Naso-orbito-ethmoid (NOE) Fractures

Background

The naso-orbito-ethmoid (NOE) region of the central face is defined by the orbits laterally, the glabella superiorly and the nose inferiorly. It is a particularly challenging region of the face to reconstruct due to its aesthetic prominence, its 3-dimensional contour and the delicate associated structures involved in the region. NOE fractures occur from direct blunt force trauma to the central face, such as striking the dashboard in a motor vehicle collision (MVC). While isolated NOE fractures accounted for only (5.8%) of all facial fractures at a busy trauma center, they are a frequent component of associated midface fractures and must be accurately diagnosed and treated to attain anatomic fracture reduction.

Surgical Anatomy

The NOE complex is comprised of the frontal process of the maxilla, internal angular process of the frontal bone, the ethmoid sinuses, and the lacrimal bone ( Fig. 1.11.1 ). As such, it contributes to the shape and volume of the medial orbits, the contour of the inferior orbital rim, the patency of the pyriform aperture, and the support of the nasal dorsum. Additionally, it serves as the drainage of the frontal sinus and the attachment of the medial canthal tendon and the trochlea, and the location of the nasolacrimal apparatus are associated structures ( Fig. 1.11.2 ).

Clinical Presentation

Patients present after blunt force trauma to the central face. They will often complain of diplopia, nasal airway obstruction, and alteration of physical appearance. They may report numbness of the central face and forehead, epiphora, and CSF rhinorrhea.

After a complete ATLS evaluation with particular attention paid to the C-spine, a focused craniofacial examination is performed. Begin with inspection of the eyes, noting telecanthus, rounding of the palpebral fissure, and lid malposition. If avulsion of the medial canthal tendon is suspected, the examiner can use forceps to pull on the tendon, noting presence or absence of a firm stop ( Video 1.11.1 ). Assess visual acuity and test extraocular muscle integrity looking for entrapment. Measure globe position noting enophthalmos or exophthalmos. The presence of an orbital fracture merits an ophthalmological consultation to rule out injury to the eye, visual system, and retina.

The examiner should note asymmetry of the nose and presence of a saddle nose deformity ( Fig. 1.11.3 ). Sequentially, assess nasal airway patency and perform a speculum exam noting integrity of the septum, nasal perforation, and presence of a septal hematoma, which requires prompt drainage. The presence of a collapsed/telescoped septal fracture may require dorsal or caudal nasal cantilever bone grafting to maintain nasal support. Proceed next with gentle palpation of the craniofacial skeleton noting point tenderness, crepitus, and bony step-offs.