CHAPTER 19
Panfacial and Naso-Orbito-Ethmoid (NOE) Fractures

Celso F. Palmieri, Jr. and Andrew T. Meram

Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA

Reduction and reconstruction of hard and soft tissue injures of the facial skeleton to allow for early and total restoration of facial form, symmetry, and function.

Indications for Reduction of Panfacial and NOE Fractures

1. To establish airway security in the presence of unstable fractures, expanding hematoma, and foreign body aspiration
2. Extensive soft tissue injury requiring debridement with primary closure
3. Profuse blood loss from facial injuries
4. Large, open, contaminated compound wounds
5. Concomitant systemic injuries requiring immediate operative intervention by another surgical subspecialty
6. Restoration of pre-injury facial aesthetics and function
7. Prevention of latent cosmetic and functional deficits

Contraindications

1. Patients with severe, compromising, concomitant systemic trauma, rendering them unstable for open reduction with internal fixation (ORIF)
2. Unstable patients requiring correction of blood volume, electrolyte, and nutritional deficits
3. Significant facial edema in stabilized patients that interferes with the ability to obtain an accurate clinical evaluation, obscures maxillofacial anatomy or surgical landmarks, and makes the surgical procedure itself more difficult
4. Increased intracranial pressure (>15 mm Hg) in patients with concomitant head injuries

Anatomy

The facial skeleton receives support and stability from a series of transverse and vertical facial buttresses. Facial buttresses represent areas of thick bone that support the surrounding thinner facial bones, sustain masticatory forces, and protect vital structures. Restoration of facial width, height, and projection is achieved by reducing and reconstructing the facial buttresses.

Transverse (Horizontal) Facial Buttresses

1. Superior transverse facial buttress (frontal bar): Orbital plate of the frontal bone and the cribriform plate of the ethmoid
2. Middle transverse facial buttress: Temporal bone, zygomatic arch, infraorbital rim and orbital floor, frontal process of the maxilla, and nasal bones. Crosses the zygomaticotemporal, zygomaticomaxillary, and nasofrontal sutures
3. Inferior transverse facial buttress: Hard palate and maxillary alveolus
4. Superior transverse mandibular buttress: Inferior alveolar ridge of the mandible
5. Inferior transverse mandibular buttress: Inferior border of the mandible from angle to angle

Vertical Facial Buttresses

1. Central nasoethmoidal buttress: Ethmoid and vomer bones
2. Nasomaxillary buttresses: Frontal process of maxilla, nasal bones, nasion and medial walls of maxillary sinuses, and orbits
3. Zygomaticomaxillary buttress: Posterior maxillary molars vertically through zygomaticomaxillary sutures, zygomatic bodies, and lateral orbital walls into the frontal bones
4. Pterygomaxillary buttresses: Pterygoid processes of sphenoid bone and posterolateral and posteromedial walls of maxillary sinuses
5. Posterior mandibular buttress: Ascending ramus and condyle

Figure 19.1 shows horizontal and vertical facial ­buttresses.

• Naso-orbital-ethmoidal (NOE) complex: often divided into two components: the interorbital space and the medial orbital wall
  1. Interorbital space: two ethmoidal labyrinths, superior and middle turbinates, and perpendicular plate of ethmoid
  2. Medial orbital wall: anteriorly—lacrimal bone, lacrimal apparatus, and lamina papyracea; ­posteriorly—body of sphenoid and medial canthal tendon
  3. Signs of NOE fractures include a lack of skeletal support on palpation of the nose, a wide and depressed nasal radix (flat nose), an upturned nasal tip, lacrimal dysfunction, a swollen medial canthal area, traumatic telecanthus, a shortened palpebral fissure, enophthalmos, ocular dystopia, cerebrospinal fluid (CSF) rhinorrhea, and a positive eyelid traction test.
• Medial canthal tendon (MCT): The MCT is formed from fibrous bands that originate from the tarsal plates of the upper and lower lids and insert at the frontal process of the maxilla (anterior limb) and at the posterior and superior aspect of the lacrimal bone (posterior limb). The segment of bone that the MCT attaches to is often called the central fragment.
• Markowitz NOE Classification System: Based on the fracture patterns of the central fragment and associated MCT attachment
  • Markowitz Type I: A large central fragment of bone without avulsion of the MCT
  • Markowitz Type II: Comminution of the central fragment without avulsion of the MCT
  • Markowitz Type III: Comminution of the central fragment with avulsion of the MCT

Figure 19.1. Transverse and vertical buttresses of the facial skeleton.

