fragility of the lamina papyracea and of the orbital floor predisposes the region to blowout fractures. The anterior and posterior ethmoidal
=Formerly, Chief Resident, Department of Oral and Maxillofacial Surgery, Allegheny General Hospital; presently, private practice, Paducah, Ky. bDirector, Department of Dentistry; Head, Division of Oral and Maxillofacial Surgery. CFormerlv. Chief Resident. Department of Oral and Maxillofacial Surgery, Allegheny General Hospital; presently, College of Dentistry, Univeristy of Nebraska Medical Center, Lincoln, Neb. dStaff Oral and Maxillofacial Surgeon. 7-12-11406 542
foramina are situated along the upper portion of the lamina papyracea at its junction with the frontoethmoidal suture. Damage to the vessels traveling in these foramina appears as orbital hematomas. The lacrimal sac is contained within the lacrimal bone. The bone of the lateral nasal wall contains the nasolacrimal duct, which enters the nasal cavity through the inferior meatus located beneath the inferior turbinate. NOE injury may easily compromise the patency of the nasolacrimal duct. The posterior aspect of the medial orbital wall is formed by the body of the sphenoid bone just anterior to the optic foramen. Severe NOE injury with fractures extending through this area may involve the optic nerve and may result in blindness. Rontal and coworkers15studied 48 orbits in 24 skulls and reported several measurements of particular interest: (1) infraorbital foramen to midpoint of inferior orbital fissure: 24 mm; (2) anterior lacrimal crest to anterior ethmoidal foramen: 24 mm; (3) anterior lacrimal crest to medial aspect of optic canal: 42 mm; (4) frontozygomatic suture to superior orbital fissure: 35 mm; (5) supraorbital notch to superior orbital fissure: 40 mm; and (6) supraorbital notch to superior aspect of optic canal: 45 mm.
Naso-orbital-ethmoid injury
Volume 69 Number 5
q q
543
NASAL MAXILLA
•m LACRIMAL &j ETHMOID
q
SPHENOID
Fig.
1. Bony architecture
of the NOE complex.
The region between the orbits and beneath the anterior cranial fossa is termed the interorbital space.9This spacecomprises two ethmoid labyrinths, each rising higher than the cribriform plate in the midline (Fig. 2). The nasal bones, vomerine bone, perpendicular plate of the ethmoid, and ethmoid labyrinths are very thin and predisposed to comminuted fractures that result in nasal airway compromise. The nasal process of the frontal bone and the frontal process of the maxilla are very strong, with comminution rare. TREATMENT
Fig. 2. Artistic description of the interorbital space. Note the ethmoid labyrinths situated between the orbits.
RATIONALE
Treatment of the NOE injury may be accomplished through various techniques. Closed reduction with external pin fixation has been recommended by several investigators. *-12This form of treatment uses external nasal compression plates fixated with transnasal wires. Acceptable results may be achieved with this method if severecomminution and displacement are absent. With severe displacement and comminution, correct elevation and alignment of the fractured region is virtually impossible without exploration and direct visualization. Often severe NOE fractures treated with external nasal plates relapse as characterized by the collapse and inward telescoping of the nasal bones with flattening of the adjacent soft tissue contour. Also, medial canthal ligament displacement associated with NOE injury cannot ordinarily be corrected with external nasal plates. Severe fractures are best treated by open reduction with internal fixation.2-5. 9, I3 The operative approach may use the open-sky incision,‘* W-shaped medial canthal incision, vertical incision, or even the bicoronial flap incision (Fig. 3).2,3,9 Fixation by either direct wiring or bone plating affords adequate stabilization. The advent of maxillofacial bone plat-
1 Open Sky
2waged
Fig. 3. Various operative NOE complex.
3 Bicorond
49ubd&ry
approaches for exposing
the
ing enables the surgeon to secure rigid fixation in the fragile architecture of the NOE region. Severe comminution with loss of bone substance may be managed with primary bone grafting. The role of primary bone grafting with either costochondral, rib, or calvarium grafts in the management of craniofacial injury has been well documented.9 Membranous and endochondral bone grafts have been shown to have significantly different rates of
544
Heine et al
ORAL SURG ORAL MED ORAL PATHOL May 1990
Table II. Glasgow coma scale Eye-opening response Spontaneous To voice To pain None Best verbal response
Oriented Confused Inappropriate words Incomprehensible sounds None
5 4 3 2 1
Best motor response
Obeys command Localizes pain Withdraws (pain) Flexion (pain) Extension (pain) None
6 5 4 3 2 1 3-15
Total Trauma score Glasgow coma scale (total 14-15 points from above) 11-13 S-IO 5-7 3-4
Fig. 4. Clinical presentationof our patient. Arrow indicates the “dished-in” appearance of the frontonasal region.
