Naso-ethmoidal fractures

Clinical features of a naso-ethmoidal fracture:

¨ Flattened nasal bridge with splaying of nasal complex

¨ Saddle-shaped deformity of nose from side

¨ Traumatic telecanthus

¨ Circumorbital oedema and ecchymosis

¨ Subconjunctival haemorrhage

¨ Epistaxis

¨ CSF rhinorrhoea

¨ Possible supra-orbital / supra-trochlear nerve paraesthesia

¨ Tenderness, crepitus and mobility of nasal complex

¨ Overlying laceration

 

With naso-ethmoidal fractures a CSF leak should be assumed to be present even if it is not clinically demonstrable, and appropriate chemoprophylaxis should be commenced. An intercanthal distance of greater than 35mm is suggestive of traumatic telecanthus, and measurement approaching 40mm are almost diagnostic.

 

Closed manipulations of these injuries gives a poor result, with a high incidence of persistent telecanthus and residual nasal deformity postoperatively. The results of secondary surgery of these abnormalities are not always satisfactory.

 

The principles of treatment are the same as for any other fractures, namely:

1. Reduction

2. Immobilisation

3. Rehabilitation

 

The naso-ethmoidal region can be accessed through the existing laceration, or through modification to a H-shaped or W-shaped incision. A bicoronal flap may be required for access to the frontal bone or orbital walls.

The naso-ethmoidal fracture often shows extensive comminution, although the nasal bridge may be intact, but depressed. This can be elevated back into position and stabilized by direct wiring, or using mini-plates to the frontal bone. Any individual fragments can be reduced, aligned and directly wired both to each other and to the surrounding intact bony skeleton.

 

The medial canthal ligament must be identified and repositioned into its position in the frontal process of the maxilla, and stabilized by wiring to the opposite anterior lacrimal crest (transnasal canthopexy). If both canthal ligaments are detached then the telecanthus can be repaired by means of wiring the two medial canthal ligaments to each other (transnasally).

 

 

 

See

Nasal Fractures