naso-orbito-ethmoidal fractures seminar abhijit joshi (nxpowerlite) / orthodontic courses by indian...

Abhijit Joshi

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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Abhijit Joshi

NASO-ORBITO-ETHMOIDAL FRACTURES


Abhijit Joshi

Contents :• Significance of NOE region & applied anatomy• Classification of NOE fractures.• Clinical features and pictures• Radiology.• Assessment of lacrimal drainage.• CSF leaks and management.• Steps in managing a NOE fracture• Managing a Post traumatic nasal deformity.


Abhijit Joshi

NOE complex• Intricate anatomical structure.

• At anatomical crossroads.

• 4 cavities involved:– Cranium– Orbits – Nasal – maxilla

• 4 bones involved: – Paired nasal– Frontal process of maxilla– Ethmoids– Lacrimal bones.


Abhijit Joshi

NOE complex

• Wedged in interorbital space.

• Basically weak

• Strength : – Vertical buttress : frontal pr of

max– Horizontal : sup/inf orbital rims

• Additional strength:– Lattice network of bones– Articulation at various angles.


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• Anatomy and applied aspects:

– Osteology

– Soft tissue anatomy


Abhijit Joshi

Osteology

• Nasal bones• Ethmoid • Frontal process of maxilla• Medial orbital rim and wall

• Other bones involved:– Perpendicular and Cribriform plate of ethmoid.– Nasal process of frontal bone.– Sphenoid bone


Abhijit Joshi

Nasal bones


Abhijit Joshi

• Anteriorly: frontal process of max + max proc of frontal.

• Lacrimal fossa : – depression on inferomedial orb rim.– Formed by max and lacrimal bones– Bound by Ant lacrimal and Post lacrimal crests.– 16mm high x 4-9mm wide x 2mm deep– Max-lacrimal suture: confluence of the 2 bones– Mean thickness of lacrimal bone here : 106microm easy perforation


Abhijit Joshi

Sutura notha/ sutura longitudinalis imperfecta of weber:

• Fine groove on frontal process of maxilla• Anterior to ant lacrimal crest• Contains small branches of infraorbital artery.• Anticipate their presence during dissection


Abhijit Joshi

Medial orbital wall• Paper thin lamina papyracea• Strength from ethmoid air cells dessipation.

• Medial blow out # assoc with orb floor # in 50% cases.

• Traversed by:– ant ethmoid art – 24mm– Post ethmoid art – 34mm

• Care taken to identify these vessels can contribute to Retro Bulbar Hemorrhage

• Entrapment of orbital fat media horizontal diplopia – restriction of abduction-retraction of globe


Abhijit Joshi

Ethmoid bone


Abhijit Joshiwww.indiandentalacademy.com

Abhijit Joshi

Ethmoid :


Abhijit Joshi

Soft tissue anatomy:

• medial canthal ligament

• Lacrimal drainage apparatus

• Associated vessels etc.


Abhijit Joshi

Soft tissues.

Right eye in primary position


Abhijit Joshi

• The U/L are suspended in space, tethered medially and laterally by canthal ligaments

• Orb. oculi attaches to the medial orbital wall via MCL

• Fibrous diamond shaped, Tripartite arrangement.

• Greater horizontally with Ant and post limbswww.indiandentalacademy.com

Abhijit Joshi

Medial canthal ligament (MCL): Complex, strong interlocking 3-D arrangment of indivisual

components and structures.

• Strength derived from complex anatomy.

• Intimately related to– lacrimal drainage apparatus.– lacrimal bone– Frontal process of maxilla –

reinforces.


Abhijit Joshi

Anterior limb:• 11.7mm length/4.9mm width – longer and more prominent.• medial attachment :

•Frontal process of maxilla just lateral to suture with nasal bone.•Superior aspect of Ant lacrimal crest and beyond (zide).

superior branch – periosteum of frontal bone(corrugator super cilli)www.indiandentalacademy.com

Abhijit Joshi

Posterior limb of MCL

• Small and poorly defined.• Attaches to posterior lacrimal crest.• Periosteum in this region is thicker and extends till

anterior lacrimal crest in a triangular fashion• Applied :

– makes post attachment strong.– Strengthens the whole structure.– Hence important to reconstruct the post segment.