Table
III
IV
V
rate
IO-24/min 25-34/min 36/min or greater I-9/min None
4 3 2 1 0
Respiratory
expansion
Normal Retractive/none
1 0
Systolic blood pressure
90 mm Hg or greater 70-89 mm Hg 50-69 mm Hg O-49 mm Hg No pulse
4 3 2 1 0
Capillary
Normal Delayed None
2 1 0
I. Classification of NOE injuries
Type I II
Respiratory
Description Isolated NOE injury Bony NOE injury and central maxilla Central maxilla only Central maxilla and one lateral maxilla Central maxilla and bilateral lateral maxilla Extended NOE injury With craniofacial injury With LeFort II and III fractures NOE injury with orbital displacement With oculoorbital displacement With orbital dystopia NOE injury with bone loss
resorption.” Membranous bone showed greater maintenance of volume than did endochondral bone iii sacrificed rabbits and monkeys when evaluated by means of cephalometric data.17Persistent enophthalmos resulting from medial orbital wall injury, extensive nasal wall comminution, and obvious facial bony
refill
Total trauma score
l-16
-
deformity are indicative of the need for primary bone grafting. It is necessary to adequately fixate the medial canthal ligament (which attaches laterally to the tarsal plates and medially to the frontal process of the maxilla on and medial to the anterior lacrimal crest) by direct wiring to the bone graft when grafting to the medial orbital wall and rim. If this fixation is not accomplished, the normal countertraction exerted by the medial canthal ligament is no longer persistent and the orbicularis oculi muscle contraction displaces the medial canthus laterally. These distraction forces dictate the need for maintenance of medial canthal wires and buttons for a minimum of 8
Volume 69
Number 5
Naso-orbital-ethmoid injury
545
weeks2 Insufficient maintenance may result in persistent traumatic telecanthus. The potential for damage to the nasolacrimal system in the NOE injury exists. Evaluation and management of the nasolacrimal system injury has been well documented in the literature.3, 4,9, 13,l4 Exploration and assessment of this system, with direct repair by means of silicone-rubber or redrubber tubing, is indicated if the separated duct is visualized.14 If no disruption in the system is noted, no further exploration is needed; however, dacryocystorhinostomy may be required later if persistent nasolacrimal obstruction should develop. Frontal sinus fractures, because of the proximity of the frontal sinusesto the NOE region, occur quite often in association with the NOE injury. Management of frontal sinus fractures varies greatly with severity of injury, posterior table displacement, persistent cerebrospinal rhinorrhea, and comminution of bony segments.6,I3 Use of maxillofacial bone plates, elevation of fractured segments with direct wiring, exploration and obliteration of the frontal sinus, and calvarium bone grafts are only a few of the many ways to treat the broad spectrum of frontal sinus fractures. CASE REPORT
A 46-year-old white man was transferred to our hospital after a motor vehicle accident in which the tractor trailer he was driving plunged approximately 100 feet down an embankment (Fig. 4). On arrival at the emergency room the patient was normotensive, with no recorded hypotensive episode, and was amnesic to the event. Trauma team evaluation elicited a Glasgow Coma Score of 15 and a trauma score of 16 (Table II).ts The patient’s injury complex included (1) right frontal open skull fracture, (2) NOE fracture, (3) multiple facial lacerations, (4) Ll compression fracture, and (5) possible renal contusion. Results of cervical spine series were negative. Initial laboratory data, chest x-ray film, and electrocardiogram were unremarkable. Preliminary evaluation by the Oral Maxillofacial Surgery Service was accomplished, and the patient was transported to the operating room. Exploration and primary closure of multiple facial lacerations were accomplished uneventfully. Facial films, including facial computerized tomograms and orbital tomograms, obtained one day after trauma revealed a LeFort II maxillary fracture with severe NOE and frontal sinus involvement (Figs. 5-7). The decision was made to harvest a membranous bone graft for repair of the comminuted NOE injury. The date of surgery was scheduled jointly by the Oral Maxillofacial and Neurosurgery services. The patient returned to the operating room on day 8 after trauma for open reduction and internal fixation of his NOE fracture, costochondral grafting to the NOE region,
Fig. 6. Water’s view. Arrow indicates disruption in the supraorbital region. Also note the cloudy appearance of the right maxillary sinus, which represents disruption of surrounding bony architecture.
