noe fractures

Nasoethmoidal Fractures

By – Dr. Anchal Agarwal

Guided by –

Dr. Rajanikanth Sir

Contents • Anatomy of Ethmoid Bone • Incidences• Classification • Clinical Features• Investigations• Management

NOE - Anatomy

Ethmoid Bone • It is an unpaired bone in the skull • Separates – Nasal cavity - from – Brain • Located – • - Roof of nose• Between two orbits

• One of the bones that make up the orbit of the eye

• Ethmoid Bone has 3 parts – 1) Cribriform plate 2) Ethmoidal Labryinth3) Perpendicular plate

• Articulations : • 2 bones of Neurocranium – FRONTAL & SPHENOID• 11 bones of Viscerocranium – - 2 Nasal Bones- 2 Maxilla - 2 Lacrimals - 2 Palatines- 2 Inferior Nasal Conchae - 2 Vomer

• Ethmoidal bone has various processes :

- Lamina papyracea - forms – medial wall of Orbit - Behind it – Ethmoidal Air cells - Cribriform Plate - forms – Floor of the Anterior Cranial Fossa.- Perpendicular plate forms - the superior part of the nasal septum

and - superiorly projects into the Anterior Cranial Fossa - Crista Galli - to

which the dura is attached

• Cribriform Plate transmits – Emissary Veins & Olfactory Nerves

Anatomy of Nasoethmoidal region

Ethmoid sinus

Frontal Bone and Frontal Sinus showing relation of Nasofrontal duct and nose

Anatomy of NOE Region

Soft Tissue Anatomy • Medial Canthal Ligament • Lacrimal Drainage Apparatus • Associated vessels

Medical Canthal Tendon

Arises from – • Anterior and Posterior lacrimal crest and • Frontal process of Maxilla

Surrounds the Lacrimal Sac & diverges to become the –• Orbicularis Occuli muscle, • Tarsal Plate • Suspensory Ligament of eyelids

Medical Canthal Tendon• Tendon Splits around the

lacrimal sac & attaches to- Anterior & Posterior lacrimal

crests, &- Frontal process of Maxilla

• Canthal Tendon diverges to become –

- Pre tarsal - Pre septal - Orbicularis Oculi muscle

MCT acts as a suspensory Sling for the Globe – Maintaining its support along the lateral canthal tendon

Lacrimal System

Nasolacrimal System

Incidence• Fracture of NOE – Infrequent – 2-15% of all facial fractures • More Victims are Male – 66-91% cases• & Young – 20-30 yrs of age

• Most fractures occur due to Motor Vehicle accidents (44-85%) cases

• NOE fractures can occur in isolation• Mostly occurs – in association with Midface fractures

• 60% patients with NOE fractures have ---- Associated Nonfacial injuries

• Nasoethmoid Fractures – results from – Forceful Blow to the centre of the face

• Fracture of nasal bone can occur in isolation or • Maybe accompanied with fractures of Ethmoidal bone , Frontal

Process of Maxilla , and Lacrimal bone

• Complex Injuries involving these bones – termed – Nasoethmoidal Complex Injuries

CLASSIFICATION OF NOE

Ayliff classification• Type I: En bloc with minimum displacement.• Type II: En bloc displaced # with large pneumatized sinus and

minimum fragmentation.• Type III: Comminuted # with inatct MCT attached to large bone.• Type IV:comminuted # with free MCT attached to boe not large

enough for plating.• Type V:Gross comminution needing grafting.

Yaremchuk classification• Type I: Isolated bony NOE• Type II: Bony NOE and central maxilla II A: Central maxilla only II B: Central and unilateral maxilla. II C:Central and bilateral maxilla.• Type III: extended NOE III A ;with craniofacial injuries IIIB: with LF II and LF III• Type IV: NOE with orbital displacement IV A: with cculo-orbital displacement IV B: with orbital dystopia• Type V: NOE with bone loss

Stranc and Robertson classification(1979)• Plane I: Injuries do not extend beyond a line joining the

lower end of the nasal bones to the anterior nasal spine.• Plane II:Injuries are limited to the external nose and do not

trangress the orbital rim.• Plane III:Injuries are more serious involve orbital and

possibly intracranial structures.