Both ant and post limbs envelope the lacrimal sac.


Abhijit Joshi

Lacrimal drainage:


Abhijit Joshi

Relationship betw excretory system and MCL

• Sac is wrapped by lacrimal fascia ( split periorbita)• Wrapped by MCL ant and post limbs• Deep portion of Pretarsal orb oculi – horner-duverney

muscle passes posterior to post limb of MCL and attaches to upper portion of PLC.


Abhijit Joshi

Other Relations:

MCL to ant cranial fossa:• Mean vertical dimension betw MCL and level of cribriform

plate : 17mm +/- 4mm McCann’1998 Invest Opthal

• Distance between common internal punctum and most ant part of cribriform plate is 25mm botek ’93 Opthal Surgery

MCL and Angular art and vein:• Superficial to MCL• 5-8mm anteromedial to ant lacrimal crest• Anticipate bleeding.


Abhijit Joshi

• Type I – central fragment

• Type II – comminuted fracture with lateral extension not involving MCL

• Type III – comminuted fracture with extension into MCL

Markowitz and Manson


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Classification - Ayliffe

Type I – en bloc minimum displaced fractures of the entire NOE complex

Type II– en bloc displaced fractures, usually associated with large pneumatized sinus and minimal fragmentation


Abhijit Joshi

Type III – comminuted fracture but canthal ligament firmly attached with bone fragments which are big enough to plate

Type IV– comminuted fracture with free canthal ligament not large enough to be plated


Abhijit Joshi

Type V – gross comminution needing bone grafting


Abhijit Joshi

Ideal proportions

The ideal nasofrontal angle 115° to 130° The ideal nasal project 1:1.

ideal intercanthal distance should be approximately 1/3. www.indiandentalacademy.com

Abhijit Joshi

In a NOE fractureDirect blow to nasal bony dorsum

Crushing of Fragile perpendicular

plate, ethmoidal air cells

post displacement

Removes dorsal support for nose.

Medial canthal ligament detaches / disarticulation of bone containing

attachement

• Rounding of medial canthal angle•Widening of intercanthal distance.

Adherent dura , Crista Galli/ cribriform plate move as a unit olfactory damage.

CSF leakwww.indiandentalacademy.com

Abhijit Joshi

Clinical features:• Reduced Dorsal nasal projection , Upturned nasal tip • Accentuation of Naso-Frontal angle.• Accentuated naso-jugal fold.• Inward Telescoping medial wall into ethmoid.

• Traumatic telecanthus (loss of stabilization of MCL).• Traumatic hypertelorism• Orbital dystopia • Mongoloid slant

• Cerebrospinal fluid leakage.• Nasolacrimal duct obstruction/severage epiphora .• Anosmia • Nasal airway obstruction

Pig snout.


Abhijit Joshi

• accentuated N-F angle • Decreased dorsal nasal projection.• Upturned nasal tip.• traumatic telecanthus www.indiandentalacademy.com

Abhijit Joshi

• Edema, emphysema, echymosis • Traumatic telecanthus • Orbital dystopia • rounding of medial canthal angle• Mongoloid slantwww.indiandentalacademy.com

Abhijit Joshi

Subconjunctival emphysema

In a patient with medial wall fracture assc with NOE # (after blowing his nose)


Abhijit Joshi

Injury to lacrimal drainage:


Abhijit Joshi

Clinical assessment.Firm palpation of ant. Lacrimal crest and frontal process of maxilla

Firm compression of MC region to displace the edema with thumb and forefinger while displacing lateral canthus laterally allows palpation of

• fractured fragment,

•mobility of MCL attachment

•Mobility of adjacent bone

Principles of management of complex craniofacial trauma; Marciani et al, JOMS ‘93


Abhijit Joshi

Physical examination

• Eyelid traction test / Furnas traction test Furnas DW, Bircoll MJ Plast Reconstr Surg. 1973 Sep;52(3):315-7

• Bimanual palpation by placing an instrument into the nose to determine canthal bearing bone fragment displaced and mobile


Abhijit Joshi

Diagnostic Imaging.Conventional : standard PNS view

Plain films are of ALMOST NO USE in diagnosing NOE fractures because most will be undetected; Edward ellis ;Sequencing treatment for NOE fractures

JOMS ‘93 www.indiandentalacademy.com

Abhijit Joshi

CT • Is of greatest value

• HRCT adds to the existing value

• What to ask for?– 1-2 mm Axial and coronal slices with 3D recon.– Top of skull-frontal sinus-orbits-maxilla– Bone window NOE bony complex– Soft tissue window brain/ocular adnexa.