Panfacial fracture and NOE reduction technique

1. The patient is positioned supine on the operating room table, the cervical spine (if involved) is stabilized and the airway are secured.
2. Corneal shields are lined with LacriLube ointment and placed over the corneas.
3. The patient's posterior oropharynx is suctioned, and a moistened Ray-Tec gauze is placed within the posterior oropharynx to serve as a throatpack.
4. The patient's oral cavity is cleaned with Chlorhexidine Gluconate 0.12% mouth rinse and a toothbrush. Care is taken to scrub the existing dentition, gingiva, and tongue ­thoroughly.
5. The patient is prepped and draped to allow for visualization of all involved structures and normal adjacent anatomy.
6. All planned incision sites are marked and subsequently injected with local anesthesia containing a vasoconstrictor.
7. Avulsive and contaminated soft tissue injuries are irrigated and debrided to remove all foreign bodies and debris, often with pulsatile lavage. Soft tissue injuries are assessed for use as possible areas of surgical access.
8. Maxillary and mandibular arch bars are placed in order to reestablish the patient's pre-trauma occlusion and to serve as a stable base for the repair of mandibular and facial bone fractures.

9. If mandibular fractures are present, attention is first turned toward the reduction of the mandibular fractures based on the patient's occlusion and known anatomical landmarks. Mandibular fractures are exposed using the standard intraoral or extraoral incisions, reduced, and internally fixated (Figure 19.5, Case Report 19.1). In cases with bilateral subcondylar fractures, at least one condyle is opened, reduced, and rigidly fixated in order to establish proper vertical height (Figure 19.4, Case Report 19.1).

10. Once the mandible is repaired, attention is directed toward midface fractures.
11. All remaining facial fractures are exposed through a combination of approaches. Existing lacerations can be utilized as well. Specific techniques are discussed in detail in preceding chapters.
12. NOE fractures are reduced and fixated by reconstructing the nasomaxillary vertical facial buttresses and the superior and middle transverse facial buttresses. Often, calvarian and columellar strut grafting and concomitant medial canthal tendon (MCT) resuspension is required.
13. Markowitz type I and mild type II fractures are repaired with repositioning of the central segment with bone plates. Markowitz III and grossly comminuted type II fractures are repaired with a combination of bone plates and transnasal wiring in order to reposition the displaced or avulsed MCT.
14. The avulsed MCT or small bone segment containing the MCT (central fragment) is identified. For unilateral Markowitz type II/III fractures, a 28– or 30–gauge wire (with or without a barb) is used to pass twice through the MCT or central fragment. The wire is passed through the nasal cavity posterior and superior to the lacrimal bone with either a bone awl or a spinal needle. A small fixation plate (anchor plate) is secured to the contralateral side within solid bone along the medial orbital wall or reconstructed nasal bridge. The wire is secured to the anchor plate to restore the intercanthal distance. For bilateral Markowitz type II/III fractures, transnasal wiring of the bilateral MCT or central fragment is performed and secured to the anchor plate to correct the intercanthal distance. In either situation, a slight overcorrection is performed.
15. After reduction and fixation of all facial fractures, maxillomandibular fixation (MMF) is released, and the occlusion is checked to ensure adequate stability. If the occlusion is non-ideal, the patient is placed back into MMF, the facial fractures are reevaluated, and adjustments are made.
16. All incisions are irrigated with copious normal saline and closed. Large, avulsive tissue injuries may require debridement and closure with either local or regional flap elevation.
17. At the completion of the procedure, the patient's oropharynx is suctioned, and the throat pack is removed and MMF is typically reapplied with either elastics or stainless steel wires.
18. The corneal shields are removed, and the eyes are flushed with balanced salt solution. All blood and prep are removed from the patient's skin with a wet and a dry lap.
19. Steri-strips and pressure dressings are applied. If indicated, a rigid c-collar is placed.

Figure 19.2. Patient presents with extensive hard and soft tissue facial injuries.

Figure 19.3.(a-d) Selected preoperative 3D reconstruction computed tomography images of the facial fractures demonstrating bilateral mandibular condyle fractures, an anterior mandibular fracture, a Le Fort II fracture, bilateral zygomaticomaxillary complex fractures, comminuted nasal fractures, bilateral infraorbital rim and floor fractures, a palatal fracture, bilateral comminuted antral wall fractures, and a type I naso-orbito-ethmoidal (NOE) fracture.

Figure 19.4. Open reduction with internal fixation of the left subcondylar fracture using the two-plate technique through a retromandibular incision.

Figure 19.5. Open reduction with internal fixation of the symphysis fracture using the two-plate technique through an existing laceration. Note anatomic reduction of the lingual aspect of the symphysis.

