Trauma nasal, frontal, NOE fractures

Question 1

Why is nasal packing generally contraindicated in treating nasal bone fractures in young children?

Answer 1

Young infants are obligate nose breathers.

Question 2

What landmark demarcates the transition point between the thicker nasal bone superiorly and the thinner bone inferiorly?

Answer 2

Intercanthal line

Most nasal bone fractures occur below this level.

Question 3

What role does age play in the pathophysiology of

nasal trauma?

Answer 3

Younger patients are more likely to sustain cartilaginous
injuries and greenstick fractures because of the greater
proportion of nasal cartilage and incomplete ossification of
nasal bones. Older patients generally have greater degrees
of comminution.

Question 4

What is the most common cause of facial fractures

in children over the age of 5 years?

Answer 4

Motor-vehicle accident

Question 5

What are the complications associated with failure
to identify a septal fracture when evaluating a
patient with nasal bone fractures?

Answer 5

Decreased projection, septal deviation, septal hematoma

Question 6

What other associated injuries may occur with

nasal bone fractures?

Answer 6

Epiphora, fractures of the lacrimal bones and ethmoid complex, widening of intercanthal distance (NOE fracture),
malocclusion and open bite deformity (Le Fort fracture), frontal sinus fracture, cribriform plate fracture, dural tears
leading to pneumocephalus and CSF rhinorrhea

Question 7

In addition to a history and physical examination,
what other social history should be obtained in
patients who sustain a blunt facial trauma?

Answer 7

Is the patient a victim of domestic abuse? About 30% to 60% of women with facial trauma from assault are victims
of domestic violence.

Question 8

What are the potential causes of hyposmia after

nasal bone fractures?

Answer 8

● Nasal obstruction secondary to edema, septal dislocation,
epistaxis, brain contusion or shearing of olfactory filaments
● Up to two-thirds of patients with severe head trauma experience some degree of olfactory dysfunction.

Question 9

What effect does telescoping of the bony or
cartilaginous fragments after nasal bone fracture
have on the nasolabial angle?

Answer 9

It increases the nasolabial angle.

Question 10

Regardless of trauma history, what percentage of patients will have a clinically apparent septal
deviation on nasal examination?

Answer 10

Approximately 80%

Question 11

Why is it difficult to distinguish old fractures from new ones on plain films?

Answer 11

Only 15% of nasal bone fractures heal by ossification.

Question 12

When is the optimal window of time to perform closed reduction of a nasal bone fracture?

Answer 12

If it is not performed immediately after the injury (before edema occurs), then it is best to wait 2-10 days after the
injury to allow swelling to subside. The development of
fibrous connective tissue within the fracture decreases the likelihood of optimal fracture reduction. This occurs 10 to 14 days after the injury.

Question 13

What is the mechanism of septal perforation after

a hematoma?

Answer 13

Septal cartilage receives its vascular supply from the mucoperichondrium. Septal hematoma results in subperichondrial dissection, which deprives the cartilage of blood supply and results in ischemic necrosis.

Question 14

Describe the potential complications of infected
septal hematoma (abscess).

Answer 14

Necrosis and subsequent perforation, contiguous spread or retrograde thrombophlebitis leading to osteomyelitis, orbital and intracranial abscess, meningitis, and cavernous
sinus thrombosis

Question 15

What is the gold standard for establishing the

diagnosis of CSF leak?

Answer 15

β2-transferrin

Question 16

What is the natural history of most CSF leaks after

nasal trauma?

Answer 16

More than 50% resolve spontaneously within 1 to 2 weeks with conservative management, including bed rest, head elevation, and stool softeners to reduce strenuous valsalva.
Coughing, sneezing, and nose blowing should be avoided.

Question 17

What can be instilled into the frontal sinus to

assess patency of the nasofrontal recess?

Answer 17

Methylene-blue or fluorescein

Question 18

What is an alternative to open reduction and

internal fixation of moderately displaced anterior table frontal sinus fractures?

Answer 18

Endoscopic reduction with miniplate fixation or fracture camouflage with porous polyethylene sheets (MEDPOR, Porex
Surgical, Inc., Newnan, GA) or hydroxyapatite placement

Question 19

Anterior frontal sinus wall fractures are typically
not aesthetically noticeable if they are displaced
less than _____?

Answer 19

2 mm

Question 20

When performing open-reduction internal fixation of a frontal sinus fracture via a coronal approach, it is important to preserve a vascularized pericranial
flap because it might be used for what purpose, if
necessary?

Answer 20

For dural repair, as a tissue filler for frontal sinus obliteration
and as a tissue barrier for isolation of the neurocranium
from the nasophyarynx during frontal sinus cranialization

Question 21

The blood supply to the pericranium comes from

what three sources?