Markhowitz classification:• TYPE I: Involves single segment central fragment fractures.• TYPE II: Comminuted central fragment with fracture lines

remaining peripheral to the MCT insertion.• TYPE III: Comminuted central fragment with fracture lines

extending beneath the MCT insertion.

Classification of NOE Fractures

TYPE I FRACTURE• In this simplest form,NOE fractures are isolated involving

only the portion of the medial orbital rim that contains medial canthal tendon.

• Type I pattern consists of single central fragment bearing the medial canthus.

• These fractures maybe bilateral ,complete or displaced.• Uncommonly ,the medial canthal tendon is torn or avulsed

completely from an intact medial bony wall.

In unilateral Markowitz type I fractures, there is a single large NOE fragment bearing the medial canthal tendon.

Involvement of the nasal bone: the nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

TYPE II FRACTURE• Type II fractures are complete and maybe unilateral or

bilateral.• They may be single segment or communited external to the

medial canthal insertion in the central segment.• MCT maintains continuity with large fractured segment of

bone,which maybe used in the surgical reduction.

In unilateral type II fractures, there is often comminution of the NOE area, but the canthal tendon remains attached to a fragment of bone, allowing the canthus to be stabilized with

wires or a small plate on the fractured segment.

The nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

Involvement of the nasal bone

The illustration shows a bilateral NOE type II fracture. In bilateral fractures the nasal bones are commonly involved. In some instances, bone grafting of the nasal dorsum may be

necessary.

Bilateral type II fracture with nasal bone involvement

TYPE III FRACTURE• Communition within the central fragment allows fracture to extend

beneath the canthal insertion characterising the type III fracture pattern.

• The canthus is rarely avulsed but it is to bone fragments that are too small to utilize in reconstruction.

In type III fractures, there is often comminution of the NOE area (as in type II fractures) and a detachment of the medial canthal tendon from the bone.

The nasal bones are usually involved and might not provide adequate dorsal support to the nasal bridge. In such cases bone graft reconstruction often is indicated.

Involvement of nasal bone

The illustration shows a bilateral NOE type III fracture. The nasal bones are usually involved. Bone graft of the nasal dorsum is usually necessary.

Bilateral type III fracture with nasal bone involvement

Buttresses – Nasomaxillary buttress

Rowe & William Classification• I] Isolated Nosoethmoid and frontal region injury – without

other fractures of the mid-face • A) Bilateral • B) Unilateral

• II ] Combined nasoethmoid and frontal region injury – with other fractures of the mid-face

• A) Bilateral • B) Unilateral

Clinical features – Based on Classification

Isolated Bilateral NOE injury • Central midface injury resulting from Direct blow over Bridge of

nose --- may occur without associated facial fractures • Clinically : • Nasal Deformity – Base of nose driven backwards into

Interorbital space & beneath Cribriform plate of Ethmoid

• Nasal Tip – upturned• Stretching of Philtrum of Upper lip • Deep Transverse Cleft at the Base of the nose

• Actual Increase in Intercanthal distance - may not be demonstrable Actual detachment may not have occurred

• Posterior displacement of Canthus – - Tension of adjacent skin - Accentuation of Nasojugal Skin Fold

- CSF Rhinorrhoea – should be assumed has occurred (even if it is not clinically manifest )

IB) Isolated Unilateral NOE Injury

• Often misdiagnosed as – Nasal fractures and treated. results in Relapse – due to instability created by associated fracture of underlying Ethmoid Bone

• Clinical Presentation - • Unilateral Nasal Deformity

IIB) Combined Unilateral NOE Injury- Frequently combined with Severe comminution of Orbit & ZMC

- Unilateral displacement of Medial Canthal Ligament – severe (maybe associated with detachment of underlying bone)