and elevation of the frontal sinus fracture (Fig. 8). A bone graft consisting of the right seventh rib and cartilage was secured. Neurosurgeons then performed a right frontal craniotomy, obliteration of the frontal sinus, and elevation of the frontal bone fracture with direct wiring. The Oral Maxillofacial Surgery team proceededwith open reduction and internal fixation of the remaining fractures and insertion of the costochondral rib graft. The planned incision, which included the bicoronial flap, a right supraorbital W-shaped eyebrow incision, and bilateral Killian incisions (see Fig. 3), was marked with a surgical marking pen. A right subciliary incision was planned in light of the right zygomaxillary complex fracture. Local infiltration by 2% lidocaine (Xylocaine) with 1:100,000 epinephrine (six Carpules) was accomplished. A No. 15 blade was used for all incisions. The right frontal-supraorbital region was evaluated first, then the right supraorbital and infraorbital regions and the nasal region. Careful, subperiosteal dissection was maintained. With complete visualization of the frontalNOE complex, multiple fractures of the right supraorbital region and comminuted fractures of the right nasal bones were evident. The right infraorbital rim was noted to be
546
Heine et al
ORAL SLIRG ORAL MEI) OK,AL PATHOI~ May 1990
6. Facial computerized tomograph. Arrow indicates disruption of the infraorbital arrow the comminution of the bony nasal-ethmoid region.
Fig.
Fig.
7. Head computerized
tomograph. Arrow indicates a break and dislocation of the frontal bone.
fractured further medially than had originally been thought. Irrigation with copious amounts of bacitracin solution (50,000 units bacitracin in 250 ml normal saline solution) and saline solution was used. Reconstruction was begun in L~ACrigill
bupraorbiiai
region
with
rim. Note below the
a five-hoic
reconstruc-
tion bone plate placed over the medial supraorbital ridge; then a four-hole reconstruction plate was placed over the lateral supraorbital region to correspond with the frontozy-
gomatic region. Rowe disimpaction forceps were used to reduce the frontonasal fracture (Fig. 9). Stabilization was provided by a four-hole reconstruction plate meticulously contoured to fit the frontonasal suture region. The right infraorbital rim fracture was reduced and stabilized with two three-hole reconstruction plates, one to stabilize the infraorbital rim and one to stabilize the anterior wall of the maxilla. The left lateral nasal wall was noted to be intact, with
Naso-orbital-ethmoid
Volume 69 Number 5
injury
547
Fig. 8. Operative appearance. Note the “dished-in” frontonasal region with the nasal bone actually situated up and below the frontal bone. (Star, frontal bone; arrow, nasal bone). Arrow is pointing to the comminuted lateral nasal wall.
Fig. 9. Minireconstruction bone plates used to stabilize stabilized: rnrcrll arrow. frontonasal fracture reduction.
the right lateral nasal wall being comminuted. The previously harvested costochondral graft was trimmed and contoured with a fissure bur and a pear-shaped bur to overlay the nasal bone. The cartilaginous portion of the graft extended toward the tip of the nose to create a lateral nasal wall. The bone graft was stabilized with a single lag screw placed in the superior aspect and secured to the nasal process of the frontal bone. The medial aspects of both orbits were explored, and the medial canthal ligaments were visualized and noted to be intact bilaterally. All
the fractures.
Large arrow, frontal
fracture
plates and screws were double-checked for stability. Irrigation was again used, and a 0.02 mm silicone rubber implant was contoured and placed over the right orbital floor because of disruption of the floor in the posteromedial region. An antral balloon with a 30 cc Foley catheter was placed into the right maxillary sinus through the right naris and infiltrated with 7 ml of normal saline solution. Direct visualization revealed the orbital floor to be properly elevated. The catheter was ligated, cut, and sutured into place.
54% Heine et al
ORALSURGORAL
MED ORAL PA~HOL May 1990
Fig. 11. Photograph taken 1 year after surgery. Slight supratarsal depression is evident.
Fig. 10. Postoperative Water’s view illustrating the reconstructive bone plates. Arrow indicates lag screw used to secure the rib graft to the nasal process of the frontal bone.
