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Nasorbitalethmoidal fracture

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naso-orbito-ethmoid fracture

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naso-orbito-ethmoid fracture management classification medial canthal tendon authoritative

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naso-orbito-ethmoid NOE fracture CT scan medial canthal tendon telecanthus

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https://pmc.ncbi.nlm.nih.gov/articles/PMC6486388

Naso-orbito-ethmoid (NOE) fracture

An NOE fracture is a high-energy central midface injury involving the junction of the nasal bones, medial orbital walls/rims, and ethmoid complex. Its defining concern is injury to the medial canthal tendon (MCT) attachment, which can produce traumatic telecanthus and major functional or cosmetic deformity if not repaired early. Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Vol 1, p. 1247.

Typical causes

  • Road-traffic collision
  • Assault
  • Fall or other blunt high-energy facial trauma

Clinical features

  • Severe periorbital edema and bruising
  • Flattened, widened nasal bridge with loss of nasal projection
  • Telecanthus: increased distance between medial canthi, often with normal interpupillary distance
  • Blunting of the medial canthal angle
  • Mobility of the medial canthus on examination
  • Epiphora due to lacrimal drainage injury
  • Diplopia, enophthalmos, restricted ocular movements if orbital injury coexists
  • Epistaxis, nasal obstruction, and possible CSF rhinorrhea, since skull-base injury can accompany NOE fractures

Markowitz classification

Based on the relationship between the central fracture fragment and the medial canthal tendon:
TypeDescriptionMCT status
ISingle, large central fragmentTendon remains attached
IICentral fragment is comminutedTendon remains attached to a bony fragment
IIISevere comminutionTendon has no attached bone fragment or is avulsed
Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Vol 1, p. 1247.

Diagnosis

  • Initial trauma assessment with airway, cervical spine, neurological and ocular evaluation.
  • Thin-slice CT of the maxillofacial bones, usually 1-2 mm cuts with multiplanar and 3D reconstructions, defines comminution, orbital involvement, skull-base injury, and surgical planning. The delayed-NOE review emphasizes careful assessment of the MCT-bearing fragment, medial orbital wall/rim, and degree of comminution.
  • Examine for visual loss, globe injury, extraocular muscle entrapment, lacrimal injury, septal hematoma, and CSF leak.

Treatment principles

Displaced NOE fractures generally require early open reduction and internal fixation by a maxillofacial, plastic, or craniofacial surgical team.
  1. Restore the central midface framework, nasal projection, and orbital contours.
  2. Rigidly fix Type I fractures with plates and screws where feasible.
  3. Precisely reposition the MCT-bearing fragment in Type II fractures.
  4. Use transnasal canthopexy or wiring for Type III, and some Type II, fractures to restore medial canthal position.
  5. Assess the nasolacrimal system and stent it if injured.
  6. Address associated orbital, frontal sinus, skull-base, maxillary, and nasal septal fractures as appropriate.
Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Vol 1, p. 1247.

Key complications

  • Persistent telecanthus
  • Saddle-nose deformity or loss of nasal projection
  • Epiphora
  • Diplopia, enophthalmos, visual impairment
  • CSF leak and meningitis risk
  • Nasal obstruction
  • Facial asymmetry and need for secondary reconstruction
Delayed repair is more difficult because scarring and distorted anatomy make accurate MCT repositioning and restoration of nasal projection harder. Recent systematic reviews also assess surgical outcomes and techniques, including PMIDs 39422367, 38697897, and 38215791.
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