Abhijit Joshi

Axial cuts.

• Position and status of frontal process of maxilla central fragment.

• Medial walls of orbit if they are “blown in” nasally,

•Anterior and posterior tables of frontal bone

•Nasolacrimal system


Abhijit Joshi

Coronal cuts

• Cuts taken from nasal

bridge to orbital apex

• junction of floor to medial

wall assessed.

• Disruption of ant. Cranial

fossa around cribriform

plate.

• CSF leak CT value

• localization of CSF leaks.


Abhijit Joshi

3D CT


Abhijit Joshi

Tests for Secretory system

Tests for drainage/excretory system

• Schirmer’s test

• basal tear secretion test

• primary dye test

Investigations of the lacrimal system

• Dye disappearance test

• Jones 1 and Jones 2

• DCG

• HRCT

• Tc 99 scan


Abhijit Joshi

Dye disappearance test:

Simplest of tests.

• Flouriscine dye placed on conjunctival fornix

• Dye disappears.

• Patency of system


Abhijit Joshi

Jone’s testJone’s 1.

• 1 drop fluorescein dye placed into conjunctuval sac.

• Cotton bud soaked in LA placed in inf meatus.

• Wait for 5 min and remove the bud.

• If bud stained with dye test +ve


Abhijit Joshi

If –ve then proceed to jone’s 2:Clear saline irrigated thru cannula

inserted into inf canaliculus

Patient bends forward

1. Nothing frm nostril

Complete obstr. distal to tip

2. Fluid regurgutates – opp. punctum

Patency of both canaliculi till int canaliculus

3. Clear fluid from nose

Dye not entered canaliculi

Blocked punctum/canaliculi

Stained fluid

+ve test


Abhijit Joshi

Dacrocystography:

• Radioactive oilbased dye injected into lacrimal drainage.

• Radiographed to know the course of duct• CT used for imaging CT dacrocystography.


Abhijit Joshi

CSF leak and management.


Abhijit Joshi

Cerebrospinal fluid.• CSF is essentially an ultrafiltrate of plasma

• Clear colourless fluid bathes brain and spinal cord.

• Fills ventricles within the subarachnoid space.

• Main funtion:– Cushions brain against trauma (sp. Gravity of brains

within 4% of that of CSF brain floats !!)– nourishment.– Removal of waste products.


Abhijit Joshi

Production and composition.Production :• Choroid plexus and ventricular ependyma• @ 500cc/day.• Volume : 150cc turnover is TID• Pressure mantained at 60-150mm H2O valsalva,

coughing, straining.

Composition:• Insoluble salts.• Ph 7.33• Total proteins content: 20.0mg/dl• Glucose : 64.0mg/dl• Beta transferrin.


Abhijit Joshi

CSF leaks

• Barriers to contain CSF and prevent its communication with external:– Dura, – Skull– Periosteum– Galea and skin.

• Barriers violated CSF leak.

• Risk of meningitis 4-50%


Abhijit Joshi

CSF leaks.

Traumatic Atraumatic - 3-4%3-4%

spontaneous

High-pressureHigh-pressure

Normal-pressureNormal-pressure

SurgicalSurgical 16%16%

Non-surgicalNon-surgical80%80%

3% closed head injuries3% closed head injuries

9% penetrating head injuries9% penetrating head injuries

10-30% basilar skull fractures10-30% basilar skull fractures


Abhijit Joshi

Common sites for CSF leak

• Cribriform plate, frontal sinus, Ant. Eth. roof.• posterior ethmoid roof,• sphenoid sinus.• temporal bone (pseudorhinoliquorrhea).


Abhijit Joshi

• Simple bed side procedure nonspecific.

• Performed upon patient arising in the morning.

• Place patients chin to chest for 1min.

• Copious leakage thru nose like an open faucet.

• Intermittent drainage:

•Use Ipratropium bromide

•Nasal secretions will stop

•CSF leaks continue.