- Antimongoloid Slant to the Palpebral Fissure – associated ZMC – Downward & Lateral displacement of eye

IIB) Combined Bilateral NOE • When NOE combined with - Midface fractures at Le Fort II & III level

• ‘Long Face Syndrome’ – Gross separation of base of nose from glabella & at FZ suture (Following lefort II & III)

• Traumatic Telecanthus – Maybe overlooked – due to characteristic – ‘Elongation of both Mid Face & Nose’

Clinical Features NOSE• Open Book Deformity – flattening of nasal bridge • Epistaxis – Hemorrhage due to rupture of Anterior and posterior

branches of Ethmoidal Artery • Tenderness , Crepitus over nasal bone • Deviated Nasal Septum • Anosmia • CSF RhinorrheaEYE• Almond Shaped Palpebral Fissure • Diplopia • Meningitis • Traumatic telecanthus • Increased Canthal Angle • Blindness

Intercanthal Distance

Intercanthal Distance

Clinical Features

Clinical Features

• Anosmia – Trauma to Olfactory Nerve – Direct extension of Gray Matter --- Lacks Regenerative potential

• CSF Rhinorrhea

• Almond Shaped Palpabral fissure – Rounding of the Medial Canthus – Fracture of Frontal Process of Maxilla – Detachment of Medial Canthal Ligament.

• Meningitis. - Ethmoidal Air Cells -- normally not exposed to External environment.

- In event of fracture -- they get exposed and infected - Infection can pass in a retrograde manner in the cranial cavity through

the veins --- resulting in the intracranial infections ----

Ethmoid Air cells

EXAMINATION

• Mobility of the nasal bones• Traumatic Telecanthus • Wide and flattened nasal dorsum • Upturned nasal tip

• From 1 hour to 5 days – there maybe enough edema to hide the contour depression

• Palpation may reveal – Crepitation and tenderness over the fracture site

Tests for CSF leakage• Halo Test • Tram line • Tilt test • B-transferrin • Glucose and chloride

CSF Leakage • Fractures involving the Frontal sinus or Cribriform plate may cause –

CSF Leakage

• Confirmation of presence of CSF – made by – collecting this fluid and comparing its concentration of GLUCOSE & CHLORIDE with patient’s serum concentration

• As little as 0.1ml of fluid is needed to determine the concentrations of Glucose and chloride

• Chloride concentrations – greater (in collected specimen) than serum • Glucose concentrations – Lesser (in collected specimen) than serum• Collected fluid can also be tested for B2-transferrin – if positive

confirms presence of CSF

Halo test – CSF Leakage

• Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign.

• If CSF is present ,it diffuses faster than blood and results in a clear halo around the central stain.

• Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF.

Distinguish Nasal from NOE fractures

• Bimanual Examination – • Place thumb and index finger over Medial Canthus bilaterally• Any Movement implies instability and requires open reduction

and stabilization • Place instrument (Kelly’s Clamp) high into the nose , with its tip

directly beneath the MCT• Gentle lifting with the Contralateral finger palpates the canthal

tendons & allows – assessment of instability of tendon attachement and necessity for open reduction

• Bowstring Test – • Pull the lids laterally while palpating the tendon area to detect

movement of fractured segments

Examination

Bow String Test

• FURNESS TEST – • Grasping skin overlying the medial canthus with a small-tissue-

forceps

• A lack of creasing or resistance by underlying bone is indicative – of an underlying fracture

Imaging • In Past :• Water’s Projection • Reverse Towne’s Projection • Lateral Skull Films • Laminar Tomograms

• Todays : • CT Scan – gold standard • High degree of detail required for imaging NOE fractures –

necessitates – AXIAL & CORONAL view – slice thickness – 1.0 or 1.5mm

Management

Sequencing naso-orbito-ethmoidal fractures Edward Ellis 1993

• Eight steps in treatment:

• Step I—exposure through existing laceration, open sky and/or W incision, coronal + lower eyelid.

