Nasal and Naso-orbito-ethmoid Fractures

Abstract

Craniofacial fractures are common among trauma patients. Nasal fractures are the most common craniofacial fracture. Understanding how to evaluate and manage craniofacial fractures is important for the craniofacial trauma consultant. This manuscript describes the appropriate workup and management of nasal and naso-orbito-ethmoid fractures.

Epidemiology

Approximately 7.2–9.6% of all trauma patients present with facial fractures. ^{1 2} Among those presenting with facial fractures, 74.5% of patients are male, ² and the most common fractures are nasal fractures, which constitute 57.4%. ¹ The incidence of nasal fractures is higher than malar/maxillary, orbital, and mandible fractures for both low energy injury mechanisms, such as falls and assaults, as well as high energy injury mechanisms, such as motor vehicle collisions (MVCs). Naso-orbito-ethmoid (NOE) fractures constitute ∼5% of adult and ∼15% of pediatric facial fractures. ³ They are typically associated with higher energy injury mechanisms.

Anatomy

Nasal fractures are the most common facial fracture because the nose is the most anteriorly projecting structure and contains small components capable of being displaced by relatively small forces. Nasal fractures involve at least one of the two nasal bones, which articulate cephalically with the frontal bone and laterally with the maxilla. Septal fractures most frequently involve the quadrangular cartilage anteriorly, however higher force trauma may involve the bony septum such as the maxillary crest inferiorly, or the vomer and perpendicular plate of ethmoid posteriorly. ⁴ The perpendicular plate of ethmoid is contiguous with the cribriform plate of the skull base and involves olfactory mucosa. Thus, fractures of this bone can result in cerebrospinal fluid (CSF) leaks and impaired olfaction.

NOE fractures involve the lateral nose, inferior orbital rim, medial orbital wall, nasomaxillary buttress, and frontal process of the maxilla. ⁵ The medial canthal tendon (MCT) inserts around the lacrimal fossa and acts as a pump for the lacrimal sac. ⁶ Thus, NOE fractures can result in dysregulation of tear film clearance and resultant epiphora. The MCT tethers the eyelid to the lateral nose, setting the intercanthal distance which can be altered following trauma due to fracture displacement or avulsion of the MCT from its bony insertion. NOE fracture involvement of the medial orbital wall and ethmoids put vascular structures and the skull base at risk, which can manifest clinically as retrobulbar hematoma and CSF leak, respectively.

Classification

Nasal fractures are described as open or closed, conditional on the presence of exposed bone, displaced or nondisplaced, and simple or comminuted. NOE fractures are frequently described using the Markowitz and Manson classification system, ⁷ wherein Type I fractures are composed of an intact medial canthal tendon (MCT) attached to one large bone fragment, Type II fractures are composed of an intact MCT attached to a comminuted bone fragment, and Type III fractures involve a MCT that has been avulsed from the lacrimal fossa and bone segment ( Fig. 1 ).

Fig. 1.

Markowitz & Manson NOE Classification System. Type I NOE fractures demonstrate an intact medial canthal tendon (MCT) attached to one large bone fragment, Type II fractures are composed of an intact MCT attached to a comminuted bone fragment, and Type III fractures involve comminution and a MCT that has been avulsed from its bony insertion.

Diagnosis

Diagnosis includes patient history and physical exam for isolated nasal fractures. Computed tomography (CT) scans are routinely performed as part of the craniofacial trauma workup and are a prerequisite for any high energy fractures and/or suspected NOE fractures. Depending on the chronology of imaging relative to the in-person evaluation, the CT scan should be used to either corroborate clinical examination findings or inform the need for directed examination maneuvers during physical assessment. Note any preexisting nasal, septal, or craniofacial deformities or pathology. Details regarding the mechanism of injury including the direction and magnitude of the applied traumatic force, history of epistaxis, and changes in nasal airflow should be documented.