Primary closure was obtained with 4.0 polyglycolic acid (Dexon) sutures for deep tissue closure, 5.0 polyglycolic acid sutures for subcuticular closure, and 6.0 nylon sutures for skin closure. Postoperative films revealed all fractures to be adequately reduced (Fig. 10). Now, 18 months after surgery, the patient is healing without incident. Facial symmetry has been maintained, and the patient, while refusing a supratarsal procedure to the right eye, is pleased with the result (Fig. 11). DISCUSSION
Diagnosis of NOE injury and the associated facial trauma should not be difficult. Proper clinical examiination will often reveal all or a combination of some of the following conditions: (1) traumatic telecanthus, (2) depressed,disrupted bony architecture, (3) orbital injury, (4) mobile midface (maxilla), (5) cerebrospinal rhinorrhea, (6) compromised nasal air\vay, (7) cnophthalmos, and (8) nasolacrimal duct damage. Because of the complex anatomy and fragile bone architecture, treatment is quite challenging. An open, direct approach with adequate exposure
and visualization accompanied by reduction and internal fixation is the treatment of choice.2M5*‘3 Often, even with adequate exposure and proper treatment, secondary procedures will be required to correct postoperative deformities. The bony architecture of the region remains very difficult to duplicate after trauma. The use of autogenous grafts is often indicated and should remain a consideration for corrective treatment.9 Rapid recognition and early surgical intervention are the key to obtaining optimal results in the patient sustaining NOE injury. REFERENCES trauma. Curr Probl Surg. 1984;21: l1. Lute EA. Maxillofacial 68. 2. Cruse CW, Blevins PK, Lute EA. Naso-ethmoid-orbital fractures. J Trauma 1980;20:551-6. 3. Epker BN, ed. Open surgical management of naso-orbitalethmoid facial fractures. In: Epker BN, ed. Transactions of the International Conference on Oral Surgery, ~014. Chicago: AMA, 1973. 4. Dingman RO, Grabb WC, Oneal RM. Management of injuries of the naso-orbital complex. Arch Surg 1969; 98~566-7 1. 5. Morgan RF, Manson PN, Shack RB, Hoopes JE. Management of naso-ethmoid-orbital fractures. Am Surg 1982; 48:449. Gruss JS. Fronto-naso-orbital trauma. Clin Piast Surg 1982; 9:577. Stranc MF. The pattern of lacrimal injuries in nasoethmoid injuries. Br J Plait Surg 1970;23:339. Converse JM. Smith B. Naso-orbital fractures. Trans Am Acad Ophthaimol 1963;67:622. Gruss JS. Naso-ethmoid-orbital fractures: classification and
Naso-orbital-ethmoid injury
Volume 69 Number 5
10. I 1. 12. 13. 14.
roleofprimarybonegrafting.PlastReconstrSurg 1985;75:30315. Converse JN, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg 1966;38:147. Merville L. Multiple dislocations of the facial skeleton. J Maxillofac Surg 1974;2: 187. Fielding JF. A spring wire clip fixation of naso-orbital fractures. Plast Reconstr Surg 1967;39:3 13. Merville - LC, Real JP. Fronto-orbit0 nasal dislocations. Stand J Plast Keconstr Surg 1981;15:287. 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 dacryocysto rhinostomy. Br J Plast Surg 1985;38:116-21.
549
15. Rontal E, Rontal M, Guilford FT. Surgical anatomy of the orbit. Ann Oto Rhino1 Laryngol 1979;88:382. 16. Champion HR, Sacco WJ, Carnazzo AJ, et al. Trauma score. Crit Care Med 1981;9:672-672. 17. Zins JE, Whitaker LA. Membranous versus endochondral bone: implications for craniofacial reconstruction. Surgical Forum 1979;30:521. 18. Converse JM, Hogan VM. Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 1970;46:396-8. Reprint requests to: Dr. R. Donald Heine 2850 Lone Oak Road Paducah, KY 42003
GENERAL
and
HOSPITAL
Trauma to the midface severe enough to cause nasal fractures will often result in fractures of the bony naso-orbital-ethmoid (NOE) complex. Extensive damage may be encountered in the interorbital area because of the fragility of the bony framework. The medial orbital walls, ethmoid sinuses, and cribriform area of the anterior cranial fossa can resist a maximum compressive force of only 30 g. NOE injuries are usually the result of either a direct blow sustained during an altercation or of a high-velocity motor vehicle accident. Quite often multiple systemic injuries serve to complicate treatment. NOE fractures present the surgeon with numerous challenges during repair. The delicate bony architecture, anatomic framework, and cosmetic expectations indicate comprehensive, thorough treatment. Damage to the eye, which is basically an extension of the brain, is of major concern. Pupillary discrepancies, retrobulbar hematoma, and damage to the optic nerve must be ruled out. Early surgical management is indicated because delayed repair or inadequate treatment prediposes the patient to defects that may be extremely difficult if not impossible to correct with secondary procedures. Numerous articles have been published describing the NOE injury. The multifaceted array of fractures seen in NOE injuries has been formulated into a comprehensive classification by Gruss. (ORAL SURG ORAL MED ORAL PATHOL 1990;69:542-9)
