Practical Tips for Surgical Management of Naso-Orbitoethmoid Fractures

Naso-orbitoethmoid (NOE) fracturesNaso-orbitoethmoid (NOE) fractures occur in an area of the face rich in anatomy, functional subunits, and esthetic concerns. This makes repairing these fractures relatively difficult regarding surgical access and technique. Most NOE fractures occur with other midfacial or frontal sinus fractures. An intricate understanding of the underlying anatomy can provide invaluable insight into when these fractures require surgical repair. Over the years, different classifications have been proposed, but the one generally accepted is the Markowitz and Manson classification, published in 1991. This classification system includes the following: Type I fractures, defined as a single-segment central fragment without injury to the medial canthal tendon (MCT); Type II fractures, defined as comminution of the central fragment without fractures involving the bony segment where the MCT inserts; and Type III fractures, defined as comminution of the central fragment with fractures involving the bony segment where the MCT inserts or detachment of the MCT. Not surprisingly, the surgery becomes increasingly more difficult with the progression from Type I to Type III fractures. Careful consideration of the Markowitz Classification system reveals indications for surgery, which include weakness or violation of the MCT, violation of nasolacrimal drainage or the nasofrontal outflow tract (NFOT), loss of the nasal buttress, and comminution to the medial orbital wall. The purpose of this chapter is to review pearls and pitfalls for surgical management of naso-orbitoethmoid fractures.