Physical Exam

Clean the skin of any dried blood or dirt that may hinder the exam. Begin with the ocular exam, checking visual acuity, red light desaturation, and extraocular muscle excursion. If there are deficits, then consider ophthalmologic consultation. If the patient wears glasses, then be sure to test with them in place or note the deficit to contextualize the result of your exam. Note the presence of enophthalmos or exophthalmos, which may indicate the presence of comorbid injuries such as orbital floor fractures, impacted or displaced zygomaticomaxillary fractures, frontal bone fractures, or suggest the presence of retrobulbar hemorrhage. Then perform the remainder of a standard cranial nerve examination.

The nasal contour from both anterior and lateral views should be assessed. Use bimanual digital palpation to assess for step-offs, contour abnormalities, mobility, and crepitus, which indicate nasal fracture. Note the extent of edema, ecchymosis, and/or the presence of hematoma, which may impact the physical examination and distort baseline nasal anatomy. Assess for intranasal trauma including mucosal laceration and septal hematoma with bimanual digital palpation and direct visualization with a nasal speculum and appropriate lighting.

Assess the intercanthal distance. If the medial canthal tendon (MCT) bearing bone is displaced or the MCT has been avulsed, then there may be lateral migration of the medial canthus, resulting in dystopia canthorum (telecanthus), which is defined as an increased distance between the medial canthi ( Fig. 2 ). Clinically, this will manifest as displacement of the medial canthus lateral to the nasal ala and blunting of the medial canthal angle with reduced scleral show compared with the contralateral side in unilateral presentations. A high index of suspicion should be maintained as soft tissue edema following acute trauma can obscure these findings. Test the MCT for laxity by palpating over the medial canthus while stretching the lateral eyelid laterally with the opposite hand. If the finger palpating the MCT detects movement or a lack of resistance, then a NOE fracture is likely present. Use of forceps to grasp the medial canthus and assess laxity can also be performed if the patient is intubated or following the use of a local anesthetic. Finally, observe the lacrimal lake and assess for epiphora; if present, then proceed with fluorescein dye tests.

Fig. 2.

Traumatic telecanthus. Increased intercanthal distance with rounding of the medial canthal angle.

Finally, assess for CSF leak. Tilt the patient's head forward while in a seated position. If there is a steady production of thin, clear or yellow-tinged fluid, then collect for laboratory analysis for the presence of β-2 transferrin.

Imaging

Imaging is not always required for isolated simple nasal fractures, however, many trauma patients have already undergone a maxillofacial CT scan as part of a protocolized trauma work-up prior to craniofacial service consultation. If this is the case, then the CT should be reviewed to improve diagnostic accuracy, catalog the craniofacial injuries, and inform preoperative planning. If a NOE or CSF leak are suspected prior to imaging, then a dedicated maxillofacial CT scan is further indicated to evaluate the integrity of the frontal sinus and the patency of the nasofrontal outflow tracks. If nasofrontal ducts are disrupted, then obliteration or cranialization of the sinus may be required to prevent mucocele formation ⁸ ( Fig. 3 ).

Fig. 3.

Patient with bilateral NOE fractures and concomitant CSF leak with frontal sinus and anterior skull base fractures. Nasofrontal ducts were compromised due to impaction of NOE fractures necessitating NOE reduction, frontal sinus cranialization, and anterior skull base reconstruction with split calvarial bone graft and bilateral pericranial flaps.

Management

Surgical Indications

Surgery is indicated for nasal fractures when the patient has a septal hematoma, reduced nasal airflow due to traumatized anatomy (i.e., not secondary to edema), and/or unacceptable cosmesis. Surgery is typically indicated for most displaced NOE fractures as secondary deformity is common and challenging to reconstruct if not addressed in the primary setting. Nasal and NOE fractures without concurrent emergent or urgent surgical needs may be managed on an outpatient basis in the subacute setting. Patients may follow-up in clinic 5–7 days post-injury once the initial edema has begun to resolve and an adequate exam can be obtained. ⁹ Epistaxis can be managed with topical vasoconstrictors for up to 3 days and intermittent nasal obstruction can be managed with nasal irrigation. Surgical intervention should ideally be performed within 14 days after injury to leverage fracture mobility and avoid early fracture consolidation that can necessitate osteotomies for mobilization prior to reduction and fixation.