• Step II—identify the medial canthal tendon/ tendon bearing bone • Step III- reduce/reconstruct the medial orbital rim. Atleast one hole is

drilled posterior to lacrimal fossa to prevent lateral splaying of posterior portion of bone fragment, which can result in telecanthus. Other wire superior to lacrimal fossa. 2–4 mm diameter hole so that ligament is pulled in the hole canthal bearing bone fixed first.

• Step IV—reconstruction of medial orbital wall with bone graft (rib, cranial bone)

• Step V—transnasal canthopexy • Step VI—reduce septal fracture/displacement (upwards, anteriorly) • Step VII—nasal dorsum reconstruction/augmentation • Step VIII—soft tissue readaptation, nasal split

Papadopoulos H . Management of Naso-Orbital-Ethmoidal Fractures . Oral

Maxillofacial Surg Clin N Am 21 (2009) 221–225

• Before 1960, the treatment of NOE fractures generally involved – - Closed reduction with external plates and splint fixation techniques.

• The most important advancement in the treatment of such fractures came in 1964, when both Mustarde and Dingman demonstrated - superior results with open reduction and internal fixation using interfragmental wiring.

• In 1970, Stranc highlighted – - incidence of the medial canthal tendon avulsion and advocated - exploration through existing lacerations or local incisions and - treatment with anterior transnasal wires.

• Current treatment modalities both combine and extend these previous contributions.

• Early Versus Late Management • Although there is no absolute consensus in literature as to - how long

one should wait before treating these fractures, • Some investigators suggested waiting no more than 2 weeks.• Waiting longer increases the likelihood of requiring osteotomies to

properly reduce and fix the fractures. • Delayed repair is particularly difficult for type III injuries, which

involve the canthal ligaments. • Once healing and scarring have begun, finding the avulsed medial

canthal ligament becomes more difficult. • Also, scarring may prevent adequate correction of the Intercanthal

distance, even with proper reduction of the bones.• Therefore, one should treat these fractures as soon as possible. • Treatment should begin as soon as the edema from the initial

traumatic event has resolved, but waiting no later than 10 to 14 days, as long as the patient is stable enough to undergo the procedure.

Papadopoulos H . Management of Naso-Orbital-Ethmoidal Fractures . Oral

Maxillofacial Surg Clin N Am 21 (2009) 221–225

• Closed Versus Open Reduction • Proper management of the medial canthal tendon and the

adjacent bones is the lynchpin to obtaining optimal results with NOE fractures.

• Closed reduction methods performed in the past, including those involving the use of external splints, have yielded poor esthetic results.

• Such techniques do not allow for the proper reduction of the medial canthal bearing segment, leading to posttreatment telecanthus.

• Closed techniques also do not afford the opportunity to reestablish nasal projection, leading to posttreatment nasal deformities.

• Therefore, open techniques are now recognized as the best way to manage NOE fractures.

Papadopoulos H . Management of Naso-Orbital-Ethmoidal Fractures . Oral

Maxillofacial Surg Clin N Am 21 (2009) 221–225

Surgical Access

• Existing Laceration• Coronal Approach – Best appproach (past decade) • “Open Sky” approach – H shaped scar over the brows • Midline Verticle incision • Bilateral Z • W- shaped • Gullwing or Spectacle incision

Coronal flap• Advantages : • Correction of associated frontal sinus fracture.• Harvesting of calvarial bone graft or primary reconstruction• Harvesting of pericranial flap of sufficient length for sealing of defects in

the ant.cranial fossa.• Disadvantage:• Cannot be used when the skull has been opened up previously for

craniotomies by the neurosurgeons.

Intraoperative Evaluation of the Nasofrontal Duct • Condition of the frontal sinus floor and the nasofrontal ducts

can be assessed by direct visualization.

• The relative patency of the duct can then be evaluated by placing an angiocatheter into the nasofrontal duct and introducing an appropriate fluid medium so that flow can be assessed.

