nasoethmoid complex fractures

NASO ETHMOIDAL COMPLEX

• Dr V.RAMKUMAR• CONSULTANT

DENTAL&FACIOMAXILLARY SURGEON

• REG NO: 4118-TAMILNADU- INDIA(ASIA)

Introduction

• Middle third fracture of the face often involves Nasoethmoid complex. The skeletal foundation of the Nasoethmoid complex consists of a strong triangular shaped frame. Fractures in this region are almost invariably comminuted and involve numerous bones.

• The skeletal structures situated in front of and behind this frame are relatively fragile and force sufficient to fracture the frame usually results in severe comminution and displacement of these thin bones.

Nasoethmoid complex

Classification ( Nasoethmoid complex )

• Isolated nasoethmoidal injury– Bilateral– Unilateral

• Combined Nasoethmoid injury + midface fractures– Bilateral– Unilateral

Classif ication:I : isolated naso- ethmoid and frontal region injury withoutother fractures of midfaceII : combined naso- ethmoid and frontal region injury with other fractures of midface

Clinical features

• Nasal deformity

• Frontal bone depression

• Cerebrospinal fluid Rhinorrhoea

• Haemorrhage (anterior or posterior branch of ethmoid artery)

• Traumatic Telecanthus

• Diplopia

Clinical features

Radiograph

• Occipito -frontal view

• Occipito -mental

• Lateral view

• CT

SURGICAL APPROACH

Nasoethmoid Fracture Emergencies

• Cerebrospinal fluid leak • Unconsciousness

• Skull fractures• Increasing intra cranial pressure• Meningitis• Persistent CSF leakage

CSF leakage Fracture of• Floor of anterior cranial fossa/base of skullEscape of CSF through• Ethmoidal sinus• Sphenoidal sinus• Cribriform plate• Frontal sinusCommunication between• Meninges• Nose• Paranasal sinusesDural laceration• Later becomes epithelialised - Fistula

• CSF leakage should be noted immediately after trauma

• Blood clot of brain tissue may obstruct fluid passage

• After lysis of clot or Increased intracranial pressure leakage is seen

• Mobile midface fractures often creates pumping action- cause increased CSF leak

In Maxil lofacial Injuries

• Higher the level of fractures more chances for CSF Rhinorrhoea, Otorrhoea

• Frequently missed– Reclining position

– Blood stained

• Later clean watery discharge

How to detect?• Pt position - Sitting and leans forward (drips from nose)

• Salty / Metallic taste• “Tram line”• “Double halo”- when dropped on gauze sponge

• Classical “bull’s eye ” ring will develop• “Clinistix ” (but colour change can occur with Lacrimal secretions )

• “Glucose test” (>30mg/dl)

• Location of leak-CT scan

• Intrathecal injection and assaying in different locations

• Fluorescein & radioactive tracers (Indium)

Tram l ine

Precaution

• Pre-nasal route intubation – avoided (but in maxillofacial injury it is safest & effective)

• Pt in – semi recumbent position• Should not

– Strain

– Sneeze

– Blow the nose

• Avoid packing nose or ear- prevent retrograde infection• Infection- Meningitis• Antibiotics

Persistent/ recurrent leak

• Duration 4-5 days (with or without fracture reduction)

• Persistent leaks beyond 3 weeks- need formal dural repair

• Surgical repair failure – Lumbo peritoneal shunting

• Meningitis may occur

Treatment

• Fracture reduction

• Dural repair

• Lumbo peritoneal shunting

• Antibiotics

Hemorrhage management • Nasoethmoid fracture with midface bleeding manifest itself as

Epistaxis

• To locate the site of bleeding good visualization is needed

• Mucous membrane should be shrunken & anesthetized with Phenylephrine hydrochloride (Neo-synephrine) or 4% cocaine solution or both

• Cotton pledget soaked with vasoconstrictor

• Cauterization with silver nitrate solution

• Merocel sponge

• Anterior nasal pack

• Posterior nasal pack

• Pressure balloon

If bleeding not stopped• Arteriogram• Embolization or Ligation

Airway obstruction

• Patient head is positioned forward to prevent drainage of

blood into pharynx which cause airway embarrassment

• Blood from nose or retropharyngeal hematoma is a

warning of potential airway obstruction

Anterior nasal pack • Starting at junction of floor & septum as far back as

possible and built in layers

• Packs to be removed after 24hrs have elapsed and replaced

with fresh pack if needed to prevent infection

Posterior nasal pack

• Use of purpose made Surgitek (Reuter Epi-tek)• Alternatively with insertion of two Foley catheter one on

either side and inflated

Posterior nasal pack

Pressure bal loon

• Foley catheter

• Silicon dual cuffed catheter (Epistat)• Double balloon tampon

• Epi-Tek nasal catheter

THANK YOU