Postoperative Management

1. Multidisciplinary management is necessary during the immediate postoperative period. This includes coordination with any and all consult teams (i.e., trauma, oral and maxillofacial surgery, plastic surgery, otolaryngology, neurosurgery, orthopedic surgery, ophthalmology, hospitalist, nutritionist, physical therapy, and occupational therapy).
2. A noncontrast computed tomography (CT) scan of the face with 3D reconstruction should be obtained immediately postoperatively to assess for proper fracture reduction and fixation. Importance should be paid to 2D views (axial, coronal, and sagittal) in particular because they may show levels of detail that are unavailable in 3D images. In cases involving the frontal sinus, additional CT scans of the head and face should be obtained at periods of 3–6 months postoperatively for the first year and then yearly for the next 5 years to ensure proper pneumatization of the sinuses, to rule out mucocele formation, and to assess for proper stability of the fracture segments.
3. A vision exam is necessary immediately upon awakening in the operating room (if applicable) and daily thereafter as indicated by ophthalmology.
4. Immediate postoperative medications include analgesics, decongestants, corticosteroids, and antibiotics. Triple-antibiotic ointment may be applied liberally to all skin wounds, and oral disinfectant mouth rinses such as 0.12% chlorhexidine gluconate (Peridex) may be used.
5. If drains have been placed, they are removed when output is less than 20–30 mL's in a 24-hour period.
6. In cases where the nasal bones are involved, hemostatic packings placed perioperatively are removed 24–48 hours postoperatively. Doyle splints are removed in 7 days. External nasal splints are left in place for 1–2 weeks postoperatively.
7. Ice packs are beneficial for the first 24–48 hours postoperatively to minimize edema.
8. Nonresorbable sutures are removed from the skin in 5–7 days. Staples are removed in 10–14 days. Patients are advised to avoid sun exposure and to apply sunscreen and/or Kelo–Cote ointment to the wounds for a period of 6 months.
9. Sinus precautions are necessary for a minimum of 3 weeks to avoid possible periorbital subcutaneous emphysema and/or oroantral fistula formation. This requires that the patient not perform nose blowing and that they sneeze with their mouths open to decrease sinus pressure. Postoperative decongestants, oxymetazoline nasal spray, and nasal saline sprays are taken as needed to minimize congestion.
10. In cases where the patient is placed into MMF, the duration of MMF is highly variable and dependent on several factors, including the degree and type of fractures involved, the type of fixation applied, the age of the patient, and the stability of the patient's occlusion. Arch bars are cleaned daily with disinfectant mouth rinses utilizing a soft toothbrush, with care made to avoid the intraoral incisions. Wax can be applied to the wires to minimize trauma to the labial mucosa.
11. In cases where MMF is utilized, the patient is kept on tube feeding immediately postoperatively until the patient has stabilized and is able to tolerate full liquids. At that time, the patient is maintained on a full liquid diet until the MMF has been released. After MMF is released, and in cases not requiring MMF, patients are limited to a soft, nonchew diet for a minimum of 6 weeks to minimize masticatory forces on the healing facial bones.
12. In cases involving mandible fractures, physiotherapy is utilized to prevent and/or address postoperative trismus and ankylosis of the condyles. The goal should be made to achieve a maximal incisal opening of 40 mm within 4 weeks postoperatively.

Complications

Complications are specific to the bones and structures involved as panfacial and NOE-type fractures involve numerous facial regions.

Early Complications

1. Decrease in posterior facial height: Occurs with significant continuity defects to the vertical buttresses of the face and with unreduced bilateral mandibular condyle fractures (typically presents as an anterior open bite). Treatment involves osteotomizing the fractures and/or orthognathic surgery.
2. Increase in facial width: Often results from nonreduced or poorly reduced palatal fractures. Also occurs when combined mandibular symphysis fractures and bilateral condylar neck fractures are not adequately reduced or fixated. Results from a tendency of the midface and mandible to splay open with or without concomitant malocclusion, when anatomical reduction is not achieved. Treatment involves osteotomizing the fractures and/or orthognathic surgery.
3. Decrease in anterior-posterior facial projection: Can occur with any fracture that increases the facial width and NOE fractures. Treatment involves osteotomizing the fractures and/or orthognathic surgery.
4. Traumatic telecanthus: Normal intercanthal distance in males is 33–34 mm, in females 32–33 mm, or an interpupillary distance of 60–62 mm. Traumatic telecanthus should be repaired early with transnasal wiring or late with canthopexy.
5. Infections and brain abscess
6. Hydrocephalus
7. Meningitis
8. Neurologic deficits, including motor and sensory (anesthesia and paresthesia) deficits
9. Nasal obstruction and/or deformities
10. CSF leak
11. Anosmia
12. Blindness
13. Subcutaneous emphysema
14. Hematoma
15. Malocclusion