T
he intent of this article is to present the diagnosis and treatment of a patient who had sustained a severe naso-orbital-ethmoid (NOE) injury. A brief review of anatomy and treatment rationale will be presented. ANATOMY
The nasal, orbital, and cranial cavities are separated by the NOE complex. The medial orbital wall is formed by the lacrimal bone anteriorly and the lamina papyracea of the ethmoid posteriorly (Fig 1). The extreme fragility of the lamina papyracea and of the orbital floor predisposes the region to blowout fractures. The anterior and posterior ethmoidal
=Formerly, Chief Resident, Department of Oral and Maxillofacial Surgery, Allegheny General Hospital; presently, private practice, Paducah, Ky. bDirector, Department of Dentistry; Head, Division of Oral and Maxillofacial Surgery. CFormerlv. Chief Resident. Department of Oral and Maxillofacial Surgery, Allegheny General Hospital; presently, College of Dentistry, Univeristy of Nebraska Medical Center, Lincoln, Neb. dStaff Oral and Maxillofacial Surgeon. 7-12-11406 542
foramina are situated along the upper portion of the lamina papyracea at its junction with the frontoethmoidal suture. Damage to the vessels traveling in these foramina appears as orbital hematomas. The lacrimal sac is contained within the lacrimal bone. The bone of the lateral nasal wall contains the nasolacrimal duct, which enters the nasal cavity through the inferior meatus located beneath the inferior turbinate. NOE injury may easily compromise the patency of the nasolacrimal duct. The posterior aspect of the medial orbital wall is formed by the body of the sphenoid bone just anterior to the optic foramen. Severe NOE injury with fractures extending through this area may involve the optic nerve and may result in blindness. Rontal and coworkers15studied 48 orbits in 24 skulls and reported several measurements of particular interest: (1) infraorbital foramen to midpoint of inferior orbital fissure: 24 mm; (2) anterior lacrimal crest to anterior ethmoidal foramen: 24 mm; (3) anterior lacrimal crest to medial aspect of optic canal: 42 mm; (4) frontozygomatic suture to superior orbital fissure: 35 mm; (5) supraorbital notch to superior orbital fissure: 40 mm; and (6) supraorbital notch to superior aspect of optic canal: 45 mm.
Naso-orbital-ethmoid injury
Volume 69 Number 5
q q
543
NASAL MAXILLA
•m LACRIMAL &j ETHMOID
q
SPHENOID
Fig.
1. Bony architecture
of the NOE complex.
The region between the orbits and beneath the anterior cranial fossa is termed the interorbital space.9This spacecomprises two ethmoid labyrinths, each rising higher than the cribriform plate in the midline (Fig. 2). The nasal bones, vomerine bone, perpendicular plate of the ethmoid, and ethmoid labyrinths are very thin and predisposed to comminuted fractures that result in nasal airway compromise. The nasal process of the frontal bone and the frontal process of the maxilla are very strong, with comminution rare. TREATMENT
Fig. 2. Artistic description of the interorbital space. Note the ethmoid labyrinths situated between the orbits.
RATIONALE
Treatment of the NOE injury may be accomplished through various techniques. Closed reduction with external pin fixation has been recommended by several investigators. *-12This form of treatment uses external nasal compression plates fixated with transnasal wires. Acceptable results may be achieved with this method if severecomminution and displacement are absent. With severe displacement and comminution, correct elevation and alignment of the fractured region is virtually impossible without exploration and direct visualization. Often severe NOE fractures treated with external nasal plates relapse as characterized by the collapse and inward telescoping of the nasal bones with flattening of the adjacent soft tissue contour. Also, medial canthal ligament displacement associated with NOE injury cannot ordinarily be corrected with external nasal plates. Severe fractures are best treated by open reduction with internal fixation.2-5. 9, I3 The operative approach may use the open-sky incision,‘* W-shaped medial canthal incision, vertical incision, or even the bicoronial flap incision (Fig. 3).2,3,9 Fixation by either direct wiring or bone plating affords adequate stabilization. The advent of maxillofacial bone plat-
1 Open Sky
2waged
Fig. 3. Various operative NOE complex.
