Questions and Answers
What are the bones that comprise the NOE complex? (Select all that apply)
What is the medial orbital wall comprised of?
Lacrimal and ethmoid bones
What region bears the insertion of the medial canthal tendon?
Frontal process of the maxilla
Is there a classification for NOE fractures?
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What is the Markowitz classification based on?
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Physical examination findings in suspected NOE fracture include which of the following? (Select all that apply)
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Match the following terms with their definitions:
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What is normal interpupillary distance?
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What does soft tissue intercanthal distance > 40mm indicate?
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How often does a nasolacrimal apparatus injury occur with NOE fractures?
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What is a Jones test?
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What is the treatment for dacrocystitis?
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Study Notes
NOE Complex and Fractures
- Comprises nasal bones, frontal processes of maxilla, nasal process of frontal bone, and medial orbital wall (lacrimal and ethmoid bones).
- Medial orbital wall includes the lacrimal and ethmoid bones.
Medial Canthal Tendon
- Inserts at the frontal process of the maxilla.
- Evaluation of injuries involves Markowitz classification.
Classification of NOE Fractures
- Markowitz classification categorizes fractures into Type I (intact tendon, no comminution), Type II (intact tendon, comminution present), and Type III (avulsed tendon, severe comminution).
- Manson and Markowitz classification relies on central fragment and medial canthal tendon integrity.
Physical Examination Findings
- Key findings include depressed nasal dorsum, telecanthus, periorbital edema, anosmia, and epiphora.
- Bowstring test can indicate movement of bone fragments linked to medial canthal tendon.
Intercanthal and Interpupillary Distances
- Normal intercanthal distance ranges from 28-35 mm (28.6-33 mm for women, 28.9-34.5 mm for men).
- Normal interpupillary distance is approximately 60 mm.
- Soft tissue intercanthal distances exceeding 40 mm indicate possible NOE fracture; >35 mm suggests medial canthal involvement.
Diagnostic Tests for Lacrimal System Injury
- Jones test assesses nasolacrimal injury; failure to detect dye may indicate blockage.
- Positive findings on Jones tests help locate obstructive pathways.
- CSF leak tests include halo test and measurement of glucose levels.
Imaging and Surgical Management
- CT scan with 1.5 mm cuts is standard for diagnosing NOE fractures, focusing on the frontal sinus and medial canthal tendon status.
- Systematic management involves surgical exposure, reduction, and reconstruction of bone fragments and canthal tendons.
Repair Techniques for NOE Fractures
- Different approaches include coronal, vestibular, and overlying laceration techniques.
- Type I repair secures the main fragment with internal fixation.
- Type III fractures necessitate canthopexy with vectors superior and posterior to the lacrimal fossa.
Post-operative Complications and Treatments
- Failure to adequately treat fractures can lead to nasal deformity or telecanthus.
- Saddle nose deformity, characterized by a shortened nose, results from loss of dorsal support.
- Dacrocystitis, inflammation of the lacrimal sac, requires antibiotic treatment.
Lacrimal System Injury Management
- Canaliculus damage can be repaired using a Silastic tube and stenting.
- Chronic epiphora may necessitate dacryocystorhinostomy, re-establishing drainage pathways.
- The procedure includes careful creation of new tear drainage routes, often with a stent to prevent scarring.
Canthopexy Techniques
- Transnasal wiring technique provides support to the medial canthal tendon, ensuring proper alignment and stability.
- Access and securing techniques involve threading sutures and wires through the nasal cavity and attaching them to the opposite orbital rim.
Advanced Repair Techniques
- In cases of comminuted fractures or inadequate bony support, grafting might be required to reinforce the medial canthal tendon fixation.
- Individual securing of canthopexies is crucial to prevent failure if one loosens.
Additional Key Points
- Proper management of lacrimal system injuries during NOE fracture repairs is essential to minimize patient morbidity.
- Regular assessment of both anatomical structures and soft tissue integrity is needed throughout treatment and recovery.
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