Naso Orbito Ethmoid (NOE) Fractures

The naso orbito ethmoid (NOE) complex is the collective name of the frontal sinus, ethmoid sunuses, anterior cranial fossa, orbits, frontal bone, and nasal bones. Naso orbito ethmoid (NOE) fractures are complex because of the intricate anatomy of this area.

Treating naso orbito ethmoid (NOE) fractures

When a naso orbito ethmoid (NOE) fracture occurs, it can lead to many long term effects like blindness, nasal deformity, cerebral spinal fluid fistula, anosmia, epiphora, sinusitis, enophthalmos, midface retrusion etc. If treated improperly, naso orbito ethmoid (NOE) fractures can cause secondary deformities that are sometimes impossible to correct.

Things to be noted while treating naso orbito ethmoid (NOE) fractures

Since this is primarily a facial area, treating naso orbito ethmoid (NOE) fractures also needs a cosmetic perspective. Damage to any structure in this region might result in abnormal facial appearance. The orbital area is also having a compact relationship with brain and eyes. The naso orbito ethmoid (NOE) complex separates the nasal and orbital cavities from the cranial cavity.

In addition to the type of fracture, the extent of it must also be assessed to understand the area of impact and the affected area. There are many approaches to identify the naso orbito ethmoid (NOE) fractures including the midfacial, endoscopic approaches and bone tissue engineering to manage them.

Identifying the symptoms of a naso orbital ethmoid (NOE) fracture

Based on the location and severity of the naso orbito ethmoid (NOE) fractures, the clinical symptoms will vary. In the earlier stage, facial edema and distortion of soft tissue landmarks, followed by the ophthalmic symptoms like diplopia, telecanthus, enophthalmos, epiphora and shortened palpebral tissue might occur. This might be due to the malformation of the orbital wall or the medial canthal tendon. The nasal symptoms of a fracture include nasal bridge retursion, anosmia due to damaged cribiform plate and nasal congestion. Other cartilaginous deformity and cerebrospinal fluid leak are also possible outcomes.

Diagnosing naso orbito ethmoid (NOE) fractures

The location, extent and displacement of fractures should be diagnosed by careful physical examination and radiographic imaging.

The palpation of the nasal dorsum can identify the fractures, if any, in the central nasal support structures (nasal bone and orbital areas). But a physical examination becomes impossible sometimes due to excruciating pain, because applying pressure on the already pained area might result in additional secondary injuries or worsen the pain the patient feels. This may seriously limit the extent of the physical diagnosis and lead to misdiagnosis. Besides, the basic physical diagnosis only identifies the seriousness of the fractures and do not give complete details about the injuries.

Radiographic imaging (a combination of 2D CT and 3D CT scans) is used to get a clearer diagnosis. 2D CT axial scans can show the severity of the injury focusing on the maxilla and medial canthal tendon, the nasal bone and the frontal sinus. The radiographic imaging method also notes the symmetry and compares with the undamaged side to identify the amount of displacement.

Classification and treatment of naso orbito ethmoid (NOE) fractures

The widely accepted classification of NOE fractures has 3 types:

Type I: the medial canthal tendon attaches a single segment central fragment

According to the location and displacement of fracture, the superior and inferior horizontal buttresses along with the vertical buttress must be made stable by junctional place and screew fixation. The minimally invasive transnasal fixation that produces midfacial symmetry with a visible scar is recommended.

Type II: the central fragment is comminuted with the MCT attached

The primary concern for this type of injury is to ensure the medial orbital wall bony fragments are restored to order with microplates or titanium mesh. The two types of mesh – absorbable mesh and titanium dynamic mesh places have similar effect for orbital wall reconstruction in long term basis.

Type III: The MCT is separated with the comminuted central fragment.

This is the most challenging type of fracture. It is challenging to repair. Reconstructing the orbital wall and rebuilding the original attachment of MCT to how they were before the trauma are the main things to be noted.

Surgery for naso orbito ethmoid (NOE) fractures

Surgical therapy must protect the orbital and intracranial contents. It must also prevent early and late complications (such as blindness) and restore the aesthetical appearance of the face (to the pre trauma stage). The surgical correction of the medial orbit and the lacrimal bone need intensive care and are arduous. Inadequate exposure, imprecise methods or poor repair will cause long term effects including disfigurement of the face.

Cosmetic after effects of naso orbito ethmoid (NOE) fractures

Since the NOE complex is primarily the shaping structure for the face, any injuries or wrong treatment might alter the shape of the face and cause deformities and pain in addition to having visibly upsetting effects. Hence the treatment for naso orbito ethmoid (NOE) fractures must always take into account the cosmetic implications and perform the methods that have minimal visible reminders but ensure maximum cure.

Dr. Debraj Shome is a trained facial plastic surgeon, who specialises in treating NOE fractures and managing the cosmetic effects of the same. He has performed countless surgeries over his years of surgical experience and has changed the lives of many patients by treating their trauma and bringing them back to their original state.


About Dr. Debraj Shome

Debraj Shome-2
Debraj Shome, MD, DO, DNB, FRCS (Glasgow), FICO (USA), MNAMS, MBA (Healthcare Management, Vanderbilt University, USA), is Consultant Facial Plastic Surgeon, Oculoplastic Surgeon & Cosmetic Surgeon at Nova Specialty Surgery, Mumbai, India..Read more

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