3 Bicorond
49ubd&ry
approaches for exposing
the
ing enables the surgeon to secure rigid fixation in the fragile architecture of the NOE region. Severe comminution with loss of bone substance may be managed with primary bone grafting. The role of primary bone grafting with either costochondral, rib, or calvarium grafts in the management of craniofacial injury has been well documented.9 Membranous and endochondral bone grafts have been shown to have significantly different rates of
544
Heine et al
ORAL SURG ORAL MED ORAL PATHOL May 1990
Table II. Glasgow coma scale Eye-opening response Spontaneous To voice To pain None Best verbal response
Oriented Confused Inappropriate words Incomprehensible sounds None
5 4 3 2 1
Best motor response
Obeys command Localizes pain Withdraws (pain) Flexion (pain) Extension (pain) None
6 5 4 3 2 1 3-15
Total Trauma score Glasgow coma scale (total 14-15 points from above) 11-13 S-IO 5-7 3-4
Fig. 4. Clinical presentationof our patient. Arrow indicates the “dished-in” appearance of the frontonasal region.
Table
III
IV
V
rate
IO-24/min 25-34/min 36/min or greater I-9/min None
4 3 2 1 0
Respiratory
expansion
Normal Retractive/none
1 0
Systolic blood pressure
90 mm Hg or greater 70-89 mm Hg 50-69 mm Hg O-49 mm Hg No pulse
4 3 2 1 0
Capillary
Normal Delayed None
2 1 0
I. Classification of NOE injuries
Type I II
Respiratory
Description Isolated NOE injury Bony NOE injury and central maxilla Central maxilla only Central maxilla and one lateral maxilla Central maxilla and bilateral lateral maxilla Extended NOE injury With craniofacial injury With LeFort II and III fractures NOE injury with orbital displacement With oculoorbital displacement With orbital dystopia NOE injury with bone loss
resorption.” Membranous bone showed greater maintenance of volume than did endochondral bone iii sacrificed rabbits and monkeys when evaluated by means of cephalometric data.17Persistent enophthalmos resulting from medial orbital wall injury, extensive nasal wall comminution, and obvious facial bony
refill
Total trauma score
l-16
-
deformity are indicative of the need for primary bone grafting. It is necessary to adequately fixate the medial canthal ligament (which attaches laterally to the tarsal plates and medially to the frontal process of the maxilla on and medial to the anterior lacrimal crest) by direct wiring to the bone graft when grafting to the medial orbital wall and rim. If this fixation is not accomplished, the normal countertraction exerted by the medial canthal ligament is no longer persistent and the orbicularis oculi muscle contraction displaces the medial canthus laterally. These distraction forces dictate the need for maintenance of medial canthal wires and buttons for a minimum of 8
Volume 69
Number 5
Naso-orbital-ethmoid injury
545
weeks2 Insufficient maintenance may result in persistent traumatic telecanthus. The potential for damage to the nasolacrimal system in the NOE injury exists. Evaluation and management of the nasolacrimal system injury has been well documented in the literature.3, 4,9, 13,l4 Exploration and assessment of this system, with direct repair by means of silicone-rubber or redrubber tubing, is indicated if the separated duct is visualized.14 If no disruption in the system is noted, no further exploration is needed; however, dacryocystorhinostomy may be required later if persistent nasolacrimal obstruction should develop. Frontal sinus fractures, because of the proximity of the frontal sinusesto the NOE region, occur quite often in association with the NOE injury. Management of frontal sinus fractures varies greatly with severity of injury, posterior table displacement, persistent cerebrospinal rhinorrhea, and comminution of bony segments.6,I3 Use of maxillofacial bone plates, elevation of fractured segments with direct wiring, exploration and obliteration of the frontal sinus, and calvarium bone grafts are only a few of the many ways to treat the broad spectrum of frontal sinus fractures. CASE REPORT
A 46-year-old white man was transferred to our hospital after a motor vehicle accident in which the tractor trailer he was driving plunged approximately 100 feet down an embankment (Fig. 4). On arrival at the emergency room the patient was normotensive, with no recorded hypotensive episode, and was amnesic to the event. Trauma team evaluation elicited a Glasgow Coma Score of 15 and a trauma score of 16 (Table II).ts The patient’s injury complex included (1) right frontal open skull fracture, (2) NOE fracture, (3) multiple facial lacerations, (4) Ll compression fracture, and (5) possible renal contusion. Results of cervical spine series were negative. Initial laboratory data, chest x-ray film, and electrocardiogram were unremarkable. Preliminary evaluation by the Oral Maxillofacial Surgery Service was accomplished, and the patient was transported to the operating room. Exploration and primary closure of multiple facial lacerations were accomplished uneventfully. Facial films, including facial computerized tomograms and orbital tomograms, obtained one day after trauma revealed a LeFort II maxillary fracture with severe NOE and frontal sinus involvement (Figs. 5-7). The decision was made to harvest a membranous bone graft for repair of the comminuted NOE injury. The date of surgery was scheduled jointly by the Oral Maxillofacial and Neurosurgery services. The patient returned to the operating room on day 8 after trauma for open reduction and internal fixation of his NOE fracture, costochondral grafting to the NOE region,
Fig. 6. Water’s view. Arrow indicates disruption in the supraorbital region. Also note the cloudy appearance of the right maxillary sinus, which represents disruption of surrounding bony architecture.
