0:01

The next category of fractures are what are often referred

0:04

to as the Naso-orbito-ethmoidal fractures or NOE fractures.

0:10

And these are generally on either side of the midline

0:13

that may affect the nasolacrimal duct,

0:16

the frontonasal duct in the paranasal

0:19

sinuses and the frontal sinus.

0:21

And what one has is a central fragment of bone which is

0:27

located in this area that I'm encircling, that

0:30

is lost because of fractured components.

0:34

And usually this is, in my experience, is indented inward

0:39

because of a crushing blow to the nasal bridge or the nasion.

0:44

So the cardinal tracts of these fracture lines are the lateral

0:47

aspect of the nose and the piriform aperture,

0:49

the nasomaxillary buttress.

0:51

You see here the nasal maxillary suture with the asterisks as

0:55

well as involvement of the inferior orbital rim and floor.

0:59

For these cases,

1:00

it's very useful to have multiplanar reconstructions

1:03

and potentially three dimensional reconstructions.

1:07

The treatment of these fractures is to preserve normal paranasal

1:11

sinus and lacrimal flow through the frontonasal duct or the

1:15

nasofrontal aperture and the nasolacrimal

1:18

duct for the lacrimal flow.

1:22

In addition,

1:22

the nasoethmoidal fractures are important because they are

1:27

involving the bony buttresses that support the medial canthus,

1:34

which obviously is associated along the medial aspect of

1:37

the orbit and will support the extraocular movement.

1:41

So there are different types of these NOE fractures.

1:45

In NOE I, you have a large fracture

1:47

piece, which is easy to repair.

1:49

It's not comminuted.

1:51

NOE II, comminuted fracture with the medial canthus attached

1:56

to one of the bony fragments and therefore your loss of the

2:00

ability to sort of anchor the medial rectus

2:03

muscle or the superior oblique muscle.

2:05

And then your NOE III where you have the avulsion of the

2:08

canthus from the anterior medial orbital wall

2:11

at the level of the lacrimal fossa.

2:13

So this is from the radiographics article on NOE

2:16

fractures. And what you see is, as I described, here's

2:20

a fracture that is involving those portions of the orbit and

2:25

nasal cavity that subsume the nasolacrimal

2:30

duct, as well as the frontonasal recess.

2:34

And you can see that these fractures have been kind of

2:37

accordioned in/on themselves because

2:40

of a blow to the nasion region.

2:43

So here's our nasion and this has been crushed inward

2:47

leading to comminution of the fractures.

2:50

And as you can see,

2:51

this is along the expected location

2:53

of the nasolacrimal duct.

2:55

You have comminuted fracture of the medial

2:57

wall. At this location, you will also obstruct

3:00

the outflow from the frontal sinus in the frontonasal duct

3:03

or frontal ethmoidal recess is another term for the

3:07

nasofrontal duct, and therefore the normal flow

3:11

of sinus secretions would be obstructed.

3:14

And then on the right side, it's just all comminuted.

3:17

There really is just soft tissue deformity.

3:19

You don't even see the bones very well.

3:22

So as I mentioned, the Markowitz-Manson classification

3:27

of NOE has a single fragment as the grade I,

3:30

the comminuted fragment as grade II.

3:33

And then grade III is the one that involves the avulsion

3:38

of the medial canthal tendon and that is a

3:42

lot harder reconstruction to reposition.

3:45

So that way there continues to be normal

3:48

extraocular muscle function.

3:51

So when you report on the Naso-orbito-ethmoidal fractures, you

3:56

want to talk about the degree of comminution, separating it from

4:00

level grade I to grade II, as well as the distance between the

4:04

medial canthi as an indicator of whether

4:07

or not the medial canthi are avulsed or not.

4:10

And then the frontal recess and nasolacrimal duct integrity for the

4:16

reconstruction to improve sinus secretion flow, as

4:20

well as the tear duct, the nasolacrimal duct flow.