Non-surgical Management

Minimally displaced nasal bone fractures can be managed expectantly with instructions to avoid activities where repeated nasal trauma is likely. Non-surgical management should only be reserved for non-displaced NOE fractures with preservation of nasal projection and profile and normal MCT integrity. Lack of timely surgical intervention for operative NOE fractures can result in long-term sequelae which are challenging to correct.

Surgical Approaches

Procedures for all traumas should be preceded by copious irrigation to remove debris and reduce the risk of infection.

The goal of operative management for a septal hematoma is to prevent devitalization of cartilage and septal mucosa resulting septal perforation. Septal hematomas may be drained in the emergency room using a large-bore needle and syringe for a compressible, early-stage hematoma. Consolidated hematomas may be drained by incising the septal mucosa and manually expressing the hematoma. Both may be performed under local anestheisa, however general anesthetic may be prudent for children. Drainage should occur immediately after diagnosis, even if there is a plan for delayed operative management. Trans-septal quilting sutures or intranasal septal splint bolsters help prevent hematoma recurrence.

The goals of operative management for nasal fractures are to improve or restore baseline nasal airflow and aesthetics. Nasal fractures may be managed operatively immediately if there is little to no edema. More commonly they are evaluated 5–7 days post-injury once initial post-traumatic edema has resolved. Most nasal fractures can be managed easily with closed reduction via manual manipulation with a Boise (“butterknife”) elevator ( Fig. 4 ). Rarely open reduction with septal cartilage excision may be required for severe fractures involving significant septal deformity causing functional airway obstruction. ¹⁰ Though closed reduction may be performed under local anesthesia, general anesthesia is associated with improved patient satisfaction with anesthesia and improved patient satisfaction with the final appearance of the nose thereby decreasing the need for revisionary surgery such as rhinoplasty, septoplasty or combined septorhinoplasty in the future. ¹¹ Closed reduction under general anesthesia with orotracheal intubation also affords a controlled environment with airway protection should there be excessive hemorrhage following nasal manipulation.

Fig. 4.

( A ) Isolated nasal bone fractures with deviation of the entire nasal pyramid to the patient's left. Note the obligatory open mouth respiration due to significant nasal airway obstruction secondary to fracture displacement. ( B ) Postoperative result following closed nasal bone reduction with external splint stabilization for two weeks. Notable improvement in the dorsal nasal aesthetic lines with centralized bony nasal pyramid. The patient is now able to breathe easily through the nose with a closed mouth.

The goals of operative management for NOE fractures are to preserve the projection and the aesthetics of the medial canthal/lateral nasal region, restore baseline vision, maintain nasolacrimal duct drainage, and ensure patency of nasofrontal duct outflow. NOE fractures are managed via open reduction with internal fixation (ORIF) under general anesthesia. ¹² The fracture may be visualized and manipulated through existing soft tissue lacerations, or through limited percutaneous approaches such as frontoethmoidal (Lynch) and extended glabelar, periorbital and transconjunctival incisions, intraoral maxillary vestibular incision, or through a coronal incision depending on the access needs for associated fractures and degree of underlying comminution ( Fig. 5 ). Type I NOE fractures are amenable to plate fixation across adjacent stable buttresses including the nasofrontal, nasomaxillary and inferior orbital rim. Type II NOE fractures may require transnasal wiring and/or suture vs wire fixation of the medial canthal bearing bone to a plate secured to the frontal bone and adapted to overlie the posterior lacrimal crest as adjuncts to the primary plating strategy described for Type I fractures. Overcorrection of nasal projection and medial canthal width should be the goal with an ideal intercanthal distance for adult Caucasian males of 33–34 mm and adult Caucasian females of 32–33 mm. Severe communication with loss of bone may require primary bone grafting. ¹³ If the nasal dorsum is severely comminuted with loss of nasal support, then reconstruction with cantilevered bone graft is required ( Fig. 6 ). Type III NOE fractures are typically accessed using a combination of coronal, periorbital, and maxillary vestibular approach, as wide visualization is needed to reduce and stabilize these extensively comminuted fractures. These fractures are some of the most complicated fractures to reduce and a detailed review of operative steps is beyond the scope of this paper. For all types of NOE fractures, one of the challenges of achieving an appropriate cosmetic outcome is achieving symmetric concavity of the medial canthal region. Some surgeons choose to use molded nasal splints to support and adapt the soft tissues overlying the bony reconstruction, however these must be shaped and secured judiciously to minimize the risk of skin necrosis.