Reservoir sign


Abhijit Joshi

• Salty taste:

• Handkerchief sign: – mucous stiffens linen on drying but csf keeps it soft

distinguishes from allergic rhinitis.

• Halo sign/double ring sign: – blood CSF mixture spreads on linen.– Dark ring of blood encircles more lightly stained CSF


Abhijit Joshi

• Tramline effect: – occurs when CSF mixed with blood.– CSf appears later as yellowish discharge mixes

with blood.– CSF higher protein content.– More viscous CSF forms central track with blood on

either side which diffuses to edge.


Abhijit Joshi

Laboratory diagnosis

• Glucose test

• Protein analysis

• Beta transferrin test

• beta-Trace Protein

• Electronic nose


Abhijit Joshi

• Glucose test : CSF collected in vial and if glucose levels are > 45mg/dl CFS existence.


Abhijit Joshi

glucose oxidase stick technique

• Normally nasal secretions are devoid of glucose whereas CSF has a glucose level related to the plasma glucose. The literature generally supports a glucose value of 30 mg/dL in rhinorrhea fluid as indicative of CSF. However, there are opportunities for false-positives and false-negatives. For example, a post-surgical patient may have a serous exudate which physiologically contains glucose.

• To measure the glucose concentration of nasal secretions in the absence or presence of rhinorrhoea


Abhijit Joshi

Beta transferrin test

• This protein is found in only three bodily fluids – CSF, perilymph, and vitreous humor .

• Unless a patient has an open globe, ongoing production of clear nasal discharge that is positive for beta-2-transferrin is highly diagnostic for CSF

• Is a protein produced by neuraminidase activity


Abhijit Joshi

b-2 transferrin

• Immunofixation electrophoresis of nasal secretions in the laboratory used to detect b-2

• This test is not sufficiently rapid to provide support for clinical decision making in emergency departments and may not be available in all hospitals, particularly in developing countries


Abhijit Joshi

Beta Trace protein.• B-TP is a naturally occurring secretory enzyme present in

human CSF concentration of 15 to 20 mg/L.

• The CSF to serum ratio of b-TP (33:1) highest of all CSF specific proteins

• Ideal marker for the detection of CSF traces.

• Most abundant protein in human CSF, (also in prealbumin, albumin, Ig G).

• Also in urine, aqueous humor, and inner ear fluids,glomerular filtr. • In healthy subjects, the serum concentration of B-TP is 0.3 mg/L.


Abhijit Joshi

• Immunoelectrophoresis / Nephelometric assay used.• In comparison to the 2-transferrin test, the b-TP assay

superior higher predictive values. • Test can be performed within 20 minutes• Smallest traces of CSF (5%) can be detected by B-TP.• Limitation : Pts with acute glomerulonephritis or

terminal renal insufficiency; in these patients, the B-TP concentration increases in the serum.

Bachmann et al Predictive Values of -Trace Protein by Use of Laser-Nephelometry Assay for the

Identification of Cerebrospinal Fluid Neurosurgery, Vol. 50, No. 3, March 2002


Abhijit Joshi

Nephelometer

• It does so by employing a light beam (source beam) and a light detector set to one side of the source beam.

• Particle density is then a function of the light reflected into the detector from the particles.

• How much light reflects dependent upon properties of the particles shape, color, and reflectivity.

An assay is a procedure where the concentration of a component part of a mixture is determined

An apparatus used to measure the size and concentration of particles in a liquid by analysis of light scattered by the

liquid.`


http://en.wikipedia.org/wiki/Detector

http://en.wikipedia.org/wiki/Density

http://en.wikipedia.org/wiki/Reflection

http://en.wikipedia.org/wiki/Concentration

http://en.wikipedia.org/wiki/Mixture

Abhijit Joshi

Electronic nose

• Vapor-sensing devises used primarily in the food and beverage industries.

• Numerous publications have addressed the medical utility of such devices.

• Electronic nose technology has been used for breath analysis to identify:– Campylobacter pylori in the stomach,– Study lactose malabsorption,– Vapor pressure in sweat analysis in screening for

cystic fibrosis.


Abhijit Joshi

A. Headspace over a liquid sample is aspirated into an analyzer (electronic nose).

B. Headspace gas (containing the sample aroma) is allowed to interact with array of 32 conducting polymers with differing sensitivities to specific chemical types (eg, alcohols, ketones).