• A 3.8 cm (1.5 inch) 18-gauge angiocatheter is the best instrument for this purpose. Patency of the nasofrontal duct can be confirmed by introducing normal saline and observing its emergence from beneath the medial turbinate or its collection in the posterior pharynx

Nasofrontal Duct Obstruction • Condition of the nasofrontal duct - most important factor in maintaining

the health of the frontal sinus.

• This duct permits the exit of mucin, seroma, or hematoma after injury.• If the duct is injured and obstructed, sinusitis, meningitis, or

osteomyelitis may develop.

• If the duct is not patent, thorough removal of every possible remnant of sinus mucosa is performed by curettage.

• This procedure is followed by removal of additional mucosa from every cul-de-sac and crevice with a small (no. 8 or larger) diamond bur under copious amounts of irrigation and with the aid of magnification.

• Any remaining remnants of the nasofrontal duct mucosa are then inverted into the nose.

Sinus Obliteration • Nasofrontal duct obstruction is necessary to seal off the frontal

sinus from nasal contaminants.• Sinus obliteration adds one more layer to the seal but also

eliminates the “dead space” or air within the sinus that may permit fluids to accumulate, thus causing a seroma or a hematoma.

• Furthermore, after cranialization, sinus obliteration cushions and protects the brain.

• Historically, sinus obliteration has been accomplished in a number of ways, :

- including inserting no substance or object (theoretically permitting bone fill after curettage) or hydroxylapatite, glass wool, bone, cartilage, muscle, absorbable gelatin sponge, absorbable knitted fabric, acrylic, or fat.• The use of fat has been reported most frequently, and this method

historically has provided the most desirable results.

NOE Reconstruction • Type I fractures - less difficult to treat - and can at times be reduced transnasally and - treated without fixation. • More often, single-segment NOE fractures are reduced through –- coronal incision and - secured at the nasofrontal junction, the maxillary buttress, and the

infraorbital rims.

- Markowitz type II or higher.• Transnasal wiring is recommended for fractures graded as• Although we are truly in an era of rigid fixation (bone plates and screws),

complete reduction of the NOE area and reattachment of the MCT, or replacement of a small bone segment, seem never to be adequate with microplates alone.

• For NOE fractures including avulsion of the MCT or in which the MCT is attached to a small bone segment, transnasal wiring should be considered.

• The point of fixation of the wires should be directed :- posterior and superior to the lacrimal fossa so that- the medial canthal distance is decreased and - widening of the nasal bones and blunting of the medial canthal area

can be avoided.

• Wires must be passed through the medial orbital bone and the superior nasal septum or the perpendicular plate of the ethmoid.

• Their passage can be facilitated with the use of a spinal needle or a wire-passing awl.

• Drill holes can also be used to aid in wire passing.

• The MCT and its bony segment can be incorporated into the transnasal wire fixation, or

• an avulsed MCT can be attached to the transnasal wire with sutures. • Slight overcorrection of the medial canthal distance is desired.

• In cases in which fracture comminution prevents adequate fixation of the MCT to a bone segment, stabilization with fixation to a calvarial bone graft has been advocated.

• In cases in which sufficient medial orbital wall remains, placing a microplate and screw for attaching the MCT behind the lacrimal crest has been suggested.

• Bone grafting may often be necessary in cases of severe comminution of the nasal bones or the medial orbital walls.

• Onlay of cranial bone grafts to maintain dorsal height and nasal tip projection can be performed through a coronal incision, and these grafts can be fixated rigidly or with wire.