Late Complications

1. Posttraumatic seizures
2. Mucocele and mucopyocele of the frontal sinus
3. Osteomyelitis
4. Contour deformities
5. Chronic headaches and/or neurological deficits
6. Scarring
7. Malunion
8. Nonunion
9. Diplopia
10. Enophthalmos
11. Entropion or ectropion
12. Upper eyelid ptosis
13. Lower eyelid retraction
14. Epiphora
15. Hardware failure
16. Temporomandibular joint dysfunction
17. Ankylosis
18. Dental problems
19. Fistula formation (oro-antral, oro-nasal, or oro-
cutaneous)

Key Points

1. Facial trauma repair is typically performed from a bottom-top (beginning with the mandible) and inside-out sequencing (repair of deep structures first and superficial structures last).
2. Often, cervical spine stabilization is required. Cervical spine stabilization involves leaving the patient within a c-collar, stabilization with a three-pronged Mayfield head clamp, or sand bags placed lateral to the neck (least preferred method). Regardless of the technique, cervical spine mobilization should be minimal.
3. Important anatomical landmarks include knowledge of the correct horizontal and vertical buttresses of the craniomaxillofacial skeleton.
4. Panfacial trauma is often associated with severe concomitant systemic injuries, and therefore necessitates a multidisciplinary team approach to management.
5. Panfacial fractures can result in widening of the facial complex with concomitant loss of the facial projection. Emphasis must be placed on anatomical reduction of the bones and restoration of the maxillomandibular arch form.
6. With sagittal palatal fractures, or in situations with a mandibular symphysis fracture associated with bilateral condylar neck fractures where anatomical reduction is not achieved, there is a tendency for the midface and mandible to splay open with possible concomitant malocclusion.
7. Traumatic telecanthus with an intercanthal distance of greater than 40 mm is nearly pathognomonic of an NOE fracture. Traumatic telecanthus is due to disruption of the MCT or the central fragment of bone that serves as an attachment for the MCT.
8. Transnasal wiring is necessary with displaced NOE fractures that involve central fragments too small to plate (some Markowitz type II fractures) and with grossly comminuted central fragments with complete avulsion of the insertion of the MCT (­Markowitz type III).
9. Goals of NOE repair include anatomical reduction of all fractures, correcting traumatic telecanthus, obtaining a midline position of the nasal septum, reconstruction of dorsal nasal deformities (calvarian strut grafts and columellar strut grafts), anatomical positioning of the lower lateral cartilages, and the correction of enophthamlos, ocular dystopia, and lacrimal dysfunction.
10. Lateral midface width and projection are dependent on the anatomical repositioning of the ZMC, with the reduction of the sphenozygomatic suture being of utmost importance.

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Case Report

Case Report 19.1. A 40-year-old male reports to the emergency department after a high-speed all-terrain vehicle accident. On arrival, a cricothyrotomy was emergently performed due to upper airway obstruction. Once the patient was stabilized, a CT scan was obtained that demonstrated panfacial fractures involving all facial bones with the exception of the frontal bone. Fractures included an NOE-type I fracture, a LeFort II fracture, bilateral zygomaticomaxillary complex (ZMC) fractures, bilateral infraorbital rim and orbital floor fractures, a midline palatal fracture, bilateral subcondylar fractures, and a symphysis fracture. In addition to his extensive facial injuries, the patient also sustained a cervical spine fracture and was stabilized in a c-collar. With the airway and cervical spine secured, the patient was taken to the operating room, and the urgent cricothyrotomy was converted to an open tracheotomy. The facial fractures were reduced and fixated utilizing a bottom-up, inside-out sequence. (See Figures 19.2 through 19.14.)

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Figure 19.6. Open reduction with internal fixation of the naso-orbito-ethmoidal and nasal bone fractures using an open-sky (“H”) incision.

Figure 19.7. Open reduction with internal fixation of the left zygomaticofrontal suture through a lateral brow incision.

Figure 19.8. Open reduction with internal fixation of the right infraorbital rim and orbital floor through a subciliary incision.

Figure 19.9. Open reduction with internal fixation of the left infraorbital rim and orbital floor through a subciliary incision.

Figure 19.10. Open reduction with internal fixation of the right zygomaticomaxillary and nasomaxillary buttresses.

Figure 19.11. Open reduction with internal fixation of the left nasomaxillary buttress and titanium mesh reconstruction of a large anterior maxillary sinus wall defect.

Figure 19.12. and 19.13. Postoperative 3D reconstruction images demonstrating appropriate reduction of mandibular and facial fractures with restoration of facial height, width and projection.

Figure 19.14. 15 months postoperatively.

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