C. Electrical resistance of each of the conducting polymers changes reproducibly after exposure to an aroma, allowing the aroma to be represented as a point in a 32-dimensional space


Abhijit Joshi

Efficacy of electronic nose

• The amount required,0.3 mL, may be obtained with only a few drops of nasal discharge

• The electronic nose was also able to reliably place unknown specimens in the appropriate category of CSF or serum Anna Aronzon et al Otolaryngology–Head and Neck Surgery (2005) 133, 16-19


Abhijit Joshi

Radiographic evaluation:

• High resolution CT : bone defect is filled with CSF density fluid extracranially.

• CT cisternography

• Radionuclide cisternography

• Intrathecal flourscien

• MRI cisternography


Abhijit Joshi

CT Cisternography

• Contrast dye oil based, nonionic (metrizimide)used.• Lumbar puncture into subarachnoid space.• Trendelenburg position.• Subject to CT scan.• High resolution CT Coronal 2mm slices obtained :

– confirm CSF leak– Locate site of leak.


Abhijit Joshi

CSF fistulas

Metrizamide CT scan showing CSF leak in left frontal sinus s/p SW to left orbit.

CSF leak


Abhijit Joshi

Use of low concentration flourescein dye

• Cotton pledgets placed in the nose.• Sterile dilution of 0.3ml flourescein + 10cc CSF made.• Infused intrathecally.• Pledgets removed after 30min to 1hr• Analyzed under ultraviolet light.

can be given simultaneously with contrast material, and thus one can use CT cisternography and endoscopic examination

in a complementary fashion .www.indiandentalacademy.com

Abhijit Joshi

Nuclear cisternography

• Sensitive method to evaluate CSF leaks• Indium 111 (bonds to CSF protiens) used ½ life of

48hrs delayed imaging.• Injected intrathecaly.• Tracer takes 2-4hrs to reach basal cisterns• Intranasal pledgets Endoscopically placed in the

middle meatus and sphenoethmoidal


Abhijit Joshi

Treatment :

• Tailored to individual

• Intracranial versus extracranial

• Endoscopic versus microscopic


Abhijit Joshi

Intracranial approach.

Advantages :– direct visualization,– ability to repair adjacent cortex,– Better chance of repairing a leak caused by

increased intracranial pressure.

Disadvantages:– increased morbidity,– longer hospitalization,– higher incidence of post-operative anosmia.


Abhijit Joshi

extracranial repair

– has decreased morbidity and anosmia, – superior exposure of the posterior ethmoid,

parasellar, and sphenoid regions.

– Disadv: less suited for defects in the frontal sinuses with prominent lateral extension and is less successful in high-pressure leaks


Abhijit Joshi

Grafts :• Free nasal mucosa,Pedicled nasal mucosa, • bone grafts harvested from the nasal septum or middle turbinate• Temporalis fascia,muscle ,Adipose tissue.• Vascularized free flap.

Graft stabilization:• with cyanoacrylate glue/fibrin glue

Packing• Microfibrillar collagen(over the graft),• Absorbable gelatin sponges• Oxidized cellulose. • All repairs intraoperatively tested Valsalva maneuver.


Abhijit Joshi

What can be used??Grafts/flaps

fat, fascia, muscle, cartilage, mucosa

simple or composite

Biological gluecollagen, fibrin, cyanoacrylate

Gelfoam, Merocel


Abhijit Joshi

Skull Base (extracranial) approaches:

Cribiform plate fistula: Transethmoidal repair• Nasal septal mucosal flap to cover ethmoid sinus.

Sphenoid sinus fistula: Transseptal transsphenoidal approach

• Recent endoscopic advances allow for a fully endoscopic transsphenoidal approach

Primary repair of dural opening is attempted• Grafts of pericardium, fascia lata, or endogenous fat


Abhijit Joshi

Endoscopic approach to a CSF leak.

CSF leak


Abhijit Joshi

Final word on CSF….

• CSF fistulae arise from a variety of etologies.

• Diagnosis based on physical, laboratory and radiologic techniques

• Treatment divided into surigical and non-surgical.

• Future holds refinement of existing techniques, development of new ones


Abhijit Joshi

Thank you


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