and elevation of the frontal sinus fracture (Fig. 8). A bone graft consisting of the right seventh rib and cartilage was secured. Neurosurgeons then performed a right frontal craniotomy, obliteration of the frontal sinus, and elevation of the frontal bone fracture with direct wiring. The Oral Maxillofacial Surgery team proceededwith open reduction and internal fixation of the remaining fractures and insertion of the costochondral rib graft. The planned incision, which included the bicoronial flap, a right supraorbital W-shaped eyebrow incision, and bilateral Killian incisions (see Fig. 3), was marked with a surgical marking pen. A right subciliary incision was planned in light of the right zygomaxillary complex fracture. Local infiltration by 2% lidocaine (Xylocaine) with 1:100,000 epinephrine (six Carpules) was accomplished. A No. 15 blade was used for all incisions. The right frontal-supraorbital region was evaluated first, then the right supraorbital and infraorbital regions and the nasal region. Careful, subperiosteal dissection was maintained. With complete visualization of the frontalNOE complex, multiple fractures of the right supraorbital region and comminuted fractures of the right nasal bones were evident. The right infraorbital rim was noted to be
546
Heine et al
ORAL SLIRG ORAL MEI) OK,AL PATHOI~ May 1990
6. Facial computerized tomograph. Arrow indicates disruption of the infraorbital arrow the comminution of the bony nasal-ethmoid region.
Fig.
Fig.
7. Head computerized
tomograph. Arrow indicates a break and dislocation of the frontal bone.
fractured further medially than had originally been thought. Irrigation with copious amounts of bacitracin solution (50,000 units bacitracin in 250 ml normal saline solution) and saline solution was used. Reconstruction was begun in L~ACrigill
bupraorbiiai
region
with
rim. Note below the
a five-hoic
reconstruc-
tion bone plate placed over the medial supraorbital ridge; then a four-hole reconstruction plate was placed over the lateral supraorbital region to correspond with the frontozy-
gomatic region. Rowe disimpaction forceps were used to reduce the frontonasal fracture (Fig. 9). Stabilization was provided by a four-hole reconstruction plate meticulously contoured to fit the frontonasal suture region. The right infraorbital rim fracture was reduced and stabilized with two three-hole reconstruction plates, one to stabilize the infraorbital rim and one to stabilize the anterior wall of the maxilla. The left lateral nasal wall was noted to be intact, with
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Fig. 8. Operative appearance. Note the “dished-in” frontonasal region with the nasal bone actually situated up and below the frontal bone. (Star, frontal bone; arrow, nasal bone). Arrow is pointing to the comminuted lateral nasal wall.
Fig. 9. Minireconstruction bone plates used to stabilize stabilized: rnrcrll arrow. frontonasal fracture reduction.
the right lateral nasal wall being comminuted. The previously harvested costochondral graft was trimmed and contoured with a fissure bur and a pear-shaped bur to overlay the nasal bone. The cartilaginous portion of the graft extended toward the tip of the nose to create a lateral nasal wall. The bone graft was stabilized with a single lag screw placed in the superior aspect and secured to the nasal process of the frontal bone. The medial aspects of both orbits were explored, and the medial canthal ligaments were visualized and noted to be intact bilaterally. All
the fractures.
Large arrow, frontal
fracture
plates and screws were double-checked for stability. Irrigation was again used, and a 0.02 mm silicone rubber implant was contoured and placed over the right orbital floor because of disruption of the floor in the posteromedial region. An antral balloon with a 30 cc Foley catheter was placed into the right maxillary sinus through the right naris and infiltrated with 7 ml of normal saline solution. Direct visualization revealed the orbital floor to be properly elevated. The catheter was ligated, cut, and sutured into place.
