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NOE: Complications and Treatment

NOE: Complications and Treatment. Craniofacial Rounds Thursday May 5, 2011. Anatomic considerations. Medial canthal tendon Bones: frontal, nasal, maxilla, lacrimal, ethmoid Medial orbital wall or orbital floor fractures Anterior cranial fossa

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NOE: Complications and Treatment

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  1. NOE: Complications and Treatment Craniofacial Rounds Thursday May 5, 2011

  2. Anatomic considerations • Medial canthal tendon • Bones: frontal, nasal, maxilla, lacrimal, ethmoid • Medial orbital wall or orbital floor fractures • Anterior cranial fossa • Vessels: Supraorbital, supratrochlear, infratrochlear, anterior and posterior ethmoidal arteries • Eye: Globe, optic nerve • Lacrimal apparatus • Cannaliculi

  3. Diagnosis • CT • Old photographs • Estimate intercanthal distance

  4. Physical Exam • Swelling • Intercanthal distance • Approx half interpupillary distance • >40 mm • Eyelid traction • Bimanual exam • CSF rhinorrhea • Eye exam • Enophthalmos • 20-25% ocular injury

  5. Facial Deformity • Telecanthus • Shortened palpebral fissures • Enophthalmos • Shortened/retruded nose • Flattening, collapse, inward telescoping of nasal bones • Ocular dystopia

  6. Treatment Indications • All displaced fractures • Medial canthal tendon insertion displacement/ disinsertion • Telecanthus • Facial deformity • Nasal airway • Tear drainage disruption

  7. Fixation • Closed reduction, external splinting, wires • Indications • Simple fractures • Pros • Simple • Cons • Cannot correct medial canthal displacement/ disinsertion • Unable to reduce medial orbital wall/rim • Collapse, flattening, telescoping of nose

  8. Fixation • Open reduction, internal fixation • Mustarde 1964, Dingman 1964 • Medial canthal tendon insertion • Stranc 1970 • Canthopexy • Suture/wire

  9. Approaches • Approaches • Existing lacerations • Local incisions • Midline vertical (Stranc) • Open sky (Converse 1970) • W incision • Coronal incision • Lower lid incision • Upper gingivobuccal sulcus incision

  10. Repair • Bony rim exposure • MCT insertion exposure • Reduction medial orbital rim • Reconstruction medial orbital wall • MCT canthopexy • Septal reduction • Nasal dorsum augmentation • Soft Tissue Readaption From Ellis JOMFS 1993

  11. 1. Bony Rim Exposure • Exposure • Orbital rims • Medial orbital wall • Anterior ethmoidal arteries – cauterize • Posterior ethmoidal arteries – optic nerve just a few mm posterior!! • Nasal bridge • Careful not to detach MCT insertion • MCT • ID fragment of insertion

  12. 2. MCT Insertion Exposure • MCT insertion

  13. 3. Reduction Medial Orbital Rim • Reduce/recon medial orbital rim • Transnasal reduction of MCT-bearing bone fragment • Simple

  14. Transnasal wiring • A: Coronal view, horizontal mattress • B: Improper placement (too anterior, lateral displacement) • C: Proper placement From Ellis JOMFS 1993

  15. 4. Reconstruction Medial Orbital Wall • Alloplastic • Titanium mesh, medpor • Autologous • Bone (rib, calvarium

  16. 5. MCT Canthopexy

  17. 6. Septal Reduction • Asch forceps

  18. 7. Nasal Dorsum Augmentation Dorsal nasal support to prevent secondary deformities • Primary bone grafting • Indicated with a severely comminuted septum • Risks dorsal support weakness

  19. 8. Soft Tissue Readaption • Recreate the naso-orbital “valley” • Stents or bolsters • Transnasal wiring for comminuted/severe cases

  20. Conclusion • NOE – complex anatomy • Secondary deformities difficult to treat • Early repair, ORIF • Restoration of intercanthal width • Proper reduction of canthal tendon bearing fragment • Early bone grafting to prevent secondary deformity

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