Sinus fractures /certified fixed orthodontic courses by Indian dental academy

Naso-orbital Ethmoid and Frontal
Sinus Fractures
INDIAN DENTAL ACADEMY
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Naso-orbital Ethmoid Fractures
Introduction
Suspect in Central Midfacial Trauma
Failure of Diagnosis Leads to Significant Facial
Deformities
Isolation of Lower 2/3 Medial Orbital Rim
Lateral Nose
Medial Orbital Wall
Nasomaxillary Buttress
Frontal Process of Maxilla / Maxillary Process of Frontal
Bone

Basic Principles in
Craniomaxillofacial Management
Early One Stage Repair
Exposure of All Fracture Fragments
Precise Anatomic Rigid Fixation
Immediate Bone Grafting as Indicated for Bony
Loss
Definitive Soft Tissue Management


Naso-Orbital Ethmoid Region Bony
Anatomy
Limits of the Naso-orbital Ethmoid Region
Horizontal Buttress
Vertical Buttress -- “Central Fragment”
Medial Orbital Wall
Nasal Bones
Ethmoid Labyrinth / Perpendicular Plate


Naso-orbital Ethmoid Anatomy
Soft Tissue Structures
Medial Canthal Tendon
Anterior / Posterior / Superior Limbs
Function
Nasolacrimal Collecting System
Ensheathed Partially by Superior and Anterior
Limbs
Inferior Aspect Prone to Injury

Signs and Examination
Medial Canthal Tendon Displacement
Traumatic Telecanthus (IC/IP > 1/2)
Lack of Eyelid Tension -- Positive Bowstring
Test
Rounding of the Medial Canthus
Shortened Palpebral Fissure


Naso-orbital Ethmoid Fracture
Lacrimal System
Inspect With Loupes if Laceration in Area
Damaged Area Canulated
Associated Ocular Injury
Enophthalmos
Diplopia
Entrapment
Vertical Dystopia
Loss of Globe Integrity

Nasal Deformity -- “pushed between the eyes”
Reduced Nasal Projection and Height
Flattened Nasal Dorsum
Septal Deviation / Dislocation
Intracranial Involvement
Cerebrospinal Fistula
Pneumocephalus
Frontal Sinus Involvement

Palpation of Nasal Bones
Allows Assessment of Integrity of Dorsal Nasal
Height
Collapse Implies Absence of Support
Click on Pressing Inward at the Medial Canthal
Ligament
Bimanual Examination

Classification
Type I-- Involves Single Segment Central Fragment
Fractures
Type II -- Comminuted Central Fragment With
Fracture Lines Remaining Peripheral to the
Medial Canthal Tendon Insertion
Type III -- Comminuted Central Fragment With
Fracture Lines Extending Beneath the Medial
Canthal Tendon Insertion

Goals of Management
Reconstitution of the Skeletal Framework of the Nasoorbital Ethmoid Region
Stabilization of the Intercanthal Width and Medial Canthal
Tendons
Orbital Reconstruction
Establishment of Nasal Support
Reconstitution of Other Craniofacial Injuries Including
Frontal Sinus
Soft Tissue Repair


Type I Incomplete Repair
No Requirement for Superior Surgical Approach
Inferior Approach via Gingivobuccal Sulcus
Incision and Transconjunctival / Subciliary
Reduction and Rigid Fixation at Inferior Orbital
Rim and Pyriform Aperture


Type I Complete
Displaced Superior Fragment Requires Superior
Approach via Coronal Flap With Reduction and
Stabilization at the Superior Medial Orbital Rim
Inferior Approach With Reduction and Stabilization
at Inferior Orbital Rim and Pyriform Aperture
Unless Severe Lateral Displacement --Transnasal
Wiring Not Indicated


Type II Repair
Repair Requirements Include:
Transnasal Reduction of Medial Canthal TendonBearing Bone Fragments
Interfragment Wiring to Link All Fragments
Rigid Fixation After Reduction
Transnasal Wire Must be Placed Superior and
Posterior to the Medial Canthal Tendon on the
Central Fragment