54% Heine et al
ORALSURGORAL
MED ORAL PA~HOL May 1990
Fig. 11. Photograph taken 1 year after surgery. Slight supratarsal depression is evident.
Fig. 10. Postoperative Water’s view illustrating the reconstructive bone plates. Arrow indicates lag screw used to secure the rib graft to the nasal process of the frontal bone.
Primary closure was obtained with 4.0 polyglycolic acid (Dexon) sutures for deep tissue closure, 5.0 polyglycolic acid sutures for subcuticular closure, and 6.0 nylon sutures for skin closure. Postoperative films revealed all fractures to be adequately reduced (Fig. 10). Now, 18 months after surgery, the patient is healing without incident. Facial symmetry has been maintained, and the patient, while refusing a supratarsal procedure to the right eye, is pleased with the result (Fig. 11). DISCUSSION
Diagnosis of NOE injury and the associated facial trauma should not be difficult. Proper clinical examiination will often reveal all or a combination of some of the following conditions: (1) traumatic telecanthus, (2) depressed,disrupted bony architecture, (3) orbital injury, (4) mobile midface (maxilla), (5) cerebrospinal rhinorrhea, (6) compromised nasal air\vay, (7) cnophthalmos, and (8) nasolacrimal duct damage. Because of the complex anatomy and fragile bone architecture, treatment is quite challenging. An open, direct approach with adequate exposure
and visualization accompanied by reduction and internal fixation is the treatment of choice.2M5*‘3 Often, even with adequate exposure and proper treatment, secondary procedures will be required to correct postoperative deformities. The bony architecture of the region remains very difficult to duplicate after trauma. The use of autogenous grafts is often indicated and should remain a consideration for corrective treatment.9 Rapid recognition and early surgical intervention are the key to obtaining optimal results in the patient sustaining NOE injury. REFERENCES trauma. Curr Probl Surg. 1984;21: l1. Lute EA. Maxillofacial 68. 2. Cruse CW, Blevins PK, Lute EA. Naso-ethmoid-orbital fractures. J Trauma 1980;20:551-6. 3. Epker BN, ed. Open surgical management of naso-orbitalethmoid facial fractures. In: Epker BN, ed. Transactions of the International Conference on Oral Surgery, ~014. Chicago: AMA, 1973. 4. Dingman RO, Grabb WC, Oneal RM. Management of injuries of the naso-orbital complex. Arch Surg 1969; 98~566-7 1. 5. Morgan RF, Manson PN, Shack RB, Hoopes JE. Management of naso-ethmoid-orbital fractures. Am Surg 1982; 48:449. Gruss JS. Fronto-naso-orbital trauma. Clin Piast Surg 1982; 9:577. Stranc MF. The pattern of lacrimal injuries in nasoethmoid injuries. Br J Plait Surg 1970;23:339. Converse JM. Smith B. Naso-orbital fractures. Trans Am Acad Ophthaimol 1963;67:622. Gruss JS. Naso-ethmoid-orbital fractures: classification and
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roleofprimarybonegrafting.PlastReconstrSurg 1985;75:30315. Converse JN, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg 1966;38:147. Merville L. Multiple dislocations of the facial skeleton. J Maxillofac Surg 1974;2: 187. Fielding JF. A spring wire clip fixation of naso-orbital fractures. Plast Reconstr Surg 1967;39:3 13. Merville - LC, Real JP. Fronto-orbit0 nasal dislocations. Stand J Plast Keconstr Surg 1981;15:287. 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 dacryocysto rhinostomy. Br J Plast Surg 1985;38:116-21.
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15. Rontal E, Rontal M, Guilford FT. Surgical anatomy of the orbit. Ann Oto Rhino1 Laryngol 1979;88:382. 16. Champion HR, Sacco WJ, Carnazzo AJ, et al. Trauma score. Crit Care Med 1981;9:672-672. 17. Zins JE, Whitaker LA. Membranous versus endochondral bone: implications for craniofacial reconstruction. Surgical Forum 1979;30:521. 18. Converse JM, Hogan VM. Open-sky approach for reduction of naso-orbital fractures. Plast Reconstr Surg 1970;46:396-8. Reprint requests to: Dr. R. Donald Heine 2850 Lone Oak Road Paducah, KY 42003