Answer 21

Vessels arising from the underlying cranial bones, deep branches of the superficial temporal, supratrochlear, and
supraorbital vessels, and interconnecting vessels arising from superficial branches

Question 22

What percentage of patients with a nondisplaced
posterior table frontal sinus fracture with a
confirmed CSF leak will have the leak resolve
spontaneously with observation?

Answer 22

50%

Question 23

Moderate to severe comminution involving greater than 25% of the posterior table is generally
considered an indication for what type of repair?

Answer 23

Frontal sinus cranialization, particularly if there is comminution of the floor of the sinus.

Question 24

What are the treatment options for traumatic

nasofrontal recess injury?

Answer 24

For mild injuries, endoscopic surgical exploration or
observing for the development of frontal sinusitis and/or
mucocele can be considered. For severe injury, frontal sinus
obliteration should be considered.

Question 25

As a general rule, why are displaced fractures of the posterior table of the frontal sinus explored?

Answer 25

Depressed fragments may cause intracranial hemorrhage or CSF leak, and there is possibility of mucocele formation.

Question 26

Why is it necessary to remove all the mucosa of
the frontal sinus before adipose tissue obliteration
when treating severe frontal sinus fractures?

Answer 26

To decrease risk of mucocele/pylocele formation

Question 27

What are the potential sequelae of trauma-related frontal sinus mucoceles?

Answer 27

Secondary mucoceles may enlarge and erode bone with invasion of the orbit or intracranial space. If the mucoid contents of the mucocele become infected (mucopyocele),
orbital abscess, osteomyelitis of the frontal bone, epidural
abscess, meningitis, or brain abscess may occur.

Question 28

What are the primary vertical and horizontal

buttresses of the NOE complex?

Answer 28

● Vertical: Frontal process of the maxillary bone

● Horizontal: Superior and inferior orbital rims

Question 29

What is a normal intercanthal distance?

Answer 29

Approximately 30 to 35 mm or one-half the interpupillary distance or the width of the alar base

Question 30

What are the typical facial deformities seen in

patients with acute NOE fractures?

Answer 30

Nasal dorsum flattening, traumatic telecanthus, increased nasal tip rotation, and decreased nasal projection

Question 31

What is the best management of epiphora in a patient with an obstruction distal to the common canaliculus of the lacrimal drainage system?

Answer 31

Endoscopic dacryocystorhinostomy

Question 32

Describe the classification system of NOE fractures.

Answer 32

Markowitz classification:
● Type 1: A single, noncomminuted central fragment
without medial canthal tendon (MCT) disruption.
● Type 2 fractures: Comminution of the central fragment,
but the MCT remains attached to a definable segment of
bone.
● Type 3 fractures: Severe central fragment comminution
with disruption of the MCT insertion

Question 33

Describe the treatment of type 1 NOE fractures.

Answer 33

● Nondisplaced fractures without an increase in intercanthal
distance may be observed; however, development of
delayed telecanthus may still occur.
● Displaced fractures require open reduction and internal fixation, which can be accomplished via coronal, trans-conjunctival, sublabial, or external eyelid approaches. Existing lacerations may also be used. Because type 1 fractures are noncomminuted by definition, one-, two-,
or three-point fixation can often be utilized. Three-point fixation will require plating at the nasofrontal, nasomaxillary, and infraorbital buttresses. Often, for type I NOE fractures, a coronal approach is not necessary to obtain adequate exposure.

Question 34

What is a common complication of malpositioned
transnasal wire placement when treating NOE
fractures?

Answer 34

Placement of transnasal wires anterior to the lacrimal fossa results in rotation of the central fragment laterally, resulting in iatrogenic telecanthus. The wires should be placed
posterior and superior to the lacrimal fossa. Wire placement should also be placed below the frontoethmoid suture line
to avoid intracranial injury.

Question 35

What examination findings are characteristic for

avulsion of the medial canthal tendon?

Answer 35

● Absent bowstring sign
● Proptosis
● Rounding of the medial canthal angle

Question 36

Describe the technique of transnasal canthopexy

for repair of an avulsed medial canthal tendon.

Answer 36

Transnasal canthopexy is typically accomplished after open reduction and internal fixation of the fractured bony segments of the NOE complex. The medial canthopexy is
completed using the wire anchor technique with or without use of a transcaruncular barb. Canthal dissection is required if a transcaruncular barb is not used. Once secured, the wire anchoring the canthal tendon should be directed posteriorly, superiorly, and medially and secured to a titanium plate along the medial wall of the orbit.