Type III Repair
Same Basic Principles of a Type II Repair
Comminuted Fractures Not Suitable for
Reconstruction -- Medial Canthal Tendon
Detached
Bone Grafts May Be Required
Medial Canthal Tendon Secured To Second Set of
Transnasal Wires -- Point of Attachment is
Superior and Posterior

Nasal Support Repair
Dorsal Bone Grafting
Reduction of Septal Fracture
Possible Use of Medial Crura Strut for Columellar
Support
Placement of Canilevered Graft Under the Dome


Naso-orbital Ethmoid Fracture
Lacrimal System Repair
Routine Exploration With Canalicular Probing Not
Indicated
Identifiable Disruption -- Canulate and Suture
Only 5% Incidence of Cases Require DCR Later


Soft Tissue Repair
Padded Bolsters Placed
Secured Through Transnasal Wiring
Lack of Bolstering Leads to Thickened Skin in this
Area Increasing the Intercanthal Soft Tissue
Difference


Orbital Repair
Restoration of Orbital Volume and Contour Must be
Addressed
Use of Bone Grafts and Alloplastic Materials in the
Orbital Floor


Complications
Persistent Telecanthus
Anteriorly Placed Transnasal Wires
Inadvertent Elevation of Tendon
Inadequate Reduction and Stabilization of Central
Fragment
Lack of Adequate Repair of the Orbit
Lack of Adequate Repair of Nasal Support
Soft Tissue Thickness Secondary to Inadequate Bolstering

Frontal Sinus Fractures
Introduction
Incidence -- 5 - 12% Craniofacial Injuries
High Morbidity and Mortality
Management Goals
Avoidance of Early and Late Complications
Cosmetic Reconstruction
Progresses of Frontal Sinus Surgery


Anatomy
Frontal Sinus Development
Anterior versus Posterior Table
Nasofrontal Duct
Arterial / Venous Blood Supply
Sensory Innervation


Diagnosis
Physical Examination
Assess for Associated Ocular Injuries
Assess for Associated Intracranial Injury
Assess for Associated Craniofacial Injury -Naso-orbital Region
CT Scanning
Difficult to Assess Patency of Nasofrontal Duct

Surgical Approaches
Frontal Sinus Trephination
Frontoethmoidectomy
Osteoplastic Flap -- Most Commonly Employed
Frontal Craniotomy


Operative Indications
Anterior Table Displacement With an Aesthetic
Forehead Deformity
Nasofrontal Duct Involvement / Obstruction
Displaced Posterior Table Fractures


Anterior Table Fractures

Nondisplaced Anterior Table Fracture
Displaced Anterior Table Fracture
Status of Nasofrontal Duct
Sinus Preservation
Sinus Obliteration
Removal of Mucosa
NF Duct Obstruction
Sinus Packing

Nasofrontal Duct Reconstruction
Intersinus Removal Allowing Drainage Through
Contralateral Duct
Placement of Catheter Through Traumatized
Nasofrontal Duct
Frontoethmoidectomy Approach When Posterior
Table Not Requiring Repair


Posterior Table Repair
Nondisplaced Posterior Table Fractures
Minimally Displaced Posterior Table Fractures-Less than One Width
Displaced Posterior Table Fracture
Nasofrontal Duct Status
Cerebrospinal Fluid Leak
Degree of Comminution

Cranialization

Coronal Incision -- Osteoplastic / Frontal Craniotomy
Preservation of Anterior Pericranium
Intersinus Septum Removal / Posterior Table Removal
Debridement of Necrotic Tissue / Repair of Dural Tears
Sinus Mucosa Removal
Nasofrontal Duct Obliteration
Interposition Pericranial Flap to Floor


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Sinus fractures /certified fixed orthodontic courses by Indian dental academy

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