GRAFTING THE NASAL DORSUM

Transnasal Canthopexy wire

• Transanasal Canthopexy wire is requires to secure Medial Canthal Tendon

• Technique to assure the position of the Medical Canthal Tendon is necessary

• 4th plate is utilized to hold the Medial Canthus in proper posterior and horizontal position (3dimensionally)

• Achieved using Anchor Technique – With or Without barb

Identifying the medial canthus

• First step in Canthopexy is identifying the Medial Canthus

• BY Forceps , through Coronal or Extended glabellar approach

• Find and pull on the medial canthus area to confirm that the proper structure has been identified

Wire placement into MCT

• Once medial canthus has been found – Transnasal wire is placed through the medial canthus

• Metal wire with a swedged-on needle that can be detached from the wire should be used

Adapt fourth bone plate and pass wire though it

• If transnasal wire not in proper 3-D position, plate is needed to support the transnasal wire.• Pass the wire through the most posterior hole of the fourth plate

and check for position

Create hole for the wire

• Depending on stability of bone in NOE, surgeon may drill hole from – contralateral side , or• Use an awl to create passage way• Extreme caution – not to advance too far , injuring the globe• Malleable or spoon retractor to protect the globe.

Pull the wire throught the hole

• Smaller needle should be used to pass needle through the ligament to avoid shredding the ligament

• Two ends of the wire are placed through the lumen of the needle and both the spinal needle and wire are pulled out of the contralateral side of NOE

Alternative – using an Awl

• Awl was first placed through the contralateral side, then advanced to the side of the NOE Type III fracture

• Wire has been placed through the medial canthus using a swedged-on needle

Fixation of the Fourth plate

• Fourth plate is placed to secure the transnasal wire to its proper location

• Plate is secured superiorly to the frontal bone

Securing Transnasal wire

• Transnasal wire is secured to a screw placed in the frontal bone. ( on the contralateral side)

• And tightened with appropriate tension needed to secure the medial canthus into its proper position

Alternative technique using wire with barb

Proper position of Transnasal wire

• Upper illustration – wire that has been placed anteriorly, resulting in lateral splaying of bone supporting medial canthus & worsening of the telecanthus

Alternative support for Transnasal canthopexy wire

• Using mesh on one of the two sides to support the transnasal wire in its proper 3-D location.

• Particularly useful when NOE combined with Medial Orbital Wall Fracture

Post - Op

External Splint

• Problem with NOE fracture – even after perfect bony reduction – lack of definition in the medial canthal area (Epicanthal fold)• Placing external nasal splints at the end of

procedure

• Some surgeons use – Percutaneous bolsters – to ensure adaptation of the skin to the underlying bone • Should be applied with great caution to avoid

underlying skin necrosis

Complications• PRINCIPAL TYPES – those that occur – - Directly at the time of injury- Infectious nature - Chronic problems

• Most devastating – Neuro problems – - displacement/penetration of frontal bones – into brain - Can Result in – Concussion , Severe Brain injury , Death

- Displacement of frontal bone – orbital damage - Most common ocular complication – Diplopia

• Trauma to the floor of the frontal sinus or displacement of the medial supraorbital rim may cause a CSF leak.

• Generally, reduction of the fractures corrects this problem. If it is persistent, however, neurosurgical repair is indicated.

• INFECTIOUS COMPLICATIONS - most frequently arise from- occlusion of the nasofrontal duct or - contamination of the sinus by penetrating foreign bodies. • Most frequently encountered infection is – meningitis.( If nasofrontal duct is occluded blood may accumulate in sinus, creating an environment that is conducive to the growth of anaerobic bacteria.)• Frontal sinus abscess is spread by direct extension through small

fractures of frontal bone orthrough transosseous anastomotic vessels.The result is brain abscess, meningitis, cavernous sinus

thrombosis, or (if the abscess is long term) osteomyelitis.

• Respiratory mucosa trapped between fracture segments or left behind during obliteration procedures may continue to grow. This continued growth may lead to formation of mucoceles or pyoceles.

• Pain and headache may be chronic and - may persist without an identifiable cause.

• Cosmetic deformities such as contour deficits and irregularities stem from several causes.

• Anosmia—the loss of the sense of smell—and • Hyposmia are known complications of NOE fractures and - can occur in as many as 38% of patients with high central midface

fractures.- In addition, 23% of patients with high midface fractures report a

decreased sense of taste (hypogeusia).