Fig. 5.

( A ) Pre-operative clinical photograph and 3D CT reconstruction demonstrating bilateral type I NOE fractures and Lefort I fracture. Note blunting of left medial canthal angle and loss of projection and widening of the radix due to NOE fracture displacement. ( B ) Intraoperative photographs of percutaneous access for NOE open reduction and internal fixation via bilateral frontoethmoidal (Lynch) incisions and bilateral mid-lid incisions. ( C ) Post-operative clinical photograph and 3D CT reconstruction demonstrating plate fixation of bilateral NOE fractures and Lefort I fracture. There is appropriate cosmesis of the percutaneous access incisions with restoration of the natural medial nasal and canthal concavities. The post-traumatic blunting of the left medial canthal angle has been corrected.

Fig. 6.

( A ) Pre-operative clinical photograph demonstrating mixed type II/III NOE fracture with avulsion of right medial canthal tendon and post-traumatic telecanthus. ( B ) Pre-operative 3D reformatted maxillofacial CT scan demonstrating right type III and left type II NOE fractures with concomitant right ZMC fracture. ( C ) Intraoperative photograph of NOE fixation with wire resuspension of R medial canthal tendon and split calvarial cantilever bone graft for restoration of dorsal nasal support. ( D ) Post-operative 3D reformatted maxillofacial CT scan demonstrating final NOE and ZMC fracture fixation and placement of dorsal cantilever bone graft.

Postoperative Course

Postoperative imaging can be performed intraoperatively or within the first few days after surgery to confirm adequate reduction and fixation. The patient's head should be kept elevated to assist with post-operative edema and pain. Sinus precautions should be instituted for 10 days following all NOE injuries to prevent orbital and soft tissue pneumatization. Travel in pressurized aircraft may be permitted 4–6 weeks postoperatively. Travel in non-pressurized aircraft, scuba diving, and other activities at high risk of barotrauma should be avoided for 12 weeks. Most providers will hold antiplatelet and anticoagulant medications including aspirin postoperatively to decrease the risk of retrobulbar hematoma however, the need to defer nonsteroidal anti-inflammatory drugs (NSAIDs) remains controversial.

Analgesia, nasal decongestants, steroids, and ophthalmic ointment should be used as indicated. Many surgeons use preoperative antibiotics, however there is no consensus on antibiotic type or need for continued prophylaxis following surgery. Any permanent sutures should be removed 7–10 days postoperatively. The patient should be counseled on standard wound care and scar considerations, such as gentle cleansing, scar massage, silicone therapy, and sun avoidance.

Follow-up

Patients should be seen in clinic 1–2 weeks following surgery to evaluate wound healing, vision, globe position, nasal airway, facial deformity, scar formation, olfactory dysfunction, tearing dysfunction, and sensory nerve function. Children should receive longer term follow-up to observe for facial asymmetries that may indicate that the fracture involved a growth center. ^{9 14 15}

Complications

Delayed or improperly repaired nasal fractures may result in nasal obstruction, nasal deformity (e.g., asymmetry, saddle nose deformity, among other deformities), olfactory dysfunction, and septal perforation. ⁶ NOE fractures that are repaired in a delayed fashion or are malreduced may result in persistent enophthalmos, telecanthus, diplopia, nasolacrimal duct obstruction, epiphora, and persistent facial deformity. Fractures associated with CSF leaks bear an elevated risk of intracranial sequelae such as meningitis and encephalitis until the dural tear has healed or is repaired. Fractures involving disruption of the nasofrontal ducts are at risk of developing mucocele, unless patency of the outflow tracks is restored, or the sinus is appropriately defunctionalized through obliteration or cranialization. ⁸

Conclusion

Nasal fractures are the most common facial fracture managed by craniofacial trauma teams. NOE fractures are less common but associated with higher energy injury mechanisms and are more complex to manage. A thorough understanding of the anatomy, classification, diagnosis, management options, and potential complications of each of these fracture patterns are crucial.