290 likes | 416 Views
Naso-orbital Ethmoid Fractures Introduction. Suspect in Central Midfacial TraumaFailure of Diagnosis Leads to Significant Facial DeformitiesIsolation of Lower 2/3 Medial Orbital RimLateral Nose Medial Orbital WallNasomaxillary Buttress Frontal Process of Maxilla / Maxillary Process of Frontal Bone.
E N D
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