• Complications can occur as late as upto 20 years postoperatively, and patients should be encouraged to have routine yearly follow-ups.

Dacryocystorhinostomy

Involvement of Lacrimal System in NOE fractures

• Any injury that involves multiple structures, appropriate sequencing of the repair is important

• If NOE + Lacrimal disruption- Reduction of fracture and - stabilization of Craniofacial Skeleton should precede any

attempt to reconstruct Lacrimal System

• If fracture along the path of the Nasolacrimal Duct – - Treatment of the fracture- Stenting of the duct - Performing Nasolacrimal duct reconstruction

( Dacryocystorhinostomy)

• OUTLINE OF METHOD OF TREATING LACRIMAL SYSTEM INJURY IN PATIENTS WITH NOE FRACTURE

• First Step – Reposition the Medial – Canthal – bearing fragment• (this will require stabilization with some form of transnasal wiring)

• Reconstruction of lacrimal system can be performed

• It is Repair of the lacrimal drainage system through creation of new “ostomy” or track from lacrimal canaliculi to the nasal cavity.

• TECHNIQUES :• Open (External)• Endonasal• Soft tissue Conjuctivorhinostomy

• Proximal portion of the lacrimal system- Inferior and Superior Canaliculi are identified – by placing lacrimal probes – within the lumen

• Distal segment of the affected canaliculi are identified within the laceration

• 6-0 – slow – absorbing – Monofilament sutures are placed but not tied superior and inferior to the affected canaliculi

• Probes are then removed

• Ritleng Introducer with the Stylette in place – passed into the distal segment – of laceration

• Advanced parallel to eyelid – through common canaliculus – - until hard stop encountered

• At this point it is in the Lacrimal Sac –

• Next rotate Ritleng Introducer 90 degree – (Perpendicular to the eyelid) – Advanced down the nasolacrimal duct

• Stylene is removed & Ritleng stent is then advanced through the Ritleng Introducer into the nose • Using Ritleng hook, stent is retrieved from the nose

• Sutures then tightened and once appropriate tension has been achieved, knots are tied and the sutures trimmed

• PIC 1. – Knot is then pulled through the upper canaliculus by applying gentle traction to Silicone tube

• Pic 2. – a Second Knot (B) is tied proximal to First (A) corresponding to level of Lacrimal sac

• This is typically approx 1.5cm above the position at which the tubes emerge from the lower and upper punctum

• Second Knot (B) is then positioned in the lacrimal sac by pulling the two ends of the stent back through the nose

• So that the first knot is again positioned at the level of the nostril

• The second knot (B) is positioned in the lacrimal sac by pulling the two ends of the stent back through the nose so that the first knot is again positioned at the level of the nostril.

• The stent are then cut just above the lower knot (A).

• Performing A Dacryocystorhinostomy At The Time Of Fracture Treatment

• Lacrimal dysfunction has not been noted to be a significant problem with NOE fractures unless treatment is delayed or performed secondarily.

• Interestingly, an increased incidence of lacrimal dysfunction has been shown with closed techniques compared with open approaches.

• Unless an obvious injury is noted, such as a laceration in the region of the nasolacrimal apparatus, routine exploration of the apparatus or a dacryocystorhinostomy is not indicated.

• A dacryocystorhinostomy should not be performed prophylactically as the incidence of nasolacrimal dysfunction after NOE injury is only 5% to 17.4%.

Papadopoulos H . Management of Naso-Orbital-Ethmoidal Fractures . Oral

Maxillofacial Surg Clin N Am 21 (2009) 221–225

References : • Peterson’s Principles of Oral and Maxillofacial Surgery – 2nd

Edition • Rowe & Williams Maxillofacial Injuries • Fonseca’s Trauma • Textbook of Oral & Maxillofacial Surgery by Dr.Rajiv M Borle

• Papadopoulos H . ‘Management of Naso-Orbital-Ethmoidal Fractures’ . Oral Maxillofacial Surg Clin N Am 21 (2009) 221–225

ORIF